Dependent Plan for UC Berkeley Students on UC SHIP
Anthem Blue Cross Prudent Buyer PPO Plan
- UC SHIP coverage period: Fall August 15-January 14, Spring January 15-August 14. LAST DAY TO ENROLL FOR THE SPRING 2012 SEMESTER IS FEBRUARY 15, 2012.
- This plan is an IN-NETWORK ONLY PPO Plan. The Network is Anthem Blue Cross Prudent Buyer Network. Except for emergencies (and certain covered non-Network services), no benefits are payable for services by non-Network providers (doctors and facilities).
- There is a $400 per plan year deductible for medical services provided outside of UHS. The deductible applies to all services described below except where noted.
- Dependent subscribers are responsible for no more than $6,000 of out-of-pocket expenses each plan year. If you have paid $6,000 in co-insurance and deductibles (not including Pharmacy co-payments), you will no longer be required to pay co-insurance for the remainder of the plan year. The out-of-pocket maximum does not apply to amounts exceeding stated benefit limits (for example, Pharmacy or Physical Therapy limits) or to services not covered by the plan.
- UC SHIP dependent plan has a $400,000 lifetime maximum.
- This plan has no pre-existing condition exclusion.
- Services provided to student dependents by non-PPO providers are not a covered benefit of the plan unless services are for urgent or emergent care. Plan payments are based on covered expense, which is the lesser of the charges billed by the provider or the following:
- PPO Providers—PPO negotiated rates. Insured persons are not responsible for the difference between the provider’s usual charges & the negotiated amount.
- Non-PPO Providers & Other Health Care Providers - The customary & reasonable charge for professional services or the reasonable charge for institutional services. When using permitted Non-PPO and Other Health Care Providers, insured persons are responsible for any difference between the covered expense & actual charges, as well as any deductible & coinsurance.
*indicates item counts towards deductible
| Graduate Dependent Plan Rates | Per Semester | Annual |
| ADULT DEPENDENT PREMIUM (Medical & Dental) |
$1653.52 | $3307.04 |
| ADULT DEPENDENT PREMIUM (Medical Only) |
$1565.54 | $3131.08 |
| CHILD(ren) DEPENDENT PREMIUM (Medical & Dental) |
$1441.87 | $2883.74 |
| CHILD(ren) DEPENDENT PREMIUM (Medical Only) |
$1344.35 | $2688.70 |
| FAMILY (Adult and Child(ren)) DEPENDENT PREMIUM (Medical & Dental) |
$3100.69 | $6201.38 |
| FAMILY (Adult and Child(ren)) DEPENDENT PREMIUM (Medical Only) |
$2909.89 | $5819.78 |
Dependent Eligibility & Documentation
Eligibility
Students enrolled in UC SHIP have the option to enroll eligible dependents in a voluntary plan. The following types of dependents may enroll:
- Spouse: Legally married spouse of the student
- Same-Sex Domestic Partner only
- Child: The student’s unmarried
- Natural child under the age of 26
- Stepchild: A stepchild under the age of 26 is a dependent on the date the student marries the child's parent
- Adopted child under the age of 26, including a child placed with the student for the purpose of adoption, from the moment of placement as certified by the agency making the placement
- Foster Child: A foster child under the age of 18 is a dependent from the moment of placement with the student as certified by the agency making the placement
NOTE: If both student parents are covered under UC SHIP, their children may be covered as the dependents of either student, but not both.
For dependent plan enrollment questions, please contact Wells Fargo Insurance Services customer service at (800) 853-5899.
Documentation
Students are required to provide proof of dependent status when enrolling their dependents in the plan. The following documents will be accepted:
- For spouse, a marriage certificate
- For same-sex domestic partner, a Declaration of Domestic Partnership issued by the State of California, or of same-sex legal union other than marriage formed in another jurisdiction, or a completed Declaration of Domestic Partnership form issued by the University
- For natural child, a birth certificate showing the student is the parent of the child
- For stepchild, a birth certificate, and a marriage certificate showing that one of the parents listed on the birth certificate is married to the student
- For adopted or foster child, documentation from the placement agency showing that the student has the legal right to control the child’s health care
ENROLLMENT
- ENROLLMENT PERIOD: Voluntary non-student enrollment must take place within the first 30 calendar days of the semester UC SHIP coverage period (August 15 or January 15). LAST DAY TO ENROLL FOR THE SPRING 2012 SEMESTER IS FEBRUARY 15, 2012. Enrollment forms are accepted 30 days prior to the UC SHIP effective date. However, student eligibility must be verified prior to acceptance of enrollment. Enrollment eligibility is determined per semester. You will have another opportunity to purchase this voluntary dependent plan in July 2012 for the Fall 2012 semester.
- ENROLLMENT PROCESS: Enrollment is handled by Wells Fargo Insurance Services, a third party administrator. Enroll by phone (800) 853-5899 or send enrollment form (see forms below) and payment by mail or fax: Wells Fargo Insurance Services, 11017 Cobblerock Drive, Ste. 100, Rancho Cordova, CA 95670, Fax (916) 231-0527.
- GRADUATE students enrolling dependents- please use the Graduate Student Enrollment Form (PDF)
- UNDERGRADUATE students enrolling dependents - please use the Undergraduate Student Enrollment Form (PDF).
