Group administrator manual

Transcription

1 Colorado Large Group Group administrator manual Effective January 2016 Employers 101+ ECOHB5458A Rev. 09/15

2 Anthem Blue Cross and Blue Shield group administrator manual Welcome Welcome to the Anthem Blue Cross and Blue Shield (Anthem) family of companies, where your complete satisfaction is the most important thing to us. Thank you for your business we look forward to a long-lasting relationship with you, our valued customer. Wrapped in the security of Blue By placing your trust and business with us, you ve made a good decision. Whether you re a new or renewing group, you ll enjoy all the benefits that come with being wrapped in the security of Blue. Our company is a convenient, single point of contact for health, dental, vision, and life and disability products and employee assistance programs for millions of people across the country. Quality health care coverage to meet changing needs Our mission is to improve the lives of the people we serve and the health of our communities. Through our targeted quality improvement programs, continuous investments in technology, ongoing service improvement efforts and the widest selection of health care providers in Colorado, we re helping build a healthier future by putting quality first. Dedicated service and support every step of the way Anthem Blue Cross and Blue Shield and our subsidiary companies, HMO Colorado and Anthem Life Insurance Company (Anthem Life), are committed to delivering the high quality and service you and your employees expect and deserve. That s why you ll have a dedicated support team working with you every step of the way. This manual will help you administer your benefits from Anthem Blue Cross and Blue Shield and our family of companies. It provides the detailed information you need to successfully bring quality benefits to your employees. Thank you for choosing Anthem Blue Cross and Blue Shield. We look forward to serving you. 1

3 Who to call Membership Services/Premium Billing Questions Call your membership representative with questions about membership, billing and COBRA for all Anthem Blue Cross and Blue Shield products. Your membership representative s name and phone number are on your premium bill. You can also send an to eligibility.team-west@anthem.com. Anthem Blue Cross and Blue Shield Health Products Customer Service Your employees who have questions about their health care claims, eligibility and benefits can call us Monday through Friday from 7:30 a.m. to 6:30 p.m. Mountain time. Contact your Membership representative directly. Your employees call the number on their health plan ID card. Anthem Blue Cross and Blue Shield Dental Products Customer Service You and your employees can call this number with questions about dental claims Anthem Blue Cross and Blue Shield Vision Products Customer Service You and your employees can call this number with questions about vision claims Anthem Life Claims Center You and your employees can call this number with inquiries about Anthem Life claims Anthem Life Conversion department Call this number with questions about converting members from group term life insurance to an individual whole life insurance policy. BlueCard program Your employees who are or will be traveling out of state and who need the names and addresses of network doctors and hospitals near their travel location can call this number. Health and Wellness programs Your employees can call this number with questions about our condition management and health improvement programs. Guest Membership HMO Colorado members who will be away from Colorado for over 90 days (but not permanently) and who need a guest membership can call this number BLUE (2583) or Relay service for the hearing impaired

4 Table of contents 3 Employer responsibilities...4 General responsibilities Group participation requirements Group changes Billing: keeping the payment process simple...6 Keeping the payment process simple Highlights Pay-as-billed policy Pay-as-billed process Premium billing statement Self-bill statement Employee and dependent eligibility requirements Eligible employees Eligible dependents Eligibility changes New employee and dependent application process Enrolling a new employee Enrolling dependents Special enrollment When medical information is required Waiving coverage Group Membership Enrollment Application/Change Form Changes in coverage: special enrollment Special enrollment due to a change in family status Special enrollment due to the involuntary loss of coverage Other changes Termination of coverage Accessing coverage away from home HMO Colorado Guest Membership benefit BlueCard Life and disability coverage Billing for life and disability products Enrollment Guaranteed issue amount ID cards Membership terminations Life and disability insurance claims Appeals procedure Continuation of coverage COBRA Employee is laid off or takes a leave of absence Coverage during disability Group life insurance conversion Notice of our information privacy policies and practices Frequently asked group administrator questions Frequently asked employee questions Forms Supply Order Form EmployerAccess quick reference guide for large groups... 44

5 Employer responsibilities General responsibilities As an employer, your responsibilities include: Meeting and consistently maintaining group eligibility requirements as described in your Employer Master Contract. Establishing and maintaining new employee enrollment procedures. These procedures include giving notice of eligibility to each employee who is or will become eligible to enroll. Obtaining complete applications for eligible employees who are enrolling in or waiving coverage and submitting the applications to us on time. Your submissions should include any additional forms, such as proof of creditable coverage, Mentally or Physically Disabled Dependent Forms, copies of marriage/civil union certificates, adoption papers, etc. For more information about forms and the application process, please refer to those sections of this manual. Ensuring information on employee applications is complete, true and correct to the best of your ability. Providing a system for making payroll deductions for the employee share of the insurance cost. Please see your Employer Master Contract for details. Paying premiums and any federal- or state-mandated fees, including employee contributions, on or before their due dates. Keeping and maintaining the accuracy of all necessary records. These records include a file for each employee with the employee s application, changes in classification, benefit amounts, beneficiary information and other relevant details. Reporting changes to the following and their effective dates to us: Employee classification. Employee earnings, if Anthem Life benefit amounts are affected. Dependent status. Employee name. Employee address. Termination of employee coverage and reason for the termination. Employer information. Anthem Life beneficiary designation. Helping employees with claims administration and filing. Helping employees and beneficiaries with filing Anthem Life claims if a death occurs. Notifying employees about COBRA eligibility, if applicable. Notifying employees about Group Life conversion eligibility upon employment termination or when coverage is lost due to other events, as stated in the certificate. Notifying us if an employee no longer meets the eligibility requirements in the group s Employer Master Contract. Holding us harmless for paying any claims made on behalf of any ineligible persons and for all costs incurred, including attorneys fees, in the defense of any claim or suit brought by an ineligible person. Reporting taxes withheld from disability benefits. Producing W-2 forms for any disability benefits received by employees. Responding to any audit we may request. Group participation requirements To avoid cancellation of your group s coverage, the following group participation requirements must be met and consistently maintained: At least 50% of total eligible employees (all employees who meet eligibility requirements) and 75% of net eligible employees (total eligible employees less those who waive coverage) must be enrolled at all times. At least five employees must be enrolled in our health coverage at all times. For dental and vision coverage, at least 10 employees must be enrolled at all times. For voluntary vision plans, at least 40 eligible employees must participate. Participation requirements vary for life and disability products. Please see the Life and disability coverage section for more details. Group audits Underwriting may request an audit to verify that your group continues to meet our eligibility guidelines. These audits are selected by a random query. 4

6 Employer responsibilities Group changes Anniversary dates All groups have an anniversary date, which is normally one year from the established service date of the new group. Thirty days before the group s anniversary date is the open enrollment period for HMO and PPO health products, and dental and vision products. During this 30-day period, groups can make changes to their Master Contract. In addition, eligible employees and dependents can enroll or make other membership changes at this time. If your group offers a multioption product, eligible employees and dependents can move from one plan to another. Note: Open enrollment doesn t apply to our life and disability plans. New hire policy A new hire policy requires that an employee must work for a company for a certain amount of time before becoming eligible for coverage. This time period is sometimes referred to as a waiting period or probationary period. A new employee can apply within 31 days from the date of hire or within 31 days after the end of the waiting period defined in the new hire policy. Where an employee is confined to an inpatient facility due to a medical or mental condition, or is otherwise on an approved medical leave of absence consistent with the terms of the plan, employers should not delay, toll or extend an employee s waiting period on the sole basis of such an absence. Your group must notify Anthem in writing if you propose any change in your group s eligibility requirements. Notice must be provided at least 60 days in advance and may be limited by us. A new hire policy can be determined based on employee classification. Your group can change its new hire policy only once per year, at your group s anniversary date. Employers can select one of the following coverage effective dates for all new hires: The first of the month following a time period of no less than 30 and no more than 60 days, as designated in the new hire policy. The date of hire. A different date as approved by our Underwriting department. For more information about your new hire policy, please see your group s Employer Master Contract. Rehire policy: If a rehire occurs in less than thirteen (13) consecutive weeks (or 91 calendar days) after a break in employment, the Waiting period will be waived. If a rehire occurs in more than thirteen (13) consecutive weeks (or 91 calendar days) after a break in employment, the employer s Waiting period may apply. Changes in group size If your group size changes, we ll usually reclassify your group appropriately at the group s next renewal. However, if your group size changes significantly, please contact your Anthem Blue Cross and Blue Shield account manager, because we may need to adjust your rates. Takeovers and mergers If your company is being affected by a takeover or merger, please notify us as soon as possible in writing, and include a census of all employees joining or leaving your company. A group s enrollment and eligibility requirements will apply to the newly formed company. New rates may apply if the takeover or merger causes a significant change in group size. Please contact your account manager for more information. Business ceases to exist If your business ceases to exist, please notify us immediately in writing and contact your account manager. Typically, insurance coverage will end, and continuation of coverage options won t be available to your employees. Group coverage termination Your group s plan will continue in force unless terminated by you, Anthem Blue Cross and Blue Shield or one of our subsidiary companies. Your group s Employer Master Contract contains details about rights of termination, including notice requirements. 5

7 Billing: keeping the payment process simple Name and address changes If the name of your business changes or if the business address changes within the state, please notify us about the changes in writing, and complete and submit an addendum to your Employer Master Application. Please contact your account manager for a copy of the appropriate addendum. Note: If your group s home office is moving to another state, other provisions may apply. Please contact your account manager for more information. Keeping the payment process simple Anthem Blue Cross and Blue Shield s premium billing system provides a simple, efficient approach to billing and premium reconciliation. This section describes our billing process and provides detailed descriptions and information about procedural flow for the following documents: Billing statements Maintenance Recap Forms Enrollment Application/Change Forms If you need additional help, please contact your assigned premium specialist or your account manager. Highlights: We ll prepare billing statements on the same calendar date each month for the following month s premium (for example, your July premium bill is prepared and sent in June). Billing statements will reflect a one-month billing period. Premium rates for employees enrolled in multiple products are grouped together and appear under each subscriber s certificate number (also called a subscriber s member identification number). Your monthly premium payments should always equal the amount due as shown on your billing statement. Please don t adjust or recalculate your monthly bills. You can submit membership changes any time during the month. If we receive membership changes by the fifth of the month before the upcoming billing period, those changes should appear on your next billing statement. Membership changes processed between billing periods are recapped in a separate section of the bill (called eligibility adjustments). When submitting membership changes, only one Maintenance Recap Form is required for all products. Golden rules: Send maintenance information (additions, terminations, COBRA election, other changes) to us separately from premium payments to expedite both payment and processing. Send premium payments to the lockbox address on your invoice. Please fax your changes and applications to You can also us at: eligibility. team-west@anthem.com or enter changes through Anthem s online EmployerAccess tool. Note: Please include your group number and invoice number on your check. We must receive notification at the latest, by the end of the month that the member becomes ineligible to be effective for that month. If we receive notification after the end of the month that the member becomes ineligible, the termination will be processed as effective on the date that we receive notification. Pay your invoice in full by the first of the month to avoid delinquency and cancellation consequences. Premium payments received after the 31st day may be subject to cancellation for nonpayment of premium and may have an impact on claims payments. Pay the total amount due on your billing statement, and don t reconcile it. We ll adjust your balance on subsequent billings. To expedite research and processing, please include your group number on all correspondence and remittance check stubs. To help avoid processing delays and to help ensure that your employees receive their health plan ID cards on time, make sure the information requested on all Enrollment Application/Change Forms is complete and legible. In compliance with the Centers for Medicare & Medicaid Services (CMS) Medicare Secondary Payer requirements, Social Security numbers are required for subscribers, dependents, and spouses or domestic partners. Failure to include this information with enrollment forms may cause a delay in eligibility and claims processing. Add new dependents (spouse, newborn and adopted children) within 31 days of the life event (for example, marriage, birth or adoption). Make sure your employees complete a new Enrollment Application/Change Form when they switch plans. A COBRA application must be completed to elect COBRA. Requests for retroactive additions are allowed for up to 90 days from the current processing date. All retroactive requests are subject to review by our Membership and/ or Underwriting departments. Note: For your convenience we have an online enrollment tool, EmployerAccess, which allows you to enter most of these member updates. 6

8 Billing: keeping the payment process simple 7 Pay-as-billed policy Our pay-as-billed policy allows you to spend less time on administration. Please follow the instructions outlined below: Pay the total amount due shown on your billing statement. Don t add or delete members by writing on your billing statement. Submit membership changes as they occur by completing an Enrollment Application/Change Form. You may submit this form via (eligibility.team-west@anthem.com), fax ( ), or by using Anthem s online EmployerAccess tool. When you submit additions on time: New members are added promptly. Employees receive their health plan ID cards on time. Access to health care is simplified for your employees. When you add or delete members after the billing date, we ll adjust your premium on the subsequent billing statement. Retroactive adjustments are reflected in the eligibility adjustments section of your billing statement. Claims processing is timely, even for members not yet listed on your billing statement, as long as: You ve submitted the membership changes. We ve processed those changes. Your group s premium is paid to the current date. Premiums must be paid in full by the due date on your billing statement. (Your group s coverage may be terminated if we don t receive payment within the guidelines specified in your group s Employer Master Contract or according to Colorado law.) Pay-as-billed process About 15 days before the due date, you ll receive a single combined billing statement for your group s health, dental, vision, life and/or disability monthly premiums. The billing statement will list all employees who were enrolled in your group s coverage at the time we prepared the bill. Please don t add names to the billing statement or add premium for employees not listed on the statement. We ll include premium for those employees on your subsequent billing statement. After receiving your billing statement: Check to make sure that all persons listed on the statement are active employees working at least the required number of hours per week and that they re still eligible for the group s coverage. Mail the full premium payment and the payment stub in the return envelope so we receive it by the due date. You must pay your bill in full on or before the last day of the grace period to avoid cancellation of coverage. You can also pay online through Anthem s EmployerAccess tool. Note: Please include your group number and invoice number on your check: Keep a copy of the billing statement for your records. If you re adding, terminating and/or changing coverage for employees, please follow the procedures outlined in the Changes in coverage section. Any changes are subject to the provisions of your group s Employer Master Contract, new hire policy and other applicable terms. Because you can submit membership changes to us throughout the month for processing, all billing adjustments are shown on your following month s statement. Your monthly premium will always equal the amount due shown on your billing statement. You don t need to make adjustments to or recalculate your monthly premium. For your convenience, your billing statement also includes a separate adjustment recap section that shows all eligibility changes we processed for you between billing periods. Here s an explanation of the billing flow you ll use: Submitting and processing membership changes You can submit membership changes any time during the month. Additions, terminations, and changes can be processed using Anthem s online EmployerAccess tool, ed to eligibility.team-west@anthem.com, or faxed to Termination notifications must be received by the end of the month the member becomes ineligible to be effective for that month. If we receive notification after the end of the month that the member becomes ineligible, the termination will be processed as effective on the date we receive notification. In the eligibility adjustments section of your next billing statement, we ll recap any membership changes we receive after the last billed date and before the fifth of the next month. Premium billing On or around the 11th of each month, we ll generate and mail your billing statement for the upcoming billing period. For example, we ll produce and mail your billing statement for July premium on or around June 11. Anthem s online EmployerAccess tool allows you to pull the invoice electronically. Reconciliation can be done in Microsoft Excel and the payment made electronically.

9 Premium payment guidelines To help us process your premium payments on time, please familiarize yourself with the premium payment guidelines below: 1. Payment is due by the first of the month. Please allow up to two weeks if the check is sent by mail, or hours if the payment is wired or made through EmployerAccess. 2. We may send you a nonpayment reminder letter if we receive your premium payment on or after the 13th day of the month but within the 31-day grace period. 3. As described in your group s Employer Master Contract, failing to pay your premium as it becomes due will result in termination of your group s coverage with us as of the last day of the grace period. For example: Billing period July 1-July 31 Premium due date July 1 Reminder letter July 13 Expiration of grace period July 31 The cancellation notice also states that we won t terminate your group s coverage if you make the payment in full within the grace period. Also, if we terminate your group s coverage for nonpayment and you want to apply for reinstatement, you must submit a new application for coverage, which we may decline, where permitted by applicable law. We have sole discretion to determine the appropriate terms and conditions for reinstatement. Premium payment Premium payment is due and payable on the first of the month. For example, the premium for the July 1 July 31 billing period is due July 1 (please note there is a 31-day grace period). The payment amount must equal the total due amount shown on the billing statement cover sheet. You must include the following with your premium payment each month: A copy of the lockbox cover page (see below for details) A check for the total due amount shown on your billing statement cover sheet that includes the group number and invoice number Note: Please don t send Enrollment Application/Change Forms with your premium payment. Please to eligibility.team-west@anthem.com, enter the change online through EmployerAccess, or mail to: Anthem Blue Cross and Blue Shield Attn: The name of your assigned premium specialist P.O. Box 5858 Denver, CO Membership changes will appear on your next month s billing statement. Premium billing statement This is a type of billing where we bill a specific amount, and the group should pay according to what we bill. Your billing statement includes the following sections: Cover page Product summary page Eligibility adjustments section Membership detail section COBRA subscribers (future cancellations and canceled COBRA participants) Understanding how the information is organized in each section can help you quickly find the data you need. Self-bill statement This is a type of billing that allows the group to pay according to their contract counts. We reconcile according to the group s records. Your billing statement includes the following sections: Cover page Product summary page Premium report Billing statement summary Understanding how the information is organized in each section can help you quickly find the data you need. Cover page The cover page summarizes all billing and payment activity since we prepared your last month s bill. It provides information about your previous billed and paid amounts, a summary of all membership change activity submitted throughout the month, and the total amount due for the current billing. Because you must return the cover page with your payment, it also contains your group name, bill entity number, billing period and due date. Fold the cover page in half, and include it with your premium payment in the remittance window envelope. 8

10 Billing: keeping the payment process simple Area 1 Recaps the previous and current month s billing amounts/totals Name field Prior bill amount Amount paid Prior balance due Eligibility adjustment subtotal Manual adjustment Membership detail subtotal Total amount due Description The total amount due for the previous month s billing The total premium payment applied toward the previous month s billing Premium discrepancy amount (debit or credit) after we reconciled the last month s billing The net total (debit or credit) for all membership changes processed after we prepared last month s billing An amount will appear here only if we processed a manual adjustment (i.e., premium adjustment) The net premium total for the current billing period only The sum of the prior balance due, eligibility adjustment, manual adjustment and membership detail ANTHEM BLUE CROSS AND BLUE SHIELD 700 BROADWAY DENVER, CO Invoice Number C Prior Bill Amount Amount Paid Prior Balance Due Billing Entity No H000 $ $ 0.00 Eligibility Adjustment Subtotal Manual Adjustment Subtotal Membership Detail Subtotal , Total Amount Due $ 13, Please Return this Page With Your Check

11 Area 2 Includes address and billing information Name field Bill entity number Invoice number Billing period Date billed Total due Enter amount paid Lockbox address Due date Sys, desk, bill entity and mbs number Description The primary group number that consolidates all suffixes under one group number for billing purposes A unique invoice number for each billing statement issued for your group The period of time your group is being billed for The calendar date when we generated your billing statement The total premium amount due The amount you re remitting to us Our remittance address The date we must receive your premium payment by For internal use only Please Fold Here for Mailing ANTHEM BLUE CROSS AND BLUE SHIELD 700 BROADWAY DENVER, CO COMPANY, INC 100 S CLAY ST DENVER, CO D1 Bill Ent No.: H000 Invoice Number: C Billing Period: to Date Billed: Total Due: $13, Enter Amount Paid _, _, _. H Make Check Payable To: Anthem Blue Cross and Blue Shield PO BOX LOS ANGELES, CA BILL MBS SYS DESK ENTITY NUMBER Due Date H C H000 ABC Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. An independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 10

12 Billing: keeping the payment process simple Product summary page Name of field Billing entity name Billing entity no. Invoice no. Page no. Group contact Premium specialist Desk no. Telephone Billing period Date billed Payment due date Group/product contract type Current count Current volume Current charges Retro Total Billing rate Total Subtotal/all products Legend Description The group s name The primary group number that consolidates all suffixes under one group number for billing purposes A unique invoice number for each billing statement issued for your group Page number The first and last name of the person we contact when we need to resolve a billing or reconcilement issue The name of the premium specialist assigned to administer your account The premium specialist s desk number The premium specialist s phone number The period of time your group is being billed for The calendar date when we generated your billing statement The date we must receive your premium payment by Your group numbers/product names with the appropriate contract type codes within each product The subscriber counts within each contract type Current total volume for life and accidental death and dismemberment (AD&D) products The premium charges being billed, by contract type, for the current month only The premium charges being billed, by contract type, for retroactive changes only The total for all current months, plus retroactive amounts being billed The rates for your group displayed by group suffix for each contract type The total for each group suffix by the number of subscribers, current month charges, retroactive charges and the total premium due The subtotal for all products Description of all contract types Note: The subtotal shown for current charges will also appear by the membership detail subtotal on the cover page. The subtotal shown for retroactive charges will also appear by the eligibility adjustment subtotal on the cover page. 11

13 PRODUCT SUMMARY Billing Entity Name: COMPANY, INC Invoice No.: C Billing Entity No. : H000 Page No.: 1 Group Contact : Premium Specialist: KAREN Desk No.: C000 Telephone: (000) Billing Period: FROM TO Date Billed: Payment Due Date: Group/Product Current Billing Contract Type Count Charges Retro Total Rate H000- COLORADO BLUE ADVANTAGE - ACT S 33 7, , P S+DEP FAM 6 4, , S+DEPS Total 44 13, , Subtotal/ALL Products 13, , Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. An independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 12

14 Billing: keeping the payment process simple Eligibility adjustments section This section of the billing statement recaps all eligibility changes we received and processed after we prepared your last billing statement. It also details all retroactive premium charges. We recommend you audit this section of your billing statement each month by comparing each entry against your Group Membership Maintenance Recap Forms to ensure we accurately processed all eligibility changes you requested. Name of field Id no. Subscriber name Dept. no. Group no. Prod type Cont. type No. cvd. From date To date Date billed Calc. Rate Prem. adj. Code Eligibility adjustments subtotal Description The subscriber s ID number (also called the subscriber s member identification number or HCID number) The employee s name The subscriber s department number, if the group requests it Each group number affected by the subscriber s membership change Each product type affected by the subscriber s membership change The new contract code corresponding with the product from the subscriber s membership change The number of members covered The membership change effective date The change end date The calendar date when we generated your billing statement The rate amount used to calculate retroactive premium (calculation rate) x (number of months/days) Premium adjustments resulting from the membership change. The premium adjustment for changes processed as of the current billing period will display with zero amount due. Premium amounts for the current billing period are charged in the membership detail section of the billing statement. Premium adjustment amounts shown here represent retroactive premiums only. Short description of the membership change processed (see the Eligibility adjustment codes section below) The net subtotal of the eligibility adjustments Note: If the change is effective as of the current billing period, the From and To dates will be the same. If the change is effective retroactive to the current billing period, the applicable date will be displayed in the From Date column. 13

15 Eligibility adjustment codes The codes listed below are used to indicate the type of activity processed by our Membership and Billing department. When applicable, these various codes will also appear in the eligibility adjustments section of your group billing statement. ADD New subscriber enrollment. This adjustment code also includes subscribers who are re-enrolled (a lapse in coverage exists). CTRCHG Change made to contract REINST Subscriber reinstated (no lapse in coverage) TERM Subscriber s contract terminated ADDDEP New dependent addition. This adjustment code also includes dependents who are re-enrolled (a lapse of coverage). TRMDEP Dependent(s) coverage terminated REIDEP Dependent(s) reinstated (no lapse in coverage) EFFCHG Effective date of change If you have questions or need help, please contact your account manager or your assigned premium specialist. BILLING DETAIL Billing Entity Name: COMPANY, INC Invoice No.: G Billing Entity No. : C Page No.: 4 Group Contact : KRISTINE Premium Specialist: KAREN Desk No.: C000 Telephone: (000) Billing Period: FROM TO Date Billed: Payment Due Date: ELIGIBILITY ADJUSTMENTS * * Eligibility changes received after the 5th of the month may be reflected on your next bill Dept Group Prod Cont Id No. Subscriber Name No. No. Type Type Cvd Date Date Mo/Da Rate Adj Code S2 NAME C00000B000 ADD LSUB / CTRCHG C00000C000 LBAS LSUB / CTRCHG C00000D000 ABDN S / CTRCHG C00000D000 ABDN S / ADD C CBAH S / CTRCHG C CBAH S / ADD S2 NAME C00000D000 ABDN 2P / ADDDEP C CBAH 2P / ADDDEP Eligibility Adjustments Subtotal 1, No. From To Calc. Prem. 14

16 Billing: keeping the payment process simple Membership detail This section of the billing statement lists all employees currently enrolled in your group s plan. Name of field Id no. Dept. no. Emp. no. Subscriber name Cobra end date Group no./suffix Grp. type Prod. type Cont. type No. cvd. Volume Prem. amt. Total subscribers Description The subscriber s ID number (also called the subscriber s member identification number or HCID number) This area will be blank unless your company uses department numbers for billing purposes This area will be blank unless your company uses employee numbers for billing purposes The employee s name The date COBRA coverage is to be terminated based on our records The group number(s) the subscriber is enrolled in The group type associated with the group suffix the subscriber is enrolled in (that is, A = active, C = COBRA, R = retiree) A brief description of the benefit associated with each group suffix, such as HMO or PPO The current contract type for each subscriber (that is, S = subscriber only, 2P = two-party contract, FAM = family) The total number of members currently covered by the subscriber s contract Life and short-term disability benefit amount and long-term disability monthly covered payroll amounts The premium amount due for the current billing period for each subscriber The total number of subscribers and the premium subtotal due for the current billing period 15

17 BILLING DETAIL Billing Entity Name: COMPANY, INC Invoice No.: H Billing Entity No. : H000 Page No.: 4 Group Contact : Premium Specialist: KAREN Desk No.: C000 Telephone: (000) Billing Period: FROM TO Date Billed: Payment Due Date: MEMBERSHIP DETAIL COBRA Group No./ Grp. End Date Prod. Cont. No. Prem. Type Cvd Amt. Id No. Dept. No. Emp. No. Subscriber Name Suffix Type Type NAME H000 A CBAH S NAME Z H000 A A VVIS CBAH S S Z000 A VVIS S NAME A000 A VDEN S H000 A CBAH S NAME Z000 A VVIS S A000 A VDEN 2P H000 A CBAH S Z000 A VVIS 2P Total Subscribers: 18 Membership Detail Subtotal 6, Total Amount Due 22, Group Number identifies the Product and Carrier Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. An independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 16

18 Billing: keeping the payment process simple Self-bill statements This is a type of billing that allows the group to pay according to their contract counts. We reconcile according to the group s records. Note: Self-bill counts can also be submitted online via our EmployerAccess Web tool. Billing Statement Summary Billing Entity Name: COMPANY, INC Invoice No.: G Billing Entity No. : E000 Page No.: 1 Group Contact : JANET Premium Specialist: KAREN Desk No.: C000 Telephone: (000) Billing Period: FROM TO Date Billed: Payment Due Date: Previous Month (Premiums Not Yet Received) Contracts Covered Prior Bill Amount Amount Paid Prior Balance Due Previous Month Total Premium Due Manual Adjustment Prior Balance Due $2, $2, $2, Adjusted Premium Due 17

19 PRODUCT SUMMARY Billing Entity Name: COMPANY, INC Membership Listing No.: G Billing Entity No. : E000 Page No.: 1 Group Contact : JANET Premium Specialist: KAREN Desk No.: C000 Telephone: (000) Billing Period: FROM TO Date Billed: Payment Due Date: Group/Product Current Billing Count Charges Retro Total Rate E000 - EAP STAND ALONE -ACT S Total Subtotal/All Products COMPANY, INC 1111 W STREETNAME BLVD CITY, ST DEE ANNA NAME Billing Statement Premium Report Invoice No. : G Invoice Date : Due Date : Bill Entity : G Page No. : 2 Current Activity Retro Activity Product Recon Current Prev Mo Prev Mo Prior Desc/ Prev Curr Total Curr Prior Rate Total Contract Month Month Curr Premium Rate Rate/ Eff Retro Type Counts Counts Rate Amount Counts Counts Date Prem E000 - EAP STAND ALONE -ACT 08/01/15 S Current Subtotal Retro Subtotal Total Premium Due 18

20 Billing: keeping the payment process simple Billing Statement Summary Billing Entity Name: COMPANY, INC Invoice No.: G Billing Entity No. : E000 Page No.: 3 Group Contact : JANET Premium Specialist: KAREN Desk No.: C000 Telephone: (000) Billing Period: FROM TO Date Billed: Payment Due Date: Instructions for Completion of the Self-Bill Statements (Current Month Counts X Current Rate) = Current Subtotal Premium Amount (Previous Month(s) Current Rate Counts X Current Rate) + (Previous Month(s) Prior Rate Counts X Prior Rate) = Retro Subtotal Premium Amount The Sum of the Current Subtotal Premium and Retro Subtotal Premium = Total Premium Due LEGEND S 2P FAM DEP DEPS S+DEP S+DEPS = = = = = = = SUBSCRIBER ONLY TWO PARTY CONTRACT FAMILY CONTRACT ONE DEPENDENT TWO OR MORE DEPENDENTS SUBSCRIBER + 1 DEPENDENT (NO SPOUSE) SUBSCRIBER + 2 OR MORE DEPENDENTS (NO SPOUSE) 19

21 Employee and dependent eligibility requirements Eligible employees An eligible employee is one who: Works the minimum number of hours specified by the employer on a regular basis, provided the employer s minimum is 24 or more hours per week. Has been employed for the minimum time period, as defined by the employer s new hire policy. Has a valid employer/employee relationship, which can be verified by payroll records subject to federal and state withholding. As a result of the Guaranteed Issue Provision, we must cover seasonal employees if the employer is required to treat them as covered employees, but we can price for the additional risk. Unless an exception in your group s Employer Master Contract applies, the types of employees listed below are not eligible for coverage: Employees who work on a temporary or substitute basis Retired employees Directors, officers, stockholders, trustees and elected officials, unless they re full-time employees Independent contractors Employees who erroneously or fraudulently enrolled in coverage Any employee who doesn t meet or ceases to meet eligibility requirements Please refer to your group s Employer Master Contract for details about eligible employees for your group. If you need to apply for an exception, please contact your account manager. The date an employee is eligible for health insurance coverage usually is the first of the month following any probationary requirement established by the employer (see the examples that follow). Example 1 A group s Employer Master Contract provides that employees and their dependents become eligible for coverage on the first of the month after the date the employee completes one month of service. Coverage would begin for a new employee hired on August 15 as follows: The date of hire is August 15 The employee completes the probationary period September 15 (the hire date plus the term of the probationary period as shown in the Employer Master Contract) Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. An independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Coverage for the new employee begins October 1, as specified in the Employer Master Contract The first billing period that the new employee s premium must be paid is October 1 October 31. The group administrator would enroll the employee before October 1. If the employee is hired August 1 (rather than August 15), coverage and the first premium payment would differ as follows: The date of hire is August 1 The employee completes the probationary period August 31 Coverage begins September 1 The first billing period that premium must be paid is September 1 - September 30 If an employee doesn t enroll in coverage by completing an Enrollment Application/Change Form within 31 days of the eligibility date, the employee and any dependents won t be allowed to enroll until the group s next open enrollment period, unless they meet the special enrollment event guidelines as outlined in state or federal regulations. Example 2 An employee covered by Anthem Blue Cross and Blue Shield has a spouse and dependents with health insurance from another carrier through the spouse s employer. The spouse loses health insurance coverage due to loss of employment. The spouse and dependents covered by the other plan are now eligible for Anthem coverage as of the date the prior coverage ended (see below). The employee must apply for Anthem coverage for the spouse and dependents within 31 days after the loss of coverage, and Anthem will require proof of loss of spousal coverage: First-of-the-month end date prior coverage end date: July 1; date coverage begins: July 1 Nonstandard end date prior coverage end date: July 15; date coverage begins: July 15 (full July premium will be charged) The above policy also applies if the employee previously declined Anthem coverage because he or she was covered by the spouse s health plan, and the spouse loses coverage due to the loss of employment. 20

22 Employee and dependent eligibility requirements Please see your group s certificate or Employer Master Contract for your group s eligibility criteria. It s important that you understand enrollment procedures so your employees and their dependents can enroll as soon as they re eligible for coverage. Eligible dependents Eligible dependents include: A lawful spouse, including a common-law spouse if the marriage is legally valid. For a common-law spouse, a Common-Law Marriage Affidavit is required. Spouse also includes a partner to a civil union, as recognized under Colorado law. For civil unions a Civil Union Certificate may be required. Children of the employee or the employee s spouse up to age 26 (consistent with state or federal law) or as specified in the group s Employer Master Contract. Children of any age who are medically certified as having a mental or physical disability and who are dependent on the employee or the employee s spouse. The employee must complete a Mentally or Physically Disabled Dependent Form and have it signed by a physician to certify continued eligibility. This form must be submitted to and approved by our Underwriting department for the period of the dependent s lifetime or for a specified period. Recertification of the dependent may be required at an interval determined by Underwriting. Grandchildren, with proof of court-appointed permanent legal guardianship or evidence of legal adoption. Unless an exception is outlined in your group s Employer Master Contract, the types of dependents listed below are not eligible for coverage: Domestic partners Grandchildren, if the conditions above are not met Designated beneficiaries Please see your group s Employer Master Contract for details about eligible dependents for your group. If you need to apply for an exception, please contact your account manager. Eligibility changes Please submit eligibility changes as needed to update existing information. Additions, terminations, and changes can be processed through Anthem s online portal sent via or faxed to Wash rule for premium billing If the employee has an a coverage effective date between the first and the 15th of the month, we bill for the entire month. If an employee has a coverage effective date between the 16th and the end of the month, we don t bill for coverage until the next month. The same is true for terminating coverage based on the last day of coverage. In order for credit to be given for the current month, terminations must be received by 3 p.m. MST on the 14th of the month; otherwise, the full month s premium will be charged. Enrollment application/change form Use our Group Membership Enrollment Application/Change Form to enroll new members and report updates to existing membership information. For a supply of the most current Enrollment Application/Change Form, please contact your account manager or download the form from large group AgentAccess at anthem.com. You can also make changes online at anthem.com if you use our EmployerAccess tool. For more information on the EmployerAccess tool, please go to the EmployerAccess Quick Reference Guide for Large Groups at the end of this manual. Please submit membership eligibility changes separately from your premium remittance: Anthem Blue Cross and Blue Shield Attn: Your assigned membership premium specialist P.O. Box 5858 Denver, CO You can also fax the forms to or them to eligibility.team-west@anthem.com. 21

23 New employee and dependent application process Enrolling a new employee New employees who want to enroll after your group s initial enrollment must meet all eligibility requirements described in the previous section of this manual and in your group s Employer Master Contract. The steps for enrolling a new employee are outlined below. Step one: The new employee must complete and sign the Enrollment Application/Change Form. Please make sure all information provided on the application, especially names, dates of birth, Social Security numbers and Anthem Life beneficiary designations, is complete and accurate. If the employee wants to waive coverage, please make sure the application s waiver of coverage section is completed. The completed application must be submitted within 31 days from the date of hire or within 31 days after the end of the waiting period, as defined in the employer s new hire policy. We suggest new employees complete enrollment forms when they re hired in case they or you are away from the office when their eligibility becomes effective. Step two: If applicable, the new employee must provide us with any supporting documentation, such as a civil union registration, Common-Law Marriage Affidavit and/or a Mentally or Physically Disabled Dependent Form. Step three: Submit the new employee s completed original Enrollment Application/Change Form and all other applicable completed forms. We ll return any incomplete applications, which can delay enrollment. An application is not considered submitted until it s complete. Enrolling dependents General information Employees must provide complete information on the Enrollment Application/Change Form for all eligible dependents they want to enroll. All applicable information for each eligible dependent, including name, date of birth, Social Security number and, for HMO Colorado coverage, the primary care physician selected, must be provided and submitted when a new employee s application is submitted. Eligible dependents who don t enroll during your group s initial enrollment must wait until your company s open enrollment period. However, a new employee can submit proof of a qualifying event within 31 days after the event that would allow for special enrollment of an eligible dependent. HMO Colorado Health Insurance Plans/POS Each applicant, including each dependent, must select a primary care physician (PCP) in our HMO Colorado network. The corresponding provider number for each PCP selected must be entered on the Enrollment Application/Change Form. If a PCP isn t indicated on the Enrollment Application/ Change Form for a member, we ll assign one. Members can change an assigned PCP online at anthem.com or by calling the Customer Service number on their health plan ID card. Typically, the coverage effective date is the first of the month following the end of the waiting period designated in the new hire policy. For more information about your new hire policy, please refer to your group s Employer Master Contract. 22

24 New employee and dependent application process Special enrollment After a group s initial enrollment, employees and dependents who were previously eligible or who are newly eligible can apply for coverage during a special enrollment period if a qualifying event has occurred. For more information about special enrollment and for a listing of qualifying events, please see the Changes in coverage: special enrollment section of this manual. Late entrants An eligible employee or dependent is a late entrant if a completed application isn t submitted within the time period specified by the group s new hire policy in the Employer Master Contract, unless the employee qualifies for special enrollment as outlined in the previous section of this manual. Late entrants can enroll only during the group s next renewal or open enrollment period. Anthem Life late entrants An eligible employee or dependent is a late entrant if a completed application isn t submitted within the time period specified by the group s new hire policy as indicated in the Employer Master Contract. If the product is noncontributory, the employee is subject to retroactive back charges. Underwriting approval is required for late entrants who apply for life and/or disability coverage. If an employee or eligible dependent who wants to waive coverage doesn t complete the waiver of coverage section when eligibility becomes effective, he or she can t enroll during a special enrollment period if coverage is lost in the meantime. Note: Renewal periods and open enrollment periods don t apply to life insurance. When medical information is required Medical information is required: When group term life insurance amounts exceed the guaranteed issue limit. As otherwise stipulated in our standard underwriting procedures and guidelines, which we may amend from time to time when enrolling in an Anthem Balanced Funding plan. Note: The medical information requirement does not apply to HMO Colorado coverage. Waiving coverage New employees and their dependents should have the opportunity to apply for coverage. If an employee doesn t want to apply, he or she must complete the waiver of coverage section on the Enrollment Application/Change Form, acknowledging that the employee and/or dependent(s) had the opportunity to enroll. 23

25 Group Membership Enrollment Application/ Change Form All employees must complete an Enrollment Application/ Change Form, even if they want to waive coverage. To avoid coverage delays, please review the forms for completeness and accuracy before submitting them to us. Here s a brief explanation of this form by section: 1. Reason for Completing Application: The employee marks the reason for completing the application. If the coverage is being changed due to a qualifying event (see Changes in Coverage: Special Enrollment section), such as marriage or the birth of a child, the employee includes the reason and the effective date of the change. 2. Benefits and Coverage Desired: The employee selects a product for the type of coverage available to your group. If an HMO or POS plan is selected, the employee must include a primary care physician in section 3 for each person being enrolled. 3. Employee and Family Information: The employee lists all eligible dependents that he or she chooses to cover for the plans available. If more than four dependent children are to be covered, attach additional enrollment forms or an additional sheet of paper with the required information. If the dependent is being covered due to court-ordered health care coverage, the employee checks the court-ordered health care coverage box and attaches a copy of the court order. If the dependent has a mental or physical disability, the employee checks the mentally/physically disabled dependent box and completes and attaches the Mentally or Physically Disabled Dependent Form, which must be signed by a physician. 4. Other Insurance: If any family members are/were covered by other health insurance coverage, such as through a spouse s employer, this section must be completed for the member to receive proper credit for previous coverage and for coordinating benefits. 5. Medicare Coverage: If any family members are covered by Medicare, please include this information so we can coordinate benefits appropriately. The Medicare claim number is the identification number listed on the member s Medicare ID card. 6. Waiver of Insurance: Employees who want to waive coverage must complete this section. If an employee doesn t want coverage for dependents, the employee simply shouldn t include their information in section Signature: The employee must sign and date all completed enrollment forms. We ll return any enrollment forms that don t include a signature with a request for the missing signature. We won t enroll individuals for coverage until we receive a completed and signed form. After an employee s eligibility effective date, health care providers will usually accept a copy of an employee s enrollment form as a temporary health plan ID card. Once we receive all completed and signed forms, we ll process the forms and mail permanent health plan ID cards to the group or the subscriber s home. If your group needs replacement ID cards for any reason, we can mail them to the group or to subscribers homes on request. Once completed enrollment forms are submitted and processed, some changes, that is, to coverage, benefits, group number or contract, will mean that we automatically process and mail new ID cards. If your group offers life and disability coverage, employees must complete, sign and date the Enrollment Application: Life and Disability section of the Group Membership Enrollment Application/Change Form. 24

26 Changes in coverage: special enrollment 25 Special enrollment is allowed when a change in coverage occurs due to a qualifying event. The most common qualifying events are described below. Special enrollment due to a change in family status After your group s initial enrollment period, an employee can apply for coverage for himself or herself or for an eligible dependent if we receive a completed Enrollment Application/Change Form and the required supporting documentation during the special enrollment period, that is, within 31 days after the qualifying event. Employee marries or enters a civil union An employee who marries or enters into a civil union and wants to add coverage for the employee, the employee s spouse, or children of the employee or the employee s spouse must complete an Enrollment Application/Change Form. We must receive the application within 31 days after the date of the marriage or civil union. Health coverage can be effective the date of marriage/civil union or the first day of the following month. Coverage must be effective no later than the first day of the following month after the date the carrier receives a completed enrollment form. Dental coverage is effective on the first day of the next month after the date of the marriage or civil union. Note: The employee may be required to submit a copy of the marriage or civil union certificate with the application. Same-sex partners: Depending on the terms of your certificate and eligibility rules, an eligible spouse may include a partner to a same-sex marriage or union. In Colorado, we will recognize the partner to a same-sex relationship, if either: a) the employee resides in Colorado and has obtained a Colorado civil union certification or license recognizing the relationship as a civil union; or b) the state where the employee resides recognizes the relationship as a spousal relationship; or c) the state where the employee entered into the relationship recognized the partnership as a spousal or substantially similar legal relationship. Employee or employee s spouse gives birth When an employee or the employee s spouse gives birth and at least one of them is covered by us, we provide coverage for the newborn for the first 31 days. This coverage may be mandated by state law and may not be coverage which the employee may waive or decline. If the employee wants to continue coverage for the child after the first 31 days, we must receive the Enrollment Application/Change Form within 31 days after the child s birth if adding the newborn changes the contract type (from employee only or employee plus spouse to employee and children or full family). In that case, we ll start charging premium for the new contract type starting on the first of the month after the birth. If the newborn arrives on the first of the month, premium is due from date of birth. For example, if the baby is born March 10, we ll provide coverage through April 10. If the employee wants to add the baby to the policy, we ll start charging the new premium (if applicable due to a change in contract type) effective April 1. If the employee does not add the baby, coverage for the baby will end April 11. Note: If an employee s covered dependent child gives birth, we provide coverage for the mother s prenatal care and through the delivery process. A grandchild is an eligible dependent and may be added to the employee s policy as a dependent if the grandparent is also a permanent court-appointed legal guardian or has legally adopted the grandchild. Any claims generated under the newborn s name will not be covered. Employee adopts a child To add dependent coverage for an adopted child, the employee must submit: A completed and signed Enrollment Application/ Change Form, even if the employee currently has dependents enrolled in our coverage. A copy of the legal adoption papers. The application must specify the desired changes and list the dependents currently covered and the dependents the employee wants to add coverage for. We must receive the application and other documentation within 31 days after the placement date or adoption date for children younger than 18 years of age. The placement date or adoption date is the date the employee assumed and retained the legal obligation for total or partial support of the child in anticipation of adopting the child. The placement date or adoption date is the coverage effective date, whether the employee adopts the dependent child through an adoption agency or independently. Note: Special provisions apply when the employee adopts a child over the age of 18. Please contact your account manager for details.

27 Employee becomes a legal guardian To add coverage for an eligible dependent that the employee is the permanent legal guardian for, the employee must submit: A completed and signed Enrollment Application/Change Form, even if the employee currently has dependents enrolled in our coverage. A copy of the permanent legal guardianship documents. The application must specify the desired changes and list the dependents currently covered and the dependents the employee wants to add coverage for. We must receive the application and other documentation within 31 days after the date the court approves permanent legal guardianship. How to enroll a covered employee s new dependents The employee must complete the appropriate sections of the Enrollment Application/Change Form. The employee must check the applicable option(s) on the Enrollment Application/ Change Form to add a spouse (indicating the date of marriage or civil union) or to add a dependent. The employee must indicate a simple reason for the coverage addition, and complete the last name, first name, age and birth date portion of the form. The employee must sign and date the Enrollment Application/Change Form within 31 days of the qualifying event. A special enrollment opportunity exists if an employee adds a new dependent due to marriage/civil union/designated beneficiary agreement, birth, adoption, placement for adoption or pursuant to a valid court order. Special enrollment due to the involuntary loss of coverage An employee or eligible dependents may experience the involuntary loss of other health or dental coverage after initially declining coverage with us when they first became eligible. If the employee or eligible dependents completed an Enrollment Application/Change Form and initialed the waiver of coverage section when they first became eligible, they can apply for coverage during a special enrollment period, if the loss of prior coverage is due to any of the following qualifying events: The employee or dependent had COBRA or Colorado State Continuation coverage, and that coverage has been exhausted The employee or dependent had other creditable group health coverage that terminated as a result of: loss of eligibility due to legal separation, divorce or death; or termination of employment or reduction in the number of hours of employment The employee or dependent had other coverage but the employer reduced or terminated the amount of the employer s contribution to the cost of that coverage (even if the employee or dependent remains eligible for that coverage) The employee or dependent had creditable group health coverage that terminated because the employer s contribution toward such coverage ceased The employee must apply for coverage within 31 days after the other creditable group coverage involuntarily ends. Coverage with us will be effective on the day following the loss of other coverage. Sixty-day enrollment opportunity Two additional special enrollment opportunities are available to elect coverage under health plans. A special enrollment period of 60 days will be allowed in the following circumstances: If an employee s or eligible dependent s coverage under Medicaid or the State Children s Health Insurance Program (SCHIP) is terminated as a result of loss of eligibility. If an employee or eligible dependent becomes eligible for premium assistance under Medicaid or SCHIP. Ninety-day enrollment opportunity Another special enrollment opportunity exists for a parent or legal guardian disenrolling a dependent, or a dependent becoming ineligible for the Children s Basic Health Plan. To utilize this special enrollment opportunity, the parent or legal guardian must request enrollment of the dependent in the Anthem health benefit plan within ninety (90) days of the disenrollment or determination of ineligibility. Employee divorces If an employee s spouse has dependent coverage, please notify us as soon as possible if the employee divorces or terminates a civil union. The spouse, and in some instances, the children of a civil union or domestic partner, will no longer be eligible for coverage as of the date on which the divorce/termination is final, unless the court orders the employee to continue the coverage. The employee must complete an Enrollment Application/Change Form requesting the spouse s dependent coverage be terminated, along with a copy of the divorce/ termination decree. COBRA coverage may be available for the spouse, and if so, a completed Continuation of Coverage COBRA application must be submitted. For more information, please see the Continuation of coverage section of this manual. 26

28 Changes in coverage: special enrollment Employee loses eligibility under the spouse s coverage When an employee loses eligibility under a spouse s coverage and wants to apply for our coverage, the employee must complete and submit an Enrollment Application/ Change Form. The employee must submit a HIPAA Certificate of Creditable Coverage (HIPAA letter) or other documentation indicating the employee s prior coverage with the Enrollment Application/ Change Form. We must receive the application and HIPAA letter within 31 days after the loss of coverage. Employee Dies If a covered employee dies, please provide us with the date of death and, if possible, a copy of the death certificate. If the deceased employee has a surviving spouse and/or eligible dependent(s), please see the Continuation of coverage section of this manual for more information. Other changes Medicare eligibility When an employee or an employee s spouse or dependents become eligible for Medicare due to age, disability or end-stage renal disease, please inform us immediately. Federal law determines the primary payer of benefits, as outlined below. Groups with 20 or more full-time and part-time employees: Medicare is the secondary payer for active employees and their spouses who are age 65 and older. Federal law requires employers to offer active full-time employees and their spouses age 65 and older the same health care benefits offered to employees and their spouses under age 65 and under the same conditions. The Omnibus Budget Reconciliation Act of 1986 (OBRA) requires employers of 100 or more full-time and/or part-time employees to continue employer group benefits as the primary payer for employees with a disability until the employee no longer has the disability, is retired or is eligible for Medicare due to age. Certain exceptions apply. Please inform us about either election; otherwise, the presumption will be that the employee elected group coverage. Dependent dies If a covered dependent dies, the employee must complete and submit an Enrollment Application/Change Form within 31 days after the date of death, specifying the date of the dependent s death and making any appropriate coverage changes. If possible, the employee should submit a copy of the death certificate. Any change in contract type and rates will be effective on the day following the date of death. If the employee has dependent life insurance coverage, the employee should file a claim with Anthem Life as soon as possible. Employee address changes Employees must call Customer Service or complete an Enrollment Application/Change Form indicating their new address. It s important that we have current employee addresses, including apartment numbers/letters, because explanation of benefits forms and other correspondence are mailed to the address we have on file. If an employee is moving out of state, please submit a written explanation, because there s a limit on how many out-of-state employees are allowed. Changes in dependent status Please notify us immediately when a dependent s status changes. For more information, please see the Employee and dependent eligibility requirements and Continuation of coverage sections of this manual. Employee voluntarily drops coverage If an employee asks to drop coverage, we must receive notification that a member is no longer eligible for coverage, at the latest, by the end of the month that the member becomes ineligible to be effective for that month. If we receive notification that a member is no longer eligible after the end of the month that the member becomes ineligible, the termination will be processed as effective on the date that we receive notification. We must receive the notification and a signed Waiver of Coverage Form within 31 days after the requested coverage termination date. The employee isn t eligible for COBRA. Employee s employment is terminated or hours are reduced Please notify us immediately when an employee is no longer eligible due to employment termination or reduction of hours. Fax this information to , or send an to our Membership department at eligibility.team-west@anthem.com. If we don t receive timely notification, you may incur additional charges. For more information, please see the Continuation of coverage section of this manual. Employee is a military retiree Employees who are military retirees, or otherwise eligible for CHAMPUS, and their dependents can enroll in your group s coverage. They re subject to the group s specific requirements, and benefits will be coordinated to prevent dual benefit payments. 27

29 Employee is a reservist or member of the national guard Your group can continue regular health and/or dental coverage for reservists or members of the National Guard who are called to active duty. You must continue the employer contribution in the same manner as for full-time employees. Your group can continue the coverage option for up to six months; an additional six months is allowed on a case-by-case basis. If your group s Employer Master Contract allows continuation of group coverage during a leave of absence of more than six months for other reasons, reservists also should be entitled to a similar offering. Dependents can be retained under family coverage, but they re not eligible for dependent-only coverage. Your group can offer continuation of coverage through COBRA to employees who are reservists or members of the National Guard called to active duty. Dependents of employees called to active duty can enroll in CHAMPUS and/or continue coverage under COBRA, if eligible. Colorado mandates that Colorado employers who aren t subject to COBRA must allow continuation of coverage for up to 180 days. Pursuant to federal law, reservists called to active duty have rights allowing them re-employment within 90 days of release from active duty. Upon returning to active work, coverage for the employee can be reinstated if your group s Employer Master Contract is still in effect. Reservists returning to work full time are entitled to participate in your group s coverage offering. No additional probationary period is required. Employee takes family and medical leave When an employee takes time off from work pursuant to the Family and Medical Leave Act (FMLA), health insurance coverage remains in force, but the employee may be required to continue paying his or her share of the premium. Please refer to FMLA rules for more information. Note: There are additional provisions for coverage during extraordinary circumstances, such as during strikes for benefits, leaves of absence and other unique situations. Please contact your account manager for more information if a special situation arises that may affect your group s coverage. Termination of coverage Unless otherwise specified in the group contract, Anthem s standard termination policy is first of the month following the employee s last day of work with the company. For example, if an employee s last day of work is April 4, that employee will be covered on Anthem s insurance until April 30. If termination is due to employee s death, the employee s coverage termination date will be the date of death and dependents will be covered until the end of the month in which the death occurred. It is very important for terminations to be reported within the month of the employee s termination. Colorado law limits our ability to retroactively terminate coverage. Retroactive termination requests cannot be processed as requested. These requests will be processed on the date received, but cannot be back-dated. This could affect premium amounts, and therefore, it is highly encouraged for employers to submit termination requests immediately. Please report all employment terminations that affect your group s health coverage. Either fax to or to our Membership department at eligibility.teamwest@anthem.com. Terminations can also be processed on our online EmployerAccess tool. Upon termination of coverage, employees and their dependents can elect one or all types of coverage they had while actively employed with you through continuation (depending on whether a qualifying event occurred). How to terminate coverage for a covered employee s dependents Employees who remove a dependent from their contract must complete the group membership enrollment/change section of the Enrollment Application/Change Form, indicating that a family member is being canceled. The employee then must complete the section indicating first and last names, etc., and sign the form. Termination of coverage due to an employee s death If coverage termination is due to an employee s death, dependents can continue their coverage unless otherwise indicated in the group s Employer Master Contract, or they may be eligible for COBRA coverage. Dependents electing to continue health coverage on a continuation plan should request information about timelines. Dependents will be covered to the end of the month in which the death of the employee occurred. Note: Terminations are time sensitive, and we want to ensure you receive the appropriate credit. Please use our online EmployerAccess tool, which allows you to process terminations in a timely manner. 28

30 Accessing coverage away from home HMO Colorado Guest Membership benefit For emergency care while away from home, members should call 911 or go immediately to the nearest emergency medical facility. The guest membership benefit is available to HMO Colorado members who plan to be away from Colorado for more than 90 consecutive days but not permanently. The program provides them with ongoing access to care as a guest member of an affiliated Blue Cross and/or Blue Shield plan. Coverage may vary, depending on the benefits offered by the guest membership HMO plan. Guest membership isn t available in all states. If you or your employees have questions about guest membership eligibility and coverage areas, please call our Guest Membership department at the number listed in the front of this manual. BlueCard The BlueCard program provides Anthem Blue Cross and Blue Shield PPO members with access to doctors and hospitals across the country and around the world. Through the BlueCard PPO Program provider network, PPO members have access to health care services while traveling or living in another Blue Cross and/or Blue Shield plan s area, and depending on the terms of your certificate, they may be covered at the same benefit level as when they re in their own service area. The program links participating health care providers and the independent Blue Cross and/or Blue Shield plans through a single electronic network for claims processing and reimbursement. How BlueCard works: The member visits a BlueCard participating provider and presents his or her Anthem Blue Cross and Blue Shield health plan ID card. The provider can verify the member s eligibility by calling BLUE (2583) toll free. After the member receives services, the provider files the claim with the local Blue Cross and/or Blue Shield plan. Members don t need to file a claim when they see a participating BlueCard provider. The local Blue Cross and/or Blue Shield plan sends the claim electronically to Anthem Blue Cross and Blue Shield. We process the claim and send payment instructions to the local plan. } } The local plan processes the payment and forwards it to the provider. Finding a BlueCard participating provider For nonemergency care while away from home, PPO members can find names and addresses of nearby participating BlueCard providers through the BlueCard Doctor and Hospital Finder at bcbs.com. Or they can call BlueCard Access toll free at BLUE (2583). For emergency care while away from home, members should call 911 or go immediately to the nearest emergency medical facility. They should then notify us about the treatment or admission within 48 hours or as soon as reasonably possible. 29

31 Life and disability coverage Billing for life and disability products To simplify administration, life and disability premiums are billed with your group s monthly health plan billing statement. Please refer to pages 7-11 of this manual for additional billing information. Please note: Premium changes to voluntary age-rated life premiums occur first of the month following the subscriber (employee) date of birth. Enrollment Eligibility To qualify for life insurance coverage, employees must meet the eligibility criteria defined in your group life insurance contract, reach your group s eligibility effective date (i.e., complete the waiting/probationary period), and enroll by completing an Enrollment Application/Change Form. Enrollment acceptance and the coverage effective date for employees and dependents are governed by the terms of your group s life insurance contract. Enrolling new subscribers New subscribers must enroll within 31 days from the date they become eligible. Employees must complete the Enrollment Application/Change Form in ink and sign and date the form. Please submit this form via (eligibility. team-west@anthem.com), fax ( ), or use Anthem s EmployerAccess online eligibility tool. Anthem Blue Cross and Blue Shield isn t responsible for retaining beneficiary information. In case a claim is filed, you must submit and maintain a copy of enrollment forms and any change in beneficiary forms. Late enrollment An eligible employee or dependent is a late entrant if an application isn t completed and submitted during the group s initial enrollment period or within 31 days of the employee s eligibility effective date (the group s new hire policy for when benefits become effective). When employees contribute to the premium (contributory coverage) If the completed application for contributory employee and/or dependent coverage isn t submitted within 31 days after first becoming eligible, the late applicant s coverage will be subject to medical underwriting. This means that evidence of insurability must be submitted. When the employer pays 100% of the premium (noncontributory coverage) If the completed application for noncontributory employee and/or dependent coverage isn t submitted within 31 days after first becoming eligible, the late applicant s coverage will be subject to retroactive premium charges. Evidence of insurability will be required only if the coverage amount applied for exceeds the group s guaranteed issue limits for that coverage. Submit the completed Evidence of Insurability Form to us with the Enrollment Application/Change Form. Any coverage amount requiring an Evidence of Insurability Form will be subject to review and approval by Anthem Life. If approved, coverage for a late enrollee will become effective on the first day of the month following Underwriting approval. This process won t be waived during open enrollment. Guaranteed issue amount With some life and disability plans, employees may be eligible for coverage over a guaranteed issue amount. In these cases, the employee must complete, sign and date the Evidence of Insurability Form. Submit the completed form to us with the Enrollment Application/Change Form. The employee will be subject to review and approval by Anthem Life. If approved, coverage exceeding the guaranteed issue amount will become effective on the first day of the month following Underwriting approval. 30

32 Life and disability coverage ID cards Life and disability insurance benefits aren t indicated on your employees health plan ID card. They can refer to their certificate for details about their life and disability insurance benefits and to their Enrollment Form (and change of beneficiary forms) for beneficiary information. Membership terminations Processing terminations When an employee s life coverage is terminated due to employment termination, you must submit the termination request via (eligibility.team-west@anthem.com), or fax ( ), or use Anthem s EmployerAccess online eligibility tool. When the employee requests that coverage be terminated (contributory coverage only), he or she must complete the personal information, coverage election and declination of coverage portions of the Life Insurance Enrollment Form. For terminations due to death, please see the Life and disability insurance claims section. COBRA does not apply to life insurance. Conversion of group life insurance You must complete the Notice of Right of Conversion for Group Life Form and provide it to each enrolled employee upon employment termination. Within 31 days from the termination date, the terminated employee must complete and mail the form to us to be eligible for coverage. Coverage: When an active employee loses group life coverage due to employment termination or the employee s benefit amount is reduced due to age or a change in class, the amount of coverage lost can be converted to whole life insurance, except where otherwise specified in your group s certificate. Group term life, supplemental life and dependent life coverage can be converted. Accidental death and disability coverage can t be converted. Deadline: To be eligible, employees must complete a Request for Group Life Conversion Information Form within 31 days of the termination or the reduction in coverage. Health evidence: Because conversion coverage is guaranteed regardless of health status if applied for within 31 days, evidence of good health isn t required. Life and disability insurance claims To submit a life insurance claim, please follow the steps outlined below: The beneficiary/claimant completes, signs and dates the claimant s statement section of the Statement of Death Group Claim Form. If no beneficiary designation is on file, the beneficiary will be as stated in the certificate. If the claim is on a dependent, the employee is the beneficiary. The beneficiary/claimant obtains a certified copy of the death certificate. The beneficiary/claimant provides you with the completed claimant s statement and the certified copy of the death certificate. You complete the employer s statement section of the claim form. You mail the above documents to the following address: Anthem Life Claims Center P.O. Box Atlanta, GA Note: For employee life claims, please also attach all life insurance enrollment forms and beneficiary change notifications, if available. Payment of life insurance proceeds For proceeds of less than $10,000, we ll pay benefits to the last designated beneficiary. We ll mail the check to the beneficiary/claimant unless we re instructed to do otherwise on the claim form. For proceeds of $10,000 or more, we deliver life insurance proceeds to beneficiaries in the form of an interest-bearing account. Once we approve a claim for $10,000 or more, a special account is established for the beneficiary. We mail a personalized Anthem Access Advantage checkbook to the beneficiary the next business day following approval of the claim. The beneficiary has immediate access to any portion or all of the proceeds simply by writing a check. This allows beneficiaries to use their account to pay immediate expenses while relieving them of the pressure of making important investment decisions during a time of stress and grief. The account begins earning interest the day it s opened. If we have no beneficiary designation on file at the time of death, we ll pay benefits according to the certificate. 31

33 Accidental death benefit claims To submit an accidental death benefit claim, please follow the steps outlined below: Follow all steps for submitting a life insurance claim listed under Life and Disability Insurance Claims When submitting the claim form and other documentation, also attach any available newspaper articles, police reports and/or coroner reports that provide details of the accident We ll deduct any dismemberment proceeds previously paid for the same accident under the insured s accidental death and dismemberment coverage from the accidental death proceeds due for accidental death Short-term disability benefit claims To submit a short-term disability benefit claim, check the short-term disability claim box at the top of the Disability Claim Form, and then follow the steps outlined below: The employee completes the statement of insured section on the Disability Claim Form. Note: Failure to complete all questions on the form may delay processing. The employee signs and dates the authorization to release medical information, part A, on the back of the form. The employee forwards the form to his or her attending physician. The employee s physician completes all applicable questions, signs and dates the attending physician statement, part B, on the back of the form, and returns the form to you. Note: Failure to complete all applicable questions may delay processing. You complete the statement of group policyholder section on the Disability Claim Form and mail the form to the Anthem Life Claims Center address listed earlier in this section of the manual. The initial disability benefit will include all benefits due from the date last worked through the current date. Thereafter, we ll issue disability payments biweekly, unless the employer has requested weekly payments. We ll mail checks to the employer for delivery to the employee, unless the employer requests that checks be mailed directly to the employee. Occasionally, Anthem Life may require an employee to provide certification of continuing disability. In those cases, we ll supply the employee with the appropriate form, which must be completed and returned to us, and request that the employee s physician certify the continuing disability. Note: Please call the Anthem Life Claims Center and notify us when an employee returns to work following a short-term disability. Long-term disability benefit claims A claim for long-term disability benefits must be submitted to the Anthem Life Claims Center 30 days before the end of the elimination period. Please refer to your group s policy and certificate to determine the length of the elimination period. To submit a long-term disability benefit claim, please follow the steps outlined below: The employee completes, signs and dates the Authorization and Disclosures Form and the employee s statement section on pages 2 and 3 of the Long-Term Disability Claim Form. Note: Failure to complete all questions on the form may delay processing. The employee forwards the forms to his or her attending physician. The employee s physician completes all applicable questions, signs and dates the physician s statement on page 7 of the form, and returns the form to you. Note: Failure to complete all applicable questions may delay processing. You complete the employer s statement and the job analysis sections on pages 4-6 of the Long-Term Disability Claim Form and mail all applicable sections of the form, along with a copy of the employee s job description, to the Anthem Life Claims Center address listed earlier in this section of the manual. The initial disability benefit will include all benefits due from the date last worked through the current date. Thereafter, we ll issue disability payments monthly. We ll mail checks to the employer for delivery to the employee, unless the employer requests that checks be mailed directly to the employee. 32

34 Life and disability coverage Occasionally, Anthem Life may require an employee to provide certification of continuing disability. In those cases, we ll supply the employee with the appropriate form, which must be completed and returned to us, and request that the employee s physician certify the continuing disability. Accidental dismemberment benefit claims To submit an accidental dismemberment benefit claim, please follow the steps outlined below: Check the dismemberment claim box at the top of the Disability Claim Form. The employee completes the statement of insured section on the Disability Claim Form. Note: Failure to complete all questions may delay processing. The employee signs and dates the authorization to release medical information, part A, on the back of the form. The employee forwards the form to his or her attending physician. The employee s physician completes all applicable questions, signs and dates the attending physician s statement, Part B, on the back of the form, and returns the form to you. Note: Failure to complete all applicable questions may delay processing. You complete the Statement of group policyholder section on the Disability Claim Form and mail the form to the Anthem Life Claims Center address listed earlier in this section of the manual. Anthem Life will issue proceeds for the applicable dismemberment benefit amount and will mail a check to the employee. Waiver of life premium benefit claims If an employee s coverage includes a waiver of life premium during total disability, the employee must file a claim to obtain this benefit. Note: If an employee also has short-term or long-term disability coverage with us, Anthem Life will automatically set up a waiver of life premium claim from the short-term disability or long-term disability claim, when appropriate per your group s Employer Master Contract. To submit a waiver of life premium benefit claim, please follow the steps outlined below: Check the waiver of life premium box at the top of the Group Disability Claim Form. Complete the steps listed under the Short-term disability benefit claims section. Appeals procedure The employer, the employee or the beneficiary can appeal a claim denial. To submit an appeal, please follow the steps outlined below: Submit the appeal to us in writing, and include the reason the claim denial is being challenged. Include any applicable documentation of the facts of the claim not provided previously. Mail the written appeal and any additional documentation to the following address: Anthem Life Attn: Claims Manager P.O. Box Atlanta, GA Because dismemberment (the amputation or loss of a body part) generally results in a disability, the employee should also follow the applicable steps for filing a short-term or long-term disability benefit claim if enrolled for either type of coverage. 33

35 Continuation of coverage As outlined in the Employer responsibilities section of this manual, employers must notify employees about their continuation of coverage options. Only one type of continuation of coverage is applicable to a group enrolled in health and/or dental insurance plans: COBRA. COBRA Federal law requires that most companies with 20 or more full-time and part-time employees offer COBRA continuation coverage for group health and dental insurance, under certain circumstances. Individuals covered by an employer-based group plan can elect to retain coverage under the group plan, after coverage would otherwise expire, if a qualifying event has occurred. COBRA coverage is available for 18, 29 or 36 months, depending on the qualifying event, and only if the application and premium payment requirements of the federal law are met. The employer must notify the employee in a timely manner about these requirements and about the availability of COBRA coverage. COBRA doesn t apply to life or disability insurance. The qualifying events and corresponding continuation periods for COBRA coverage are outlined below: COBRA coverage is available to employees and their dependents for 18 months from the date of the following qualifying events: When an employee loses coverage due to a reduction in work hours, including layoffs and strikes. When an employee loses coverage due to the voluntary or involuntary termination of employment, including retirement and excluding gross misconduct. COBRA coverage is available to employees and their dependents for 29 months under a disability extension as follows: If the Social Security Administration determines that an employee or dependent is disabled and the group administrator is notified in a timely manner, the entire family of the employee or dependent may be entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total maximum of 29 months. The disability must have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage. Notice of the disability must be given to the group administrator within 60 days of receiving the determination from the Social Security Administration. COBRA coverage is available to the following individuals for 36 months from the date of the following qualifying events: The surviving spouse and surviving children of a covered employee, when the covered employee dies. Dependents of covered employees, if the covered employee became eligible for Medicare benefits before COBRA election. Spouses and children of a covered employee, when the employee and the spouse separate or divorce. Children of current covered employees, when they lose eligibility as a dependent. COBRA coverage is available to newborn or adopted children for the remainder of either an 18-month or 36-month COBRA continuation period. The qualifying event that triggered the COBRA coverage will determine the length of the continuation period. Note: Due to recent judicial opinions regarding the federal Defense of Marriage Act (DOMA), a partner to a same-sex marriage may qualify as a spouse under COBRA. Administration of COBRA premium billing and receipt of payment Employers can choose one of the following parties to handle COBRA premium billing and receipt of payment: Anthem Blue Cross and Blue Shield or HMO Colorado, as specified in the group s Employer Master Contract A third-party administrator The employer premiums charged to the individual for COBRA coverage can be 100% of the total premium due to the insurance carrier, plus an administrative charge not exceeding 2% of the premium. Employees who receive Social Security disability payments can be charged up to 150% of the premium due to the carrier. 34

36 Continuation of coverage Application for COBRA coverage The employer must notify the individual about the availability of COBRA coverage within 30 days after the qualifying event. The COBRA-eligible person has 60 days from the receipt of the employer notification or from the date coverage would otherwise end, whichever is later, to elect COBRA continuation coverage and to inform the employer about the election. To apply for COBRA coverage, the eligible person must complete an application and select COBRA coverage. You must complete the employer section, sign the application and submit it to us within 31 days of the eligible person electing coverage. Failure to timely notify the individual about COBRA coverage, or failure to timely submit the application, may result in our denial of the COBRA application and may obligate the employer to secure coverage for the individual elsewhere. After electing COBRA continuation coverage, the individual must pay the premium due within 45 days. Termination of COBRA coverage COBRA continuation coverage can terminate before the continuation period expires if: All health plans provided to the group s employees are terminated. The individual with COBRA coverage fails to pay premium. The individual becomes covered by another health plan after electing COBRA, subject to any additional COBRA rules. The individual becomes entitled to Medicare after electing COBRA. Status changes due to legal separation or divorce. Employee is laid off or takes a leave of absence For life insurance plans: If an employee is laid off or takes an approved leave of absence, you can continue an employee s group term life insurance, which also includes accidental death and dismemberment, supplemental group term life insurance, and group term life insurance for dependents, for up to three consecutive months by paying the required premium. If the employee hasn t returned to active, full-time work at the end of the three-month period, please notify us to terminate coverage. Coverage during disability For life and disability insurance plans: If an employee is no longer actively at work due to illness or injury, you can continue his or her life and disability coverage for up to six consecutive months by paying the required premium. If the employee hasn t returned to active, full-time work at the end of the six-month period, please notify us to terminate coverage. 35

37 Group life insurance conversion An employee whose coverage terminates may have the right to convert from group term life insurance to an individual whole life insurance policy without evidence of insurability. Coverage for dependents also may be converted at the same time. A brief description of the conversion right follows. For more information, please see the certificate or call the Anthem Life Conversion department at the phone number listed in the front of this manual. The employer must notify Anthem Life about any requested changes to the employee s group life insurance coverage. The notice must be in writing on the employer s letterhead and signed by the employer s authorized signer. Note: The employer must notify eligible individuals about their conversion right. Anthem Life doesn t send conversion notices to terminated employees. If the employer doesn t provide timely notice of the conversion option to the eligible individual, Anthem Life won t extend the time period allowed for a person to apply for a conversion policy. Conversion right The right to purchase a conversion policy is available when the employee s life coverage ends for a reason other than the group s coverage ending or changing. The individual must apply in writing to Anthem Life for conversion or complete a Notice of Conversion Form and pay the initial premium on the policy within 31 days after the group term life insurance ends. The individual can choose to be insured for the same or a lesser amount as the insured amount under the group plan. Premium will be calculated according to the individual s age and class of risk. The conversion policy will be effective on the date that group term life insurance ends, provided the individual applies and pays the conversion premium within the required 31 days. Conversion is also available when an employee loses coverage because the group plan terminates or changes. In these cases, the following additional limitations apply: The amount available for conversion is limited to the lesser of $2,000 or the difference between the group life amount Anthem Life provided and any new group coverage that becomes available during the conversion period The individual must have been covered under the group life policy for at least five years Note: The life insurance conversion period won t be extended due to delayed notice to eligible individuals. If the individual dies within the time period allowed for life conversion, Anthem Life will pay the benefit that the person could have converted, unless death benefits are payable under another provision of the group plan. 36

38 Notice of our information privacy policies and practices HIPAA Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. We keep the health and financial information of our current and former members private as required by law, accreditation standards and our rules. This notice explains your rights. It also explains our legal duties and privacy practices. We are required by federal law to give you this notice. Your protected health information We may collect, use and share your Protected Health Information (PHI) for the following reasons and others as allowed or required by law, including the HIPAA Privacy rule: For payment: We use and share PHI to manage your account or benefits or to pay claims for health care you get through your plan. For example, we keep information about your premium and deductible payments. We may give information to a doctor s office to confirm your benefits. For health care operations: We use and share PHI for our health care operations. For example, we may use PHI to review the quality of care and services you get. We may also use PHI to provide you with case management or care coordination services for conditions like asthma, diabetes or traumatic injury. For treatment activities: We do not provide treatment. This is the role of a health care provider such as your doctor or a hospital. But we may share PHI with your health care provider so the provider may treat you. To you: We must give you access to your own PHI. We may also contact you to let you know about treatment options or other health-related benefits and services. When you or your dependents reach a certain age, we may tell you about other products or programs you may be eligible for. This may include individual coverage. We may also send you reminders about routine medical checkups and tests. To others: You may tell us in writing that it is OK for us to give your PHI to someone else for any reason. Also, if you are present and tell us it is OK, we may give your PHI to a family member, friend or other person. We would do this if it has to do with your current treatment or payment for your treatment. If you are not present, if it is an emergency, or you are not able to tell us it is OK, we may give your PHI to a family member, friend or other person if sharing your PHI is in your best interest. As allowed or required by law: We may also share your PHI, as allowed by federal law, for many types of activities. PHI can be shared for health oversight activities. It can also be shared for judicial or administrative proceedings, with public health authorities, for law enforcement reasons, and to coroners, funeral directors or medical examiners (about decedents). PHI can also be shared for certain reasons with organ donation groups, for research, and to avoid a serious threat to health or safety. It can be shared for special government functions, for workers compensation, to respond to requests from the U.S. Department of Health and Human Services, and to alert proper authorities if we reasonably believe that you may be a victim of abuse, neglect, domestic violence or other crimes. PHI can also be shared as required by law. If you are enrolled with us through an employer-sponsored group health plan, we may share PHI with your group health plan. We and/or your group health plan may share PHI with the sponsor of the plan. Plan sponsors that receive PHI are required by law to have controls in place to keep it from being used for reasons that are not proper. Authorization: We will get an OK from you in writing before we use or share your PHI for any other purpose not stated in this notice. You may take away this OK at any time, in writing. We will then stop using your PHI for that purpose. But if we have already used or shared your PHI based on your OK, we cannot undo any actions we took before you told us to stop. 37

39 Your rights Under federal law, you have the right to: Send us a written request to see or get a copy of certain PHI or ask that we correct your PHI that you believe is missing or incorrect. If someone else (such as your doctor) gave us the PHI, we will let you know so you can ask them to correct it. Send us a written request to ask us not to use your PHI for treatment, payment or health care operations activities. We are not required to agree to these requests. Give us a verbal or written request to ask us to send your PHI using other means that are reasonable. Also let us know if you want us to send your PHI to an address other than your home if sending it to your home could place you in danger. Send us a written request to ask us for a list of certain disclosures of your PHI. Call Customer Service at the phone number printed on your health plan ID card to use any of these rights. They can give you the address to send the request. They can also give you any forms we have that may help you with this process. How we protect information We are dedicated to protecting your PHI. We have set up a number of policies and practices to help make sure your PHI is kept secure. We keep your oral, written and electronic PHI safe using physical, electronic and procedural means. These safeguards follow federal and state laws. Some of the ways we keep your PHI safe include offices that are kept secure, computers that need passwords, and locked storage areas and filing cabinets. We require our employees to protect PHI through written policies and procedures. The policies limit access to PHI to only those employees who need the data to do their job. Employees are also required to wear ID badges to help keep people who do not belong out of areas where sensitive data is kept. Also, where required by law, our affiliates and nonaffiliates must protect the privacy of data we share in the normal course of business. They are not allowed to give PHI to others without your written OK, except as allowed by law. Potential impact of other applicable laws HIPAA (the federal privacy law) generally does not preempt, or override, other laws that give people greater privacy protections. As a result, if any state or federal privacy law requires us to provide you with more privacy protections, then we must also follow that law in addition to HIPAA. Complaints If you think we have not protected your privacy, you can file a complaint with us. You may also file a complaint with the Office for Civil Rights in the U.S. Department of Health and Human Services. We will not take action against you for filing a complaint. Contact information Please call Customer Service at the phone number printed on your ID card. They can help you apply your rights, file a complaint or talk with you about privacy issues. Copies and changes You have the right to get a new copy of this notice at any time. Even if you have agreed to get this notice by electronic means, you still have the right to a paper copy. We reserve the right to change this notice. A revised notice will apply to PHI we already have about you as well as any PHI we may get in the future. We are required by law to follow the privacy notice that is in effect at this time. We may tell you about any changes to our notice in a number of ways. We may tell you about the changes in a member newsletter or post them on our website. We may also mail you a letter that tells you about any changes. Note for Spanish speakers Si necesita ayuda en español para entender este documento, puede solicitarla sin costo adicional, llamando al número de servicio al cliente que aparece al dorso de su tarjeta de identificación o en el folleto de inscripción. 38

40 Frequently asked group administrator questions 39 Do I need to submit the original Enrollment Application/ Change Forms? We prefer to receive the original applications for adding coverage, because it s important that we have the employee s original signature on file. We prefer to receive termination of coverage notification immediately so we can process the information on time for billing. If you fax information to us, please don t also mail the information, because this may cause delays in the enrollment process. Where do I send Enrollment Application/Change Forms and other supporting documentation? Please send completed Enrollment Application/Change Forms and other supporting documentation to the address, fax number or box below: Anthem Blue Cross and Blue Shield P.O. Box 5858 Denver, CO Fax: eligibility.team-west@anthem.com What fields are required on the Enrollment Application/ Change Form? All applicable fields must be completed. If the employee is submitting changes, be sure to indicate whether the changes are for health, dental, vision and/or life coverage. In compliance with the Centers for Medicare & Medicaid Services (CMS) Medicare Secondary Payer requirements, Social Security numbers are required for subscribers, dependents, and spouses or domestic partners. Failure to include this information with enrollment forms may cause a delay in eligibility and claims processing. What if an employee wants to waive coverage? Eligible employees must complete the Enrollment Application/ Change Form and the waiver of coverage section any time they elect not to accept the insurance coverage you re offering. What s the difference between termination of coverage and waiver of coverage/declining coverage? Termination is when the eligible employee s coverage is ending because the employee and/or dependents are no longer eligible. When an employee and/or dependents waive coverage, they re eligible, but they decide they don t want the coverage and decline the offer of coverage. Employees who are declining coverage due to other group coverage must complete the waiver of coverage section of the Enrollment Application/ Change Form to qualify for a special enrollment at a later date. Whom do I call if a member isn t in your system? Please call your designated Membership representative. What s guest membership and whom do I call to establish it for a member? Guest membership is a benefit of the Away from Home Care program that s available to HMO Colorado members who plan to be away from home for more than 90 consecutive days. The program ensures that members have ongoing access to the care they need by setting them up as guest members at an affiliated Blue Cross and/or Blue Shield plan. The member must call our Guest Membership department at the number in the front of this manual to establish guest membership. Whom do I call with billing questions? Please contact your premium specialist. Your premium specialist s name and phone number is on your billing statement. How do I change a member s address? Members can call the Customer Service number on the back of their health plan ID card or complete and submit an Enrollment Application/Change Form via (eligibility.team-west@anthem.com) or fax ( ). How do I terminate an employee s coverage? Please complete and submit an Enrollment Application/ Change Form with the appropriate termination date, and immediately submit it to us via (eligibility.team-west@anthem.com) or fax ( ). Do I need to mail separate payments for health, dental, vision and life premiums? No, all premiums will be included on your monthly billing statement, and you can submit a single payment for the amount due. How do I enroll a member in COBRA or Colorado State Continuation coverage after the employee s employment has terminated? Please see the Continuation of coverage section of this manual. When is my open enrollment period or renewal period? Normally, your open enrollment or renewal period is the 30-day period before your group s anniversary date. However, there are exceptions to this rule, so please refer to your group s Employer Master Contract or call your account manager to confirm the date. How can I order more new hire packets and other additional forms? Please complete and submit a Supply Order Form. This form and additional directions for submission are located in the Forms section of this manual.

41 Frequently asked employee questions How do I order a new health plan ID card if mine is lost or stolen? Go to Member Services at anthem.com, or call the Customer Service phone number on your health plan ID card. What should I do if my pharmacy can t fill a prescription because its records show I m not eligible? Ask the pharmacy to call to confirm eligibility. Also, before having a prescription filled, you can confirm eligibility by calling the Customer Service number on your health plan ID card. How do I access health care when I m traveling? You re always covered worldwide for any medical emergency. If you need immediate care, call 911 or go to the nearest emergency facility. If the medical situation isn t life or limb threatening, call BLUE (2583) to locate a participating BlueCard provider in the area, depending on your type of coverage (PPO, HMO, POS). After I submit my Enrollment Application/Change Form, when will I receive my health plan ID card(s) and certificate? Health plan ID cards and certificates are usually mailed within 30 days after we receive the completed Enrollment Application/Change Form. Whom do I call if a claim is denied? If it s a health insurance claim, call the Customer Service number on your health plan ID card. If it s a dental claim, call the dental Customer Service number on your ID card. If it s a vision claim, call the vision Customer Service number on your ID card. If it s a life insurance claim, call the Anthem Life Claims Center toll free at What s a drug formulary? A drug formulary is a preferred list of medications that s been reviewed for safety, quality and cost effectiveness by our pharmacy therapeutics committee, which includes practicing physicians and clinical pharmacists. The formulary promotes a current assessment of the safety and effectiveness of the medications. You can learn more about our formulary by going to the prescription information section at anthem.com. Will I have to pay the higher nonformulary copayment if my doctor prescribes a nonformulary drug? Yes, if you re on a tiered copayment drug plan. However, we strongly encourage you to ask your doctor to prescribe medications from our formulary. What if a prescribed drug doesn t have a generic equivalent? In those cases, you ll be responsible for paying the higher copayment if you re on a tiered copayment drug plan. What if my doctor requires me to take a brand-name drug, even if a generic equivalent is available? If you re on a tiered copayment drug plan, you ll be responsible for the higher copayment and for the difference between the billed amount and our allowable amount for the drug. What is a preauthorization? Preauthorization, sometimes referred to as precertification, is the process used to confirm whether a proposed service, procedure or drug is medically necessary. Whenever possible, preauthorization should occur before you receive treatment. The doctor who schedules an admission or orders the procedure, service or drug is often responsible for obtaining preauthorization. Providers should call the provider authorization number on the back of your health plan ID card to confirm whether preauthorization is required. You can also call Customer Service at the number on the back of your ID card to find out whether a proposed test, equipment, service, procedure or drug requires preauthorization. I m an HMO Colorado member. Do I need a referral to see a specialist? You don t need a referral to see an in-network physician specialist. However, we encourage you to consult with your primary care physician (PCP) before seeing a specialist for provider recommendations and coordination of care. Some services, such as surgical procedures, radiology services, occupational, physical and speech therapies, and behavioral health care services, require preauthorization. 40

42 Frequently asked employee questions I m an HMO Colorado member. Do I need a referral to see an in-network optometrist or ophthalmologist for an eye exam? No, a referral isn t required for an eye exam related to a medical condition or for routine eye exams, if your health plan covers such exams. I m a PPO member. What s the difference between a preferred provider and a participating provider for health insurance benefits? Preferred providers are in our preferred provider network, and participating providers are not. Participating providers are available to members who have out-of-network benefits, such as members of our BluePreferred plans. When you receive covered services from a participating provider, your coverage is lower than when you receive care from a preferred provider, and a separate deductible may apply. To maximize your savings if you have out-ofnetwork benefits, we encourage you to receive care from preferred providers. When I visit my doctor or dentist, is my copayment due at the time of my appointment? Yes, any copayments required by your group s plan are due at the time of your office visit. 41

43 Forms Below is a list of forms you may regularly need as you administer your group s insurance plan(s) with us. This list includes the form name, the form number, a description of the form and a description of when to use the form. To order forms, please complete a Supply Order Form. Go to large group AgentAccess at anthem.com to download forms. Home Delivery Pharmacy Order Form Health plan members complete and submit this form when using Express Scripts Home Delivery Service. This mail service program is designed for members who use continuous therapy medications like those used to treat asthma, diabetes, high blood pressure or arthritis. Members simply complete the form and mail it, along with the original prescription and the appropriate copayment, in the envelope provided. Continuation Of Coverage Application: COBRA This application form must be completed and submitted when a terminated employee wants to continue health or dental coverage. Enrollment Application/Change Form New applicants must complete and submit this form when applying for coverage. In addition, use this form to submit changes, additions or terminations for members with health, vision and/or life insurance. Always submit this form to us with any applicable supporting forms and documentation, when required. Group Disability Claim Form Anthem Life members must complete and submit this form to file short-term disability, dismemberment, waiver of life premium and extended death benefits claims. Group Term Life Insurance Notice of Conversion Privilege This form is used to request conversion information from Anthem Life members. Upon employee termination, you must give this form to the employee. Health Statement for Life and Disability Employees applying for life or disability coverage as a late entrant or employees applying for life or disability coverage amounts over the group s guaranteed issue limits must complete and submit this form. Long-Term Disability Claim Form Anthem Life members use this form to file a long-term disability claim. Mentally or Physically Disabled Dependent Form Subscribers who want to add group coverage for a dependent with a mental or physical disability must complete and submit this form. Prescription Drug Claim Form Members who get a prescription from an out-of-network pharmacy and who are seeking reimbursement for the prescription must complete and submit this form. Members also can use this form when they can t present their health plan ID card when getting a prescription from an in-network pharmacy, or when they get a prescription in an emergency situation and they don t present their ID card. Statement of Death Group Claim Form When a member dies, this form must be completed and submitted for Anthem Life insurance claims. 42

44 Forms Statement of Death Group Claim Form When a member dies, this form must be completed and submitted for Anthem Life insurance claims. Subscriber Submitted Claim Members paying for a service and seeking reimbursement must complete and submit this form. Evidence of Insurability When medical underwriting is required for an applicant, the applicant must complete and submit this form. Typically, the form is required when the group is contributory and the applicant is applying for a life insurance amount over the guaranteed issue amount or when the applicant is a late entrant. Continuity of Care Form New members who are receiving ongoing care or who have upcoming services scheduled must complete and submit this form. The information provided on the form helps us ensure that the new member s ongoing care or scheduled services are properly authorized and that the member s care isn t disrupted. Supply Order Form 1. To order additional forms, please complete the Delivery Instructions and Supplies requested sections of this form. We must have your complete address to deliver your forms. 2. Fax the completed Supply Order Form to your account manager. 3. Please allow two weeks for delivery. Delivery instructions Group number Group name Street address City, State, ZIP / / Deliver to attention of Phone number Supplies requested Form number Form name and description Quantity (Please make copies of this blank form for future use.) 43

45 EmployerAccess quick reference guide for large groups Introducing EmployerAccess Anthem s easy-to-use, online benefits management system Managing your employees benefits just got easier Anthem has redesigned and enhanced our online benefits management system, which is now named EmployerAccess. The new system retains many of the features that originally made it popular, plus it s added many new capabilities that will help you: Manage online enrollment Perform contract maintenance Handle benefit inquires Access reports Pay bills online (one-time payments or scheduled payments) And more all from one Web portal! Membership page get all the information you want in quick-click time EmployerAccess s new Membership page lets you navigate and access information quickly and easily just by selecting: View pending activity View or change subscriber information Add new subscribers View billing entities Change log-in information Reset passwords Find information quickly and easily The Employee/Dependent Details page makes locating everything about an employee s coverage point-and-click easy: Get a complete overview of any employee s coverage Add or change coverage Cancel coverage Request ID cards Edit personal information Re enroll Change PCPs and more... Make no mistake about it EmployerAccess also helps you get employee enrollment right the first time. Automatically saves your unfinished work and lists it in the Pending Activities Report for future completion Complete, quick and convenient With all the dynamic operations available, you ll be able to: Enroll employees in one place. Assign medical, dental, vision, life and disability all on one page. EmployerAccess is the fastest way to get enrollment initialized, so your employees can begin using their benefits. Instant reports no waiting Take the wait and headache out of generating reports the information you re looking for is now easy to find with EmployerAccess. Review: Activity reports Pending activity Provider finder Subscriber/dependent listing Employee life coverage Claim status reports Also: Review all employees by group. Find employee names and addresses. Sort data and download listings in Excel or comma-delimited files. In compliance with the Centers for Medicare & Medicaid Services (CMS) Medicare Secondary Payer requirements, Social Security numbers are required for subscribers, dependents, and spouses or domestic partners. Failure to include this information with enrollment forms may cause a delay in eligibility and claims processing. 44

46 EmployerAccess quick reference guide for large groups Billing questions? We ve got answers. Now it s easy to make payments, manage your billing operations and get prompt, accurate answers to all your questions: Review, download and print all invoices and payments from the past 24 months Pay bills online Easily view invoice details by selecting invoice numbers Like to know more? Visit anthem.com/employeraccess/co/lg or contact your dedicated Anthem representative. 45