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.

Employees

To terminate an employee’s coverage, submit an Enrollment Application form within 31 days of any change listed below.

Please note that omitting a member from an application or simply not paying for the member will not terminate the member’s coverage.

Coverage for an employee may be terminated for any of the following reasons:

  • Employment has ended
  • Employee has a reduction in hours resulting in loss of eligibility
  • Employee voluntarily requests to terminate coverage
  • Employee takes a leave of absence (We will allow an employee to retain coverage upon your group’s leave of absence policy.)

Termination date of benefits is always the last day of the last month the employee was eligible, e.g. if the employee terminates employment June 3, then health coverage ends June 30.

Download the Form

Spouses

To terminate a dependent’s coverage, submit an Enrollment Application form within 31 days of any change listed below.

Please note that omitting a member from an application or simply not paying for the member will not terminate the member’s coverage.


Coverage for a spouse of a member may be terminated for any of the following:

  • An employee voluntarily requests coverage to be terminated
  • A divorce decree has been finalized
  • The spouse no longer resides or works in our service area

Download the Form

Dependent children

To terminate a dependent’s coverage, submit an Enrollment Application form within 31 days of any change listed below.

Please note that omitting a member from an application or simply not paying for the member will not terminate the member’s coverage.

Coverage for a dependent child of a member may be terminated for any of the following:

  • An employee voluntarily requests coverage to be terminated
  • The dependent child no longer resides or works in our service area, unless there is a standing health coverage court order
  • The dependent child reaches the maximum dependent age as defined by the group agreement or ceases to meet other dependent eligibility requirements

Download the Form

Directly from Sharp Health Plan

The time period to renew or make changes to your health coverage for 2020 is from October 15, 2019 to January 15, 2020.

  • Sharp Health Plan will automatically re-enroll you and members of your household into your current health plan, if you do not actively renew your insurance or select a different health insurance plan, if you remain eligible and your plans are still available.
  • Even after you have been automatically re-enrolled, you will be able to make changes to your health plan until Dec. 15, 2019, for coverage beginning Jan. 1, 2020, and you will have until Jan. 31, 2020, for coverage beginning Feb. 1, 2020.
  • You will continue to receive your monthly bill from Sharp Health Plan. Please pay your premium (monthly cost) directly to Sharp Health Plan by the due date to continue your coverage for Jan. 1, 2020. Please do not send your payment to Covered California.
  • IMPORTANT REMINDER: If you pay your premium through Sharp Health Plan’s auto pay program online, you will need to update your account with your new 2020 premium amount before Dec. 26, 2019. This will ensure accurate and timely premium payments and prevent any disruptions in your coverage.
  • Individual plans purchased directly from Sharp Health Plan do not allow you to receive financial assistance to lower your monthly premiums or your out-of-pocket costs. Beginning Oct. 15, you can visit CoveredCA.com and click “Shop and Compare” or “Find Help” to see if you qualify for premium assistance. Even if you were not eligible for financial assistance in the past, you may be eligible to lower your monthly premium next year.

What if I want to change my health plan for 2020?

  • Contact the Sharp Health Plan Individual and Family Plan Sales department at 1-858-499-8211 or email IFPsales@sharp.com, Monday – Friday, 8 am to 5 pm. You can also review your options and compare rates on the Get a Quote page.
  • Contact your agent for help. If you do not have an agent, you can find an agent or certified enrollment counselor by clicking “Find Help” at CoveredCA.com.
  • To learn more about Covered California, and to see if you qualify for lower costs, go to CoveredCA.com and use the “Shop and Compare” tool beginning Oct. 15. You can also contact Covered California at 1-800-300-1506 or (TTY 888-889-4500).

Questions?

Through Covered California

The time period to renew or make changes to your health coverage for 2020 is from October 15, 2019 to January 15, 2020.

  • Covered California will renew you and your eligible dependents into the health plan you have now, if you do not log into your account to renew your health coverage, choose a new plan, or cancel your coverage. If your current health plan is no longer available, Covered California will automatically enroll you and your eligible dependents into a similar health plan. Covered California will use the newest information in your application to renew your coverage.
  • Even after you have been automatically re-enrolled you can still make changes to your health plan coverage. You have until Dec. 15, 2019 to make changes to your health plan for coverage beginning Jan. 1, 2020, and until Jan. 31, 2020, for coverage beginning Feb. 1, 2020.
  • You will continue to receive your monthly bill from Sharp Health Plan. Please pay your premium (monthly cost) directly to Sharp Health Plan by the due date to continue your coverage for Jan. 1, 2020. Please do not send your payment to Covered California.
  • IMPORTANT REMINDER: If you pay your premium through Sharp Health Plan’s auto pay program online, you will need to update your account with your new 2020 premium amount before Dec. 26, 2019. This will ensure accurate and timely premium payments and prevent any disruptions in your coverage.

Important information about your premium assistance (tax credits)

  • The amount of premium assistance you will receive in 2020 could be different based upon changes in your household size, income, and the health coverage rates in your area.
  • To get the maximum premium assistance (tax credits) you qualify for, update your information at CoveredCA.com/Renew.
  • Note:  If you received premium assistance (tax credits) in 2019, you will have to “reconcile” using IRS Form 8962 when you file your federal tax return. You will compare the amount of premium assistance (tax credit) you received in advance during 2019 with the amount you actually qualify for based on your final 2019 household income and other eligibility information you report on your tax return. If the amounts are different, your tax refund or tax owed will be higher or lower.

Important information if you are not receiving premium assistance

  • Even if you were not eligible for premium assistance (tax credits) in the past, you may be eligible to lower your monthly premium. Beginning October 15, visit CoveredCA.com and click “Shop and Compare” or “Find Help” to see if you qualify for premium assistance.

What if I want to change my health plan for 2020?

  • You can review other plan options with Sharp Health Plan or see coverage options with a different health plan company beginning October 15 by using the “Shop and Compare” tool at CoveredCA.com.
  • You can keep your current plan or make a change by logging into your account at CoveredCA.com.
  • Contact the Covered California Service Center at 1-800-300-1506 or (TTY 888-889-4500).
  • Contact your agent for help. If you do not have an agent, you can find an agent or certified enrollment counselor by clicking “Find Help” at CoveredCA.com.

Questions?

  • Call us toll-free at 1-800-359-2002 or 1-858-499-8300, or email us at customer.service@sharp.com. We are available to assist you Monday – Friday, 8 am – 6 pm.
  • The Covered California Service Center is open Monday – Friday, 8 am to 6 pm at 1-800-300-1506 or (TTY 888-889-4500). Please check CoveredCA.com for extended open enrollment days and hours.
  • Call a Covered California Certified Enrollment Counselor or Certified Licensed Agent for help. To find free local help in your area, please visit CoveredCA.com and click “Find Help.”

Cal-COBRA

Cal-COBRA applies to employers with 2 – 19 employees*, as well as employers with 20+ employees who have exhausted their federal COBRA.

California law requires that insurers and HMOs provide continuation coverage known as Cal-COBRA.

Employers with 2 to 19 employees* Employers with 20+ employees
Cal-COBRA — up to 36 months COBRA — 18 or 36 months
(depends on the qualifying event)

Cal-COBRA — If COBRA was 18 months, 18 more months of Cal-COBRA is available.

At a glance

Cal-COBRA AB1401 Cal-COBRA
  • State requirement placed on health plan
  • 2-19 employees
  • Benefit plan mirrors employer plan
  • Administered by the Plan
  • State requirement placed on health plan
  • 20+ employees
  • Benefit plan mirrors employer plan
  • Administered by the Plan

Your obligations

Notify Sharp Health Plan of Certain Qualifying Events: You must notify Sharp Health Plan in writing within thirty (30) days of an Enrolled Employee’s Cal-COBRA Qualifying Event. Qualifying events include:

  • Termination of employment
  • Reduction in hours worked

If the Member fails to apply for Cal-COBRA within sixty (60) days of the event, that Member will be disqualified from receiving Cal-COBRA Continuation Coverage.

Who may choose Cal-COBRA

A Member may choose Cal-COBRA for one or all of the family members who were enrolled at the time of the qualifying event. In other words, the Member can elect coverage for the spouse or one or more Dependent children without being covered under the Cal-COBRA continuation coverage as a Member.

If a child is born or placed for adoption with the former Member during the period of Cal-COBRA coverage, the child would be a Qualified Beneficiary and could be added to the Cal-COBRA policy.

Qualifying events and subsequent eligible period of coverage

Termination of employment 18 months^
Reduction in hours 18 months^
Transfer to ineligible class 18 months^
Death of the employee 36 months
Divorce or legal separation 36 months
Employee becomes eligible for Medicare 36 months
Dependent child becomes ineligible 36 months

Payment for Cal-COBRA

The Member must pay Sharp Health Plan 110% of the applicable group rate charged for employees and their Dependents.

The Member must remit the first payment within forty-five (45) days of submitting the completed enrollment form to Sharp Health Plan. The first payment must cover the period from the last day of prior coverage to the present. There can be no gap between prior coverage and Cal-COBRA continuation Coverage.

All subsequent payments must be made on the first day of each month. If payment is not received by the first of the month, Sharp Health Plan will send a letter warning that coverage may terminate if payment is not received by the Plan.

Changes in benefits under Cal-COBRA coverage

If a Member or any Dependents elect Cal-COBRA coverage, benefits will remain the same as the benefits for active Members of your current Group policy. If you change the benefits provided to active Members enrolled in your current Group policy, benefits will also change for Members and Dependents on COBRA.

 

* You employed fewer than 20 eligible employees on at least 50% of its working days during the previous calendar year.

^ If COBRA coverage was initially effective on or after January 1, 2003, and the eligible period of coverage is less than 36 months, members may elect to continue coverage through Cal-COBRA for a period up to 36 months from the date that COBRA coverage was originally effective.

COBRA

Federal COBRA applies to employers that cover 20 or more employees.

COBRA (the Consolidated Omnibus Budget Reconciliation Act) is a United States federal law that, among other things, requires employers of 20 or more employees to offer continuation of coverage to employees and their dependents when a qualifying event that results in the loss of group eligibility occurs.

At a glance

COBRA AB1401 Cal-COBRA
  • Federal requirement placed on employer
  • 20+ employees
  • Benefit plan mirrors employer plan
  • Administered by the employer (or the employer’s COBRA administrator)*
  • State requirement placed on health plan
  • 20+ employees
  • Benefit plan mirrors employer plan
  • Administered by the Plan

Key facts

Eligibility

Employers must notify employees about the right to continue coverage when a qualifying event that results in the loss of group eligibility occurs.

Duration

Depending on the qualifying event, COBRA and/or Cal-COBRA may last for up to 36 months.

Administration

Sharp Health Plan neither provides nor administers federal COBRA services. All employers are responsible for administering their own federal COBRA program. Sharp Health Plan administers Cal-COBRA when an employer is subject to it under state law.

Groups have the option to self-administer their federal COBRA benefits or choose a third-party COBRA administrator.

Deadline

Employees must sign up with the health plan within 60 days of receiving notice of eligibility for federal COBRA or Cal-COBRA.

Cost

For COBRA, employees are responsible for the entire cost, up to 102% of the group rate.

Tier 1

Your HMO level benefits and care.

When accessing health services through this tier, you get the care you need from doctors and hospitals in Sharp Health Plan’s Choice Network. You’ll be able to choose your own personal doctor — primary care physician, or PCP — who will coordinate all of your care, including referrals to specialists. Any specialists you see will need to be in the same plan medical group as your PCP.


View Choice Hospitals  Find a doctor


Here’s what to remember about Tier 1:

  • Your PCP is your main point of contact for all of your health care needs. They’ll handle your care, coordinate any treatments, refer you to a specialist if you need one, and more.
  • Preventive care services are offered at no extra cost.
  • Copays or coinsurance costs apply for most other care visits and services.

Tier 2

Your out-of-network level benefits and care.

With Tier 2, you can get care from the Aetna Open Choice PPO provider network, as well as out-of-network providers — with no referral needed. It’s important to remember that when you choose to get care from the Aetna Open Choice PPO provider network or out-of-network providers, your out-of-pocket costs will be higher. Out-of-network providers include any U.S. licensed health care professionals and facilities.

Use the tool below to search for an Aetna provider. Be sure to select the Open Choice PPO plan. 


Find an Aetna provider


Here's what to remember about Tier 2:

  • You can make appointments directly with providers in the Aetna Open Choice PPO network, or with any licensed health care providers in the U.S.
  • Copays or coinsurance costs apply to every visit and service, in addition to your deductible.
  • You’ll need to get precertification before you can receive most out-of-network services.

Precertification

Precertification means prior approval from Sharp Health Plan. It’s a good idea to talk to your out-of-network provider before you receive services, to make sure they receive any required precertification from Sharp Health Plan in advance. This will help manage your out-of-pocket costs.


Download the form

Directly through Sharp Health Plan

Follow these simple steps to get the most out of your new health plan. You can also use this checklist if you applied for health coverage through Covered California.

checkbox Carry your member ID card
Your member ID card is your key to accessing care. You will need it whenever you seek medical services, such as visiting your doctor or filling a prescription. Your member ID card also contains important benefit information, like which networks of doctors you have access to.
  • If you or a member of your family has not received an ID card, log in to Sharp Connect to request an ID card or print a temporary card.

checkbox Activate your member account
Visit sharphealthplan.com/login to register for our all-access, secure member portal. You can view your unique plan information, see what you can expect to pay for office visits and more. Everything you need to manage your plan, and your health, is at your fingertips.
  • Most plan medical groups offer a patient portal that lets you manage appointments, health records and more. Sharp Rees-Stealy and Sharp Community Medical Group members can log in or register for FollowMyHealth. If your doctor isn't a part of these medical groups, please visit sharphealthplan.com/your-patient-portal for more information.

checkbox Set up automatic payments
We offer convenient options to pay your premium bill online. Set up automatic payments or view your payment history through our secure online portal. Register or log in at sharphealthplan.com/payment.

checkbox Transfer your prescriptions
Under your health plan, there’s a lot of pharmacies to choose from. Use this helpful online tool to search for a pharmacy that is close by and works for you and your family. Just let your new pharmacy know that you need your prescriptions transferred from your old pharmacy. Also, let your primary care physician (PCP) know of any existing special authorizations for prescriptions that may need to be re-authorized.
  • Mail order is an easy and affordable way to get the medications you and your family need, along with the convenience of home delivery. Sign up here. 

checkbox Transfer any existing referrals and medical records
If you have existing referrals to see a specialist, ask your new PCP to re-authorize the referral with your new coverage. For medical records, please contact your previous doctor for assistance to transfer your protected health information to your new doctor.

checkbox Get care
We’re here to help you get the right care at the right time. Here are a few different ways you can get the care you need in any situation:
  • Get to know your PCP by setting up your first appointment. If you would like to switch doctors, fill out this form.
  • Receive after-hours and weekend medical advice in a single phone call to our specially trained registered nurses with Sharp Nurse Connection®. Just call 1-800-359-2002.
  • Our nationally-accredited wellness program provides free meal plans, exercise routines, and health coaching to keep you feeling your best. Get your free wellness score by registering for Best Health.

checkbox Manage your plan
Need a little more guidance on how best to manage your health plan? Take this shortcut to the most popular member actions on our website, from adding dependents to changing your primary care physician.

Through your employer

Follow these simple steps to get the most out of your new health plan.

checkbox Carry your member ID card
Your member ID card is your key to accessing care. You will need it whenever you seek medical services, such as visiting your doctor or filling a prescription. Your member ID card also contains important benefit information, like which networks of doctors you have access to.
  • If you or a member of your family has not received an ID card, log in to Sharp Connect to request an ID card or print a temporary card.

checkbox Activate your member account
Visit sharphealthplan.com/login to register for our all-access, secure member portal. You can view your unique plan information, see what you can expect to pay for office visits and more. Everything you need to manage your plan, and your health, is at your fingertips.
  • Most plan medical groups offer a patient portal that lets you manage appointments, health records, and more. Sharp Rees-Stealy and Sharp Community Medical Group members can log in or register for FollowMyHealth. If you doctor isn't a part of these medical groups, please visit sharphealthplan.com/your-patient-portal for more information.

checkbox Transfer your prescriptions
Under your health plan, there’s a lot of pharmacies to choose from. Use this helpful online tool to search for a pharmacy close by and works for you and your family. Just let your new pharmacy know that you need your prescriptions transferred from your old pharmacy. Also, let your PCP know of any existing special authorizations for prescriptions that may need to be re-authorized.
  • Mail order is an easy and affordable way to get the medications you and your family need, along with the convenience of home delivery. Sign up here. 

checkbox Transfer any existing referrals and medical records
If you have existing referrals to see a specialist, ask your new PCP to re-authorize the referral with your new coverage. For medical records, please contact your previous doctor for assistance to transfer your protected health information to your new doctor.

checkbox Get care
We’re here to help you get the right care at the right time. Here are a few different ways you can get the care you need in any situation:
  • Get to know your PCP by setting up your first appointment. If you would like to switch doctors, fill out this form.
  • Receive after-hours and weekend medical advice in a single phone call to our specially trained registered nurses with Sharp Nurse Connection®. Just call 1-800-359-2002.
  • Our nationally-accredited wellness program provides free meal plans, exercise routines, and health coaching to keep you feeling your best. Get your free wellness score by registering for Best Health.

checkbox Manage your plan
Need a little more guidance on how to best manage your health plan? Your HR department is your best resource for the most popular members actions, such as adding and removing dependents.
We offer nine different plans for individuals and families. Each one’s designed to give you the flexibility you need, at a price you like.
Healthy employees are happy, productive employees. Explore our plan options designed to meet the needs of your employees and their families.
If you’re eligible for Medicare or would like to learn more about our Medicare Advantage plans, visit our dedicated website.      

Our Plans

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Add or remove someone on your plan

When a life event occurs that requires you to update the dependents on your plan, there’s a few things you should know. Find out when changes can be made and which forms are required.

WHAT YOU NEED TO KNOW ➜

Get a new member ID or temporary card

Getting a new member ID card is simple. Sign in to your Sharp Connect account, request a replacement, and a new card will be mailed within seven to ten days. In the meantime, you can view and print a temporary ID card.

LOG IN TO MY ACCOUNT
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Health Care Reform and your health

By law, your coverage can’t be dropped or denied if you have a pre-existing medical condition or if you get sick. Because of the Health Care Reform, you can get health insurance regardless of the current state of your health, and you can’t be charged more because of your existing health or medical condition. When you get care for your pre-existing condition or a new health condition, you’ll still need to pay any deductibles, copayments, and coinsurance your plan requires.

LEARN MORE

Quick and easy out-of-state care with CVS MinuteClinic

If you’re traveling and run into a minor illness or injury stop by a CVS/pharmacy® store. Their MinuteClinics are equipped to care for you, and you’ll only need to provide a $40 copayment anywhere in the the United States.

Looking for a dentist nearby? You have options

Premier Access Dental plan members have access to a broad network of care providers. Visit their site to find a dentist, just select “Dental HMO (Health Maintenance Organization)” under “State Exchange Plans” to begin your search, no login needed. If you are still having trouble, call Premier Access member services at 877.702.8800.

Find a Dentist

The best of San Diego is in your network.

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Featured article

Get the most health from your health plan

Sharp Health Plan’s Chief Medical Officer Dr. Cary Shames is quoted in this article on how to get the most out of your health plan. For the new year, members should take advantage of all the preventive health benefits available to them without a copay.

Find out how
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Featured article

Staying healthy when others are sick

First one person in your home gets sick with a cold or flu — perhaps your school-aged child, partner or roommate. Then you start feeling that slight tickle at the back of your throat or mild ache near your temples, and you sense that you’re next in line for the illness.

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Better health with better benefits

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