Common use of Applying for Coverage Clause in Contracts

Applying for Coverage. You may apply for dental coverage for yourself and/or your Dependents. No eligibility rules or variations in premium will be imposed based upon your health status, dental condition, claims experience, receipt of health care, dental history, genetic information, evidence of insurability, disability, or any other health status related factor. You will not be discriminated against for coverage under this Plan on the basis of race, color, national origin, disability, age, sex, gender identity, or sexual orientation. Variations in the administration, processes or Benefits of this Contract that are based on clinically indicated, reasonable dental management practices, or are part of permitted wellness incentives, disincentives and/or other programs do not constitute discrimination. You may enroll in or change dental coverage for yourself and/or your Dependents during one of the following enrollment periods. Your and/or your Dependents’ Effective Date will be determined by the Plan and the Exchange, as appropriate, depending upon the date your application is received, payment of the initial premiums no later than the day before the Effective Date of coverage, and other determining factors. The Plan and the Exchange, as appropriate, may require acceptable proof (such as copies of legal adoption or legal guardianship papers, or court orders) that an individual qualifies as a Dependent under this Contract. You may apply for or change dental coverage for yourself and/or your Dependents during the annual open enrollment period designated by the Exchange and/or the Plan, as appropriate. When you enroll during the annual open enrollment period, your and/or your Dependents’ Effective Date will be the following January 1, unless otherwise designated by the Exchange and/or the Plan, as appropriate. This section “Annual Open Enrollment Periods/Effective Date of Coverage” is subject to change by the Exchange, the Plan and/or applicable law, as appropriate. Special enrollment periods have been designated during which you may change dental coverage for yourself and/or your Dependents. You must apply for dental coverage within 60 days from the date of a Special Enrollment Event detailed below. Except as otherwise provided below, if you apply between the 1st day and the 15th day of the month, your Effective Date will be no later than the 1st day of the following month, or if you apply between the 16th day and the end of the month, your and/or your Dependents’ Effective Date will be no later than the 1st day of the second following month. You must provide acceptable proof of a special enrollment event. “Special Enrollment Events” are described in detail below. The Plan will review this proof to verify your eligibility for a special enrollment. Failure to provide acceptable proof of a special enrollment event will delay or prevent enrollment under this Contract. Please call the Customer Service number shown on your Identification Card for additional information. • You experience a loss of Minimum Essential Coverage. New coverage for you and/or your Dependents will be effective no later than the first day of the month following the loss. • You gain a Dependent or become a Dependent through marriage. New coverage for you and/or your Dependents will be effective no later than the first day of the following month. • You gain a Dependent through birth, adoption or Placement for Adoption or court-ordered Dependent coverage. New coverage for you and/or your Dependents will be effective on the date of birth, adoption, or Placement for Adoption. If your membership includes at least one Dependent, coverage for a newborn will be effective on the date of birth and continue for 31 days. In order to extend the coverage beyond 31 days, your application to add coverage for the newborn must be received within 31 days following the child's birth; and you must make the required contribution for such coverage from the date of birth. • Your enrollment or non-enrollment in an Exchange-Certified Dental Plan is unintentional, inadvertent, or erroneous as evaluated and determined by the Exchange and/or the Plan, as appropriate. • You adequately demonstrate to the Exchange that the Exchange-Certified Dental Plan in which you are enrolled substantially violated a material provision of its Contract in relation to you. • You are determined newly eligible or newly ineligible for Advance Premium Tax Credit or have a change in eligibility for cost-sharing reductions, regardless of whether you are already enrolled in an Exchange- Certified Dental Plan. • You gain access to new Exchange-Certified Dental Plans or other individual coverage as a result of a permanent move. In addition to the “Special Enrollment Events” outlined above, if you have purchased this coverage through the Exchange, the following Special Enrollment Events apply: • You are an Indian, as defined by section 4 of the Indian Health Care Improvement Act. You may enroll yourself or your Dependents in an Exchange-Certified Dental Plan or change from one Exchange-Certified Dental Plan to another one time per month. • You demonstrate to the Exchange, in accordance with the guidelines issued by Health and Human Services (HHS), that you meet other exceptional circumstances as the Exchange may provide.