Employee eligibility

Here’s the information you need to determine if an employee or dependent is eligible to become a member.

Employees

Eligibility criteria for new employees, as well as rehired and formerly ineligible employees

New employees

To be eligible to enroll as a member with Sharp Health Plan, an employee must:

  • Be a full-time, active employee and satisfy the minimum hours per week requirement as defined in the group agreement
  • Have completed the waiting period defined by your group
  • Work or reside within the service area of San Diego County and southern Riverside County
  • Satisfy all eligibility requirements as defined in your group agreement
  • Elect health care coverage through Sharp Health Plan by submitting eligibility details through a form approved by Sharp Health Plan within thirty-one (31) days of the eligibility effective date
  • Never have had coverage terminated for him/herself or any dependents for cause by Sharp Health Plan

Each enrollee should be provided an enrollment kit. Please contact your account manager for a supply of these kits.

Important reminder

Be sure to send new enrollment notifications as they occur. Timely notification of enrollment changes will help us serve members in the following ways:

  • Member eligibility will be visible to providers.
  • Members will be able to access care on their effective dates.
  • Billing adjustments will be processed and appear sooner.
  • Members will receive their member ID card in a timely manner.

Formerly ineligible employees

An employee changing from part-time to full-time status will be eligible for coverage the first day of the month following the completion of the waiting period after becoming full time.

Rehired employees

Employees who have been rehired will be subject to the rehire waiting period as defined by your employer.

Dependents

Eligibility criteria for an employee's spouse and dependents

A dependent’s eligibility for enrollment is contingent upon the subscriber’s eligibility for membership in Sharp Health Plan. Eligible dependents include:

  • The spouse of an enrolled employee
  • The dependent child of an enrolled employee or the enrolled employee’s spouse, who is either
    • Under age 26
    • Who at the time of attaining age 26 is incapable of self-sustaining employment by reason of a physically or mentally disabling injury, illness, or condition and is chiefly dependent upon the enrolled employee for support and maintenance. Proof of incapacity and dependence must be furnished to Sharp Health Plan by the enrolled employee as outlined in the group agreement
    • Any other person under age 26 for whom the enrolled employee or the enrolled employee’s spouse is (or was before the person's 18th birthday) the court-appointed guardian. We may require the eligible employee to furnish evidence, on a periodic basis, of the IRS status, residency or guardianship of such person.

Please note, an adult dependent child enrolled in a grandfathered plan is only eligible for coverage as a dependent with Sharp Health Plan if the adult child is not eligible for his or her own employer-sponsored coverage. A grandfathered plan is a health benefit plan that was in existence on March 23, 2010, and continuously covered someone in that same plan since that date.

Questions?

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