Administrator Checklist

Transcription

1 Administrator Guide

2 Administrator Checklist For your convenience, here s a list of things health plan administrators are responsible for: Letting employees know if they re eligible to enroll in a timely manner Submitting all your employees applications, notices and inquiries Making sure enrollment information is complete before you submit it Distributing health plan notices to covered employees Paying premiums on time Notification of the following changes and effective dates: o Change in classification (full-time to part-time) o Change in dependent status o Name and address changes o Termination of coverage and the reason o Change of employer information o Employee becomes eligible for Medicare o Termination of employment Helping covered employees understand how to file claims Notifying employees of Consolidated Omnibus Budget Reconciliation Act (COBRA) or continuation coverage eligibility (Over 20 employees) Providing Qualified Medical Child Support Order (QMCSO) determinations Tracking when an employee becomes ineligible If applicable, reporting employment status to the insurance carrier: Ensuring that all eligible employees are enrolled for group term life insurance whenever the employer contributes 100% of that premium. The information contained in this Administrator Guide is not specific to an insurance carrier. The information provided is a generalized guide. Your company s insurance carrier may have specific rules that are different than those presented in this checklist. Please consult your insurance policy or PROES representative for rules specific to your company.

3 General eligibility rules To be eligible, an employee must be: A full-time employee working at least 30 hours and paid by W-2. A full-time working owner or partner. An eligible dependent may be: The employee s spouse. The employee s or spouse s child. A child whose legal guardian is the employee or the employee s spouse. A child who is covered under a QMCSO, as determined by the group. Note: Children must be within the age limit. The child must qualify as an eligible dependent. Proof is needed to confirm legal guardianship. An employee has disabled dependent(s) Disabled dependents may continue coverage past the age limit. However, proof of disability and dependency must be provided. Please complete the form within 60 days of the dependent reaching the age limit. If the dependent meets the requirements, coverage continues unless: The dependent marries. The dependent no longer resides with the certificate holder. The dependent overcomes the disability. The dependent s parent s coverage is terminated. We may request proof of continued disability and dependency.

4 Effective dates for your employees Timely enrollment The insurance carrier must receive the enrollment application within the time stated in the contract in order to be considered as timely. Effective dates options are: Date of Hire (no waiting period). 30, 60 or 90 days First of the month following 30 or 60 days Late enrollment Open enrollment will be 31 days before and after the renewal effective date. If we receive the application more than 31 days after the renewal date, then the applicant is a late enrollee. He or she must wait until the next open enrollment. If the application is received by the insurance carrier within the 31 days prior to the group s renewal date, coverage will be effective on the renewal date. Note: Additional information related to special enrollment, open enrollment, COBRA can be found in the following pages.

5 Application Process We ll supply the forms you need to administer benefits. Remember to: Fill out the Employer section of the application form. Make sure your employees use blue or black ink. Complete the Other Health coverage section. Keep copies for your records. Submit paperwork on a timely basis. Notify us of any changes by completing Add/Change/Termination Form. Applying for coverage To find out who can apply for coverage, please see the following sections or the contract. To apply for coverage, the employee must be Actively at Work. The insurance carrier must receive the Enrollment Application form within 31 days to ensure the effective date for the employee, spouse and dependent(s). Note: If the insurance carrier doesn t receive the application on time, the applicant may be considered a late enrollee. He or she may only enroll at the group s next open enrollment. Waiving coverage To waive coverage, an employee must complete the Enrollment Application, including the Waiving coverage section. This will show that the employee was given the chance to enroll. If the group contributes 100% of the health plan premium, all net-eligible employees must be enrolled. If the group contributes less than 100%, employees may waive coverage. Group participation rules must always be met. Note: We are available to explain coverage, help with completion of paperwork, and submitting forms to the insurance company. These roles may be fulfilled by your personnel or our agency exclusively; or shared. The responsibilities should be agreed upon in writing and performed with absolute consistency.

6 Changes in Coverage Any change in coverage requires a new Add/Change/Termination Form or Enrollment Application. A change in an employee s type of coverage is effective the date the employee is eligible for the change. We must receive the application on time. If it s late, the person is a late enrollee and the change may be made at the group s next open enrollment. New dependent s coverage becomes effective on the date they meet the eligibility requirements. Adding Employees New Employees Provide an explanation of coverage available upon hiring Follow the application process Current Employees Following initial enrollment opportunity, employees (and / or dependents) can only be added at open enrollment (if available), or upon Qualifying Events. Loss of Other Coverage - o The Employee (and / or Dependent) requesting to be added must have declined coverage initially due to other coverage. And, o The coverage is lost due to no fault of their own (COBRA coverage ends, loss of eligibility for coverage, employer stops contributions or cancels plan, loss of coverage due to termination of employment). Change in Status o Employee is eligible to add spouse due to marriage o Employee is eligible to add dependents due to birth, adoption, or placement for adoption. Coverage is effective on the date of loss of coverage or event, upon timely enrollment.

7 Adding Dependents An employee marries If an employee is planning to marry and wants coverage for a spouse or dependents, he or she should submit an Enrollment Application within 31 days of getting married. Coverage becomes effective on the marriage date. Newborn children A newborn is automatically covered the first 31 days after birth. An Application Form is required. Adopted children An employee wishing to add an adopted child should submit an affidavit or copy of legal adoption papers along with an Enrollment Application form. Please see insurance company rules for effective date and other details An employee becomes a legal guardian A child will become eligible for coverage through permanent legal guardianship as long as: The legal guardianship papers are presented to the insurance carrier. The employee submits an Enrollment Application.

8 Removing Coverage Death of an employee Please provide us with the employee s date of death. If there is a surviving spouse or eligible dependents, please refer to the Continuation of health coverage section of your policy. Death of a spouse or dependent Upon the death of a covered dependent, the employee should complete a Change Form. The form needs to specify the date of the dependent s death and show appropriate changes to the type of health coverage, if necessary. Any changes of coverage type will be effective after the date of death. Divorce Please notify us immediately of a divorce. The spouse becomes ineligible for coverage on the first of the month following the date of the divorce. COBRA coverage may be available. Refer to the Continuation of coverage section of your policy for more information.