Community First Health Plans - EOC: Certificate of Group Health Care Coverage

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Certificate of Group Health Care Coverage

Evidence of Coverage PDF (552K)

Table of Contents

Evidence of Coverage

CERTIFICATE OF GROUP HEALTH CARE COVERAGE

Community First Health Plans, inc. (Community First)certifies that it will provide Group Health Benefit Coverage to You and Your Dependents, in accordance with the terms of the Group Contract. The Group Contract includes the following documents:

This Certificate of Coverage and any riders attached to the Certificate;
The Schedule of Copayments attached to this Certificate;
The forms You and Your Employer filled out to obtain this coverage and
The Group Contract document provided to the Group Contract Holder, which is Your Employer or an Associated Company of Your Employer.

Covered Employee:	You are eligible to become covered under the Group Contract if You are in the “Covered Classes” shown below and meet ERS’ rules governing eligibility for coverage. See Part I, Rules Governing Eligibility. ERS also determines when your coverage ends. Rules governing when coverage ends are described generally in Part VIII.G, “When Your Coverage Ends.

Contract Holder:	Employees Retirement System of Texas

Group Contract No.:	0010180000

Certificate Date:	September 1, 2009, this Certificate describes the benefits under the Group Health Care Coverage as of the Certificate Date.

Covered Classes:	All Eligible Employees of the Contract Holder who live, work or reside in the Service Area. All Retirees, who live or reside in the Service Area. All eligibility is determined by The Employees Retirement System of Texas.

Limiting Age for Dependents:	Age 25 for unmarried children. However, the age 25 limit does not apply to a child more than age 25 who wholly depends on You for support and maintenance.

Service Area:	Click here to view service areas.

Community First's Address:	Mailing Address: 4801 NW Loop 410, Suite 1000. San Antonio, Texas 78229
	Physical Address: 4801 NW Loop 410, Suite 1000. San Antonio, Texas 78229

Community First's Telephone Number:
	210-227-2347

Member Services Number:
	210-358-6262 or 1-877-698-7032

Arbitration Provision:	See Section VIII.A.5 of the Certificate.

Cost of the Coverage:	Your contribution is based on the amount marked below:
	[ ] Both Employee and Dependent Coverage is Contributory Coverage. You will be informed of the amount of Your contribution when You are asked to enroll.
	[ ] Both Employee and Dependent Coverage is Non-contributory Coverage. The entire cost of the Coverage is being paid by the Contract Holder.
	[X] The Employee Coverage is Non-contributory Coverage.
	[X] The Dependent Coverage is Contributory Coverage. You will be informed of the amount of your contribution when you enroll in the plan.

EOC

Definitions

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Community First Health Plans is an affiliate of the University Health System.