Common use of Resides Clause in Contracts

Resides. For tax households with Members in multiple Exchange Service Areas: 1. If all of the members of a tax household are not living within the same Exchange Service Area, any member of the tax household may enroll in a Qualified Health Plan through any of the Exchanges for which one of the Tax Filers meets the residency requirements. 2. If both spouses in a tax household enroll in a Qualified Health Plan through the same Exchange, a Tax Dependent may only enroll in a Qualified Health Plan through that Exchange, or through the Exchange that services the area in which the Dependent meets a residency standard. Dependents To be eligible for coverage to enroll as a Dependent, You must be listed on the enrollment form completed by the Subscriber, be determined by the Exchange to be a Qualified Individual, meet all Dependent eligibility criteria established by the Exchange, and be: 1. The Subscriber’s legal spouse. 2. The Subscriber’s Domestic Partner. Domestic Partner means a person who has established a Domestic Partnership under California law. For purposes of this Agreement, a Domestic Partner shall be treated the same as a spouse. 3. The Subscriber’s or the Subscriber’s spouse’s or the Subscriber’s Domestic Partner’s children who are under age twenty-six (26), including stepchildren, ▇▇▇▇▇▇▇ and legally Adopted Children. 4. Children for whom the Subscriber or the Subscriber’s spouse or Subscriber’s Domestic Partner is a legal guardian and who are under age twenty-six (26). An enrolled Dependent child who reaches age 26 during a benefit year may remain enrolled as a Dependent until the end of that benefit year. The Dependent coverage shall end on the last day of the benefit year during which the Dependent child becomes ineligible. ▇▇▇▇▇▇ Children and grandchildren are not covered. The attainment of age 26 shall not operate to terminate the coverage of a Dependent child while the child is and continues to be (1) incapable of self-sustaining employment by reason of physically or mentally disabling injury, illness, or condition; and (2) chiefly dependent upon the Subscriber for support and maintenance. In other words, eligibility will be continued past the age limit only for those already enrolled Dependent children who cannot work to support themselves by reason of intellectual or physical disability. These Dependents must be allowed as a federal tax exemption by the Subscriber or Subscriber’s spouse. The Dependent’s disability must start before the end of the period he or she would become ineligible for coverage. The Exchange must certify the Dependent’s eligibility. The Plan will notify the subscriber that the dependent child(s) coverage will terminate upon attainment of the limiting age unless the subscriber submits proof of the criteria described in subparagraphs (1) and (2) of paragraph (1) to the plan within 60 days of the date of receipt of the notification. The Plan will send this notification to the subscriber at least 90 days prior to the date the child attains the limiting age. Upon receipt of a request by the subscriber for continued coverage of the child and proof of the criteria described in subparagraphs (1) and (2) of paragraph (1), the Plan shall determine whether the child meets that criteria before the child attains the limiting age. If the plan fails to make the determination by that date, it shall continue coverage of the child pending its determination. Exchange Qualified Individuals are only permitted to enroll in a Qualified Health Plan (QHP), or as an enrollee to change QHPs, during an annual open enrollment period or a special enrollment period for which the Qualified Individual has experienced a qualifying event. Open Enrollment for 2017 Plans will begin on November 1, 2017 and end on January 31, 2018. Enrollees may change QHPs during that time according to rules established by the Exchange. American Indians may move from one QHP to another QHP once per month. A special enrollment period is a period during which a Qualified Individual or enrollee who experiences certain qualifying events or changes in eligibility may enroll in, or change enrollment in, a QHP through the Exchange outside of the annual open enrollment period. Length of special enrollment periods: Unless specifically stated otherwise, a Qualified Individual or enrollee has sixty (60) calendar days from the date of a triggering event to select a QHP. The Exchange must allow Qualified Individuals and enrollees to enroll in or change from one QHP to another as a result of the following triggering events: ● A Qualified Individual or Dependent loses Minimum Essential Coverage, for example due to a loss of employer- sponsored coverage;

Resides. For tax households with Members in multiple Exchange Service Areas: 1. If all of the members of a tax household are not living within the same Exchange Service Area, any member of the tax household may enroll in a Qualified Health Plan through any of the Exchanges for which one of the Tax Filers meets the residency requirements. 2. If both spouses in a tax household enroll in a Qualified Health Plan through the same Exchange, a Tax Dependent may only enroll in a Qualified Health Plan through that Exchange, or through the Exchange that services the area in which the Dependent meets a residency standard. Dependents To be eligible for coverage to enroll as a Dependent, You must be listed on the enrollment form completed by the Subscriber, be determined by the Exchange to be a Qualified Individual, meet all Dependent eligibility criteria established by the Exchange, Exchange and be: 1. The Subscriber’s legal spouse. 2. The Subscriber’s Domestic Partner. Partner - Domestic Partner means a person who has established a Domestic Partnership under California law. For purposes of this Agreement, a Domestic Partner shall be treated the same as a spouse. 3. The Subscriber’s or the Subscriber’s spouse’s or the Subscriber’s Domestic Partner’s children who are under age twenty-six (26), including stepchildren, ▇▇▇▇▇▇▇ and legally Adopted Children. 4. Children for whom the Subscriber or the Subscriber’s spouse or Subscriber’s Domestic Partner is a legal guardian and who are under age twenty-six (26six(26). An enrolled Dependent child who reaches age 26 during a benefit year may remain enrolled as a Dependent until the end of that benefit year. The Dependent coverage shall end on the last day of the benefit year during which the Dependent child becomes ineligible. ▇▇▇▇▇▇ Children and grandchildren are not covered. The attainment of age 26 shall not operate to terminate the coverage of a Dependent child while the child is and continues to be (1) incapable of self-sustaining employment by reason of physically or mentally disabling injury, illness, or condition; and (2) chiefly dependent upon the Subscriber for support and maintenance. In other words, eligibility Eligibility will be continued past the age limit only for those already enrolled Dependent children Dependents who cannot work to support themselves by reason of intellectual or physical disability. These Dependents must be allowed as a federal tax exemption by the Subscriber or Subscriber’s spouse. The Dependent’s disability must start before the end of the period he or she would become ineligible for coverage. The Exchange must certify the Dependent’s eligibility. The Plan will notify the subscriber that the dependent child(s) coverage will terminate upon attainment Exchange must be informed of the limiting age unless the subscriber submits proof Dependent’s eligibility for continuation of the criteria described in subparagraphs coverage within sixty (160) and (2) of paragraph (1) to the plan within 60 days of the date of receipt of the notification. The Plan will send this notification to the subscriber at least 90 days prior to after the date the child attains Dependent would normally become ineligible. You must notify the limiting age. Upon receipt of a request by Exchange if the subscriber Dependent’s tax exemption status changes and if he or she is no longer eligible for continued coverage of coverage. The Exchange may require the child and Subscriber to submit proof of the criteria described in subparagraphs (1) and (2) of paragraph (1), the Plan shall determine whether the child meets that criteria before the child attains the limiting age. If the plan fails to make the determination by that date, it shall continue coverage of the child pending its determinationcontinued eligibility for any enrolled child. Exchange Qualified Individuals are only permitted to enroll in a Qualified Health Plan (QHP), or as an enrollee to change QHPs, during an annual open enrollment period or a special enrollment period for which the Qualified Individual has experienced a qualifying event. Open Enrollment for 2017 Plans will begin on November 1, 2017 2016 and end on January 31, 20182017. Enrollees may change QHPs during that time according to rules established by the Exchange. American Indians may move from one QHP to another QHP once per month. A special enrollment period is a period during which a Qualified Individual or enrollee who experiences certain qualifying events or changes in eligibility may enroll in, or change enrollment in, a QHP through the Exchange outside of the annual open enrollment period. Length of special enrollment periods: Unless specifically stated otherwise, a Qualified Individual or enrollee has sixty (60) calendar days from the date of a triggering event to select a QHP. The Exchange must allow Qualified Individuals and enrollees to enroll in or change from one QHP to another as a result of the following triggering events: ● • A Qualified Individual or Dependent loses Minimum Essential Coverage, for example due to a loss of employer- sponsored coverage;; • A Qualified Individual gains a Dependent or becomes a Dependent through marriage, birth, adoption or placement for adoption, or through a Qualified Medical Child Support Order or court order; • An individual, not previously a citizen, national, or lawfully present gains such status; • A Qualified Individual’s enrollment or non-enrollment in a QHP is unintentional, inadvertent, or erroneous and is the result of an error of the Exchange or the Department of Health and Human Services (HHS), or its instrumentalities as determined by the Exchange. In such cases, the Exchange may take such action as may be necessary to correct or eliminate the effects of such error; • An enrollee demonstrates to the Exchange that the QHP in which he or she is enrolled substantially violated a material provision of its contract in relation to the enrollee; • An individual is determined newly eligible or newly ineligible for Advance Payments of the Premium Tax Credit or has a change in eligibility for cost-sharing reductions, regardless of whether such individual is already enrolled in a QHP; • The Exchange must permit individuals whose existing coverage through an eligible employer sponsored plan will no longer be affordable or provide minimum value for his or her employer’s upcoming Plan Year to access this special enrollment period prior to the end of his or her coverage through such eligible employer-sponsored plan; • A Qualified Individual or enrollee gains access to new QHPs as a result of a permanent move; and A Qualified Individual or enrollee demonstrates to the Exchange, in accordance with HHS guidelines, that the individual meets other exceptional circumstances as the Exchange may provide; • An individual was receiving services from a contracting provider under another health benefit plan and that provider ceases to participate in that plan, providing that the services are for an acute condition, serious chronic condition, pregnancy, terminal illness, the care of a newborn child between birth and 36 months, or performance of a surgery or other procedure that has been authorized by their previous plan and is documented by the provider to occur within 180 days of the contract’s termination date or within 180 days • of the effective date of coverage for a newly covered enrollee (see the part CONTINUITY AND TRANSITION OF CARE for details); • An individual demonstrates to the Exchange that he or she did not enroll in a health benefit plan during the immediately preceding enrollment period available to the individual because he or she was misinformed that he or she was covered under minimum essential coverage; • An individual is a member of the reserve forces of the United States military returning from active duty or a member of the California National Guard returning from active duty service; and • An individual has been released from incarceration.