Evergreen Health Small Group Eligibility and Enrollment Guidelines

Transcription

1 3000 Falls Road, Suite 1 Baltimore, MD evergreenmd.org (855) Evergreen Health Small Group Eligibility and Enrollment Guidelines This material is for informational purposes only and is not intended to be exhaustive. Other policies and guidelines may apply. Note: State and Federal legislation/regulations, including Small Group Reform, HIPAA, MD statutes and regulations, and PPACA requirements take precedence over any and all Eligibility and Enrollment rules. Exceptions to eligibility and enrollment guidelines require approval of Evergreen Health. All eligibility and enrollment guidelines below are subject to change without notice. Licensed Appointed Producers Only appropriately licensed agents/producers appointed by Evergreen Health may market, present, sell and be paid commission on the sale of Evergreen Health products. New Group Case Submission Dates All new business submissions should be received by Evergreen Health Eligibility and Enrollment by the 15th of the month prior to the effective date in order to ensure timely enrollment. o For example: if requesting an effective date of October 1, all new business paperwork should be received by Evergreen Health Eligibility and Enrollment by September 15. o Any cases received after the cut-off date may require additional implementation time and could extend the effective date to the following month. o Any cases received after the cut-off date will require the submission of New Business Late Submission Acknowledgement Form signed by the broker and the employer. No case will be accepted after the requested effective date of the policy. New Group Enrollment Forms & Census Data Enrollment forms must be provided for all employees including active enrollees, COBRA/State Continuation enrollees, and employees waiving coverage*. *Waivers are required for SHOP groups, to ensure participation requirement is met. New Group Effective date

2 The effective date must be the 1st of the month. The employer may request an effective date up to 60 days in advance. New Group Plan selection Evergreen Health allows for up to three benefit plan offerings, for age-band rated groups. Groups choosing composite premium rating must only select one plan offering. Each employer has the responsibility to offer a POS option to employees at the time of sale. o If any employee selects a POS plan and the group chooses composite premium rating, all members of the group must select the POS offering. There is no minimum enrollment requirement in each offered benefit plan. Eligible employees who live outside the Service Area must enroll in either a POS plan or an HMO National plan. Mid-year additions Please refer to the applicable Evidence of Coverage document for your group, as qualified life events are defined in this document. Employer Definition A Small Employer means an employer that, during the preceding calendar year, employed an average of not more than 50 full time equivalent employees. Calculation of Number of employees: The number of employees an employer has must be determined by adding the number of full-time employees with the number of full-time equivalent employees, which must be calculated for a particular month by dividing the aggregate number of hours of service of employees who are not full-time employees for the month by 120. After adding the number of full-time employees and full-time equivalent employees for each month, you must divide this value by 12 and round down to the nearest whole number to determine the employer s number of employees. If an employer is only in business for part of the calendar year, divide by the number of months in business instead of 12 to determine the number of employees. Special Circumstances: If an employer was not in existence throughout the preceding calendar year, the determination of whether the employer is a small employer must be based on the average number of employees that the employer is reasonably expected to employ on business days in the current calendar year. Employer Eligibility 2

3 Groups that do not meet the above definition of a small employer (up to 50 full time equivalent employees, in the previous calendar year) are not eligible for coverage. Organizations must not be formed solely for the purpose of obtaining health coverage. Plans can be offered to sole proprietorships, partnerships or Corporations with at least one non-owner, benefit eligible, and W-2 wage earner. Associations, Taft-Hartley groups, professional employer organizations (PEO)/employee leasing firms, closed groups (groups that restrict eligibility through criteria other than employment) and groups where no employer/employee relationship exists are not eligible. Employer must have a physical place of business in the state of Maryland. Post Office Boxes are not acceptable. Prior Evergreen Health Coverage Groups that have been terminated for nonpayment by Evergreen Health must pay all outstanding premiums owed on the prior Evergreen Health plan before the new plan will be issued. Employee Eligibility An "eligible employee" is an employee who is offered coverage under a health benefits plan by a small employer. Eligible employees may include, at the employer's option, only full-time employees, or both full-time and part-time employees. A full-time employee means, with respect to a calendar month, an employee of a Small Employer who works, on average, at least 30 hours per week. Full-time employee does not include a seasonal employee as defined in federal law. Part-time employee defined: an employee who has a normal work week of at least 17.5 hours and is not a full-time employee. Sole proprietor, a partner of a partnership, and owners who are active at work are eligible to enroll in the plan. Coverage must be extended to all employees meeting the above conditions unless they belong to a union class excluded as the result of a collective bargaining arrangement. While the union employees must be included in the count in determining whether or not the group is a small employer, the employer may carve out union employees as an excluded class. Ineligible employees Employees not eligible for group health coverage include: temporary, seasonal, 1099, substitute, uncompensated employees; employees making less than equivalent minimum wage; volunteers; retirees; 3

4 inactive owners; shareholders only; officers who are not active; managing members who are not active; investors; silent partners. Dependent Eligibility Eligible dependents include: o Spouse of employee o Domestic partners and their eligible children; Domestic partners enrolling as a dependent are required to submit a Domestic Partner Affidavit. o Children: Dependent children are eligible, as defined in plan documents, in accordance with applicable state and federal laws under age 26 on the policy effective date, regardless of financial dependency, employment, eligibility of other coverage, student status, marital status, tax dependency or residency. This requirement applies to natural and adopted children, stepchildren, and children subject to legal guardianship. Children can only be covered under one parent's plan when both parents work for the same company. When the child and parent are employed by the same company, the child may enroll as an employee OR as a dependent under the parent's plan if the child also qualifies as an eligible dependent. Grandchildren are eligible if court ordered. A copy of the court papers must be submitted. If spouses/partners work for the same company, they may enroll as subscriber and dependent or separately. Individuals cannot be covered as an employee and dependent under the same group plan. Dependents must enroll in the same benefits options as the employee. Disabled dependents: A Disabled Dependent Form must be submitted with all requests to enroll a dependent over the age of 26. Waiting Period The employer must select a waiting period at the time of sale. o At initial submission of the group paperwork, the waiting period may be waived for current Employees, upon the employer's request. The employer may also elect to waive the waiting period for employees rehired within 6 months of their termination date. A change to the waiting period may only be made on the plan anniversary date. No retroactive changes will be allowed. Waiting periods must be consistently applied to all employees, including newly hired key employees. One or two waiting periods may be selected and must be consistently applied within a class of employees as defined by the employer. 4

5 Coverage for a newly eligible employee will be effective on the first day of the month following the date of hire unless otherwise specified on the group contract. o Waiting period may not exceed 90 days from the date of hire. If On the 90th day of employment is selected, the enrollment eligibility date will begin 90 calendar days from the date of hire (including date of hire). Late Applicants An employee or dependent enrolling for coverage more than 31 days from the date first eligible is considered a late enrollee and will not be eligible for group coverage until the plan anniversary date. Eligible applicants who experience a qualifying life event (e.g., marriage, divorce, newborn child, adoption, loss of spousal coverage, etc.) are eligible to enroll during the special enrollment period. NOTE application for enrollment, and all necessary supporting documentation, must be received within the special enrollment period. Voluntary cancellation of coverage is NOT a qualifying event. Plan Change Employee Level Employees are not eligible to make mid-year benefit plan changes (except for qualified special enrollment events). All plan selections should be confirmed once the member s ID cards are received. If discrepancies are not reported within 45 days of the effective date, members will not be allowed to change plans until the group s next open enrollment period. Plan Change Group Level Employers are not eligible to make mid-year benefit plan offering changes. All plan selections should be confirmed once the first billing invoice is received. If discrepancies are not reported within 45 days of the effective date, members will not be allowed to change plans until the group s next open enrollment period. Initial Premium Payment For new groups not enrolling through a TPA, the initial premium payment should be in the amount of the first month's premium in the form of a check. Submit a "copy" of the Initial premium check payable to Evergreen Health, for non-tpa groups. The initial premium submission does not bind Evergreen Health to provide coverage. 5

6 If the request for coverage is denied due to business ineligibility or other permissible reasons, or withdrawn, the premium will be returned to the employer. If the Initial premium check is returned for non-sufficient funds, coverage will be terminated retroactively to the effective date. Newly Formed Business (In operation less than 3 months) Newly formed businesses must provide the following: Sole proprietor - A copy of the business license (not a professional license) Partnership or limited liability partnership - A copy of the partnership agreement Corporation - A copy of the articles of incorporation that includes the signature page(s) of all officers (must be followed up with a copy of the statement of information within 30 days of filing with the state) Each newly formed business must also provide: Proof of employer identification number/federal tax identification number; and Quarterly Wage and Tax Statement. If not available, confirmation of when one will be filed; and Most recent two consecutive weeks of payroll records that include hours worked, taxes withheld, check numbers and wages earned; or A letter from a CPA with the following information: o A list of all employees, including owners, partners, officers (full-time and part-time) o Number of hours worked by each employee o Weekly salary for each employee o Date of hire for each employee o Whether payroll records have been established o Whether Quarterly Wage and Tax Statement will be filed; if so, when QWTS will be filed. PEO (Professional Employer Organization) Groups Covered Under PEO As long as the PEO provides payroll specific for the small group and we can determine it is a small group, even though the small group may be reported under the PEO tax ID number, the group may be considered subject to Eligibility and Enrollment approval. Two or More Companies - Affiliated, Associated or Multiple Companies, Common Ownership Employers who have more than one business with different tax identification numbers (TINs) may be eligible to enroll as one group and are required to be considered one group for eligibility purposes if the following are met: Must be shown by owner that: o One owner has controlling interest of all businesses to be included; or 6

7 o The owner files (or is eligible to file) an Affiliations Schedule, IRS Form 851, a combined tax return for all companies to be included. If they are eligible, but choose not to file Form 851, please indicate as such. A copy of the latest filed tax return must be provided; and All businesses filed under one combined tax return must be enrolled as one group. For example, if the employer has three businesses and files all three under one combined tax return, then all three businesses must be enrolled for coverage. If the request is for only two of the three businesses to be enrolled, the group will be considered a carve-out. The enrolling business (the group that is being used as the policy name), as well as the other businesses to be combined, must have the minimum number of employees required by the state. There are 50 or fewer employees in the combined employer groups. Businesses with equal controlling interest may be considered, if the owners of the company designate an individual to act on behalf of all the groups. Evergreen Health reserves the right to final Eligibility and Enrollment review and may consider common ownership on a case-by-case basis. Common Ownership Certification must be completed. Example One owner has controlling Interest of all companies to be Included: Company 1-Jim owns 75 percent and Jack owns 25 percent. Company 2-Jim owns 55 percent and Jack owns 45 percent. Both companies can be written as one group and must be considered one group for group eligibility purposes since Jim has controlling interest in both businesses. Municipalities and Townships A township is generally a small unit that has the status and powers of local government. A municipality is an administrative entity composed of a clearly defined territory and its population, and commonly denotes a city, town or village. A municipality is typically governed by a mayor and city or municipal council. Eligibility and Enrollment requirements: o Quarterly Wage and Tax Statement (QWTS) o W-2: Elected or appointed officials and trustees "may" be eligible for group coverage based on the charter or legislation. If so, they may not be on the QWTS; rather, they may be paid via W-2. In that case, provide a copy of their prior year W-2. o If elected officials are to be covered, provide a copy of the charter or contract indicating which classes or employees are to be covered, the minimum hours required to work per week to be eligible for coverage, and confirmation that coverage will be offered to all employees meeting the minimum number of required hours. 7

8 Medicare (MSP) for CMS Reporting All carriers must report to CMS (Centers for Medicare & Medicaid Services) the number of Medicare Secondary Payer (MSP) groups and the number of employees, each year, based on the number of employees provided by the employer. Medicare Secondary: 20 or more employees: Medicare Secondary Payer (MSP) is the term used by Medicare when Medicare is not the first payer as provided by Coordination of Benefits (COB). This would generally occur when the Evergreen Health plan would pay primary to Medicare for active employees and would pay first when there are 20 or more total employees (full- and part-time) for 20 or more weeks during this calendar year or prior calendar year. Counting: Both full- and part-time employees are counted based on the number the employer employed for at least 20 or more calendar weeks during the current or prior calendar year. o Include: full-time, part-time, seasonal, temporary, union, owners, partners, officers o Exclude: self-employed persons, independent contractors (1099), directors, leased employees Rating Information Groups may choose one of two rating methods age banded or composite premium. Composite rates are based on final enrollment. Final rates will be billed based on those filed and approved by the Maryland Insurance Administration. If there is a discrepancy on the rate sheet or an error during the quoting process, the quoted rate will be overridden by the filed and approved rates. All quotes are subject to change based on additional information that becomes available in the quoting process and during case submission/installation, including any change in census. If any of the information Evergreen Health receives is determined to be incomplete or incorrect, we reserve the right to adjust rates. If it is determined that a signed rate sheet is incorrect for any reason, Evergreen Health reserves the right to adjust rates to match those filed and approved by the Maryland Insurance Administration. No minimum employer contribution percentage is required by Evergreen Health. Signature Dates The Evergreen Health Employer Group Application and all Employee Enrollment forms must be signed and dated prior to and within 60 days of the requested effective date. All Employee Applications must be completed by the employee himself/herself. Tax Information/ Documents for Groups With 2 to 50 Eligible Employees 8

9 Groups with 2 to 50 eligible employees must provide a copy of the most recent Quarterly Wage and Tax Statement (QWTS) containing the names, salaries, etc., of all employees of the employer group. o Newly hired employees should be written in on the Quarterly Wage and Tax Statement. Additionally, two weeks of payroll must be provided, showing hours worked, taxes withheld, check numbers for issued checks, and wages earned. If payroll is not available, W-4 and letter on company letterhead, stating that the employee works on a FT basis is required. o Reconciled QWTS must be signed and dated by the employer. Any handwritten comments added to the QWTS must be signed and dated by the employer. The Eligibility and Enrollment department may request payroll in questionable situations. Churches must provide Form 941, including a copy of payroll records (at least two weeks) with employee names, wages, taxes withheld and hours. For clergymen without taxes withheld, previous year s W-2 is required. Seasonal industries, such as lawn and garden services, construction, concrete and paving, golf courses, farm laborers, etc., must provide four consecutive quarters of wage and tax reports to verify consistent, continuous employment of eligible employees. Non-Profit Organizations must provide IRS Form 501 (C)(3) determination and two weeks of payroll showing hours worked, wages earned and taxes withheld. Sole proprietors, partners and corporate officers not listed on the QWTS need to submit the following documents, along with a written statement, on company letterhead, verifying that these individuals work full time hours. This list is not all inclusive. The employer may provide any other documentation to establish eligibility (subject to Eligibility and Enrollment approval). Sole proprietor For example: franchise, limited liability company [operating as sole proprietor] IRS Form 1040 along with Schedule C (Form 1040) IRS Form 1040 along with Schedule SE (Form 1040) IRS Form 1040 along with Schedule F (Form 1040) IRS Form 1040 along with Schedule K-1 (Form 1065) Additional documentation may be provided at the discretion of the Plan. Partner For example: partnership, limited liability partnership IRS Form 1065 Schedule K-1 IRS Form 1120 S Schedule K-1 along with Schedule E (Form 1040) Partnership agreement if established within two years - eligible partners must be listed on agreement Additional documentation may be provided at the discretion of the Plan. Corporate officer For example: limited liability company [operating as C Corp], C corporation, personal service corporation, S corporation IRS Form 1120 S Schedule K-1 along with Schedule E (Form 1040) IRS Form 1120 W (C Corp and Personal Service Corp) 9

10 1040 ES (Estimated Tax) (S Corp) IRS Form 8832 (Entity classification as a corporation) W-2 Articles of Incorporation If established within two years- corporate officers must be listed Additional documentation may be provided at the discretion of the Plan. FTE Certification For new business cases, the Full Time Equivalent Calculation Form is required in addition to sold case paperwork. Product Rules Select (High Performance Network) o Employer must be based in Allegany County Anne Arundel County, Baltimore City, Baltimore County, Calvert County, Caroline County, Carroll County, Dorchester County, Frederick County, Howard County, Kent County, Montgomery County, Prince Georges County, Queen Annes County, Somerset County, Talbot County, Washington County, Wicomico County and Worcester County. o Employees must live or work in Anne Arundel County, Baltimore City, Baltimore County, Howard County, Somerset County, Washington County, Wicomico County and Worcester County. HMO o Employees must live or work in the state of Maryland, employees are presumed to meet this requirement if their home address is in: Delaware District of Columbia Pennsylvania: Adams, Bedford, Chester, Fayette, Franklin, Fulton, Lancaster, Somerset and York counties. Virginia: Accomack, Arlington, Fairfax, King George, Loudoun, Prince William and Stafford counties. West Virginia: Berkeley, Grant, Hampshire, Jefferson, Mineral, Morgan, Preston and Tucker counties HMO National o Employees must work for a Maryland Employer. (Eligibility of Employees who do not live or work in Maryland subject to review and approval by Evergreen Health) Point of Service o Employees must work for a Maryland employer. (Eligibility of Employees who do not live or work in Maryland subject to review and approval by Evergreen Health) Reinstatement 10

11 Reinstatement must be received within 30 calendar days of the group termination date. Each group is eligible for one reinstatement per plan year. Reinstatement payments must be made via certified check within 30 days of the group's termination and include the grace period premium and the current month's premium. (Direct Groups Only) Retro Termination Requests For retroactive terminations received within 30 days of the requested termination date, the requested termination date will be honored. For retroactive terminations received more than 30 days after the requested termination, coverage will terminate at the end of the month preceding the termination notification receipt date. This material is for information purposes only and is not an offer or invitation to contract. An application must be completed to obtain coverage. Rates and benefits may vary by location. Health benefits, health insurance, and health plans/policies contain exclusions and limitations. Plan features and availability may vary by location and group size. Providers are independent contractors and not agents of Evergreen Health. Provider participation may change without notice. Evergreen Health does not provide care or guarantee access to health services. Contact your doctor first with any concerns or questions regarding your health care needs. If you are in a plan that requires the selection of a primary care physician and your primary care physician is part of an integrated delivery system or physician group, your primary care physician will generally refer you to specialists and hospitals that are affiliated with the delivery system or physician group. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features are subject to change. The information in this document is believed to be accurate; however, it is subject to change. For more information about Evergreen Health plans, refer to 11