CalPERS staff told employers that a provider or medical-group contract termination is not a qualifying event for changing health plans. Richard Ramsey, answering enrollment and eligibility questions, said contract changes and terminations occur frequently and CalPERS cannot guarantee continuity of a relationship with a provider if that provider leaves a plan network.

“Changes to medical groups and contract terminations occur often and throughout the course of the year, and so these are not qualifying events,” Ramsey said. He noted the California Department of Managed Health Care requires health plans to maintain sufficient providers in network and that members in an active course of treatment may request a continuity-of-care plan to complete treatment with their provider.

Qualifying events and timing: Ramsey said moving is a qualifying event that permits a plan change, as are retirement and Medicare eligibility. For qualifying events, members have 60 days from the event date to request a health-plan change. He gave a scenario where a member retiring in October and transitioning to a Medicare plan on Dec. 1 could change plans effective Dec. 1 using retirement or Medicare eligibility as qualifying events.

Disabled dependents and documentation: For adding a child over age 26 because of disability, Ramsey said required paperwork includes the Disabled Dependent Member Questionnaire and medical reports (HPD-34) and an authorization to disclose protected health information (BDS-35) for the provider. The HPD-34 includes a member section and a provider section; providers must send completed documentation directly to CalPERS by fax or mail. Ramsey said parents are not eligible dependents under employer-sponsored plans; eligible dependents include spouses, registered domestic partners, natural and adopted children, stepchildren, assumed parent–child relationships, and certified disabled dependent children age 26 and older.

Appeals and access: Ramsey said members dissatisfied with access can appeal to CalPERS in writing; appeals are evaluated case by case. He emphasized that most contract negotiations result in new agreements, but when members lack access they may request continuity of care or pursue an appeal.