Frequently Asked Questins fr Blue Shield Prducers Guarantee Issue fr Children Under Age 19 Updated June 7, 2011 What are the new health refrm requirements fr applicants under age 19? The Affrdable Care Act (ACA) requires that cverage cannt be denied based n pre-existing cnditins fr any applicants under the age f 19. This mandate became effective fr grup plans n September 23, 2010, and fr individual and family plans n January 1, 2011. What des this mean fr Blue Shield? Under this mandate, Blue Shield must accept and underwrite any applicant under the age f 19 wh wishes t enrll in available individual r family cverage n matter what their heath cnditin may be prir t cverage, as lng as the applicant therwise meets the eligibility criteria fr the cverage. Can an under age 19 applicant apply fr any individual plan available frm Blue Shield? Yes, applicants under the age f 19 may apply fr any Blue Shield individual plan. Des an under age 19 applicant need a special applicatin t apply fr individual cverage? N. Blue Shield accepts ur standard individual/family applicatin fr individual under age 19 cverage. What are the rating Rules fr under age 19 applicants The mandate requires that during certain designated perids, and cnditins, applicants under age 19 may be rated at ur standard rate, r up t a maximum f twice the standard rate, depending n the applicant s health cnditin. Under age 19 applicants wh apply utside f the designated perids may be rated higher than twice the standard rate. What are the designated perids and cnditins under which applicants under the age f 19 are limited t a maximum f twice the standard rate? Applicants under the age f 19 may apply fr cverage and be underwritten up t a maximum f twice the standard rate during the mnth f their birth, and upn the ccurrence f certain qualifying events. These events include: Birth r adptin f a child. The child is brn as a resident f Califrnia and did nt enrll in the mnth f birth. Lss f grup cverage. Lss f an emplyer s cntributin tward an emplyee r dependent s cverage.
Lss f cverage because f a legal separatin, divrce, r death f the persn thrugh whm the child was cvered as a dependent. Lss f cverage under the Healthy Families Prgram, the Access fr Infants and Mther s Prgram, r the MediCal Prgram. The child becmes a Califrnia resident. Cverage is mandated by a state r federal curt rder. In rder t qualify fr cverage under ne f these qualifying events, an applicatin fr cverage must be received within sixty-three (63) days f the qualifying event. Wh qualifies under the qualifying event that states: The child is brn as a resident f Califrnia and did nt enrll in the mnth f birth? This is essentially a newbrn child wh did nt enrll within 31 days f birth. The child nw has an additinal 32 days t submit an applicatin t meet the 63 day special enrllment deadline. T get the rate limitatin due t applying during their birth mnth, des an under age 19 applicant have t apply n their birthday r any time during their birth mnth? The applicant can apply anytime during the mnth f their birth. Fr example, if the applicant s birthday is July 17 th, they can apply any time between July 1, and July 31, and be rated frm ur standard rate, up t a maximum f twice the standard rate, hwever the current effective date rules fr the mandate still apply. What if an under age 19 applicant applies fr cverage utside f their birth mnth, r a qualifying event? If an applicant under the age f 19 applies fr cverage utside f their birth mnth, r 63 days f a qualifying event, the enrllee will be fully underwritten and rated accrdingly. This rate may be higher than twice the standard rate. Can a member wh is rated higher than twice the standard rate request t have their rate lwered? If an under age 19 enrllee is rated higher than twice the standard rate, they will receive ntificatin in their apprval letter and then 60 days prir t their birth mnth that they can submit a request t be rated at twice the standard rate. This change will nly be made during their birth mnth. Are there additinal fees assessed if an under age 19 applicant applies utside f a qualifying event? if the under 19 applicant applies fr cverage n their wn plan, utside f a qualifying event, and des nt have at least 90 days f cntinuus prir cverage frm the signature date n the applicatin, an additinal surcharge equal t 20% f their mnthly premium fr 12 mnths will be assessed. This surcharge is in additin t their mnthly premium.
Des the surcharge apply if the under age 19 applicant applies fr cverage n their wn plan, during their birth mnth? Yes, if the applicant applies during their birth mnth, they will be eligible t be underwritten at n mre than twice the standard rate, but they will als be subject t the surcharge if they d nt have at least 90 days f cntinuus prir cverage. Is the 90 days f cntinuus cverage determined frm the applicatin date, r frm the date that cverage begins? The 90 days f cntinuus cverage must be frm their applicatin signature date. Will Blue Shield remve the surcharge if the enrllee prvides prf f 90 days f cntinuus cverage prir t the applicatin date? If acceptable prf f prir creditable medical cverage is received within 30 days f the effective date f the Blue Shield cverage, the surcharge will be discntinued and any surcharge amunt paid will be credited back t the member s accunt. What cnstitutes prf f creditable medical cverage? Acceptable dcumentatin f creditable cverage includes at least ne f the items belw A Certificate f Creditable Cverage Letter frm an emplyer n the cmpany s letterhead attesting t credible cverage fr the under 19 year ld Billing statement t prve three mnths f cverage/banking statements (Fr individuals withut emplyer cverage). Payment receipts r bank statements demnstrating cverage payments fr past 3 mnths Ntificatin f lss f CHIP r Medicaid cverage frm the state prgram. What if prf f creditable medical cverage is received 30 days after the effective date? If acceptable prf f prir medical cverage is received after 30 days f the effective date f the Blue Shield cverage, the surcharge will be remved effective the first day f the mnth that the prf f prir medical cverage was received. The surcharge amunt paid fr that mnth will be credited back t the member s accunt. Example: Member is enrlled and assessed the surcharge with a 4/1 effective date. Member sends prf f prir medical cverage in June (mre than 30 days after the effective date). The surcharge will be remved effective 6/1. The surcharge amunt paid in June will be credited back t the member s accunt.
If an under age 19 enrllee wh was rated higher than twice the standard rate, later requests the lwer rate due t their birth mnth, d they still have t pay the surcharge? During their birth mnth, the under 19 enrllee can request t be rated at twice the standard rate, hwever the surcharge will remain until 12 calendar mnths have ended. Is cmmissin paid n the 20% surcharge? N, the 20% surcharge is nt eligible fr prducer cmmissin. Hw des this mandate affect cverage fr newbrn babies? If a newbrn is applying within 63 days f birth fr their wn plicy, an applicatin must be submitted. A birth certificate r hspital dcumentatin may be required t shw prf f a qualifying event and t avid the surcharge. Parents must still request t have their newbrn added within 31 days as they were required t d befre the mandate. The newbrn s effective date wuld be the date f birth. An applicatin des nt need t be submitted and the newbrn will nt g thrugh underwriting. If, the parents d nt ntify us within the initial 31 days frm date f birth, qualifying event rules abve apply fr days 32-63: 1. An applicatin must be submitted fr the under <19 applicant (newbrn)* 2. The newbrn will g thrugh underwriting, the entire family culd be rerated if the newbrn in underwritten higher than the ther family members. 3. The newbrn will be underwritten and rated t a maximum f twice the standard rate 4. The effective date assigned will fllw current child-nly effective date rules (ex. first f the fllwing mnth r first f the secnd mnth) A birth certificate r hspital dcumentatin will be required t shw prf f a qualifying event If a request is received n day 64 r later frm the date f birth and n ther qualifying event rules apply... 1. An applicatin must be submitted fr the under 19 applicant(newbrn) 2. The newbrn will g thrugh underwriting the entire family culd be rerated 3. The newbrn culd be rated higher than twice the standard rate 4. The effective date assigned will fllw current child-nly effective date rules(ex. first f the fllwing mnth r first f the secnd mnth)
If a family n a grandfathered plan wanted t add an under age 19 dependant t their plan, wuld the dependant get guaranteed issue? N. The mandate des nt apply t grandfathered plans. If an under age 19 dependant is added t a grandfathered family plan, they will be subject t full underwriting What are the rules fr effective dates? Fr PPO plans: Individual applicatins fr enrllees under age 19 can be given an effective date any day f the mnth, 15 days after the applicatin receipt date. Example: an applicatin fr an under age 19 applicant is received n August 3rd. The earliest effective date allwed will be August 18 th. Fr HMO plans: Effective dates fr individual applicatins fr enrllees under age 19 must be the 1 st day f the mnth, 15 days after the applicatin receipt date. Example: an HMO applicatin fr an under age 19 applicant received n July 28, will be assigned a September 1 effective date