Membership. Mem ber ship at a Glance...3. El i gi bil ity...5. En roll ment Ba sics Effective Dates and Probationary Periods...

Transcription

1 Membership Mem ber ship at a Glance...3 El i gi bil ity...5 En roll ment Ba sics...11 Effective Dates and Probationary Periods...13 Ini tial Group En roll ment...17 Open En roll ments...19 Spe cial En roll ments...21 Mem ber ship Changes...25 Con ver sion to In di vid ual (Nongroup) Cov er age...31 Con ver sion to Ver mont Blue January

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3 Membership at a Glance Membership at a Glance Type of Event Deadline for Receipt Change Effective Date For more information: *New Hire/Rehire No later than 60 days from date of eligibility First of the month following date of receipt, but not prior to completion of probationary period. See page 18. *Marriage/Civil Union Within 31 days following marriage/civil union. First of the month following marriage/civil union. See page to 60 days following marriage/civil union. First of the month following receipt. *Birth Within 31 days following birth. Date of birth for child and 32nd day after the birth for the membership type change. See page 23. *Adoption Death 32 to 60 days following birth. First of the month following receipt. See page 23. Within 31 days following adoption (or placement for adoption). 32 to 60 days following adoption (or placement for adoption). Within six months of the date of death. Date of adoption (or placement for adoption). First of the month after we receive the request. See page 23. See page 23. First of the month following death. See page 27. Divorce Within 60 days of divorce. First of the month following divorce. See page 27. Qualifying Loss of Coverage Voluntary Cancellation Left Employment COBRA Eligibility Medicare Supplemental Coverage Addition of Employee who refused initial enrollment. Within 31 days after loss of coverage. Retroactive to date of coverage loss. See page 15. Must sign and submit Group Enrollment Form. Submit Group Membership Update form indicating key word as LE Remove subscriber immediately. If subscriber accepts COBRA within 60 days, he or she can be retroactively reinstated. Within 90 days of the date of Medicare coverage. Prior to the Anniversary or Open Enrollment month. During the Anniversary or Open Enrollment month. First of the month following receipt. See page 26. First of the month following receipt. See page 31. Date of Medicare entitlement. If received prior to Medicare effective date, coverage will be effective to coincide with Medicare. First of the Anniversary or Open Enrollment month. Continuation of Benefits section of this manual. See page 33. See page 21. First of the month following receipt. See page 21. *Requests not received as indicated above can be processed on your anniversary or open enrollment. Notes: All Group Enrollment Forms must be signed and dated by the subscriber. All Membership Update forms must be signed and dated by the appropriate group representative. Some small groups do not have open enrollments because of state laws forbidding them. Members of these groups may add eligible members at any time. January

4 Membership at a Glance 4 January 2007

5 Eligibility Eligibility This sec tion pro vides a sum mary of our el i gi bil ity re quire ments. For spe cific in for ma tion on par tic u lar sit u a tions not men tioned here, please con tact your BCBSVT mar ket ing rep re sen ta tive or your bill ing an a lyst. Employees The fol low ing em ploy ees are el i gi ble for cov er age with us through your group: permanent full-time employees permanent part-time employees who work more than 17½ hours per week (or the minimum number of hours to qualify for benefits at your organization, if that number is higher than 17½ hours) retirees, if your organization has established Blue Cross and Blue Shield of Vermont retiree coverage, and former employees who have elected to extend coverage through COBRA or Vermont continuation of benefits provisions (see the Continuation of Benefits section of this manual) re-hired employees returning to work within six months who were previously enrolled with BCBSVT (if there is no re-hire probationary period, an employee may enroll on the first day of the month after his or her return) We re fer to em ploy ees who en roll in our plan as sub scrib ers. We call sub scrib ers and their de pend ents mem bers. Ex am ples of those whom we do not ac cept for cov er age in clude: temporary or seasonal employees permanent part-time employees who do not work more than 17½ hours per week trustees and members of a board of directors silent partners parents, grandparents or household employees of owners or employees of an organization anyone not on the company payroll (wage and tax reports) January

6 Eligibility retirees, if your organization has not established a retiree group with us, and any employee who has not fulfilled the probationary period set by your organization Dependents El i gi ble de pend ents of em ploy ees in clude: the subscriber s spouse or the other party to a subscriber s civil union the domestic partner of a subscriber, provided that the employer chooses to administer domestic partnership coverage as part of its group plan (see below for more information on domestic partnerships) the natural or adopted children of the subscriber and the natural or adopted children of his or her spouse, party to a civil union, or eligible domestic partner, provided the children are under the age of 19 and unmarried over-age dependents (such as full-time students and incapacitated children) described in the sections on pages 8 and 9 in certain cases, a child for whom the subscriber, spouse, party to a civil union or eligible domestic partner has assumed legal guardianship, and dependents who lose coverage, but decide to continue coverage under federal or state continuation of benefits provisions (these dependents get their own coverage) Ex am ples of de pend ents who are not el i gi ble for cov er age in clude: subscribers parents or any other relatives besides spouses, parties to civil unions, dependent children or step-children described above dependent children who marry, regardless of age, and dependent children over the age of 19 who do not meet guidelines for over-age dependents Domestic Partners Blue Cross and Blue Shield of Ver mont em ployer groups may choose in de pend ently whether or not to of fer do mes tic part ner cov er age as 6 January 2007

7 Eligibility part of their group plans. Do mes tic part ners and their de pend ents are el - i gi ble for cov er age only if their groups elect to extend cov er age to em - ploy ees' do mes tic part ners and only if they meet all of the fol low ing cri te ria: each party is the sole domestic partner of the other each party is at least 18 years of age and competent to enter into a contract in the state in which he or she resides the parties currently share a common legal residence and have shared the residence for at least six months prior to applying for domestic partnership coverage neither party is married or party to a civil union the parties are not related by adoption or blood to a degree of closeness that would bar marriage in the state in which they legally reside the parties are in a relationship of mutual support, caring and commitment and intend to remain in such a relationship in the indefinite future the parties are jointly responsible for basic living expenses such as the cost of basic food, shelter and any other expenses of the common household (the partners need not contribute equally or jointly to the payment of these expenses as long as they agree that both are responsible for them), and neither party terminates a domestic partnership within the preceding nine months Em ploy ees seek ing do mes tic part ner ship cov er age are re quired to pro vide a com pleted and no ta rized State ment of Do mes tic Part ner ship. Ad di tional doc u men ta tion may be required, including: proof of common residence proof of financial interdependence, such as joint bank accounts or credit cards, executed powers of attorney, listing of a domestic partner as a beneficiary on the other's insurance policy, and/or designated signatures on safety deposit boxes Fed eral and state laws do not pro vide the same con tin u a tion of ben e - fits rights to do mes tic part ners and their dependents as to other mem - bers of your group. For that rea son, we rec om mend that groups of fer ing domestic part ner ship cov er age care fully re view the Con tin u a tion of Benefits sec tion of this man ual. Also please be aware that, in ac cor dance with Fed eral law, do mes tic partners are not en ti tled to the tax sav ings re lated to Health Sav ings Ac - counts and other con sumer-di rected health plans. Please con tact an at - tor ney and/or an ac coun tant for more in for ma tion. January

8 Eligibility Dependent Students A de pend ent who is a full-time stu dent be tween the ages of 19 and 25* is el i gi ble for cov er age. A full-time stu dent is de fined as a stu dent who takes 12 or more cred its per se mes ter, or the equiv a lent, in an ac - cred ited sec ond ary or pre pa ra tory school or college. The em ployee must pro vide you with a Stu dent Cer tif i ca tion Form. (See Ex hibit #16 for an ex - am ple of the form.) You should for ward these doc u ments to BCBSVT as soon as pos si ble. Em ployees who have stu dent de pend ents must fill out the Cer tif i ca - tion form at the fol low ing times: when the student turns 19 and would otherwise lose dependent status every year as long as the student remains on the plan as a full-time student, and when the dependent is no longer a full-time student (to inform us that he or she is no longer eligible for coverage) Please note dead lines: Em ployees who have stu dent de pend ents when they join the group should com plete the Cer tif i ca tion on the Group En roll ment Form im me di ately upon en roll ment. When a stu dent is cov ered un der an em ployee s fam ily mem ber - ship and then turns 19, we must re ceive the Cer tif i ca tion form be - fore the first of the month af ter his or her birth day. Oth er wise, the de pend ent may lose cov er age and can not be added un til the next open en roll ment date, and may also sac ri fice con ti nu ity of cov er - age (for more in for ma tion on open en roll ments, see page 19). If a de pend ent turns 19 and is re moved from the mem ber ship and then be comes a stu dent, the em ployee may add him or her as a de - pend ent at that time. We must re ceive the Cer tif i ca tion form within 60 days af ter the de pend ent be comes a stu dent. Cov er age will be come ef fec tive the first of the month fol low ing the re ceipt of the cer tif i ca tion. Incapacitated Dependents De pend ents over the age of 19 who are deemed in ca pac i tated may be cov ered on par ents mem ber ships. To meet our def i ni tion of in ca pac - i tated, a de pend ent must meet the fol low ing cri te ria: * Some large groups choose another age for cut-off for full-time students. 8 January 2007

9 Eligibility he or she must be incapable of self-support because of a physical or developmental disability, mental illness or mental retardation the incapacitating disability must have begun while the dependent was still a child, and the dependent must depend primarily on the subscriber, spouse, party to a civil union, eligible domestic partner or estate of one of those entities for support and maintenance To pro vide cov er age for the de pend ent, we will need the fol low ing doc u ments: an Incapacitated Dependent Certification Form to continue coverage for the dependent, and physician certification of the extent and nature of the disability (see Exhibit 7 in this manual) We will ask for in for ma tion from the de pend ent s phy si cian and re view the status an nu ally. In some cases, we will con tact the sub scriber or the dependent s physician directly. Please note dead lines: If an em ployee s de pend ent is in ca pac i tated on the date the sub - scriber ap plies for cov er age with us, the above forms should be sub mit ted at the time of en roll ment. If the de pend ent be comes in ca pac i tated while he or she is cov - ered, we must re ceive the above ma te ri als within 31 days of the date the de pend ent would oth er wise lose cov er age. January

10 Eligibility 10 January 2007

11 Enrollment Basics Enrollment Basics The Enrollment Process Before en roll ing each em ployee, you must de ter mine: his or her el i gi bil ity which type of mem ber ship the employee will need Please read the guide lines in the pre ced ing El i gi bil ity chap ter if you need help making these de ter mi na tions. Each em ployee wish ing to en roll must sub mit a com pleted Group En - roll ment Form. (A sam ple form ap pears as the Ex hibit 3 in this man ual.) Oc ca sion ally, employees may be re quired to pro vide ad di tional doc u - men ta tion. Any em ploy ee who does not wish to take ad van tage of his or her el i gi - bil ity for group cov er age un der your plan must also com plete and sign a Group En roll ment Form in di cat ing Re fusal. If the em ployee has re fused cov er age, he or she may usu ally not join the group un til your next open en roll ment date. (See Loss of Cov er age on page 21 for ex cep tions to this rule.) Membership Types Em ploy ees may be en rolled in the fol low ing mem ber ship types: single, for employees who have no dependents or who do not wish to cover any dependents two-person, for an employee plus one dependent (this may be a child, a spouse, the party to a civil union or an eligible domestic partner if your group offers domestic partner coverage) family, for employees with more than one eligible dependent We do not per mit em ploy ees to enroll some of their el i gi ble de pend - ents and not oth ers, ex cept that the em ployee's spouse, party to a civil un ion, or el i gi ble do mes tic part ner may refuse cov er age. Even if an el i gi - ble spouse, party to a civil un ion or do mes tic part ner de clines coverage, his or her de pend ents re main el i gi ble. January

12 Enrollment Basics Primary Care Physician Choice If the en roll ing mem ber has a man aged care plan, he or she must se lect a Pri mary Care Phy si cian in or der for mem ber ship to be come ef fec tive. To avoid en roll ment de lays, check to make sure each sub scriber com - pletes the sec tion on pri mary care phy si cian choice by entering the phy - si cian's full name and pro vider num ber and in di cat ing whether he or she is a cur rent pa tient. 12 January 2007

13 Effective Dates and Probationary Periods Effective Dates and Probationary Periods The ef fec tive date of a new em ployee and his or her el i gi ble de pend - ents de pends on sev eral fac tors: the timeliness of the complete and accurate request your organization s probationary period the size of your group (see open enrollments and small group exceptions, p. 19) the inpatient status of family members on the effective date (if a prospective enrollee is hospitalized, a previous carrier may be required to maintain coverage until the patient's discharge) Timeliness of Enrollment Request We must re ceive a Group En roll ment Form for a new em ployee within 60 days of his or her el i gi bil ity date. Oth er wise, the em ployee will not be able to en roll un til your or ga ni za tion s next open en roll ment date.* If you do not have a pro ba tion ary pe riod, an em ployee must sub mit a form within 60 days af ter his or her date of hire. It is im por tant to in form em - ploy ees of this rule. You may find it best to have new em ploy ees com plete pa per work im - me di ately upon hire and send it in immediately, re gard less of your pro - ba tion ary pe riod. We will ap ply pro ba tion ary pe ri ods in our mem ber ship files and be gin cov er age on the ap pro pri ate date. Em ploy ees may ini tially choose not to take ad van tage of group cov er - age for them selves or their de pend ents im me di ately upon hire. If your group has open en roll ment pe ri ods, please no tify them that they will have to wait un til an open en roll ment pe riod to en roll in the fu ture. The only ex cep tions to these rules oc cur when em ploy ees or de pend ents meet spe cial en roll ment cir cum stances due to loss of cov er age or fam ily sta tus changes. (For more in for ma tion on spe cial en roll ment cir cum - stances, see page 21). *Some small groups do not have open enrollment dates. Members of these groups may enroll at any time. See page 19. January

14 Effective Dates and Probationary Periods Probationary Periods The pro ba tion ary pe riod is the length of time your em ploy ees must wait be fore they are el i gi ble for health ben e fits. Your or ga ni za tion sets the pro ba tion ary pe riod, how ever Blue Cross and Blue Shield of Ver mont must ad min is ter it con sis tently. The pro ba tion ary pe riod be gins on the em ployee s date of hire. When a part-time em ployee who is not el i gi ble for ben e fits in creases his or her hours and be comes el i gi ble, the pro ba tion ary pe riod starts on the day that his or her sta tus changes. Cov er age may be gin on the first day of the month af ter an em ployee com pletes the or ga ni za tion s pro ba tion ary pe riod. If the em ployee com - pletes the pro ba tion ary pe riod on the first day of the month, cov er age may be gin on that day. Your or ga ni za tion may choose not to have a pro ba tion ary pe riod. In that case, cov er age can be gin on the first day of the month af ter an em - ployee s date of hire. Em ploy ees who be gin em ploy ment on the first day of the month may en roll im me di ately, pro vided they meet the guide lines in Time li ness of En roll ment above. When em ploy ees leave em ploy ment and then re turn within six months per haps from a leave of ab sence or a lay-off a new pro ba - tion ary pe riod is of ten not re quired. These em ploy ees may en roll on the first day of the month af ter their re turn, and must fol low all other mem - ber ship guide lines. If your group chooses, how ever, you may im pose a re - hire pro ba tion ary pe riod. Transfers from Other Groups or Individual Coverage When an em ployee joins your or ga ni za tion and is still cov ered by an - other mem ber ship, spe cial rules ap ply. Re gard less of whether the em - ployee was cov ered by Blue Cross and Blue Shield cov er age or by an other in surer, he or she may not have to meet all or part of the wait ing pe ri ods for pre-ex ist ing con di tions un der your plan. When we take over a mem ber ship from an other car rier who pro vided ba si cally the same ben e fits as we do un der your con tract, we will credit the new em ployee with any time he or she ac crued to ward meet ing wait - ing pe ri ods un der prior cov er age. If your BCBSVT con tract has wait ing pe - ri ods equal to those of the prior cov er age, and the em ployee has met the old wait ing pe ri ods, he or she does not have to meet wait ing pe ri ods un - der our con tract. 14 January 2007

15 Effective Dates and Probationary Periods If an em ployee has met part of his or her wait ing pe ri ods with the prior car rier, we will credit him or her with par tially meet ing our wait ing pe ri - ods. For ex am ple, if Jane Doe has met four months of your prior car rier s nine-month wait ing pe riod for pre-ex ist ing con di tions, she must only meet an other five months of our nine-month wait ing pe riod. In or der to ad min is ter cred its for wait ing pe ri ods, we may ask you for re cords from the new em ployee s pre vi ous car rier. Dropping Coverage Em ploy ees may drop their cov er age at any time by com plet ing a Group En roll ment Form. January

16 Effective Dates and Probationary Periods 16 January 2007

17 Initial Group Enrollment Initial Group Enrollment When We Re place An other Car rier If you pre vi ously had in sur ance with an other car rier, we will re quest in - for ma tion about your prior ben e fit pro gram from you and oc ca sion ally from your prior car rier in or der to en sure that your em ploy ees re ceive the appropriate coverage and credits. Some times your prior car rier will pro - vide us with in for ma tion to load onto our sys tem. In any event, we usu ally re quire em ploy ees to com plete pa per work as well. Deductible Credit When we re place your old car rier in the mid dle of your ben e fit pe riod, we credit your em ploy ees with any amounts they have paid to meet the prior car rier s de duct ibles. If your old con tract had a carry-over pro vi - sion for de duct ibles (i.e., amounts paid to ward the de duct ible in Oc to ber, No vem ber and De cem ber are ap plied against the cur rent and the next year s deductible),* we will honor that pro vi sion as well. In or der for us to credit de duct ibles, we may ask em ploy ees to com - plete de duct ible credit forms. We may also ob tain in for ma tion from your prior car rier. Credit for Meeting Waiting Periods When we take over your ac count from an other car rier who pro vided ba si cally the same ben e fits as we do un der your con tract, we may credit your em ploy ees with any time they ac crued to ward meet ing your prior car rier s wait ing pe ri ods. If your BCBSVT con tract has wait ing pe ri ods equal to those in your con tract with your prior car rier, and an em ployee has met the other car rier s wait ing pe ri ods, that em ployee may not have to meet wait ing pe ri ods un der our con tract. If an em ployee has met part of his or her wait ing pe ri ods, we may credit him or her with par tially meet ing our wait ing pe ri ods. We give credit for wait ing pe ri ods if: the member has not had more than a 90-day break in coverage (as defined by law) before obtaining this coverage; and *HSA-compatible plans do not typically have carry-over provisions, as tax laws govern the minimum amount of deductible allowed in any calendar year. January

18 Initial Group Enrollment the member s previous coverage had substantially the same covered services as this coverage. For ex am ple, if Jane Doe has met four months of your prior car rier s nine-month wait ing pe riod for pre-existing con di tions, she must only meet an other five months of our nine-month wait ing pe riod. In or der to ad min is ter cred its for wait ing pe ri ods, we may ask you or the mem ber for re cords from your prior car rier. 18 January 2007

19 Open Enrollments Open Enrollments What Is Open En roll ment? An open en roll ment period is a spe cific pe riod of time, usu ally a month, dur ing which new members can join and other spe cific mem ber - ship changes can be made. The open en roll ment dates of your group are usu ally the an ni ver sary of your orig i nal en roll ment and the date six months fol low ing it. If your group has an open en roll ment pe riod, you need to be aware of dead lines and en sure that your em ploy ees re ceive am ple no ti fi ca tion and op por tu nity to make changes. Cer tain small groups are ex empt from open en roll ment pe ri ods by Ver mont state law (al though small groups that ob tain cov er age through as so ci a tion groups such as the Ver mont League of Cit ies and Towns or the Vermont Retail Association may be subject to those associations' open en roll ment pe ri ods). If your group does not have an open en roll - ment pe riod, your mem bers may make the changes listed below at any time, and the fol low ing sub sec tions on open en roll ments and special en - roll ments do not ap ply to you. If you are un sure whether your group has open en roll ments, please call your sales and ser vice rep re sen ta tive. Open Enrollment Activities Groups with open en roll ment may do the fol low ing on their an ni ver - sary date: change the organization s benefit plan change probationary periods for employees allow employees to switch from another carrier s coverage to Blue Cross and Blue Shield of Vermont coverage add to the plan any employees or dependents who refused coverage at the time of hire or during their initial eligibility periods In ad di tion, the an ni ver sary date is the date we use to check: eligibility of group members whether you meet the requirement that 75 percent of your eligible employees are enrolled (please see the Small Group Certification Form, #8 in the Exhibits section of this manual if your group has 50 or fewer employees) January

20 Open Enrollments On the open en roll ment dur ing the sixth months af ter your an ni ver - sary date, your em ploy ees may: submit applications for additional dependents (if they initially refused dependent coverage or failed to add dependents by guidelines listed in Membership Changes), apply for membership in the plan, unless they are covered under another group plan sponsored by your organization Your em ploy ees must sub mit mem ber ship changes prior to an Open En roll ment. Changes will be on the an ni ver sary or open en roll ment, which ever is applicable. 20 January 2007

21 Special Enrollments Spe cial En roll ments For groups with open enrollments, cer tain events trig ger spe cial en - roll ment pe ri ods when an em ployee may change or add de pend ents out side of open en roll ments. These events fall within three cat e go ries: loss of cov er age changes in fam ily sta tus changes in employment status At the time of spe cial enrollment, we will al low the sub scriber to switch to any of the health cov er age op tions of fered to the group, not only the one in which he or she is cur rently en rolled. The fol low ing sec tions dis cuss these in de tail. Please note that even in these cir cum stances, strict dead lines ap ply. Loss Of Coverage Some times an em ployee re fuses cov er age or elects a sin gle mem ber - ship be cause he or she (or a de pend ent) is cov ered un der the plan of another per son (per haps an other de pend ent). We will al low the em - ployee to en roll or add his or her de pend ents be tween open en roll ment dates if the al ter nate cov er age then be comes un avail able for one of the following reasons: the cov ered per son ter mi nates em ploy ment or his or her em ployer drops health cov er age the cov ered per son no lon ger lives, re sides or works within his or her HMO ser vice area, the HMO does not pro vide cov er age for that rea son, and there is no other cov er age un der the plan for the in di vid ual a de pend ent loses cov er age be cause he or she reaches a par tic u lar age a claim is de nied be cause a per son has reached a life time limit on ben e fits on his or her pre vi ous plan the covered de pend ent loses cov er age be cause his or her pre vi ous plan dis con tin ues ben e fits to a whole class of similarly sit u ated in di vid u als (such as part-time work ers) the car rier for the other plan stops of fer ing group cov er age January

22 Special Enrollments Qualifying events do not in clude a change in ben e fits or re quired in - crease in the em ployee's con tri bu tion level. To add mem bers and/or ad just a mem ber ship type, the fol low ing doc - u ments are required: ac cept able proof of loss of cov er age a com pleted Group En roll ment Form Please note that ac cept able proof of loss would in clude a Cer tif i cate of Cred it able Cov er age from the prior car rier and/or a let ter from the pre vi ous em ployer in di cat ing the rea son for the loss. Both must in clude the date of loss of cov er age. We must re ceive the ap pli ca tion within 31 days af ter loss of cov er age. We will then make cov er age ret ro ac tive to the date of loss. Change in Family Status When there is a change in fam ily status, we al low new de pend ents to join your group be tween open en roll ments. They must do so, how ever, within cer tain pe ri ods of time af ter the fam ily change. Marriage/Civil Union* When an em ployee mar ries or en ters into a civil un ion,* you may add the new spouse/party to a civil un ion into the group as early as the first of the month af ter the date of mar riage/civil un ion. You may also add any el - i gi ble de pend ents of the new spouse/party to a civil un ion at that time. In or der to make the change ef fec tive on the first of the next month, we must re ceive a Group En roll ment Form within 31 days af ter the mar - riage/civil un ion. You may wish to en cour age em ploy ees to com plete the ap pli ca tion in ad vance of the ceremony. You can then send in the form im me di ately af ter the mar riage oc curs. Then you can make the change as soon as pos si ble af ter the mar riage/civil un ion. Please re mind any em - ployee in a man aged care plan to in clude a pri mary care phy si cian choice for the new spouse/party to a civil un ion. He or she must also in clude the pri - mary care phy si cian s full name and pro vider num ber and fill in the sec - tion that asks if the mem ber is an ex ist ing pa tient. * Please note that special enrollment circumstances in this section apply only to marriages and to civil unions created pur su ant to 15 V.S.A. Chap ter 23, which en ti tles the par ties to the ben e fits and protections of spouses and sub jects them to the re spon si bil i ties of spouses. Companies that choose to offer domestic partnership coverage may add their employees' eligible domestic partners only during regular enrollment periods. For more information, see page January 2007

23 Special Enrollments If we do not re ceive the Group En roll ment Form within 31 days of an em ployee s mar riage/civil un ion, but we do re ceive it within 60 days, we can make changes ef fec tive on the first of the month af ter we re ceive the form. If we do not re ceive the form within 60 days of the date of mar - riage/civil un ion, we can not al low a spe cial en roll ment. The em ployee must wait un til the next open en roll ment pe riod to add de pend ents. New de pend ents re sult ing from a mar riage/civil un ion do not have to ful fill wait ing pe ri ods if: the subscriber has already fulfilled his or her waiting periods, or they have creditable coverage (see page 22) and we receive the change within 60 days of the date of marriage/civil union. If we add a new spouse/party to a civil un ion or de pend ent dur ing open en roll ment, we ap ply any ap pli ca ble wait ing pe ri ods to the mem - ber ship (ex cept when they have prior cred it able cov er age). Birth of a Child When a cov ered em ployee or spouse/party to a civil un ion gives birth to a child, the in fant is cov ered un der the sub scriber s mem ber ship for 31 days at no ad di tional charge, re gard less of the sub scriber s mem ber ship type. Within that 31 days, the em ployee must sub mit a Group En roll ment Form to add the child and, if nec es sary, up grade the mem ber ship. Please note that a sub scriber in a man aged care plan must pick a pri mary care phy - si cian for his or her new born. Re mind em ploy ees to in clude the full name and pro vider num bers for pri mary care phy si cians. If we re ceive the change af ter 31 days, but be fore 60 days af ter the child s birth, we will make the mem ber ship ef fec tive on the first of the month fol low ing the date we re ceive it. Please note that this will cause a break in cov er age, there fore we rec om mend you sub mit changes to us within 31 days af ter a birth. When a cov ered de pend ent child or over-age de pend ent gives birth to a child, the cur rent mem ber ship cov ers the in fant for the first 31 days only. Em ploy ees grand chil dren are not el i gi ble to remain on the pol icy un less the em ployee is the grand child s le gal guard ian and pro vides le - gal doc u men ta tion of guard ian ship of the child. The de pend ent child can ap ply for a new In di vid ual mem ber ship to cover him or her self and the new in fant. To achieve con ti nu ity of cov er - age and avoid waiting periods under Individual coverage, the dependent must do this within 31 days af ter the baby s birth. January

24 Special Enrollments Adoption and Placement for Adoption In case of adop tion, the child is cov ered un der the sub scriber s mem - ber ship for 31 days af ter adop tion or, if ap pli ca ble, place ment for adop - tion, at no ad di tional charge. Within that 31 days, the em ployee must sub mit a Group En roll ment Form to add the child and, if nec es sary, up - grade the mem ber ship. Have the em ployee sub mit doc u men ta tion from the adop tion agency to show that the child was placed and who is guard - ian for the child. If we re ceive the change af ter 31 days, but be fore 60 days af ter the child s adop tion or place ment for adop tion, we will make the mem ber - ship ef fec tive on the first of the month fol low ing the date we re ceive it. Please note that this will cause a break in cov er age, there fore we rec om mend you sub mit changes to us within 31 days af ter adop tion or place ment for adoption. 24 January 2007

25 Membership Changes Membership Changes For groups with open en roll ment restrictions, most changes can be made only dur ing open en roll ment pe ri ods. How ever, can cel la tions and ba sic mem ber in for ma tion up dates can be com pleted at any time. Certain events in a mem ber's life can trig ger a spe cial en roll ment pe riod for add ing de pend ents. We outline the tim ing for var i ous types of changes in the sec tion be low. (For more in for ma tion on open en roll ment pe ri ods, see page 19). Mem bers of small groups that are ex empt from open en roll ment lim i - ta tions can en roll or make changes at any time. To verify whether your small group is ex empt by law, call your sales and ser vice representative. All changes are made by us ing the Group En roll ment Form and be - come ef fec tive the first of the month af ter we re ceive the form. We must re ceive changes in writ ing for them to be come ef fec tive. To avoid de lays, never send changes in the same en ve lope as your subscription pay ment. Changes must be mailed sep a rately be cause we pro cess them at dif fer ent lo ca tions. Updating Basic Information Name And Ad dress Changes Your em ploy ees can make name and ad dress changes by com plet ing a Group En roll ment Form at any time. We in clude ex am ples of the forms for each of our plans in the Ex hib its sec tion of this man ual. Make sure em - ploy ees check Ad dress Change or Name Change in the top cen ter of the form and fill out the ap pro pri ate new in for ma tion on the ap pro pri ate part of the form and then sign it. It is not nec es sary to fill out the en tire form only the sec tions that show changes. Please note that you may also up date ad dresses by call ing our cus - tomer ser vice de part ment at the num ber on the back of the mem ber's ID card or by vis it ing our web site at Changing Primary Care Physicians To change Pri mary Care Phy si cians, a mem ber should: January

26 Membership Changes Look at a directory of primary care physicians for the plan to which he or she is enrolled. The member can then choose a new physician. Either call customer service at the number on the back of his or her I.D. card, visit our web site at bcbsvt.com or mail a Group Enrollment Form to BCBSVT (or The Vermont Health Plan), Account Services, P.O. Box 186, Montpelier, VT The PCP change takes ef fect the first of the month af ter BCBSVT re - ceives it. Adding A Dependent To An Existing Policy To add a de pend ent to an ex ist ing policy, have the em ployee com plete a Group En roll ment Form. You can find an ex am ple of this form in the Ex - hibits sec tion of this man ual. Make sure em ploy ees check the rea son for the change in Sec tion 2 of the form. Use Open En roll ment, Mar - riage/civil Union, Adop tion or Birth for the ap pro pri ate ad di tion or change. When em ploy ees want to add do mes tic part ners, el i gi ble de - pend ent stu dents or in ca pac i tated chil dren, be sure they have checked the ap pro pri ate box and have at tached the re quired pa per work to the form. (See the El i gi bil ity sec tion of this manual for in struc tions.) Also check man aged care en roll ment forms to en sure that em ploy ees have se lected pri mary care phy si cians, in cluded pro vider num bers and marked whether he or she is a current pa tient with that physician. Removing Members From An Existing Policy Current Employees And/Or Dependents Em ploy ees may choose to can cel their own cov er age or change to a sin gle mem ber ship type at any time, not just dur ing an open en roll ment pe riod. The em ployee must com plete a Group En roll ment Form to re - quest the change. Please note that if an em ployee can cels one de pend ent s cov er age, he or she must can cel all de pend ents cov er age, un less: the cancelled dependent is the spouse, party to a civil union, or domestic partner of the employee one dependent is no longer eligible for coverage, or we receive a copy of a court order that mandates coverage for only one dependent or only certain dependents, but not others. 26 January 2007

27 Membership Changes Em ploy ees who re move de pend ents may need to change from a fam - ily to a sin gle or two-per son mem ber ship or from a two-per son to a sin - gle mem ber ship. In the Case of Legal Separation, Divorce or Dissolution of Civil Union When an em ployee di vorces, le gally sep a rates or dis solves his or her civil un ion, the spouse/party to a civil un ion must be re moved from the pol icy the first of the month fol low ing. We must re ceive a Group En roll - ment Form within 60 days af ter the di vorce, le gal sep a ra tion or dis so lu - tion of civil un ion to make the change. (Please see Cov er age Op tions Avail able to Em ploy ees Who Leave the Group on page 29, for more in for - ma tion). In Case of Termination of Domestic Partnership When a cov ered party no lon ger meets re quire ments for do mes tic part ner sta tus, the sub scriber must no tify us within 30 days of the change in sta tus. Ter mi na tion will be ef fec tive on the first day of the month fol - low ing our re ceipt of no tice. In the Case of Death In the event of death of a sub scriber, the group or a de pend ent of the sub scriber may com plete a Group En roll ment Form to ad just to the ap - pro pri ate type of mem ber ship. In the event of death of a sub scriber, his or her de pend ents may do any of the fol low ing: remain on your group through continuation of benefits (see the Continuation of Benefits section of this manual), transfer to another group, if they are eligible, or convert to individual coverage. In the event of the death of a de pend ent, the group or the sub scriber may com plete a Group En roll ment Form to ad just to the ap pro pri ate type of mem ber ship. When an Employee Becomes Eligible for Medicare When em ploy ees or their de pend ents be come newly eligible for Medicare, they main tain the right to con tinue cov er age un der your group pol icy, al though some may choose to switch. If a covered em - January

28 Membership Changes ployee does elect Medicare over group cov er age, his or her de pend ents may con tinue their group cov er age. Once a mem ber be comes el i gi ble for Medicare, you in cur the re spon si - bil ity of providing spe cial pe ri odic no ti fi ca tions to that mem ber. (For more in for ma tion, see the Medicare Sec ond ary Payer sec tion of this man - ual.) Suspending Coverage During Military Service When a re serv ist en ters ac tive duty, he or she gen er ally be comes el i gi - ble for Tricare. Some em ploy ers choose to main tain cov er age for em ploy - ees dur ing tem po rary ac tive status in the ser vice. In any event, re serv ists on ac tive duty can re main on the group un der fed eral CO BRA laws (see the Con tin u a tion of Cov er age sec tion of this man ual). If, how ever, you would like to sus pend cov er age dur ing an em ployee s ac tive duty, you should file a Group En roll ment Form. We will re in state cov er age when the re serv ist re turns from ac tive duty. To do this, we must re ceive a Group En roll ment Form within 60 days of the em ployee s re lease from ac tive duty. At that time, he or she may ap ply to cover any el i gi ble de pend ents in the fam ily, re gard less of the type of mem ber ship in force at the time of the tem po rary sus pen sion. We will pro vide ben e fits from the date of the re serv ist s re lease from duty. In the Case of a Leave of Absence Your or ga ni za tion s em ploy ment pol icy de ter mines whether an em - ployee re tains cov er age dur ing a leave. Employers may give em ploy ees the right to stay on the group dur ing a leave of absence. The Fam ily and Med i cal Leave Act of 1993 re quires cer tain em ploy ers to of fer this coverage. If your com pany does not offer this ben e fit, you may re move the mem - ber from your group ef fec tive the first of the month fol low ing the start of the leave of absence us ing a Group En roll ment Form. Like any can cel la - tion of cov er age, this re quires you to no tify the em ployee and each cov - ered de pend ent whether he or she is eligible to continue group ben e fits un der fed eral or state law. (Please see the Con tin u a tion of Ben e fits sec tion of this man ual for more in for ma tion.) When the em ployee re turns to work, the group may re-add him or her ef fec tive the first of the month fol low ing the re turn to ac tive em ploy - ment. 28 January 2007

29 Membership Changes Cancellation of Coverage Em ploy ees may choose to can cel their cov er age at any time by sub - mit ting a signed Group En roll ment Form marked Vol un tary Can cel la - tion. They do not need to wait for an open en roll ment pe riod to make this change. Please note that a vol un tary can cel la tion re quires the sub scriber's sig - na ture on the Group En roll ment Form. When em ploy ees leave your com pany or be come in el i gi ble for your group plan, you can sub mit a signed Group Mem ber ship Up date form not ing the rea son for the can cel la tion. Please re fer to the Keywords lo - cated at the bot tom of the Group Mem ber ship Up date Form. Be fore you can cel cov er age, how ever, you must thor oughly un - der stand your com pany's re spon si bil i ties for con tin ued cov er age un der fed eral or state law. Em ploy ees and de pend ents who lose cov er - age of ten have the right to con tinue re ceiv ing group ben e fits for a cer - tain pe riod of time. The law re quires that you no tify them promptly re gard ing their rights. (For more in for ma tion on your com pany's re spon - si bil i ties in re gard to con tin u a tion of cov er age, please see the Con tin u a - tion of Ben e fits sec tion of this man ual.) Coverage Options Available to Employees Who Leave the Group In di vid u als who are per mit ted un der state and fed eral con tin u a tion laws may choose to re main en rolled in your group plan. (For more in for - ma tion about how those pro grams work, see the Con tin u a tion of Ben e fits sec tion of this man ual.) They may choose to en roll in ei ther of the fol low - ing for which they may be el i gi ble: in di vid ual cov er age a Medicare sup ple men tal plan such as Vermont Blue 65 (for those enrolled in Medicare) These op tions also ex ist for those not el i gi ble to re main on your group plan. Be cause you may find your self an swer ing many ques tions about cov - er age avail able af ter the em ployee leaves the group, we de scribe the con ver sion pro cess to other BCBSVT pol i cies on the fol low ing pages. Please note that fed eral law does not rec og nize par ties to civil un ions as de pend ents. There fore, CO BRA (the fed eral Con tin u a tion of Ben e fits January

30 Membership Changes pro vi sions) does not ap ply to these in di vid u als. The Ver mont Con tin u a - tion of Ben e fits stat ute does ap ply. Do mes tic part ner ships, how ever, are not ad dressed un der fed eral law. 30 January 2007

31 Conversion to Individual (Nongroup) Coverage Conversion to Individual (Nongroup) Coverage Some members choose to continue group coverage. Continuation plans man dated by state and fed eral law are dis cussed in depth in the Con tin u a tion of Ben e fits sec tion of this man ual. Some mem bers, how ever, are not el i gi ble for con tin u a tion cov er age. As long as a mem ber and his or her de pend ents are not el i gi ble for any group plan (ex clud ing con tin u a tion coverage), we of fer them In di vid ual coverage.* If these em ploy ees and de pend ents trans fer to In di vid ual cov er age within 60 days of their ter mi na tion of group cov er age, we will not ap ply wait ing pe ri ods if prior cov er age ex ceeded 12 months. Have the sub scriber com plete and sub mit to us an In di vid ual Cov er - age Ap pli ca tion and Change Form to con vert to In di vid ual cov er age. In or der to ensure con tin u ous cov er age, we must re ceive the re quest no later than 30 days af ter ter mi na tion of group cov er age. The sub scriber and any de pend ents will be cred ited with wait ing pe ri ods (or any por tion of wait ing pe ri ods) already met un der group cov er age if the member did not have more than a 63-day break in coverage (as defined by law) before obtaining nongroup cov er age. There are several stan dard ben e fit plans avail able to in di vid ual sub - scrib ers and their fam i lies. Ben e fits un der these plans may dif fer from those un der their group cov er age. If em ploy ees have ben e fit-related ques tions, please re fer them to our in di vid ual prod uct lines de part ment at *Vermont law does not allow us to sell non-group coverage to a person that is group eligible. January

32 Conversion to Individual (Nongroup) Coverage 32 January 2007

33 Conversion to Vermont Blue 65 Conversion to Vermont Blue 65 Both re tired and ac tive em ploy ees and their dependents may be el i gi - ble for Ver mont Blue 65 Medicare Sup ple men tal cov er age, if they are: 65 or older disabled, or suffering from end stage renal disease. We of fer this cov er age if: the individual is enrolled in Medicare Parts A and B, and the individual has no other health care coverage, and federal Medicare Secondary Payer (MSP) rules allow the employer to provide Vermont Blue 65 coverage. For de tailed in for ma tion on Medicare Sec ond ary Payer rules and whether they ap ply to your group, please con sult the Medicare and Your Group sec tion of this man ual. For pur poses of this sec tion, let us say that, in gen eral, many still-active em ploy ees may not be el i gi ble for Ver mont Blue 65 pro grams, even if they re en ti tled to Medicare. We al low those in - di vid u als to main tain reg u lar cov er age with your group. We will not al low an em ployer to pur chase Ver mont Blue 65 for them. In di vid uals who sub scribe to Ver mont Blue 65 may not main tain reg u - lar group cov er age (un less you have a carve-out ar range ment to sup - ple ment Medicare). When we de ter mine that an em ployee or an em ployee s spouse, party to a civil union or do mes tic part ner will soon be el i gi ble for Medicare, we no tify the in di vid ual that he or she must en roll in Parts A and B of Medicare and trans fer to Ver mont Blue 65 cov er age. If we get no re sponse, we send a sec ond no ti fi ca tion, stat ing that cov er age will soon be can celed. (We send a copy to the Group Ben e fits Man ager as well. It may be help ful for you to talk with em ploy ees about how to en roll in Ver mont Blue 65.) Our nor mal un der writ ing reg u la tions af fect Ver mont Blue 65, but Ver - mont Blue 65 sub scrib ers must fol low other rules as well. Em ployees must no tify us of their in tended en roll ment in Ver mont Blue 65 cov er age be fore their 65th birth days or within 90 days af ter their birth days. Also, em ploy ees may not en roll in Ver mont Blue 65 if they have any other in - surance coverage. Em ployees who wish to con vert to Ver mont Blue 65 cov er age must send us: copies of their Medicare cards, and January

34 Conversion to Vermont Blue 65 Group Medicare-Supplement Application and Change Forms. To trans fer an em ployee s spouse/party to a civil union to Ver mont Blue 65: have the employee fill out a Group Enrollment Form to downgrade the family membership (remove the spouse/party to civil union if necessary) have the spouse/party to civil union complete a Medicare-Supplemental Application and Change Form enclose a copy of the spouse/party to a civil union s Medicare card What we do from there de pends on the type of Medicare-supplemental cov er age your group main tains for its em ploy - ees. Some em ploy ers es tab lish spe cial re tiree sec tions and pro vide Ver - mont Blue 65 cov er age. We al low you to do this if your ac tive sec tion (non-retired em ploy ees) has more than 50 em ploy ees and 75% of your el i gi ble ac tive em ploy ees par tic i pate in the group. You should fol low these steps to trans fer an em ployee s mem ber ship to the re tiree sec tion: remove the employee from the regular group coverage by completing a Group Membership Update Form (see Exhibit 1 in this manual), and complete a Medicare-Supplemental Application and Change Form for the retiree plan. If you have a carve-out sec tion, please have em ploy ees fol low the above pro ce dures. We will then move em ploy ees to the carve-out sec - tion. If your group does not have a Ver mont Blue 65 or carve-out sec tion, but is el i gi ble, your group should es tab lish one. We will change Ver mont Blue 65 em ploy ees I.D. num bers to their Medicare I.D. num bers so we can prop erly ad min is ter their ben e fits. For carve-out, we change the em ploy - ees sec tion num bers, but their I.D. numbers re main the same. If you have ques tions about Ver mont Blue 65 rules, please call your BCBSVT sales and ser vice rep re sen ta tive at January 2007

35 A Adoption, 24 In dex B Birth of a Child, 23 Board of Di rec tors, 5 C Certificate of Transfer, 31 CHAMPUS, 28 Civil Un ion, 22 D Death of Sub scriber, 27 Deductible Credit, 17 Disabled Children, 8 Divorce, 27 E Eligibility, 5-8,10 Eligible Dependents, 6 Enrollment new em ploy ees, F Family Memberships, 11 I Incapacitated Dependents, 8 Individual Coverage, L Leave of Ab sence, 28 M Marriage/Civil Union, 22 Medicare Sec ond ary Payer, 33 Members, 5 Mem ber ship Changes, Military Service, 28 O Over-Age Dependents, 6 P Participation Requirements, 19 Part-time Employees, 5 Probationary Periods, 14 R Retirees con ver sion to Ver mont Blue 65, S Single Membership, 11 Subscribers, 5 T Temporary Employees, 5 Trans fers to BCBSVT, 14 Trustees, 5 V Ver mont Blue 65, W Waiting Periods credit for, 17 January