California Carrier Administration Guidelines

Transcription

1 California Carrier Administration Guidelines Aetna American General Anthem Blue Cross Blue Shield of California Delta Dental Guardian Health Net Humana Kaiser Permanente MetLife Premier Access Principal Sharp Health Plan UnitedHealthcare VSP T: (800) F: (800) Warner Pacific Insurance Services Agoura Road Westlake Village, CA CA Insurance License No CO lnsurance License No

2 1. EMPLOYER QUESTIONS TABLE OF CONTENTS Aetna, American General & Anthem Blue Shield, Delta Dental & Guardian HealthNet, Humana & Kaiser MetLife, Premier Access & Principal Sharp, UHC & VSP o When will the group administration kit be sent? o Will the kit be sent to the agent or client? o If the broker would like a copy of the kit, who do they contact? o What is included in the administration kit? o Can a kit be sent to someone else besides the default? o When should a group expect their first billing statement? o Who is responsible for sending future enrollment materials? 2. EMPLOYEE QUESTIONS Aetna, American General & Anthem Blue Shield, Delta Dental & Guardian HealthNet, Humana & Kaiser MetLife, Premier Access & Principal Sharp, UHC & VSP o When will the member ID card be mailed and are they sent to the group or member? o Are temporary ID cards available? o Are personalized ID cards sent and are they paper or plastic? o If personalized ID cards are sent, do they list each dependent name on them? o Are separate ID cards generated if enrolled in dental and/or vision along with the same carrier medical plan? o If yes, do the ID cards list each dependent on them? Aetna, American General & Anthem Blue Shield, Delta Dental & Guardian HealthNet, Humana & Kaiser MetLife, Premier Access & Principal Sharp, UHC & VSP o Will each member receive an evidence of coverage book? o If yes, when are they mailed and will they go to the group or to the member s home? 3. NEW HIRED EMPLOYEES Aetna, American General & Anthem Blue Shield, Delta Dental & Guardian HealthNet, Humana & Kaiser MetLife, Premier Access & Principal Sharp, UHC & VSP o Will new hire ID cards be sent to the group or the member s home? o Will new hires receive evidence of coverage books? o If yes, where will they be mailed? P a g e 1

3 4. OPEN ENROLLMENT Aetna, American General & Anthem Blue Shield, Delta Dental & Guardian HealthNet, Humana & Kaiser MetLife, Premier Access & Principal Sharp, UHC & VSP o Does the carrier offer a true open enrollment? o When is the open enrollment period? Aetna, American General & Anthem Blue Shield, Delta Dental & Guardian HealthNet, Humana & Kaiser MetLife, Premier Access & Principal Sharp, UHC & VSP o What is allowed at open enrollment? o What paperwork is required? o Can someone who initially declined coverage enroll at any other time of the year? 5. DOMESTIC PARTNER Aetna, American General & Anthem Blue Shield, Delta Dental & Guardian HealthNet, Humana & Kaiser MetLife, Premier Access & Principal Sharp, UHC & VSP o What verification procedures will you require? Same sex - no age limit or Opposite sex - 62 years and older. o What verification procedures will you require? Opposite sex under 62 years of age. o Will the partner be eligible for federal COBRA? Same sex no age limit or Opposite sex 62 years and older. o Will the partner be eligible for Cal COBRA? Same sex no age limit or Opposite sex 62 years and older or Opposite sex and under 62 years of age. o Will the partners be required to be registered domestic partners? 6. DISABLED DEPENDENT CHILD Aetna, American General & Anthem Blue Shield, Delta Dental & Guardian HealthNet, Humana & Kaiser MetLife, Premier Access & Principal Sharp, UHC & VSP o Is an over-age disabled dependent eligible to continue coverage through this new insurance carrier if they were covered under their parents previous policy? o Is an over-age disabled dependent eligible to continue coverage through this new insurance carrier if they were not covered under their parents previous policy? o What documentation will be required if the disabled child is eligible to continue coverage? o o How often will the disabled depend child be required to recertify this disability? If the answer is no to any of the above questions, would you consider allowing the child to enroll under Cal COBRA / COBRA? P a g e 2

4 7. DEDUCTIBLE CREDIT PROCEDURES Aetna, American General & Anthem Blue Shield, Delta Dental & Guardian HealthNet, Humana & Kaiser MetLife, Premier Access & Principal Sharp, UHC & VSP o Which documents are acceptable to provide proof of prior deductible met? o At what point should the documentation be provided for processing? o Which department should the documentation be directed to? o By what means will the documentation be accepted? o Will a member receive any notification that their deductible has been credited? o Where could someone call to check status on processing? P a g e 3

5 Employer Questions When will the group administration kit be sent? days from the effective date, a hard copy administration kit is automatically generated. It is also available through . Once the case has been approved, a hard copy administration kit is automatically generated. Clients should receive it within business days hours after the group is loaded, a hard copy administration kit is automatically generated. Will the kit be sent to the agent or client? It will be sent to the client, unless otherwise specified. It will be sent to the client, unless otherwise specified. The designated party on the employer application will be sent the kit. If the broker would like a copy of the kit, who do they contact? ASG Broker Services (877) Client Services (877) , press 4, then press 4, then press 4 Customer Service (800) What is included in the administration kit? A welcome letter with instructions on how a group administrator can access their administration manual online. A welcome letter, administration manual, group case summary, premium sheet, instructions and login / password for Online Administration (Virtual Administrator). Group level: Welcome letter with instructions on how to access the administration manual online, employee notices, master agreement, rate sheets, one EOC of each of the contracts enrolled. Can a kit be sent to someone else besides the default? When should a group expect their first billing statement? Who is responsible for sending future enrollment materials? Yes, it must be indicated during underwriting. Within 30 days after the original effective date. Yes, the client will need to indicate this at case set up. Within 30 days of inception. The first bill will include inception and first month billing. Employee level: Welcome letter, ID cards, EOC (one per subscriber per contract enrolled), and employee notices. Yes, it must be indicated during underwriting. Bills are generated around the 4th or 5th of each month. Warner Pacific American General Life Warner Pacific or Anthem Blue Cross P a g e 4

6 Employer Questions When will the group administration kit be sent? Will the kit be sent to the agent or client? If the broker would like a copy of the kit, who do they contact? What is included in the administration kit? Within 31 days after the effective date. It will be sent to the client. Producer Services (800) A welcome letter, administrative manual, commonly used forms, EOC and the group contract. Within 1 week after approval, a welcome will go out with instructions on how to access this information online. The client will receive the kit through . Group level: Contract, signature page, HIPAA business associate agreement, notice of privacy practices, EOC, declination form, enrollment form, how to find a dentist, how to print ID cards. Once the case has been approved, a hard copy administration kit is automatically generated. Clients will receive it in business days. It will be sent to the client, unless otherwise specified. Customer Response Unit (800) cru@glic.com A welcome letter, administration manual, plan administration materials, sample forms and instructions for members on how to best utilize their benefits and programs. Employee level: Personalized ID cards and extra generic ID cards. Can a kit be sent to someone else besides the default? Yes, once the group has been approved, you may contact Group Services to request the kit be mailed to a different address. (800) No Yes, the client will need to indicate this at case set up. When should a group expect their first billing statement? Within 30 days after their original effective date. By the second week of the month following approval. The billing statement will be available online at GuardianAnytime.com within 2-5 business days from approval. Who is responsible for sending future enrollment materials? Blue Shield of California upon request. Allied Administrators Employers and employees can access forms, summary benefit information and certificates of coverage online at GuardianAnytime.com. P a g e 5

7 Employer Questions When will the group administration kit be sent? Will the kit be sent to the agent or client? Medical: Within 7-10 business days after group is loaded in the system. Dental: Within 1 week from approval, a hard copy administration kit is automatically generated. Medical: The client, unless otherwise specified. Humana does not send an administration kit. A welcome letter is mailed out in 5-7 days once ALL documents are received. A welcome letter is mailed to the client and broker. Within 30 days after the group is active in the system, a hard copy administration kit is automatically generated. Group If the broker would like a copy of the kit, who do they contact? Dental: Group Account Management (800) Small Business Accounts (800) What is included in the administration kit? Medical: Employer manual, rate tables, and welcome letter. A welcome letter acts as Humana s administration kit. Administrative handbook and group agreement. Dental: unknown Humana directs their customers and members to humanadental.com. They provide one copy of an EOC. Can a kit be sent to someone else besides the default? Medical: Yes, it must be indicated during underwriting. A welcome letter is typically only sent to the customer and the broker. Yes, upon written request. When should a group expect their first billing statement? Dental: Yes, upon request in writing. Medical/Dental: It varies and is based on when the group is loaded in the system. Premium statements are generated around the 15 th of each month. It depends on when the group is loaded in the system. Billing statements are mailed around the 15th of each month. Who is responsible for sending future enrollment materials? Health Net All materials are located online at humanadental.com. Kaiser Permanente P a g e 6

8 Employer Questions When will the group administration kit be sent? Within 7-10 days after groups approval. Within days after the effective date. No hard copy administration kit is generated. Principal will include the Administration Guide as part of the welcome . Will the kit be sent to the agent or client? Whichever party is designated on the employer application. The kit is mailed to both the Client and the Agent/Broker. Group If the broker would like a copy of the kit, who do they contact? What is included in the administration kit? Client Broker Services (800) Master contract, employee applications, supply request form, and directory. Broker Services (888) A welcome letter, contact information, copy of the contract, schedule of benefits, certificate of insurance/evidence of coverage, enrollment forms. <50 lives (800) ext >50 lives (800) ext Administrative guide, ERISA information, customer service information, employee applications, waiver forms, COBRA forms, employee change forms, employer change forms, and claim forms. Can a kit be sent to someone else besides the default? Yes, it must be indicated during underwriting. Yes Yes, it must be indicated during underwriting. When should a group expect their first billing statement? It depends on when the group is loaded in the system. Within 30 days after the original effective date. Within 3 weeks after underwriting releases the case. Who is responsible for sending future enrollment materials? MetLife Premier Access Warner Pacific P a g e 7

9 Employer Questions When will the group administration kit be sent? Will the kit be sent to the agent or client? If the broker would like a copy of the kit, who do they contact? What is included in the administration kit? 2-3 weeks after approval, the group agreement is sent to the client. Included with that agreement are instructions on how to request an administration kit. It is also available through and the SHP website. Medical: 10 days after the policy is generated. PPO or Dual Option: Employer receives instructions on how to access the admin kit online. HMO: Administration manual is ed to the employer. Within hours from the group being loaded, an administration kit is automatically generated and ed from VSP to the broker and Warner Pacific Sales Executive. Dental: 30 days after the group is loaded in the system. Agent decision Group Broker and Warner Pacific Sales Executive Sharp Health Plan assigned Account Service Representative. Administration manual Medical: Account Mgmt. (800) option 2 Dental: Account Mgmt. (800) PPO: Contract documents, federal notices, admin manual and marketing materials. HMO: Admin manual, employer contact sheet, employer webinar invite, and marketing materials. The broker receives the Administration Manual. They may make a copy for themselves. The approval letter, administration guide, first month invoice and member benefit summaries. Can a kit be sent to someone else besides the default? When should a group expect their first billing statement? Who is responsible for sending future enrollment materials? Yes It depends on when the group is loaded in the system. Dental: Administration manual, directory, benefit summaries, EE apps. Yes, by written request or phone call. Medical: It depends on when the case is approved. Dental: Within 1 week after the group is loaded. P a g e 8 No Approximately hours after loading. The first billing statement is included in their administration kit. Warner Pacific United HealthCare HealthSmart will send electronic PDF only.

10 Employee Questions When will the member ID card be mailed and are they sent to the group or member? 7-10 days after case approval. They are mailed to the member s home. They do not produce ID cards. Within hours after the group is loaded. The cards are mailed to the group. Are temporary ID cards available? Yes, the member must register online before they are printable. No Are personalized ID cards sent and are they paper or plastic? If personalized ID cards are sent, do they list each dependent name on them? Are separate ID cards generated if enrolled in dental and/or vision along with the same carrier medical plan? Yes, plastic cards are generated. HMO: Each individual receives their own personalized card. All other plans: The subscriber name and all family members will be listed on the subscriber cards. The medical ID card will be used for Pediatric Dental, Pediatric Vision and Aetna Dental. The medical ID cards reference the Pediatric Dental but not any additional dental plan they may have purchased. Yes, 2 plastic cards are generated. HMO: Dependents will receive separate ID cards with their name on it if they choose a different IPA/PMG from the subscriber. PPO/EPO/Lumenos: No Yes, unless the subscriber is on the BeneFits Hospital Preferred plan with the embedded Dental and Vision, then it is one card with the medical. Aetna Vision will have a separate ID card. If yes, do the ID cards list each dependent on them? Medical, Dental: No Vision: No No P a g e 9

11 Employee Questions When will the member ID card be mailed and are they sent to the group or member? Are temporary ID cards available? Are personalized ID cards sent and are they paper or plastic? 7-10 business days after group approval/installation and they are mailed to the members home. Yes, members must register online then the cards are printable. Personalized ID cards are sent. Dependent cards will have the subscribers information. PPO: 2 weeks after approval and mailed to the group. HMO: 2 weeks after approval and are mailed to the members home. Yes, member must register online then the cards are printable. Yes, paper ID cards are sent. Standard process is to the group an electronic ID card in a pdf format within 3-7 business days from approval. Members can print their ID cards online at GuardianAnytime.com. No Generic or personalized ID cards (group has choice) are available. The default is generic. If personalized ID cards are sent, do they list each dependent name on them? Are separate ID cards generated if enrolled in dental and/or vision along with the same carrier medical plan? If enrollment is employee only, one ID card will be sent. If enrollment is employee plus one or more dependents, two ID cards will be sent. HMO: The subscribers name and all family members will be on the subscriber cards. All other plans: The subscribers information will be on the cards. Dental receives ID cards, see above. Vision does not provide ID cards. Only the subscribers name appears on the ID cards. Cards are available online at HMO: Yes, ID cards will have dependents names listed. PPO: No If yes, do the ID cards list each dependent on them? Separate pediatric dental ID cards are sent to enrollees homes. See above P a g e 10

12 Employee Questions When will the member ID card be mailed and are they sent to the group or member? Medical/Dental: Within 7-10 business days from date the group is loaded in the system and is mailed to the members home. Approximately 10 days after coverage is issued and they are mailed to the members home. Within 10 days after enrolled in the system and they are mailed to the members home. Are temporary ID cards available? Yes, members must register online then the ID cards can be printed. Yes, the Group Administrator must register the account online then the ID cards can be printed. Yes, the temporary membership form is available online, no registration is necessary. Are personalized ID cards sent and are they paper or plastic? Yes, a mixture of paper and plastic cards are generated. Only members receive ID cards with dependents listed. Yes, plastic cards are generated. If personalized ID cards are sent, do they list each dependent name on them? Both the subscriber and dependents names will appear on the cards. Yes Are separate ID cards generated if enrolled in dental and/or vision along with the same carrier medical plan? If yes, do the ID cards list each dependent on them? Dental: Yes EyeMed Vision: No Separate pediatric dental ID cards are sent to enrollees homes. Dental: The subscriber name will be listed and there is a portion that says Dependent Coverage. This would be followed by yes or no. Yes Medical ID card is used for pediatric dental. Groups purchasing Delta Dental HMO will receive separate ID cards to enrollee s homes. PPO or FFS plans, no ID cards are issued. No P a g e 11

13 Employee Questions When will the member ID card be mailed and are they sent to the group or member? Within 7-10 days after the group has been approved. DHMO: Members home PPO: Group 7-10 days after case approval and they are mailed to the members home. If requested, the ID cards can be mailed directly to the group contact days after enrolled in the system and they are mailed to the group. Temporary ID cards are available at Are temporary ID cards available? Yes, member can register online to obtain a copy of ID cards. A digital ID card is available through Smartphone and ipad. Yes, the Group Administrator must register the account online through e-service before the ID cards are printable. Are personalized ID cards sent and are they paper or plastic? Yes, paper ID cards are generated. Yes, paper ID cards are generated. Yes, 2 plastic ID cards are generated. If personalized ID cards are sent, do they list each dependent name on them? Yes Yes, each member will receive their own ID card. No, the subscriber name is listed with the dependents name underneath. Are separate ID cards generated if enrolled in dental and/or vision along with the same carrier medical plan? If yes, do the ID cards list each dependent on them? P a g e 12

14 Employee Questions When will the member ID card be mailed and are they sent to the group or member? Are temporary ID cards available? 2-3 weeks after approval and are mailed to the group. Yes, the Group Administrator and/or member must register online first. Medical: 7-10 days after the group is loaded, and they are sent to the member. Dental: 48 hours after the group is loaded, ID cards are sent to the members, unless otherwise specified. PPO: Yes, the member must register online first. HMO: No VSP does not use ID cards. Are personalized ID cards sent and are they paper or plastic? If personalized ID cards are sent, do they list each dependent name on them? Are separate ID cards generated if enrolled in dental and/or vision along with the same carrier medical plan? Yes, paper ID cards are generated. Yes Sharp offers a vision rider through VSP and a discount dental program through First Health Dental. The First Health and VSP logo will appear on the medical ID card they elected this rider. PPO: Issued 1 card per employee and 1 for enrolled spouse. No ID cards for dependent children. HMO: Issued 1 card per enrolled member. PPO: Show the names of all members covered. HMO: Subscribers and dependents each receive separate cards with only their own name. Separate dental ID cards are sent to enrollees homes. Separate pediatric dental ID cards are sent to enrollees homes. If yes, do the ID cards list each dependent on them? Separate ID cards for these benefits are not issued. Members are issued 2 cards. For DHMO if any dependents select a different dental provider, that PCP will be listed on the cards. P a g e 13

15 Employee Questions Will each member receive an evidence of coverage book? If yes, when are they mailed and will they go to the group or to the member s home? New Hired Employees Will new hire ID cards be sent to the group or the member s home? Will new hires receive evidence of coverage books? If yes, where will they be mailed? Open Enrollment Does the carrier offer a true open enrollment? By request only. A subscriber will receive a postcard from Aetna, which they must fill out and return if they wish to receive an EOC. Members home. By request only. A subscriber will receive a postcard from Aetna, which they must fill out and return if they wish to receive an EOC. Medical: Yes Dental: No A Certificate of Coverage booklet is ed and mailed directly to the group. The Group Administrator may then copy or print for each member. Life Insurance does not produce ID cards. A Certificate of Coverage booklet is ed and mailed directly to the group. The Group Administrator may then copy or print for each member. No Yes, it is included with the administration kit. Within hours after the group is loaded, they are mailed to the group. Each employee will receive their own EOC. Home, if not designated. Yes Home, if not designated. Yes When is the open enrollment period? Within the month prior to the groups anniversary date. Within the month prior to the group anniversary date. P a g e 14

16 Employee Questions Will each member receive an evidence of coverage book? If yes, when are they mailed and will they go to the group or to the member s home? New Hired Employees Will new hire ID cards be sent to the group or the member s home? It is the responsibility of the Employer to distribute EOCs to eligible employees. Members home. One hard copy EOC is generated and mailed to the Group Administrator. The group is then responsible for making copies for each employee as requested. EOCs are mailed 2 weeks after approval are included in the administration kit. DPO: members will not receive ID cards unless the member specifically requests one. It would go to the members home if requested. A copy of the certificate of coverage is ed to the employer for their records. Member access is available online at Guardian Anytime.com. Electronic ID cards are available online at GuardianAnytime.com. Will new hires receive evidence of coverage books? If yes, where will they be mailed? Open Enrollment Does the carrier offer a true open enrollment? When is the open enrollment period? It is the responsibility of the employer to distribute EOCs to eligible employees. Medical: Yes Dental: Yes Within the month prior to the groups anniversary date. DHMO: Members home. Upon request Group Yes, provided the member is making payments through payroll deductions using pretax dollars. Within the month prior to the groups anniversary date Yes Certificate of Coverage booklets are available online at GuardianAnytime.com. Yes, if Section 125 is inforce. The month prior to the groups renewal / anniversary date. P a g e 15

17 Employee Questions Will each member receive an evidence of coverage book? If yes, when are they mailed and will they go to the group or to the member s home? New Hired Employees Will new hire ID cards be sent to the group or the member s home? Will new hires receive evidence of coverage books? If yes, where will they be mailed? Open Enrollment Does the carrier offer a true open enrollment? A member will receive a letter notifying them that they may access their EOC online after they register. Hard copies are no longer provided. This letter is sent separately from their ID cards. Each member will receive a hard copy EOC. These are mailed to the members home along with their ID cards. EOCs are also available online. Members need to call Kaiser Permanente Member Services to request an EOC be mailed to them. Members home. Members home. Members home. A member must register online in order to access their EOC. Hard copies are no longer provided. Medical/Dental: Yes Yes, members home. Yes. A load may be associated with the Large Group products (100+). It depends on case size, product offering, & whether it is a voluntary product offering. The employer is responsible for distributing a new hire enrollment kit which includes the EOC. Yes When is the open enrollment period? Medical/Dental: During the month prior to the groups anniversary date. Small group (2-99) includes the Open Enrollment provision with no load. 31 days before and after the employer groups renewal date. The month before the anniversary date. P a g e 16

18 Employee Questions Will each member receive an evidence of coverage book? If yes, when are they mailed and will they go to the group or to the member s home? New Hired Employees Will new hire ID cards be sent to the group or the member s home? Will new hires receive evidence of coverage books? If yes, where will they be mailed? Open Enrollment Does the carrier offer a true open enrollment? When is the open enrollment period? Yes, within 7-10 business days after the groups approval. Employer discretion as to where they are mailed. Members home. Yes, members home. PPO: All groups of 10 or more eligible lives include annual open enrollment. HMO: Yes, it is built into the plan automatically. During the month prior to the anniversary date. If requested, an EOC can be sent to the member. The member can also register on our website to obtain a copy of their EOC. Members home unless requested to send to the group. If requested, an EOC can be sent to the member. The member can also register online to obtain a copy of their EOC. Dental: For an open enrollment, a group must have at least 25 employees enrolled and have a calendar year max of less than $2,000 at the time of their renewal. During the month prior to the group anniversary date. A group must designate on their employer application if they want a hard copy EOC. EOCs are available online. If they request a hard copy EOC, then after administration is complete a copy would be mailed to the group. Group Yes, the group will need to keep a supply on hand to distribute. Yes During the month prior to the anniversary date. P a g e 17

19 Employee Questions Will each member receive an evidence of coverage book? If yes, when are they mailed and will they go to the group or to the member s home? Hard copy EOCs are automatically generated and mailed to each members home. Medical- PPO: Certificates are available online for either member or Group Administrator to view. HMO: Employer is issued a hard copy EOC with their contract and they are responsible for providing hard copies to employees. There is one EOC provided and that will be sent to the group. Dental: Same time as the ID cards and they go to the members home unless otherwise specified. New Hired Employees Will new hire ID cards be sent to the group or the member s home? Will new hires receive evidence of coverage books? If yes, where will they be mailed? Open Enrollment Does the carrier offer a true open enrollment? Members home, unless otherwise specified. Instructions are included in the administration kit on how to download the EOC off the website. Medical: Members home. Dental: Members home, unless otherwise specified. Medical: The employer is responsible for distributing a new hire kit, which includes an EOC, to each employee. Dental: Yes, it will be mailed to the member home unless otherwise specified. Yes Medical/Dental: Yes No No No When is the open enrollment period? Within the month prior to the anniversary date. Medical/Dental: Within 30 days prior to the groups anniversary date. P a g e 18

20 Open Enrollment What is allowed at open enrollment? Employees can change plans if the employer offers other plans. Employees can change plans if the employer offers other plans. What paperwork is required? Can someone who initially declined coverage enroll at any other time of the year? Employees or dependents can enroll if they originally declined. Employee Application. The paperwork may be submitted prior to the anniversary date up through the end of the anniversary month. The effective date will be the anniversary date. No, only with a non-voluntary qualifying event. Yes, late entrant penalties will apply. Employees or dependents can enroll if they originally declined. Change of Coverage application / Employee Addition Application. The paperwork may be submitted prior to the anniversary date up through the end of the anniversary month. The effective date will be the anniversary date. No, only with a nonvoluntary qualifying event. P a g e 19

21 Open Enrollment What is allowed at open enrollment? Employees can change plans if the employer offers other plans. See footnote (1) at the end of this document. Employees or dependents can enroll if they originally declined. What paperwork is required? Employees or dependents can enroll if they originally declined. Employee Application for those that are enrolling for the first time. Subscriber Change Form for those already enrolled and making renewal changes. Employee Application is required to add, change or switch an employee and dependent. Employee Application. The paperwork may be submitted prior to the anniversary date up through the end of the anniversary month. Can someone who initially declined coverage enroll at any other time of the year? Only when enrolling due to a qualifying event. See footnote (1) at the end of this document. The effective date will be the anniversary date. Yes, late entrant penalties will apply. P a g e 20

22 Open Enrollment What is allowed at open enrollment? Medical: Employees can change plans if the employer offers other plans. Employees or dependents can enroll if they were originally declined. Dental: PPO: Employees and dependents who initially declined coverage can come onto the plan with applicable waiting periods. Enrolling in benefits when previously waiving coverage, Add dependents, Move from one plan to another when the group offers more than one plan. Eligible employees and dependents who did not elect coverage when eligible may enroll. Employees may change health carriers and or benefits if the employer offers other plans. What paperwork is required? Can someone who initially declined coverage enroll at any other time of the year? DHMO: Employees and dependents that initially declined coverage can come onto the plan but with no waiting periods applied. Medical/Dental: Employee Application. The paperwork may be submitted prior to the anniversary date up through the end of the anniversary month. The effective date will be the anniversary date. Medical/Dental: No, only with a non-voluntary qualifying event. An enrollment form or change form is required to add or change benefits. If the group has an Open Enrollment provision and a late applicant applies for coverage outside of the OE period, the application will not be processed and the member will need to enroll during the next OE period. Enrollment Application. The paperwork may be submitted prior to the anniversary date up through the end of the anniversary month. The effective date will be the anniversary date. No, only with a nonvoluntary qualifying event. P a g e 21

23 Open Enrollment What is allowed at open enrollment? What paperwork is required? Can someone who initially declined coverage enroll at any other time of the year? Employees can change plans if the employer offers other plans. Employees and dependents can enroll if they originally declined. Employee Application, Change Form and Reconciliation Worksheet. The paperwork may be submitted prior to the anniversary date up through the end of the anniversary month. The effective date will be the anniversary date. HMO: No, only with a nonvoluntary qualifying event. PPO: Yes, with a non-voluntary qualifying event. Employees who do not elect coverage during their 31-day application period may elect coverage later, subject to plan waiting periods. Employees can change plans if the employer offers other plans. Employees and dependents can enroll if they originally declined. Employee Application. The paperwork may be submitted prior to the anniversary date up through the end of the anniversary month. The effective date will be the anniversary date. If the member wants to enroll and doesn t have a non-voluntary qualifying event, they can enroll but are subject to the following waiting periods: 6 month wait for Basic Services 12 month wait for Major Services 12 month wait for Ortho Services (if applicable) Employees can change plans if the employer offers other plans. Employees and dependents can enroll if they originally declined. Employee Application, Change Form and Reconciliation Worksheet. The paperwork must be signed and dated prior to the anniversary date but can be submitted within 30 days after the anniversary month. The effective date will be the anniversary date. No, only with a nonvoluntary qualifying event. P a g e 22

24 Open Enrollment What is allowed at open enrollment? Any benefit eligible employee and their legal dependents can enroll, even if they previously declined coverage. Medical: EE/Dep who declined coverage can come onto the plan. EE may change plan if other plans are offered. All eligible employees and dependents must enroll at initial enrollment or within 30 days of the qualifying event. What paperwork is required? Can someone who initially declined coverage enroll at any other time of the year? Employee Application. The paperwork may be submitted prior to the anniversary date up through the end of the anniversary month. The effective date will be the anniversary date. No, only with a non-voluntary qualifying event. Dental: EE/Dep who declined coverage can come onto the plan. EE/Dep may disenroll if they originally enrolled and no longer want coverage. Employees may change plan if other plans are offered. Medical/Dental: Member Enrollment/Change of Status Form. The paperwork may be submitted prior to the anniversary date up through the end of the anniversary month. The effective date will be the anniversary date Medical/Dental: No, only with a non-voluntary qualifying event. Employee Application. The paperwork may be submitted prior to the anniversary date up through the end of the anniversary month. The effective date will be the 1st of the anniversary month if the paperwork is submitted prior to the anniversary month and 1st of the following month for any paperwork received after the 1st of the anniversary month. No, only with a nonvoluntary qualifying event. P a g e 23

25 Domestic Partners Small and Large Group Small and Large Group Small and Large Group What verification procedures will you require? Same sex - no age limit or Opposite sex - 62 years and older. What verification procedures will you require? Opposite sex under 62 years of age. Will the partner be eligible for federal COBRA? Same sex no age limit or Opposite sex 62 years and older. Will the partner be eligible for Cal COBRA? Same sex no age limit or Opposite sex 62 years and older or Opposite sex and under 62 years of age. Will the partners be required to be registered domestic partners? Small group: No documentation required. Large group: If the group elects to extend coverage to both same sex and opposite sex of any age, the group would need to sign a Domestic Partner Agreement, but the member does not need to provide any documentation. Small group: No documentation required. Affidavit of Domestic Partnership. Affidavit of Domestic Partnership. Large group: If the group elects to extend coverage to both same sex and opposite sex of any age, the group would need to sign a Domestic Partner Agreement, but the member does not need to provide any documentation. Yes No Yes No documentation required. No documentation required. Employer discretion to offer this as an option to the opposite sex, under 62 years of age. Yes No Yes Law states Domestic Partners have to be registered with the Secretary of State. No No P a g e 24

26 Domestic Partner Small Group Small and Large Group What verification procedures will you require? Same sex - no age limit or Opposite sex - 62 years and older. What verification procedures will you require? Opposite sex under 62 years of age. Will the partner be eligible for federal COBRA? Same sex no age limit or Opposite sex 62 years and older. Will the partner be eligible for Cal COBRA? Same sex no age limit or Opposite sex 62 years and older or Opposite sex and under 62 years of age. Will the partners be required to be registered domestic partners? SG: No documentation required. No documentation required. No affidavit required for the same or opposite sex domestic partners. SG: No documentation required. No documentation required. No affidavit required for the same or opposite sex domestic partners. Yes Yes Yes Yes Yes Yes The law states Domestic Partners have to be registered with the Secretary of State. No No P a g e 25

27 Domestic Partners Small and Large Group Small and Large Group Small Group What verification procedures will you require? Same sex - no age limit or Opposite sex - 62 years and older. What verification procedures will you require? Opposite sex under 62 years of age. Will the partner be eligible for federal COBRA? Same sex no age limit or Opposite sex 62 years and older. No documentation required. No documentation required. No documents required. Kaiser reserves the right to request proof of eligibility at any time. No documentation required. No documentation required. No documents required. Kaiser reserves the right to request proof of eligibility at any time. Yes Yes Kaiser will accommodate an employers request to offer Federal COBRA to the domestic partner and his/her dependents if all carriers are offering the same eligibility. Will the partner be eligible for Cal COBRA? Same sex no age limit or Opposite sex 62 years and older or Opposite sex and under 62 years of age. Will the partners be required to be registered domestic partners? Yes Yes Kaiser will accommodate an employers request to offer Cal-COBRA to the domestic partner and his/her dependents if all carriers are offering the same eligibility. No No No P a g e 26

28 Domestic Partners Small and Large Group Small and Large Group What verification procedures will you require? Same sex - no age limit or Opposite sex - 62 years and older. What verification procedures will you require? Opposite sex under 62 years of age. Will the partner be eligible for federal COBRA? Same sex no age limit or Opposite sex 62 years and older. Will the partner be eligible for Cal COBRA? Same sex no age limit or Opposite sex 62 years and older or Opposite sex and under 62 years of age. Will the partners be required to be registered domestic partners? Employer discretion. No documentation required. No documentation required. Employer discretion. No documentation required. No documentation required. Yes Yes Yes Yes Yes Yes Employer discretion. The law states Domestic Partners have to be registered with the Secretary of State. This is not an option for opposite sex under 62 years of age. No P a g e 27

29 Domestic Partners Small and Large Group Small and Large Group Small and Large Group What verification procedures will you require? Same sex - no age limit or Opposite sex - 62 years and older. What verification procedures will you require? Opposite sex under 62 years of age. Will the partner be eligible for federal COBRA? Same sex no age limit or Opposite sex 62 years and older. Will the partner be eligible for Cal COBRA? Same sex no age limit or Opposite sex 62 years and older or Opposite sex and under 62 years of age. Will the partners be required to be registered domestic partners? No documentation required. No documentation required. No documentation required. Affidavit of Domestic Partnership. No documentation required. No documentation required. Yes Yes VSP does not determine if the partner is covered for Federal COBRA, but will accept COBRA eligibility for domestic partners Yes Yes VSP does not determine if the partner is covered for Cal-COBRA, but will accept Cal-COBRA eligibility for domestic partners. Same sex, no age limits or opposite sex over 62 years of age. State registration form is required when enrolling outside of open enrollment. Opposite sex under 62 years of age. Affidavit of Domestic Partnership required when outside of open enrollment. Employer discretion. No, VSP has always covered domestic partners without required proof. P a g e 28

30 Disabled Dependent Child Is an over-age disabled dependent eligible to continue coverage through this new insurance carrier if they were covered under their parents previous policy? Is an over-age disabled dependent eligible to continue coverage through this new insurance carrier if they were not covered under their parents previous policy? What documentation will be required if the disabled child is eligible to continue coverage? How often will the disabled depend child be required to recertify this disability? If the answer is no to any of the above questions, would you consider allowing the child to enroll under Cal COBRA / COBRA? Yes, pending approval from Patient Management Group Department at Aetna. No Yes, with approval from American General Life Companies. Subject to review by American General Life Companies. 2 forms: Social security Proof of prior coverage. Request for continuation of medical coverage documentation or doctor records. Attending physician statement Decided by the patient Usually just once unless the Every 2 years. management group specific disability is not department, usually every 1-2 permanent. years. No No May be reviewed by underwriting to determine if they will allow them to enroll into Cal-COBRA/COBRA. Yes No P a g e 29

31 Disabled Dependent Child Is an over-age disabled dependent eligible to continue coverage through this new insurance carrier if they were covered under their parents previous policy? Is an over-age disabled dependent eligible to continue coverage through this new insurance carrier if they were not covered under their parents previous policy? What documentation will be required if the disabled child is eligible to continue coverage? How often will the disabled depend child be required to recertify this disability? IF the answer is no to any of the above questions, would you consider allowing the child to enroll under Cal COBRA / COBRA? Yes, pending approval from Patient Management Group Department at BSC. Yes Yes, with approval from Guardian Life No Yes Subject to review by Underwriting. Late entrant penalties may apply. 2 forms: Request for Continuation of Medical Coverage Attending Physician Statement Decided by the patient management group department, usually every 1-2 years. Physician certification that the dependent is disabled. Only at initial enrollment. No Date of disability (must be prior to reaching limiting age) and enrollment on prior group for New Business. For inforce plans, adding a new overage disabled dependent, an eligibility form will be required. Periodic proof may be requested, however, after two years, proof will not be requested more than once per year. P a g e 30

32 Disabled Dependent Child Is an over-age disabled dependent eligible to continue coverage through this new insurance carrier if they were covered under their parents previous policy? Is an over-age disabled dependent eligible to continue coverage through this new insurance carrier if they were not covered under their parents previous policy? What documentation will be required if the disabled child is eligible to continue coverage? How often will the disabled depend child be required to recertify this disability? If the answer is no to any of the above questions, would you consider allowing the child to enroll under Cal COBRA / COBRA? Yes, pending underwriting exception. Yes Yes, provided the disability occurred prior to reaching the age limit for dependents. Subject to review by a Kaiser physician. No Yes Yes, provided the disability occurred prior to reaching the age limit for dependents. HealthNet Disabled Dependent certification form. Decided by underwriting. If granted permanent certification then only one time required. If granted temporary certification usually every 1-2 years. Yes None Subject to review by a Kaiser physician. Kaiser disabled dependent form. Determined by a Kaiser physician. P a g e 31

33 Disabled Dependent Child Is an over-age disabled dependent eligible to continue coverage through this new insurance carrier if they were covered under their parents previous policy? Is an over-age disabled dependent eligible to continue coverage through this new insurance carrier if they were not covered under their parents previous policy? What documentation will be required if the disabled child is eligible to continue coverage? How often will the disabled depend child be required to recertify this disability? IF the answer is no to any of the above questions, would you consider allowing the child to enroll under Cal COBRA / COBRA? Yes Yes Yes, subject to review by Principal medical underwriters. Yes No No No documentation required. An attending physician statement. Principal s Application to Continue Handicapped Child Form. Recertification will be required only if an end date is submitted on the physician s statement. Annually No Subject to review by underwriting. P a g e 32

34 Disabled Dependent Child Is an over-age disabled dependent eligible to continue coverage through this new insurance carrier if they were covered under their parents previous policy? Is an over-age disabled dependent eligible to continue coverage through this new insurance carrier if they were not covered under their parents previous policy? What documentation will be required if the disabled child is eligible to continue coverage? How often will the disabled depend child be required to recertify this disability? IF the answer is no to any of the above questions, would you consider allowing the child to enroll under Cal COBRA / COBRA? Yes Yes Statement from the Social Security Administration (SSA) indicating that the individual meets the federal definition of disabled. If no information is available from the SSA then documentation from a physician must be provided via medical records and/or statement signed by the physician. Annually, during January through March. Yes, subject to review by a UnitedHealthcare Medical Director. Must provide an Attending Physician Statement with new case submission. Yes, subject to review by a UnitedHealthcare Medical Director. Must provide an Attending Physician Statement with new case submission. Paperwork from Social Security that deems the dependent disabled. Determined by a UnitedHealthcare Medical Director. Yes, must provide a HIPAA certificate. Yes Yes No documentation is required. Internally Warner Pacific underwriting needs to notify HealthSmart when submitting the case that this dependent is overage and should labeled as relationship type H. P a g e 33

35 Deductible Credit Procedures Which documents are acceptable to provide proof of prior deductible met? At what point should the documentation be provided for processing? Explanation of Benefits (EOB) from the prior carrier showing deductible met AND Aetna Deductible Credit letter. During underwriting or after case approval. Once group is approved each member will receive the Aetna Deductible Credit letter which they need to complete and return. Explanation of Benefits (EOB) from the prior carrier showing total deductible met for the year. After case approval. Which department should the documentation be directed to? By what means will the documentation be accepted? Will a member receive any notification that their deductible has been credited? Where could someone call to check status on processing? Aetna claims (866) Claims Department Medical fax: (877) accumulatortransfers@wellp oint.com Fax Mail, fax or No No Member Services Medical: MC/PPO (888) HMO (888) Dental: (877) Customer Service Medical: (800) P a g e 34