For Large Groups (51+ Eligible Employees)

Transcription

1 Your New Business Quote Guide For Large Groups (51+ Eligible Employees) Thank you for considering Empire BlueCross BlueShield. We re happy to help with your health benefit needs. For an accurate and faster quote, please make sure we receive all of the requested information. Current Picture For Groups Detailed benefit summaries for the last 24 months you ve been with your current carrier. A current bill, including rate information. Renewal support materials for the current carrier (renewal letter with corresponding renewal rates). Employer contributions across all tiers and products. Number of years with your current carrier. If less than five years, please include the name of your prior carrier. Claim history, if it s available. Complete Census (in excel format) Include all eligible employees. Include date of birth, gender, zip code and contract status. Identify waivers, Medicare and COBRA contracts. Include spousal waivers if your group s participation is less than 75%. Identify any excluded classes of employees. Claims/Enrollment Activity For Groups 100+ (all of the above documents are needed plus the below) Monthly claims activity for the most recent period up to and including past 24 months if available. Please include the most recent month available. For example, if you re sending data on July 15, it should include paid claims through at least May 31, or March 31 for incurred claims (no more than 6 months older than the effective date). Large claims activity corresponding to the claims period(s) provided. 1. Total dollars paid for each claimant that goes over the pooling level. 2. Status of claimant(s) active/inactive. 3. Prognosis. Monthly contract counts, broken down by tier, corresponding to the claims period(s) provided. Renewal support materials for the current carrier (renewal work-up) 37864NYBENEBS 5/13

2 Guidelines for Large Groups Establish eligibility Empire BlueCross BlueShield now makes it easier than ever for you to sell and enroll large groups. Enroll Large Groups: Establish eligibility Submit the paperwork Plans include: PPO EPO POS HMO Empire Total Blue SM In order to establish eligibility, your groups must meet the following requirements: Group Size Large Groups are defined as businesses that have more than 50 eligible employees. Eligible employees Eligible employees are defined as permanent hourly/salary wage employees who are regularly scheduled to work at least 30 hours per week throughout the year. Commissioned employees who receive W-2 IRS filing from their employer are eligible if they meet all other eligibility requirements. The employer may request a reduced minimum number of hours for eligibility; but not less than 17.5 hours per week or as necessary for Union requirements, which is subject to Underwriting consideration and/or approval. The employer must clearly define all eligible classes in a non-discriminatory manner. Ineligible employees Part-time employees (working fewer than designated number of hours) as defined in eligible employee guideline Independent/Commissioned contractors who receive 1099 IRS filing Stockholders Trustees/Members of the Board of Directors/Elected officials unless full-time employees Any member who erroneously or fraudulently enrolled in coverage Any other individual who does not meet or ceases to meet eligibility requirements Continued

3 Minimum participation In-area Requirements PPO/EPO and Total Blue and POS family of plans: All contract sizes 20% Total Min In-area For Non-HMO family of plans, at least 20% enrollment must be in Empire s service area (including CT and contiguous NJ counties). No more than 25% can be in any one non-wellpoint market (excluding contiguous NJ counties). No more than 40% enrollment can be in parts of CA, VA, GA, CO, IN, KY, ME, MO, NV, NH, OH and WI. ASO without Stop loss: no restrictions. ASO with specific Stop loss: follow the guidelines shown above. HMO coverage requires a minimum participation of 11 covered employees. Participation guidelines for non-hmo plans are as follows: Total eligible All employees who meet eligibility requirements Net eligibles Total eligibles less valid waivers (see valid waivers below) Contributory (Employees contribute a portion of cost) 75 percent of net eligible subscribers enroll and 50 percent of total eligible Non-contributory (Employer contributes 100 precent of cost) 100 percent of net eligible subscribers enroll and 50 percent of total eligible Valid waivers: Spousal group coverage Medicare/Medicaid Military Coverage through prior employer FEP Retiree State low income plan Coverage through other employer Non Group Medicare Supplement Participation guideline specific for Prism SM EPO/PPO: Full replacement is required for groups taking Prism plans Employer location Businesses must have a bona fide New York address within Empire s Operating Area. Empire s Operating Area is divided into three regions, which include the following counties: Downstate: Bronx, Kings, Nassau, New York, Queens, Richmond, Rockland Suffolk and Westchester Mid-Hudson: Dutchess, Orange, Putnam, Sullivan and Ulster Upstate: Albany, Clinton, Columbia, Delaware, Essex, Fulton, Greene, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Warren and Washington Employee location Depending on the plan selected, groups must have a certain percentage of their eligible employees residing in Empire s Operating Area or in the following contiguous counties of New Jersey and Connecticut: New Jersey contiguous counties include: Bergen, Hudson, Middlesex, Monmouth, Passaic, Sussex and Union Connecticut contiguous counties include: Fairfield and Litchfield Please see chart on the left for in-area requirements.

4 Effective dates and submission dates Effective dates for new business are on the 1st and 15th of the month. New business must be submitted at least 30 business days prior to the effective date. Any incomplete portions of a sales package may result in the delay of your client s effective date. Mailing address Please send your completed sales package to your assigned Empire sales representative. Empire support Broker website For the most up-to-date eligibility guidelines, plan information, and necessary forms, please visit empireblue.com and click on the Broker tab. Sales package requirements Signed group application Group name, address Federal tax ID GBA name (if GBA is not employed by group, authorization letter required) New employee eligibility Company contribution Manner of payment Tier structure Coverage options, including all rider information Broker declaration Rates Renewals Group contract for Community HMO Provide all requested information, including additional riders and open enrollment period New member application Include member s Social Security number and dependent information For employees over 65, where Medicare is primary coverage, submit copy of Health Insurance Benefit (HIB) cards Financial agreement for PPO, EPO, POS and Empire Total Blue Please note that riders must remain in effect for a minimum of 12 months. If a group discontinues a rider, that group may not repurchase that rider for at least 12 months following the date of discontinuance. Also note that changes in group eligibility, rate structure, or benefits may be made only on the group s renewal date. Additional HRA or HSA documents for Empire Total Blue plan offerings Please contact your Empire sales representative for additional details. For standard plans, please submit a complete sales package at least 30 days prior to the next effective date. For non-standard, please allow more advance time.

5 Plan combination guidelines All multi-option plans are subject to selection loads. Rate spreads are measured between the highest and lowest plan rates. All plan combinations are available with a maximum rate spread of 50% with the following exceptions. 1. For POS/PPO combinations of 51 to 500 total enrollment, the PPO plan must have the same benefit design (or closest match) as the POS (except POS options 8, 20, 39, 46 and 51 which may be offered with a PPO plan with a maximum 50 percent rate spread). 2. For PPO/HMO combinations there can be no greater than a 25 percent rate spread. 3. All high/low HMO offerings must be on a full replacement basis and are subject to a 15 percent maximum rate spread. These plan combinations are not permitted: EPO/HMO POS/HMO Total Blue EPO with HRA or HSA/HMO Prism PPO can not be offered as an out-of-area plan with Direct POS. Each plan in a combination offering must have the same rating tier structure (e.g., 3 tier for all plans) and rate relationship between the tiers. CDHP should be treated as a PPO in all combinations outlined above. Note: Prism EPO and Prism PPO should be treated as EPO and PPO in all statements in the guideline except otherwise specified. This document is for broker reference purposes only. Empire reserves the right to modify, amend or delete these procedures. Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.