Employee Coverage Cancellation

Employees are no longer eligible for Blue Shield group coverage when their employment is terminated or their employment hours are reduced to fewer than 30 hours per week, unless coverage is purchased for part-time employees.

To cancel an employee's coverage for either a Blue Shield of California plan or a Blue Shield of California Life & Health Insurance Company plan, follow these steps:

• Fill out an Eligibility Change Transmittal form.
• List the employee's name, Blue Shield ID number or Social Security number and employment termination date.
• Mail or fax the Eligibility Change Transmittal form to Blue Shield's Membership Eligibility Processing Unit:

For companies with 1 to 100 eligible employees
Blue Shield of California
P.O. Box 3008
Lodi, CA 95241-1912
Fax: (209) 367-6475

For companies with 101 or more eligible employees
Blue Shield of California
P.O. Box 629014
El Dorado Hills, CA 95762-9014
Fax: (916) 350-8800

Please note: Cancellation requests must be submitted within 30 days of the termination date. Blue Shield will only give up to one month credit unless subject to the provisions in Part III Eligibility of your group contract.

Dependent Coverage Cancellation

Dependents are no longer eligible for Blue Shield group coverage when the employee through whom they were covered dies, terminates employment or no longer works the minimum hours required for eligibility.

Dependent children must also be canceled when they:

• Marry
• Reach your group contract's maximum age limit for coverage, which is effective the first day of the month following the birthday, unless disabled.
• Lose full-time student status (for dependents ages 19 to 25 only).
  NOTE: Blue Shield continues coverage for full-time students if they are on an approved medical leave of absence.
• Permanently move outside of plan service area if enrolled in an HMO or POS plan.

Employees are responsible for informing you when a dependent is no longer eligible for coverage. To cancel a dependent's coverage when the employee continues to be covered, follow these steps:

• Have the employee complete a Subscriber Change Request form and list the name(s) of the dependent(s) to be disenrolled and the date(s) of cancellation.
• The employee should complete this form during the month the dependent becomes ineligible for coverage.
• Verify that the form is properly completed, signed and dated, and give the employee a copy of the form.
• List the employee's name and Subscriber ID number on the Eligibility Change Transmittal form.
• If your group is self-reporting and does not receive a billing statement, enter the employee name on the Self-Reporting Group Subscriber Report and the dependent dues/premiums in the “Current Dues Deletions” column. Under “Remarks” note that a dependent is being disenrolled and indicate the effective date.

Mail or fax the Subscriber Change Request form and Eligibility Change Transmittal/Self-Reporting Group Subscriber Report to Blue Shield's Membership Eligibility Processing Unit.

Please note: Cancellation requests must be submitted within 30 days of the termination date. Retroactive cancellations for dependents that exceed 30 days will not be approved for small groups.

Coverage Options after Cancellation

In addition to COBRA or Cal-COBRA continuation coverage, employees and dependents may have other health coverage options. Please click on the following links to learn more about Blue Shield coverage options after cancellation:

• Blue Shield Individual and Family Plans
• A Blue Shield individual conversion plan
• A Blue Shield HIPAA Guaranteed Issue plan
• A Blue Shield of California Medicare Supplement plan (if applicable)

Please note: Benefits of each plan option listed above differ from those of your Blue Shield group plans.

Please see your Administrator's Guide for more information.