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Frequently Asked Questions - HealthChoice
A qualifying event is a life status change that allows a person to make midyear changes to insurance coverage.
For current employees, your employer's Section 125 Plan may recognize only certain qualifying events as defined by the IRS. Check with your employer's plan administrator for specific information.
Qualifying events may include:
- Change in your legal marital status, including marriage, divorce or death of your spouse
- Change in the number of your dependents, such as the birth of a child
- Change in employment status that affects the eligibility of you, your spouse or your dependent
- Change in your dependent's eligibility status
- Change in coverage of your spouse or dependent under another employer's plan or loss of individual coverage
- Commencement or termination of adoption or guardianship procedures
- Judgments, decrees or orders
- Medicare eligibility
- Medicaid – limited to two changes per plan year; once out and once back in or vice versa
- Family and Medical Leave Act
All changes to coverage must be in compliance with the provisions of your employer's Section 125 Plan, or if no 125 Plan is offered, in compliance with allowed midyear coverage changes as defined by Title 26, Section 125, of the Internal Revenue Codes (as amended) and pertinent regulations. Current employees must contact their insurance/benefits coordinator at work within 30 days of the qualifying event to make changes to coverage. Changes are effective the first day of the following month.
For former employees, eligible dependents can be added only within 30 days of the following qualifying events:
- Birth, adoption or legal guardianship
- Loss of other group coverage; certain exceptions apply to the loss of individual health coverage. Refer to HIPAA Special Enrollment Rights for more information.
Former employees must provide proof of the qualifying event to EGID.
If you receive dental care outside the United States, you must:
- Make arrangements to pay for the services or supplies
- Submit an itemized statement for reimbursement
- Have claims translated into English with U.S. dollar amounts before you file your claim*
- File the original claim along with the translation; the plan does not pay any costs for translating claims or dental records
*Charges must be converted to U.S. dollars using the exchange rates applicable for the dates of service.
Itemized bills should be sent to:
P.O. Box 99011
Lubbock, TX 79490-9011
Allowable fees are paid at the non-network benefit level and are subject to plan provisions.
Other Dental Plans
Contact your dental plan for benefit information.
HealthChoice High, High Alternative, Basic, and Basic Alternative Plans, and High Deductible Health Plan
HealthChoice network providers are required by contract to submit claims for you using the appropriate form. Payment is made to the network provider.
Non-network providers are not required to submit claims on your behalf. In these situations, you are responsible for ensuring your claim is filed using the appropriate form for processing. Items such as cash register receipts, pull-apart forms and billing statements are not acceptable.
If you use a non-network provider, you can ask if the provider can submit the claim on your behalf using the appropriate form or if they can provide you with a completed form so that you can file the claim yourself.
Note: Due to copyright laws, these forms cannot be made available on the HealthChoice website, and HealthChoice does not maintain a supply of these forms.
Non-network claims are usually paid to you; however, you can choose to have your benefits paid directly to your provider.
Send your claims to:
P.O. Box 99011
Lubbock, TX 79490-9011
For questions or additional information, call the HealthChoice medical and dental claims administrator toll-free at 800-323-4314. TTY users call 711 or toll-free 800-545-8279.
HealthChoice SilverScript Medicare Supplement and HealthChoice Medicare Supplement Without Part D Members
Once Medicare processes your claim, it is automatically filed with your HealthChoice Medicare supplement plan. Be sure your provider has a copy of your most current Medicare and HealthChoice ID cards.