Operating Guidelines. Section I: Enrollment

Transcription

1 Operating Guidelines Section I: Enrollment A. Eligibility Requirements B. Waiting Periods C. Late Entrants D. Member Eligibility Requirements E. Dependent Spouse Eligibility Requirements F. Qualifying Events G. Dependent Child H. Adding/Updating a Dependent Child(ren) I. Verification of Student Status J. Retro Add to the policy K. Waiver of Premium L. Retirees M. Member Termination N. Cobra O. Exception Processing Section II: MDG Enrollment A. Waiting Period B. Eligibility C. Effective Date of Coverage D. Primary Care Dentist s E. Cobra/State Continuation F. Billing Section III: FCW Enrollment a. Waiting Period b. Eligibility c. Effective Date of Coverage d. Cobra/State Continuation e. Billing 1

2 Section I: Enrollment (ALL Coverages) Eligibility will be transmitted accurately to Insurer electronically on a weekly basis via an electronic data interchange (EDI). The EDI combination file shall be separated by Insurer plan number with a footer and header. If the EDI feed is not active after the effective date has passed the Administrator shall be responsible for sending a weekly change only census until the EDI feed is active. Eligibility changes received shall be submitted on the next EDI file on the expected day of the week. If there are any issues the Administrator shall notify Insurer prior to the expected date of arrival of the EDI File. If the issue takes longer than 2 days to resolve, the Administrator will need to submit eligibility via a change census as an interim solution. The Insurer will send an EDI reconciliation report which may include a request for missing information. The administrator shall respond to any missing information requests and make every attempt to make the correction before the next file to the insurer. The Administrator shall comply with all federal and state mandates relevant to eligibility and shall make every effort to advise Insurer of any such required changes so that these Operating Requirements may be amended. The Administrator is responsible for configuring their system in accordance with the Guidelines set forth in the Policy Holder s contract/certificate booklet and plan/benefit set up documentation. If the Administrator s system cannot accommodate multiple configuration guidelines for one benefit, ie. Dental PPO & Dental DHMO, the Administrator shall set the configuration of all Dental products to be 1st of the month effective dates for members and dependents and shall only term members and dependents at the end of the month in the following states: California, Colorado, Florida, Illinois, Indiana, Michigan, Missouri, New Jersey, New York and Texas. This is due to the availability of the MDG & FCW Coverages. A. Eligibility Requirements (Excludes MDG & FCW) 1. The enrollment process begins with determining who is eligible. Eligible means qualified, as in meeting the specific criteria set forth in a contract. If an individual meets the Plan Sponsor's eligibility requirements, they may be covered for benefits. 2. Once it is determined who is eligible, a true family indicator is assigned; this represents everyone who is eligible, even if the member has chosen to decline benefits for a family member 3. The Eligibility Date is the date a member is entitled to benefits once they have completed their waiting period. 2

3 B. Waiting Periods (Excludes MDG & FCW) 1. A request to waive the eligibility waiting period for a particular member is reviewed on an exception basis. The request must be in writing from the Administrator explaining why the request is needed, which will then be escalated to Insurer. 2. A Plan Sponsor may request to have their eligibility waiting period changed. The request must be in writing and must be approved by Insurer. This requires a Plan Sponsor amendment with the effective date. 3. ACA Qualified plans a. Group sitused in any state except California: Maximum of 90-day limit; maximum is calculated based on consecutive day limits, including week-ends and holidays. Plan Sponsors may not delay enrollment until first of month following attainment of the 90 day anniversary of the date on which an individual meets all eligibility requirements (which may be the date of hire). b. Group sitused in California: Maximum of 60-day limit; maximum is calculated based on consecutive day limits, including week-ends and holidays. Plan Sponsors may not delay enrollment until first of month following attainment of the 60 day anniversary of the date on which an individual meets all eligibility requirements (which may be the date of hire). C. Late Entrants & Over Guaranteed Issue (Excludes MDG & FCW) 1. If a member/dependent does not enroll within thirty one (31) days of their Eligibility Date or Qualifying event. 2. If a member/dependent is electing coverage over the Guaranteed Issue amount on volume based benefits. 3. If a member/dependent is considered a Late Entrant or has elected an amount over the Guaranteed Issue, they are subject to the penalties listed below: Benefit Late Entrant Penalties Over Guaranteed Issu Accident None not applicable Basic Life/AD&D EOI must be completed EOI must be complete Cancer Health question(s) must be answered not applicable Critical Illness Health question(s) must be answered not applicable FCW Dental Benefit cannot be elected until next open enrollment not applicable Guardian Dental Limited benefit for up to 24 months not applicable Long Term & Short Term Disability EOI must be completed EOI must be complete MDG Dental Varies by state not applicable Optional Life/Optional AD&D EOI must be completed EOI must be complete Vision (Lock in/out) Benefit cannot be elected until next open enrollment not applicable Vision (Stand alone or tied) None not applicable 3

4 D. Member Eligibility Requirements (ALL Coverages) 1. The member must meet the eligibility requirements reflected in the Plan Sponsor's contract. 2. The member must meet the hourly work requirement. The standard hourly requirement is 30 hours per week, unless otherwise stated in the contract. 3. Insurer usually does not cover individuals overseas. However, if a request is received to add a member with a foreign address, underwriter approval is required prior to enrolling the member. 4. The member must enroll within the appropriate amount of time, within the waiting period plus the 31-day grace period 5. If both the husband and wife are both employed by the same employer, they may be individually covered as a member and each may cover their children as dependents. However, our contracts state that a member cannot be insured as both a member and a dependent under the same policy. E. Dependent Spouse Eligibility Requirements (ALL Coverages for which dependents are eligible) 1. The spouse must be legally married to the member (or meet the common law or domestic partner requirements). 2. The spouse cannot be a member of the same policy and already be covered as a member. In other words, a spouse cannot be covered as a member and a dependent on the same policy at the same time. 3. The spouse cannot be on active duty with the armed forces, except for Colorado situs plans. 4. The spouse must permanently reside in the United States. If a spouse lives abroad permanently, they are not eligible until arriving in the United States 5. The spouse is not eligible if he/she is divorced from the member. A spouse that is legally separated from the member is still eligible. a. A court order which requires a member to provide coverage for an ex-spouse may need to be denied. The ex-spouse is no longer considered an eligible dependent in most states and cannot be covered under the member's record any longer. The court order mandates the member to provide the coverage, not Insurer. As an alternative, the ex-spouse may be eligible for COBRA or state continuation under normal guidelines. F. Qualifying Events (Applies to Guardian PPO, FCW and MDG Dental, Vision w/ Lock In/Lock Out). (See Attached QE Setup doc) 4

5 G. Dependent Child (ALL Coverages for which dependents are eligible) 1. The dependent child cannot be married. 2. The child must be within the readable age. The first age indicated is for a dependent child who is not a full-time student. The second age indicated is for a dependent child who is a full-time student at an accredited college. 3. The child cannot be a member of the same policy and already be covered as a member. 4. The child cannot be on active duty with the Armed Forces. 5. The child must permanently reside in the United States. If a child lives abroad permanently, they are not eligible until arriving in the United States. H. Adding/Updating a Dependent Child(ren): 1. If an eligible child is being added for contributory benefits, the dependent can be timely or late (Excludes FCW & MDG Dental). a. Timely: Notification enrolled within 31 days of the eligibility date. b. Late: Notification is not within 31 days of the eligibility date. 2. First Eligible Child (Applies to Guardian PPO, FCW and MDG Dental, Vision w/ Lock In/Lock Out) a. If this is the member s first eligible newborn and the child was reported to Insurer within 31 days from the date of eligibility (date of birth), the child may be added and covered from the date of eligibility. b. If a member of the Plan Sponsor submits a written request for a specific effective date for coverage after the date of birth but within 31 days from date of birth, the Administrator will submit the requested date requested and note the explanation along with actual date of birth to Insurer. 3. Additional Children (Applies to Guardian PPO, FCW and MDG Dental, Vision w/ Lock In/Lock Out) a. If a member requests to add a dependent child after the initial 31 day grace period, determine if the premium will change with the addition of this child i. Dental/Vision benefits: Enroll the dependent with a current effective date without late entrant penalties. ii. All other coverages: If child is late, request EOI. 4. Non-Standard Dependent (Guardianship, Grandchild, Nephew, Niece, etc.) (Applies to Guardian PPO, FCW and MDG Dental, Vision w/ Lock In/Lock Out) a. If a request is received to add a Grandchild, Nephew, Niece or dependent due to Guardianship: i. Request the appropriate documentation (i.e. tax forms, POA (Power of Attorney), court documentation, Guardianship papers, etc). ii. Do not enroll the dependent and do not collect payment for that dependent, alert the member that the dependents enrollment requires review and will be notified of the decision. iii. Alert the member that they will have 30 days to submit the appropriate documentation to The Administrator, otherwise they will need to wait unit the next Open Enrollment. iv. When the documentation is received, The Administrator will verify that Non-Standard request is a dependent of the member. 5

6 v. If eligible - enroll the dependent as of the 1st of the month following the and collect the pertinent premium. vi. If not eligible - do not enroll and alert the member I. Verification of Student Status (ALL Coverages for which dependents are eligible and age limits require verification): 1. If a dependent meets the first limiting age, Administrator verifies that the dependent is a full time student. 2. If the dependent is between the first and second limiting age, verification of student status is required each year by the Administrator until the dependent reaches the second limiting age or until the dependent is no longer a full time student. a. 3 months prior to the month a dependent with active coverage reaches the first limiting age, the member is notified by the Administrator that the child is reaching the first limiting age. If the child is a full-time student, the member returns the notification and advises if the child is a student, where they go to school, and what the expected graduation date is. b. If the dependent with active coverage is not a full-time student, the Administrator will terminate the dependent as of 1st of the month following the child s birthday in which they have reached the 1st limiting age, when the group has a first of the month waiting period for the coverage. If the coverage has a conventional waiting period, not following the first of the month, coverage will end on the child s date of birth. c. If the dependent with active coverage is a full-time student and their Graduation date is reported as prior to June 1, the dependent s termination date should be 9/1 of the current year. d. If the dependent with active coverage is a full-time student and their expected Graduation date is reported as June 1 or after, the dependent s termination date should be 9/1 the next year. e. On 6/1 of each year, Administrator will notify members with a dependent(s) with active coverage that verification is needed of a dependent s is a full-time student, and then go back to Step B. 3. When the dependent reaches the 2nd limiting age they will be termed on the (31) of the month where they reach the limiting age when the benefit waiting period is first of the month. If the benefit has a conventional waiting period, coverage will end as of the date of birth.. J. Retro Add to the policy (Excludes FCW & MDG Dental) 1. If the enrollment was timely by the member and the request is received within 180 days, an exception to retrospectively add a member as of the policy s effective date may be granted. 2. If the request is not received within 180 days, request the enrollment and payroll documentation. Any request greater than one year needs to be reviewed and approved by Insurer. 6

7 K. Waiver of Premium (Applies to Life, Short Term Disability and Long Term Disability) 1. Life Waiver of Premium a. Life waiver of premium is available for member basic & optional life products; however, does not provide continued coverage for AD&D benefits. b. If the employee is disabled, they must meet the definition of total disability (total disability means that due to sickness or injury, you are: (a) not able to perform any work for wages or profit; and (b) you are receiving regular doctor's care appropriate to the cause of disability). c. The member appears on the billing statement; however a premium charge does not appear for their life coverage. d. The employee is only eligible for the life volume that they had at the time that they applied for waiver of premium. They are not eligible for any life benefit volume increases until they return to work. 2. Short Term Disability (STD) Waiver of Premium a. Waiver of STD premium is standard on voluntary STD plans. Waiver of premium is available on non-voluntary (non-contributory and contributory) STD plans, however, it is not very common and the waiver of premium provision must be approved by underwriting. This benefit does not apply to ASO STD plans. b. The waiver of STD premium begins after an employee satisfies the elimination period and STD benefits commence to be paid. The premium waiver continues through the period of disability, even if the STD maximum benefit has been reached or limited payments are made due to a pre-existing condition. The waiver of premium ends on the date the employee returns to full-time work. Retroactive premium charges are made for any late submission of the return to work date. c. The waiver of premium (WOP) provision allows an employee's coverage to continue without premium being charged while they are on disability. This benefit does not apply to ASO STD coverage. 3. Long Term Disability (LTD) Waiver of Premium a. All LTD plans include a waiver of premium provision, including LTD conversion plans. b. LTD contracts state that the premiums must be paid during a disabled employee's elimination period. When the elimination period is satisfied and LTD benefits begin to be paid, the LTD Waiver of Premium begins. c. The employee remains eligible for waiver of premium as long as they are receiving LTD benefits (e.g. if the employee returned to work part-time but we are still paying LTD benefits, the employee is still eligible for the waiver of premium). 4. Guardian determines who is qualified for waiver of premium. L. Retirees (ALL Coverages) 1. Retirees are generally not covered under this agreement, unless stated in the Plan Sponsor s contract 7

8 M. Member Termination 1. A member s termination date in most cases follows the guidelines for the effective date of the benefit. For benefits with an effective date on the first of the month, will terminate on the last day of the month. There are some benefits however that will always end on the last day of work. The below chart indicates termination guidelines. Waiting Period Type Effective date Benefit(s) When Coverage End Conventional Waiting Period Specific Waiting Period Can be effective on any day of the month Effective date is based on a specific day - typically 1st of the Month All Dental, Vision, Accident & Cancer Critical Illness, Long and Short term disability, Life/AD&D afer Last day of work Last day of the month Last day of work N. Cobra 1. Qualifying Events for Cobra (Will not be administered through Insurer): 8

9 2. Who is Administering COBRA on behalf of the Benefit Sponsor a. Benefit Sponsor/Other (Benefit Sponsor chooses COBRA Administrator) 3. Channel Partner is not Administering COBRA: a. The Channel Partner must make the Benefit Sponsor aware that they are responsible for reporting/paying premium for Members on COBRA i. If the Benefit Sponsor has a vendor administering COBRA on their behalf, the vendor or the Benefit Sponsor is responsible for the details outlined in Section The EDI File may contain COBRA Members. This is determined at the group Level and Channel Partner will need to let Guardian know on each Plan 5. What does Guardian Need for Members on COBRA a. Determine how Members on COBRA will be communicated to Guardian i. Census with Enrollment Details (See COBRA Form for specifics) ii. EDI File iii. Guardian COBRA Form O. Exception Processing (ALL Coverages) 1. Any requests for exceptions to the rules noted above shall be made in writing to the Insurer contact designated in Customer, Eligibility and Payment Services. Section II: MDG Enrollment A. Waiting Period 1. The waiting period must always be set up for the effective date to be the first of the month. 2. A Member becomes eligible for MDG coverage upon completion of the waiting period. If the Member completes their enrollment within 31 days, they will be effective on their eligibility date for the MDG benefit. 3. If the Member does not enroll within the 31 day grace period of their eligibility date, the Member is considered late. He/she cannot enroll for MDG coverage until the next open enrollment period. B. Eligibility 1. The member must live in the state the benefit is offered in to be eligible for the DHMO coverage. C. Effective Date of Coverage 1. Open enrollment occurs once a year. During open enrollment, members are allowed to transfer between traditional Dental (if available) and MDG. 2. A member must request the transfer in writing by using the appropriate form. The transfer date and open enrollment period will be specified in the contract. Coverage is effective on the specified transfer date. a. The begin date is the date open enrollment starts. b. The Number of Days field represents the length of the open enrollment. c. The Transfer Date field reflects the date on which benefits are effective. d. The enrollment form must be signed within the open enrollment period or on the transfer date. If the open enrollment period and the transfer date are not 9

10 consecutive months, the enrollment form must be signed within the open enrollment period. If an enrollment form is signed after the transfer date, a request for an exception will be required. D. Primary Care Dentist s 1. DHMOs require that members select a primary care dentist (PCD) from participating dentists who have agreed to accept a flat fee per month for each member in their care. The fee is paid to the dentist every month by Guardian, whether or not they provide services to the member. The flat fee covers all care provided to the member regardless of the number of visits or the type of services provided. a. The member must use their selected PCD for all dental services, or obtain a referral from the PCD to obtain services from a specialist. b. If the PCD refers the patient to a specialist, the specialist is paid at a discounted fee schedule rate. c. The patient is responsible for sharing the cost of this treatment by making copayments for each office visit or for individual services. 2. To locate a MDG PCD, complete the below steps. a. Access the Guardian Anytime site. b. Under the Quick Links section, click on PCD Provider Look Up. c. Click Find a Dentist d. Complete the below fields. Fields Select Your Dental Plan Search by Your Location Distance Select Your Dental Network Type of Dentist About the Dentist Coding Information DHMO/MDG/Prepaid Search by Location Member s zip code 5 miles Managed Dental Care Primary Care Dentist Office Status Accepting New Patients e. Click Continue at the bottom of the page to display a list of available dentists. f. When a list of dentists display, randomly choose a dentist (do not always choose the first one listed) When no available dentists display, complete step 4 again using the group's zip code E. Cobra/State Continuation (Will not be administered through Guardian): 1. Plan Sponsors are provided with Cobra forms, if the plan is classified as a true group. COBRA, which is an employer law, requires that continuation be offered to terminating members whose employer has employed 20 or more individuals on at least 50% of all business days in the previous year. 2. COBRA employees and dependents - When employees or dependents are placed on COBRA, the EDI Feed needs to be updated with the future termination date 3. COBRA for MDG - the termination date should always be the last day of the month, which means the EDI feed would be coded with the first of the month as date of no coverage. 10

11 4. State continuation may be available for plans with less than 20 employees. Review state guidelines to determine state specifics. a. It allows for continued coverage, after the expiration of COBRA, for a surviving, divorced, or legally separated spouse over age 55 and their dependents. 5. Continuation ends when: a. the person fails to pay premium b. the date the group policy is terminated and not replaced c. the date the spouse becomes insured under another group health plan d. the date the spouse remarries and becomes insured under a group health plan e. the date the spouse reaches age For group policies issued on or after the following mandate applies only to policies that are not subject to Cobra: a. Health continuation must be provided for terminated member and former spouses whose coverage terminates due to dissolution of marriage or death of the member. Continuation is also available to dependents b. Continuation shall only be available where the member was insured under the group for three months immediately prior to termination. Continuation is not available where the person is eligible for Medicare or other group coverage. Continuation does not have to include dental or vision care c. Continuation must include maternity if those benefits were provided under the group. d. The employee must request continuation within 31 days of the date his group coverage would terminate and pay the group policyholder the amount of his premium on a monthly basis. 7. Continuation shall terminate on the earliest of: a. Nine months after the date the employee's group coverage terminated b. If the member fails to pay the required premium c. The date on which the group policy terminates. However, if the group is replaced the employee shall have the right to coverage under the replacing policy for the balance of the continuation period. 8. The individual on continuation has the right to conversion policy at the end of the continuation period. F. Billing 1. All MDG plans must have a 1st of the month billing date and must be billed monthly. 2. Non-monthly (quarterly, semi-annual, annual) billing cycles are not permitted because this is a prepaid dental product. Section III: FCW Enrollment A. Waiting Period 1. The waiting period must always be set up for the effective date to be the first of the month. 11

12 2. A Member becomes eligible for FCW coverage upon completion of the waiting period. If the Member completes their enrollment within 31 days, they will be effective on their eligibility date for the FCW benefit. 3. If the Member does not enroll within the 31 day grace period of their eligibility date, the Member is considered late. He/she cannot enroll for FCW coverage until the next open enrollment period. B. Eligibility 1. First Commonwealth does not have an hourly work requirement. It is up to the policy sponsor to determine who is eligible for benefits and only allow those who are eligible to enroll. 2. If the employee does not enroll within 31 days of becoming eligible, the employee is not eligible for FCW benefits. There are no late entrants, if they do not enroll within the 31 days, he/she cannot enroll for FCW coverage until the next open enrollment period. 3. If the plan is sold with Guardian benefits, they will be considered a late entrant (as is standard) for all other contributory Guardian benefits. This will be calculated based on waiting period, hire and enrollment dates. 4. Late entrants are not allowed on DHMO or PPO FCW coverage(s). 5. If member is deemed a late entrant for any FCW coverage, the Administrator will enroll the employee and waive the benefit. The Administrator will contact the policy sponsor to inform them that the member enrolled late and that they will need to wait until the next open enrollment period C. Effective Date of Coverage 1. Open enrollment occurs once a year. 2. Enrollment will always be effective on the 1st of the month following the end of the waiting period. D. Cobra/State Continuation (Will not be administered through Guardian): 1. Plan Sponsors are provided with Cobra forms, if the plan is classified as a true group. COBRA, which is an employer law, requires that continuation be offered to terminating members whose employer has employed 20 or more individuals on at least 50% of all business days in the previous year. 12

13 2. COBRA employees and dependents - When employees or dependents are placed on COBRA, the EDI Feed needs to be updated with the future termination date 3. COBRA for FCW - the termination date should always be the last day of the month, which means the EDI feed would be coded with the first of the month as date of no coverage. 4. State continuation may be available for plans with less than 20 employees. Review state guidelines to determine state specifics. a. It allows for continued coverage, after the expiration of COBRA, for a surviving, divorced, or legally separated spouse over age 55 and their dependents. 5. Continuation ends when: a. the person fails to pay premium b. the date the group policy is terminated and not replaced c. the date the spouse becomes insured under another group health plan d. the date the spouse remarries and becomes insured under a group health plan e. the date the spouse reaches age For group policies issued on or after the following mandate applies only to policies that are not subject to Cobra: a. Health continuation must be provided for terminated member and former spouses whose coverage terminates due to dissolution of marriage or death of the member. Continuation is also available to dependents b. Continuation shall only be available where the member was insured under the group for three months immediately prior to termination. Continuation is not available where the person is eligible for Medicare or other group coverage. Continuation does not have to include dental or vision care c. Continuation must include maternity if those benefits were provided under the group. d. The employee must request continuation within 31 days of the date his group coverage would terminate and pay the group policyholder the amount of his premium on a monthly basis. 7. Continuation shall terminate on the earliest of: a. Nine months after the date the employee's group coverage terminated b. If the member fails to pay the required premium c. The date on which the group policy terminates. However, if the group is replaced the employee shall have the right to coverage under the replacing policy for the balance of the continuation period. 8. The individual on continuation has the right to conversion policy at the end of the continuation period. E. Billing 1. All FCW plans must have a 1st of the month billing date and must be billed monthly. 2. Non-monthly (quarterly, semi-annual, annual) billing cycles are not permitted because this is a prepaid dental product. 13