1. Applying For Coverage
1. Am I eligible for Non-Group insurance?
2. What is COBRA and why does it affect my eligibility for your Non-Group insurance?How do I qualify as a resident?
3. Should my former Vermont employer with less than 20 employees offer employees and/or their eligible dependents health coverage continuation benefits?
4. How do I qualify as a resident?
5. Who qualifies as my dependent?
6. When can my coverage be effective?
7. What if I am covered by another BCBS plan?
8. What if I am covered (or was recently covered) by a non-BCBS insurance provider?
9. Can I purchase health coverage solely for a child?
10. In a divorce situation, can I cover a child for whom I am responsible, but do(es) not reside with me?
11. In a divorce situation, if my dependent child(ren) live with me and the child(ren)'s health insurance coverage is provided by the non-custodial parent, do I need to include information about my child(ren) in Sections 2 and 3 of the Non-Group application?
12. If my child(ren) is/are covered by the State of Vermont's Dr. Dynasaur program do I need to include information about my child(ren) in Sections 2 and 3 of the Non-Group application?
13. Can I cover my child who is over the age of 18?
14. How does my child who is graduating from school get his/her own individual coverage?
15. I have Power of Attorney (or other legal authority to secure health coverage) for a relative (or other third party). What is the enrollment process in this situation?
16. How will I know that you have received my application?
17. Will I receive a certificate of coverage and an ID card?
18. What if I need to use my benefits before I receive my ID card?



2. Using Your Health Plan
19. What is a deductible?
20. What is coinsurance?
21. What is a co-payment?
22. What expenditures are applied to the deductible?
23. What expenditures are included in the "out-of-pocket" expense category, and are they credited towards the deductible?
24. When do doctor "visit fee" co-payment benefits begin?
25. When do pharmacy co-payment benefits begin?
26. What is the lifetime maximum?
27. Am I covered if I travel out of state?
28. What is a pre-existing condition?
29. Are pre-existing conditions covered?
30. Is there a pre-existing condition waiting period for maternity benefits?



3. Billing Questions
31. When are premium bills sent out and due?
32. Can I pay for more than one month's premium in advance?
33. Can I pay my premiums by credit card, debit card, or by automatic debit to my bank checking account?
34. Is there a late-payment grace period?
35. Can my premium bills be mailed to a third party?

A. Applying For Coverage:

1. Am I eligible for Non-Group insurance? In order to be eligible for this coverage you must be a Vermont resident from the age of 18 to age 65 and not on Medicare. You or your spouse must not be eligible for group insurance through an employer, through COBRA (see question 2), or under Vermont's continuation of coverage statutory provisions (see question 3). If you are employed but not eligible for group insurance, please note that Vermont State Law states that your employer may not pay for or sponsor your health insurance in any way. top...



2. What is COBRA and why does it affect my eligibility for your Non-Group insurance? The federal Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985, (P.L. 99-272) requires that employers of 20 or more employees, maintaining health care coverage plans, offer employees and/or their eligible dependents who lose group health benefits for eligibility reasons the option of continuing health coverage at their own cost, under the employer's group plan. (See question 3 for information concerning employers with less than 20 employees.)
   
   COBRA is, therefore, an extension of benefits under a group health plan. If you have become eligible for COBRA due to a qualifying event there is a 60-day election period following the qualifying event. While you are in the 60-day election period or have elected COBRA coverage, you are ineligible for non-group coverage because you are eligible for coverage by your group health plan under COBRA. If, however, at the termination of your 60-day election period you do not elect COBRA, or the COBRA period ends (i.e. end of the 18, 29 or 36 month extension) or if you stop paying premiums and lose coverage, you will become eligible for non-group because you will no longer be eligible for coverage under your group health plan through your COBRA entitlement. top...



3. Should my former Vermont employer with less than 20 employees offer employees and/or their eligible dependents health coverage continuation benefits? Yes. The Vermont Banking and Insurance Statute (Title 8 Section 4090) requires that employers of 19 or less employees, maintaining health care coverage plans, offer employees and/or their eligible dependents who lose group health benefits for eligibility reasons the option of continuing health coverage for six months at their own cost, under the employer's group health plan.
   
   Similar to COBRA, Vermont's continuation of benefits requirement is an extension of benefits under a group health plan. If you have become eligible for Vermont's continuation of benefits program due to a qualifying event, such election must be made in writing within 60 days if the employee or member is deceased, or within 30 days if the employee has been terminated, the covered employee becomes divorced or legally separated, or a dependent child ceases to be a dependent child under the generally applicable requirements of the policy, of the date that coverage under the group policy would otherwise terminate, or the date the person is given notice of the right of continuation, whichever is sooner. While you are in the 60-day or 30-day election period or have elected continuation coverage then you are ineligible for non-group coverage because you are eligible for coverage by your group health plan under Vermont's statutory provisions. If, however, at the termination of your election period you do not elect to continue benefits, or the election period for those continuation benefits ends (i.e. end of the six-month extension) or if you stop paying premiums and lose coverage, you will become eligible for non-group at that time because you will no longer be eligible for coverage under your group health plan through your statutory entitlement. top...



4. How do I qualify as a resident? "Resident" means a person as defined in Title 18 V.S.A., Section 9402(12) "who is domiciled in Vermont as evidenced by an intent to maintain a principal dwelling place in Vermont indefinitely and to return to Vermont if temporarily absent, coupled with an act or acts consistent with that intent." A resident also includes a dependent and a dependent child attending school outside Vermont. top...



5. Who qualifies as my dependent? On a nongroup plan, "Dependent" means a subscriber's spouse; the other party to a subscriber's civil union (a partner with whom the subscriber has entered into a legally valid civil union); the subscriber's child under the age of 19; an over-age dependent covered under your contract (e.g., full-time student up to the age of 25, or certified as incapacitated by a physician and deemed incapacitated by our medical director); or a court-ordered dependent (proof of the court order must be submitted to BCBSVT). Domestic partners who are not parties to a legally valid civil union are not eligible to be covered as dependents on your nongroup plan. top...



6. When can my coverage be effective? You must choose the effective date on which you want your coverage to begin. Assuming eligibility requirements have been met, you can choose to be effective on the date we receive your application or any date thereafter. You must indicate this date on the application in Section 1on the line labeled "Effective Date". top...



7. What if I am covered by another BCBS plan? If you are moving to Vermont, or for any other reason have a BCBS plan with another state, you should notify your current plan that you will be transferring to BCBSVT and submit an application and documentation of your prior coverage to us. The prior coverage information must include the original effective date and termination date of your prior coverage. This information may entitle you to credit against your waiting periods for some or all services, including pre-existing conditions. You do not need to include a check for your first month's premium with your application. top...



8. What if I am covered (or was recently covered) by a non-BCBS insurance carrier? If you are still covered, you should notify your current carrier that you will be terminating your coverage, and ask the carrier to send you your prior coverage information including its original effective date and termination date. If your coverage has already been discontinued, please send us your prior coverage information. This information may entitle you to credit against your waiting periods for some or all services, including pre-existing conditions. You must include a check for your first month's premium with your application. top...



9. Can I purchase health coverage solely for a child*? No. The child must be covered on the policy of an adult 18 years or older who is legally the custodial party and/or responsible for providing his or her health coverage. (*Child is defined as a minor under the age of 19 or a full-time student age 19-25) top...



10. In a divorce situation, can I cover a child for whom I am responsible, but who does not reside with me? Yes, if you have legal responsibility to do so. If the child does not reside with you, fill in the appropriate information in Section 2 of the Non-Group application and submit the application with documentation that shows your legal responsibility for the child's health insurance coverage. top...



11. In a divorce situation, if my dependent child lives with me and the child's health insurance coverage is provided by the non-custodial parent, do I need to include information about my child in Sections 2 and 3 of the Non-Group application? Yes. Fill in the required information and submit the application with a copy of the documentation that shows the non-custodial parent's legal responsibility for the child's health insurance. top...



12. If my child is covered by the State of Vermont's Dr. Dynasaur program do I need to include information about my child in Sections 2 and 3 of the Non-Group application? Yes. Fill in the required information and submit the application with a copy of the letter of acceptance you received from the State showing that your child is eligible and actively covered by Dr. Dynasaur. top...



13. Can I cover my child who is over the age of 18? Yes, you can cover your child up to the age of 25 if your child is your dependent and a full-time student. Indicate this information in Section 4 of the application. top...



14. How does my child who is graduating from school get his or her own individual coverage? If the child was your dependent on your policy first check with your health plan to see if the child can be offered conversion options. If the plan was a BCBSVT or TVHP plan please contact the business service and retention department at 1-800-909-8427 for information about transferring the child's coverage to a Non-Group policy. If the child is not transferring from a BCBSVT or TVHP plan, have this young adult submit his or her own Non-Group application with a check for the first month's premium. Standard eligibility requirements apply. top...



15. I have Power of Attorney (or other legal authority to secure health coverage) for a relative (or other third party). What is the enrollment process in this situation? Complete the application and submit it with a copy of the legal documentation granting you the authority to act for the applicant, and a check for the first month's premium if needed. top...



16. How will I know that you have received my application? We will mail you a letter within two business days of receiving your application, confirming its receipt and the intended effective date, or requesting further information from you. top...



17. Will I receive a certificate of coverage and an ID card? Yes. You will receive a certificate of coverage, and an ID card in a separate envelope, within 30 days following the date we received your fully completed application and check, if required, and any required attachments. top...



18. What if I need to use my benefits before I receive my ID card? Call the individual in the sales department who mailed you your confirmation letter and request instructions.top...

B. Using Your Health Plan:

19. What is a deductible? A "deductible" is an amount you must pay each calendar year before your plan begins to pay for a particular service. top...



20. What is coinsurance? "Coinsurance" is a percentage of our allowed price you must pay, as shown on your Outline of Coverage, after you meet your deductible. top...



21. What is a co-payment? "Co-payment" is a fixed dollar amount you must pay (such as co-payments for office visit fees and other professional care visit fees). For example: You pay a co-payment each time you visit a provider's office. Co-payments are not credited towards your deductible or your out-of-pocket limit. top...



22. What expenses are applied to the deductible? All expenses for covered services, except for office visits; prescription drugs purchased at a pharmacy or through mail order; and maternity services. Examples of covered services subject to your deductible are lab fees and X-rays. top...



23. What expenses are included in my out-of-pocket limit, and are they credited towards the deductible? Expenses included in your out-of-pocket limit are your deductible and your coinsurance payments. After you've met your out-of-pocket limit, your benefits will be paid at 100% of our allowed price for the rest of that calendar year (except for your co-payments). top...



24. When do doctor co-payment benefits begin? Right away. You do not need to meet a deductible or out-of-pocket limit in order to begin using your co-payment benefits. top...



25. When do pharmacy co-payment benefits begin? After you have met your prescription drug deductible amount. top...



26. What is the lifetime maximum? The lifetime benefit limit is 1 million dollars per person. top...



27. Am I covered if I travel out of state? If you need care and are out of state, your Vermont Freedom Plan provides you the highest level of benefits available under your program if you use out-of-state providers who are "participating" or "participating preferred" providers in their local BlueCard network. The provider should be able to tell you if he/she is a participating or participating preferred provider. If not, the local BCBS plan can give you this information. The out-of-state participating provider should file the claim with the local plan. If the provider does not participate, you may have to pay up front for your services and submit the claim to us. You should arrange for routine care or care for chronic conditions before you leave Vermont. top...



28. What is a pre-existing condition? "Pre-existing condition" means the existence of symptoms which would cause an ordinary, prudent person to seek diagnosis, care or treatment or those conditions for which medical advice or treatment was recommended by or received from a physician or other medical professional during the six-month period preceding the effective date of coverage. top...



29. Are pre-existing conditions covered? Yes, but there is a 12-month waiting period for anything pre-existing. This may be waived if you currently are covered or have had less than a 63-day break in coverage. Section 4 of the application states that in order for us to consider giving you credit you must provide us with documentation from your previous insurer. This information must include the original date your prior coverage became effective and the date it was terminated (or will be terminated). top...



30. Is there a pre-existing condition waiting period for maternity benefits? Yes. Maternity benefits are covered the same as any other health condition, and are subject to waiting periods. top...

C. Billing Questions:

31. When are premium bills sent out and due? Premium bills are sent out the first week of each month for the following month's coverage. Payment must be received by the first day of each month in advance. (Example: your premium for June coverage is due June 1st). top...



32. Can I pay for more than one month's premium in advance? Yes, you may pay your premiums as far in advance as you wish. You will continue to receive a monthly billing statement. top...



33. Can I pay my premiums by credit card, debit card, or by automatic debit to my bank checking account? No. Not at this time. top...



34. Is there a late-payment grace period? No. Your premiums are due on the 1st of each month in advance of the month for your covered service. top...



35. Can my premium bills be mailed to a third party? Yes. The monthly premium bills will be sent to the address that you have written as the "mailing address" on the application that you have signed. However, it is important that you understand and are aware that if you designate a third party's address as your mailing address all medical information and correspondence in connection with your policy will also be sent to that address. top...

Thank you for your interest in Blue Cross and Blue Shield of Vermont.

Please contact our sales department for further information or if you have any questions.

We appreciate the opportunity
to serve you.
1-800-255-4550