GENERAL INFORMATION

PerfectHealth Employee: Benefits at-a-Glance (PDF, 38k)

Member Communication
Member Communication (PDF, 38k)

A Quick Guide To Your Plan
Plan Guide (PDF, 61k)

Benefit Booklet
Each insured employee receives a Benefit Booklet with a validation page indicating the coverage and effective date. Benefits, exclusions and limitations can be found in the Benefit Booklet.

Claims Payment
Claims are paid directly by our group claims office to the insured or a network provider. We do not assign benefits to non network providers.

Eligible Employees
All full-time employees who have completed the required waiting period, if any, are eligible to enroll. Full-time means working at least 30 hours per week, excluding time worked at home. Employees working 20- 29 hours per week can be included at the employer's discretion.

Employees must enroll within 30 days of becoming eligible, otherwise they may be considered a late enrollee. (Special exceptions apply. See the Special Enrollment Period section). Details on special enrollment procedures will be provided in the administration kit.

Late Enrollees
"Late enrollees," will be enrolled and subject to a 18 month pre-existing condition limitation. Late enrollees are individuals who declined coverage when it was first offered to them and are not enrolling during a Special Enrollment Period. (See the Special Enrollment Period section for more details.) Late enrollees will be given credit towards satisfaction of this pre-existing condition limitation for prior creditable coverage. However, the period of time between when the person was eligible to enroll, and when he or she actually enrolled as a late enrollee will not be counted as a waiting period, and therefore will not run concurrently with this pre-existing condition period.

Special Enrollment Period
An employee or dependent who is eligible for coverage under the Plan, and who declines coverage during the initial enrollment will be allowed to enroll during a Special Enrollment Period if he or she meets the following conditions:

1. The employee or dependent declined this coverage initially because they stated in writing at the time of enrollment that they had other coverage AND the other coverage:
   
   

   • terminated as a result of loss of eligibility for that coverage (due to legal separation, divorce, death, termination of employment, or reduction in the number of hours of employment); or
   • was COBRA continuation which exhausted, or
   • terminated as a result of employer contributions towards such coverage ceasing.
     In these cases, enrollment must be made no later than 30 days after the date such coverage in above terminated.
     or


2. If an employee gains a dependent through marriage, birth, or adoption or placement for adoption, they may enroll themselves and their newly acquired dependent under this Special Enrollment provision no later than 30 days after the date the person is eligible for coverage. or


3. A court has ordered coverage to be provided for a spouse or minor or dependent child under a covered employee's health benefit plan and request for enrollment is made within 30 days after issuance of the court order. Individuals enrolling during a Special Enrollment Period will be given credit towards satisfaction of this pre-existing condition limitation for prior creditable coverage.

Guarantee Renewability
All group medical plans are guarantee renewable. A carrier may not deny an employer continued participation or access to the same or different coverage under a plan except for the following reasons:

• Non-payment of premium
• Fraud or misrepresentation
• Violation of participation or contribution requirements
• Non-compliance with plan provisions
• For network plans, when there is no longer any member working or living in the service area
• When the carrier discontinues a particular product (subject to state and federal guidelines)
• When a carrier discontinues all coverage in either the large group or small group market, or both, in a state (subject to particular state guidelines)

Plans Available
PerfectHealth offers PPO medical plans that are HSA-compatible and High Deductible Health Plans that are not HSA-compatible as well.
PPO plans are available for groups that have two or more employees and EPO plans are available for groups of one.

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