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There are two types of membership with Atlantis:

1. You are an employee or member of a Group who remits premium payments to Atlantis on your behalf; or,

2. You apply directly to Atlantis and make direct premium payments for your health insurance coverage. This contractual arrangement is referred to as an Individual Membership Contract or Direct-payment coverage.

Your Subscriber Contract provides details on eligibility and enrollment in the Plan. Please carefully review the terms and conditions of coverage. As a reminder, the following membership regulations apply:

Member Eligibility

To be eligible to enroll as a Group Member, you must be an employee or member of an organization having a Remittance Agreement with Atlantis Health Plan, meet the eligibility requirements of the Group, and reside, live or work in the Plan’s service area.

To be eligible to enroll as an Individual Membership Subscriber, you must meet the eligibility requirements under the Individual Contract, or meet the Individual Conversion Privileges guidelines, and live in the Plan’s service area.

Enrollment

· Effective enrollment of the Subscriber and any dependents listed on the application form is subject to AHP acceptance of the Subscriber and his or her dependents.

· All dependent children must be unmarried and within the age limits stated in the Subscriber Contract or any attached Rider.

· Dependent children with developmental disabilities, or a physical handicap over the age of nineteen (19), who cannot support themselves due to their condition, may qualify for continued membership as a dependent. However, the condition must have been documented by a participating AHP primary care physician, and must have existed before the dependent reached the age of nineteen (19).

Enrollment Changes

It is important to notify AHP whenever there is a change in your family status.

AHP automatically covers newborn or newly adopted children for the first thirty-one (31) days of their lives. However, in order to continue coverage with the Plan, you are required to complete an AHP “change in dependent status” form, pay any additional premium or contribution and submit it to AHP within the thirty-one days.

Should you get married and wish to change from single to family status, or convert a family Member who is no longer eligible as a dependent to his/her own coverage, please notify us.

Group members should submit notification of changes to your employer or remitting agent. If the form is not submitted in a timely fashion, you may have to wait until the next open enrollment period to add a child or spouse to the Plan or make other changes to your family status.

Benefit Coverage

Timely payment of premiums is required in order to continue health care coverage and benefits. The Plan may terminate coverage and benefits based on non-payment of premiums as defined in the Subscriber Contract and or Group Remittance Agreement.

Coordination of Benefits for Group Members

If you are covered under any other health insurance plan, tell your doctor and AHP.

Any time more than one Group health insurance policy is effective for an individual, the insurance companies must coordinate their payments to ensure all covered services are paid, and that the combined payments do not exceed the charges for the services rendered.

The rules that determine which insurance carrier is primary or secondary are standard in the insurance industry. However, all AHP procedures must be followed in order for AHP to assume payment, even if AHP coverage is not primary. Therefore, remember to see your Primary Care Provider for referrals to participating AHP providers. Should you have questions about Coordination of Benefits after carefully reading the information in your Subscriber Contract, please call the AHP Member Services Department at 1-866-747-8422.

In each calendar year, you are responsible for a portion of the cost of most benefits. When using In-Plan services, your share of the cost is called a co-payment.

Termination of Coverage

Your coverage and or the coverage of your dependents may terminate for the following reasons:

· If your premium is not paid per contractual terms.

· If you move outside the service area (unless you continue to work in the area and receive all of your covered health care within the AHP service area).

· If you use your AHP ID card in a fraudulent manner.

· If an employer provides your group coverage and you leave the company.

· If you decide to cancel the contract with AHP or the group remittance agreement is canceled by the remitting agent.

· If AHP decides to discontinue this class of HMO contract.

Coverage for dependents and or your spouse will end:

· If your marriage is terminated, coverage for your spouse will end on the date of your divorce or annulment.

· If a dependent ceases to meet eligible age requirements, coverage will end on the last day of the month in which the qualifying age was met.

Continuation of Group Coverage

Should you or your dependents become ineligible for coverage through your current group, you may be able to continue the coverage if you qualify as required by the Federal Consolidated Omnibus Budget Reconciliation Act (COBRA) or the laws of the State of New York. Please contact your employer for further details of this and other applicable laws.

Conversion to Individual Membership

If you or a covered dependent are not eligible for continuation of group coverage, you may convert to an individual membership contract with Atlantis on a direct-payment basis.

Note: Prescription, vision and or any dental “Riders” which may have been available to you from your group remittance coverage ARE NOT convertible to individual membership coverage.

A complete description of enrollment regulations may be found in your Subscriber Contract.

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