PacificSource Health Plans - Electronic Application

Index | Plan Limitations | Eligibility | Locate Providers | Download Application
Plan Benefits:
Elect Premiere | Elect Preferred | Elect HSA | Elect Value Option
Plan Rates:
Elect Premiere | Elect Preferred | Elect HSA | Elect Value Option

Eligibility

Clients may apply for a PacificSource Elect policy if they are Oregon residents and are not covered by Medicare. They may also apply to include their legal spouse, domestic partner, and dependent children under the age of 26.

Coverage effective dates

Once we receive an application, it is reviewed and underwritten. We will then offer or decline coverage based on health. If we offer coverage, the policy can become effective on either the 1st or the 15th of the month following approval.

Open enrollment

People under the age of 19 are not subject to underwriting and may not be denied coverage based on their health. However enrollment is limited to the following circumstances:

• We are currently in a one-time open enrollment period which began November 1, 2010, and ends December 31, 2010, with coverage effective January 1, 2011. This special enrollment period is for individuals whose coverage ended because they reached their plan’s previous lifetime limit. Those who may qualify for this special enrollment period under PacificSource policies received information by mail.
• During one of the following designated open enrollment periods:
  • The month of February of each year, with coverage becoming effective on March 1 of that year
  • The month of August of each year, with coverage becoming effective on September 1 of that year
• During the 30-day period after PacificSource receives notice of a loss of other coverage if:
  • The notice is provided to PacificSource no later than 60 days after the loss of coverage.
  • The loss of other coverage results from legal separation, divorce, cessation of dependent status, death of the primary policyholder, or incurrence of a claim that meets or exceeds a lifetime limit on all benefits.
  • And, the individual under age 19 is not eligible for group coverage. Coverage will become effective the day following the loss of coverage upon payment of premium.
• During the 31-day period following the birth of a child to a member who is currently insured on an Elect policy. Coverage for the newborn will become effective on the child’s date of birth.
• During the 31-day period following a child’s adoption by, or placement for adoption with, a member who is currently insured on an Elect policy. Coverage for the child will become effective on the date of adoption or placement for adoption.

The above enrollment opportunities are not available if the applicant had PacificSource coverage during the 12 month period prior to the time application, that was terminated due to rescission, failure to abide by the terms and conditions of the policy (such as non-payment of premium), or voluntary termination by the policyholder.

Premiums

A premium schedule for all Elect plans is available on our Web site. Rates are based on the age of the oldest family member on the policy. When a birthday pushes a member into a higher age bracket, the premium will be adjusted on the first day of that month. If family members are added or subtracted from coverage, the premium will be adjusted on the effective date of the change. PacificSource reviews its Elect premium rates annually on January 1. If a rate adjustment is needed, we will notify the member 30 days in advance.