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To enroll, you must be age 64-3/4 or younger,a permanent legal resident of California, and a U.S. resident for at least the last 3 months;the applicant’s spouse, age 64-3/4 or younger;the applicant’s child, or the child of the applicant’s enrolling spouse, under 19 years of age; or the applicant’s unmarried dependent child between the ages of 19 and 23 (“dependent as defined by the Internal Revenue Service).

Medical Underwriting Requirement.We believe that the cost of covering someone whose health can be predicted to require costly care, should not be subsidized by someone with minimal health care needs. Accordingly, Blue Cross offers various levels of coverage, ensuring an overall balance of risk. To determine individual medical risk factors, all enrollments are subject to medical underwriting. Depending on the results of underwriting review, a number of things may happen: you may be offered coverage at the standard premium charge.you may be offered the plan you selected at a higher rate, or you may not qualify for the plans listed in this brochure.

If you have a significant medical condition and do not qualify for the plans in this brochure, we may provide you with applications for coverage under our Level III Coinsurance plan and the California Major Risk Medical Insurance Program (MRMIP). Benefits under both of these plans are the same; the Level III Coinsurance plan provides health care coverage to those on the waiting list for MRMIP. If you are pregnant, you may also qualify for the state-sponsored Access for Infants and Mothers (AIM) plan. For more information on AIM eligibility, call (800) 433-2611.

Blue Cross and other Individual health care companies by law must provide coverage to anyone who qualifies for certain coverage regardless of health under the Health Insurance Portability and Accountability Act (HIPAA).

To qualify for a HIPAA plan, you must have completed a minimum 18 months of continuous health coverage, most recently under an employer-sponsored group health plan;have elected and exhausted continuation of coverage under COBRA or Cal-COBRA, if available;have lost coverage within the last 63 days; an not be eligible for MediCal, Medicare or any other group medical coverage. If you want to find out if you qualify, contact us so that we can determine your eligibility and tell you about the available HIPAA plans.

Waiting Periods
For PPO plans, there is a specific six-month waiting period for coverage of any condition, disease or ailment for which medical advice or treatment was recommended or received within six months preceding the effective date of coverage. If you apply for coverage within 63 days of terminating your membership with another “creditable health care plan, then you can use your prior coverage for credit toward any six-month waiting period. Blue Cross will credit the time you were enrolled on the previous plan.

Consult with your Blue Cross agent or representative if you have a question about the underwriting process.

Terms of Coverage
Coverage remains in force as long as you pay the required subscription charges on time and for as long as you remain eligible for membership. Coverage will cease if you become ineligible because of
residency requirements and/or duplicate coverage of non-group insurance.
Members who become divorced or who have children’s coverage and become overage dependents will be moved to their own policy. Blue Cross may change or terminate coverage for all covered persons with the same plan, rating area and deductible (if applicable), including changing rates, with 30 days prior written notice. Blue Cross does not change coverage or rates unless the change applies to all covered persons of the same class.If you have just discontinued group coverage, please contact your agent for information about individual coverage options.

Mental Health Coverage
Blue Cross provides the same level of coverage as other medical diagnoses for the medically necessary treatment of severe mental illnesses in persons of any age. Severe mental illness, as defined by the American Psychiatric Association in the Diagnostic and Statistical Manual (DSM), includes the following diagnoses:

Schizophrenia
Chicaneries disorder
Bipolar disorder (manic-depressive illness)
Major depressive disorders
Panic disorder
Obsessive-compulsive disorder
Pervasive developmental disorder or autism
Anorexia nervosa
Bulimia nervosa
Blue Cross also provides the same level of coverage as other medical diagnoses for serious emotional disturbances in children that result in behavior inappropriate to the child's age, according to expected development norms.

For all PPO plans, coverage is provided for non-severe mental and nervous disorders and substance abuse as follows:

Inpatient Hospital (30 days/year maximum) You pay all charges except $175/day
Professional Services (1 visit/day; 20 visits/year maximum) - You pay all charges except $25/visit.
For more details regarding these benefits, refer to the Evidence of Coverage.
Emergency Care
Blue Cross covers emergency services necessary to screen and stabilize your condition. No authorization or pre certification is required if you reasonably believe an emergency medical condition exists. A medical emergency is an unexpected acute illness, injury or condition that could endanger your health if not treated immediately. Examples of medical emergencies include:
Severe Pain
Chest Pains
Heavy Bleeding
Difficulty breathing or shortness of breath
Sudden loss of consciousness
Active natal labor (childbirth)
Sudden weakness or numbness of the face, arm or leg on one side of the body
When you consider a medical condition to be an emergency, immediately call 911 or go to the nearest hospital emergency room. Once your condition is stabilized, it is important for the hospital, you, or a family member to contact your physician or Blue Cross about the authorization of additional services.
If you have HMO coverage, you or a member of your family must notify your Primary Care Physician or medical group as soon as possible, but not later than 48 hours after the initial care has been provided.