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and select the benefit package of his or her choice. Although
petitioner did not deny membership to enrollees with preexisting
medical conditions, some SelectMed benefit plans denied enrollees
full coverage for certain preexisting conditions during the first
12 months of membership.
Petitioner could terminate coverage for any employer group
(subject to offering conversion coverage for individual members)
based upon any of the following events: (1) Failure of the
employer to pay all premiums in full when due; (2) written notice
of termination given by either party; (3) fraud or material
misrepresentation by the employer; or (4) failure by the employer
to continue to meet the plan’s minimum enrollment or underwriting
obligation. Petitioner could terminate coverage for any
individual enrollee for the following reasons: (1) Enrollee
fraud or misrepresentation in the enrollment process or in the
use of plan services or the services of participating providers
or facilities; (2) failure to meet eligibility requirements; and
(3) failure to make required payroll deductions, applicable
copayments, coinsurance or deductible payments, or other
authorized charges.
Petitioner did not own or operate any medical facilities,
nor did it directly employ any physicians or other health care
professionals. Petitioner fulfilled its obligation to arrange
for its SelectMed enrollees to receive physician services by
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Last modified: May 25, 2011