Benefit Administrator’s Manual - 2014

Transcription

Benefit Administrator’s Manual - 2014
How to administer your company’s health coverage
For the most up-to-date information, go to anthem.com. You’ll find the latest version
of this manual, as well as all the forms you’ll need to administer your benefits.
16286NHEENABS Rev. 10/13
1
The contents of this manual do not constitute legal advice
or recommendations. Your group’s own attorney should be
consulted in matters of interpreting the group’s legal
responsibility under its employee health plan, as well as
state and federal laws and regulations. The contents of this
manual are subject to change at anytime.
2
Table of contents
Section 1: Important phone numbers and address .................................................................................... 5
Phone numbers 5
Mailing address 5
Section 2: Introduction .............................................................................................................................................. 6
Section 3: Eligibility ..................................................................................................................................................... 7
Employees 7
Dependents 7
Who is not eligible? 9
Probationary period (waiting period) 9
Pre-existing condition exclusion period 10
Portability, availability and renewability of health coverage 10
Section 4: Enrollment ................................................................................................................................................ 11
Paper enrollment 11
Special enrollment considerations 11
When to send enrollment forms 12
Section 5: Membership changes .........................................................................................................................15
Adding an employee or dependent during a special enrollment period 15
Removing a dependent
16
Changing a name or address 17
Changing a primary care provider (PCP)
17
Removing a subscriber 18
Other insurance 19
Section 6: Billing and reconciliation ..................................................................................................................20
Payment 20
Reinstatement 20
3
Table of contents
Section 7: Medicare eligible members ............................................................................................................. 21
Eligibility
21
Medicare Supplementary coverage
21
Who initiates notification and when
22
Determining primary coverage
22
An active employee or dependent is turning 65
24
Employee is under age 65 and becomes Medicare eligible
25
Section 8: Continuation of Coverage ................................................................................................................. 26
Steps you take with Anthem to continue coverage
29
Steps you take with Anthem to remove a member from Continuation of Coverage
29
Section 9: Retirees ..................................................................................................................................................... 30
Obtaining retiree coverage
30
What to do when an employee retires and your group has no retiree coverage
What to do when an employee retires and your group has retiree coverage
Canceling group retiree coverage
31
31
32
Section 10: Online tools and resources ........................................................................................................... 33
Online tools and resources for employers
33
Section 11: Glossary .................................................................................................................................................. 35
4
Section 1: Important phone numbers and address
Account representatives/account managers
E-business support
A specific person:
Dial direct
888-241-0626
Customer service
We’ve consolidated to make things easier!
When you renew on a Small Group ACA compliant plan on
or after January 1, 2014, there will be only two Customer
Service numbers to call. Please see below for details:
Main switchboard:
603-695-7000
Ask to speak with an Account Representative/
Account Manager
Account representatives’/account managers’ fax
For Medicomp, and Large Group, as well as Small
Group plans effective prior to January 1, 2014
Main fax:
603-695-7709
BlueChoice® (2 and 3 tier):
800-438-9672
Alternate fax:
603-695-7194
BlueChoice® New England:
800-870-3122
Mailing address
Anthem Blue Cross and Blue Shield
Enrollment and Billing
3000 Goffs Falls Road
Manchester, NH 03111-0001
Matthew Thornton BlueSM:
800-870-3057
Small Group Sales Support call center
Indemnity:
800-225-2666
HMO Blue® New England:
800-870-3122
Lumenos HSA:
888-224-4896
800-250-5420
Medicomp:
800-227-4641
Enrollment and Billing for Medicomp and Large
Group, as well as Small Group plans effective prior
to January 1, 2014
Preferred Blue® PPO:
800-852-6592
Billing call center:
800-273-2521 (press 1)
Customer service fax
Collections call center:
888-894-8053
603-695-7067
Enrollment and billing fax
For Small Group plans effective on or after
January 1, 2014
603-645-5830
Anthem direct (off-exchange):
855-330-1103
Enrollment and Billing for Small Group plans
effective on or after January 1, 2014
Anthem through Health Insurance Exchange
(on-exchange):
855-748-1805
Enrollment and billing call center:
855-250-7763
Customer service fax
Enrollment and billing fax
855-750-2227
855-750-2227
For the most up-to-date Customer Service numbers, please refer
to the number referenced on the back of the member ID Card.
5
Section 2: Introduction
The purpose of the Benefits Administrator’s Manual is to give you, the benefits administrator, what you need
to help you successfully administer your employees’ benefit. This includes clear and concise information,
procedure and process descriptions, phone numbers, and more.
Use this manual as your first line of support in performing your benefits administrator’s responsibilities.
The manual is designed to function as both a training guide and a reference tool, depending on your needs.
This manual is periodically updated. The most updated copy is available on anthem.com. You can also go to
our website for all the forms you need to administer your benefits.
Our responsibilities
Throughout the year, as you administer the Anthem health plan for your employees,
Anthem will:
Send you educational materials or benefit information as changes occur.
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Mail or deliver your renewal package consisting of premium information, benefit options and benefit
literature in advance of your anniversary date.
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Send you monthly invoices.
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Be available to answer your questions by phone, letter and onsite, whenever possible.
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Use your suggestions and evaluate your concerns to help improve our service to you.
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Your responsibilities
Acting as a liaison between Anthem and your employees.
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Submitting appropriate paperwork for enrollment and membership changes within the required
timeframes.
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Distributing Anthem materials to your employees.
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Mailing premium payments and settling past due accounts.
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Reviewing Anthem health care benefits with new employees.
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Referring employees to the appropriate Anthem department for problem resolution.
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Communicating service concerns and issues to Anthem.
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Terms used in the manual
Subscriber: The person under whose name coverage is listed, the policyholder.
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Dependent: Any individual who is eligible to receive health insurance through a subscriber’s coverage
certificate, such as a spouse or child.
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Member: Each person eligible for health plan benefits and enrolled under the group contract, including
the subscriber and all eligible dependents.
}}
6
Section 3: Eligibility
This section outlines the eligibility criteria for employees and their dependents. Members of your Anthem plan consist of
employees and their dependents. Most often, the employee is the subscriber. To become members, employees and their
dependents must meet certain eligibility criteria.
Employees
Full-time, part-time, former and retired employees are eligible, as outlined below, once they have completed their
probationary period, if applicable.
Full-time employees
Anthem defines full-time as 30 or more hours per week. An employer has the option to set a higher number of hours
for eligibility.
Part-time employees
Anthem defines part-time as at least half the weekly hours of a full-time employee, but no less than 15 hours per week.
An employer is not required to offer benefits to part-time employees; however, employers who offer benefits to
part-time employees must offer benefits to all part-time employees who meet the same criteria.
Rehires
An employee is considered to be a rehire if their return to work takes place no more than 12 months after employment
was terminated.
Former employees
Former employees may be eligible to elect to extend their coverage under federal or state continuation of
coverage laws.
Retirees
Retirees are eligible only if your group has a qualified retiree group under Anthem underwriting regulations.
(See ‘section 9: Retirees’ for more information.)
Foreign exchange visitors
Under federal regulation, sponsors of foreign exchange visitors must require each exchange visitor to carry accident
and health insurance. If your group is such a sponsor, contact your Account Manager.
Dependents
Spouse/Civil union partner
The legal spouse or civil union partner of a subscriber is eligible to enroll.
Legally separated or divorced
If the subscriber is legally separated or divorced from an enrolled spouse, spouse may be eligible for coverage if
continuation of coverage is elected under federal or state law. (Please refer to ‘section 8: Continuation of coverage’ for
details about eligibility.)
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As of January 1, 2008, New Hampshire law allows a divorced spouse who is currently covered under the
group plan to remain on the subscriber’s plan. (Refer to SB197.)
Domestic partner
Same-sex domestic partner coverage (including coverage for that person’s dependents) is available to
groups [who choose to elect it]. (Go to anthem.com for the necessary forms.) The rider must be added at
the time of the new sale or at renewal. The following criteria must be followed:
Domestic partners must be at least 18 years of age and unmarried.
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Domestic partners must have lived together continuously for 12 months and provide proof of
joint residence.
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A formal declaration or affidavit must be signed by both partners, notarized and sent with an Enrollment
and Change Forms. A copy should be retained by the group. The effective date is the date when the
affidavit is signed.
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If a domestic partner relationship is terminated, the employee must sign an Enrollment and Change
Form and cannot add a new domestic partner until the next open enrollment period.
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The employee may re-enroll the former partner if the Enrollment and Change Forms is received within 31
days of the termination.
Children
Anthem defines a child as one of the following dependents of a subscriber or of the subscriber’s
enrolled spouse:
A natural or legally adopted child
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A child for whom one or both of the above-mentioned adults has been appointed legal guardian
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A stepchild
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A child placed with the subscriber or subscriber’s enrolled spouse, and for which legal obligation for
total or partial support is retained in anticipation of adoption, and such child has not reached age 18
as of the date of the adoption or placement (foster children are not included)
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Benefits for newborns are automatically provided for the first 31 days. If the newborn is being added to an
existing policy an Enrollment and Change Forms must be received within 31 days of the date of birth.
Eligibility
A child is eligible to be enrolled as a dependent:
Up to age 26.
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If they are incapacitated and incapable of self-support due to a mental disorder, developmental
disability, mental retardation, or physical handicap. The child may continue to be enrolled past the age
of 26 with appropriate documentation. The disability must have occurred before the child reached age
26. Anthem must receive an application for this incapacitated status, and medical confirmation by a
physician of the extent and nature of the disability, within 30 days of the date coverage would
otherwise end.
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Who is not eligible?
Individuals ineligible for group coverage include, but are not limited to:
Temporary employees
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Trustees
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Silent partners
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Board members not on the company payroll
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Anyone not on the company payroll
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Retirees, unless your group has qualified for a retiree group
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Any employee who has not fulfilled the probationary period as outlined
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Parents
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Grandparents
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Grandchildren
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Household employees
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A child will no longer be eligible beginning the first of the month following the date of either one of the
following events:
The child turns 26 years old.
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The child, 26 years or older who had been physically or mentally incapable of self-support, becomes
capable of self-support.
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Please go to account manager with eligibility questions.
Probationary period (waiting period)
Probationary periods cannot be greater than 90-days as of January 1, 2014. A probationary period is a
period of time that an employer requires all newly-hired employees to wait before becoming eligible to
receive company benefits. Probationary periods are set by employers and cannot be greater than 90 days.
Anthem recommends that you submit the Enrollment and Change Forms as outlined below or as specified
by your contract. The date by which you submit an enrollment form impacts the effective date for the
employee’s medical coverage as follows:
Probationary period
Receipt of Enrollment and Change Forms
Effective date
Date of hire
Within 31 days of date of hire (DOH)
Date of hire
More than 31 days, but up to 90 days,
from DOH
The group’s next anniversary date
unless a qualifying event occurs
Within 31 days from the potential
effective date
First of the month following the
completion of the probationary period
after completion of probationary period
Time period other than none
Your probationary period may be changed during your anniversary month without review by Anthem’s
Underwriting department.
Any probationary period changes made after the anniversary date must have Underwriting approval.
Please put your request in writing and send it to your Account Manager.
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Changes will take effect on the first of the month following receipt of the written request. The change will
affect employees hired on or after the effective date of the change.
Generally, when an employee’s eligibility status changes because a part-time employee becomes a fulltime employee, the date of such change in status should be considered the date of hire for purposes of
determining the beginning of any probationary period.
To be considered a “rehire,” an employee must be hired again within 12 months from the date they were
terminated. If they are rehired more than 12 months after termination, they are subject to a “new hire”
probationary period.
There are two choices for the termination policy – either end of month (EOM) or date of termination (DOT).
Portability, availability and renewability of health coverage
New Hampshire law specifies that compliant groups who have waiting periods for pre-existing conditions
must allow new employees to present evidence of prior coverage when enrolling. The new enrollee must
obtain evidence of prior coverage from their previous health insurer. For coverage to be considered
creditable, the evidence of prior coverage cannot indicate a break of more than 63 days from the previous
insurer. Most carriers issue a Certificate of Group Health Plan Coverage to terminating members, as
required by New Hampshire law (and HIPAA). This document should accompany the employee’s enrollment
form but may be presented at any time.
Enrollment is the process of adding eligible employees and their dependents to your group’s Anthem plan.
The purpose of this section is to describe the enrollment process. There are four circumstances which
trigger the need for enrollment:
1. Open enrollment
Open enrollment occurs once a year. It is the 30-day period prior to the anniversary month of your contract
signing with Anthem. During this time employees may:
Make changes in their membership.
}}
Apply for coverage if they previously declined.
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2. Special enrollment
New Hampshire law allows for a special enrollment period when an employee, including those who
declined enrolling in the group health plan when first eligible, experiences a qualifying event such as
marriage, birth, adoption or placement for adoption. (See ‘section 5: Membership changes’ for a list of
qualifying events.)
3. Hiring a new employee
Over the course of a benefit year, new employees join your company and need to enroll in your health
care plan. (A special consideration for new hires is the probationary period. See ‘section 3: Eligibility’ for
more information).
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Section 4: Enrollment
4. Family status change
Over the course of a benefit year, employees may experience a change in their family status including
divorce, death of a spouse, or a spouse’s job loss that requires them to enroll in your health care plan.
(See ‘section 5: Membership changes’ for more information.)
Electronic enrollment
Web enrollment
File-based transfer
Business size
All sizes
Large
Description
The same process on paper, but online.
Complete enrollment applications
through online forms.
Ideal for high volumes of enrollment
transactions when a group prefers to
send an enrollment file.
Platform
Web-based, accessed through a browser.
Site specific, PC-based, Mainframe
Allows enrollment by Benefits
Administrator
Yes
Yes
Allows enrollment by employees
Yes
No
Features
New employee enrollment
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Open enrollment management
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Membership maintenance (add,
change, delete)
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128-bit encryption for safe, secure
transfer of information
}}
}}
}}
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24/7 access
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New employee enrollment
Open enrollment management
Eligibility maintenance (add,
change, delete)
Secure
24/7 access
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Quicker ID turnaround and member
benefit realization
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Automated member set up
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2 to 4 days faster processing than
paper forms, on average
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Quicker ID turnaround and member
benefit realization
}}
Groups should review the file-based
legal agreement to evaluate its
advantages and disadvantages.
Paper enrollment
Employee actions
Employee completes the Enrollment and Change Forms.
}}
Employee selects a primary care provider (PCP) for HMO Blue New England and Access Blue New
England plans – as well as Matthew Thornton BlueSM and Lumenos BlueChoice® New England CDHP
HSA and HRA plans.
}}
Employee keeps a copy and gives a copy to the Benefits Administrator.
}}
Benefits administrator actions
Check the Enrollment and Change Forms for accuracy and completeness.
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Keep a copy for your records.
}}
Mail the original or fax a copy to Anthem Blue Cross and Blue Shield. (See ‘section 1: Important phone
numbers and address.’) If you send your forms in by fax, do not mail the original paper copy.
}}
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Federal law requires insurers and third-party administrators to gather and report information about
Medicare recipients who have other group coverage. This helps the Centers for Medicare & Medicaid
Services (CMS) and health insurers coordinate benefit payments so claims can be paid promptly
and correctly.
As part of this process, members are asked to provide their Social Security numbers. If any of your covered
members are unable or unwilling to do so, they must fill out an exception form each year.
If a group member does not either provide a Social Security number or complete the enclosed form
annually, both Anthem and your group may be penalized.
Special enrollment considerations
For the following situations, additional forms are also required:
Dependent child, incapacitated, incapable of self support
A Request for Coverage for a Mentally or Physically Incapacitated Dependent Child Form.
}}
An adopted child
Proof of adoption or placement.
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Adding a child, court order
A copy of the court order.
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Domestic partner
A notarized Domestic Partner affidavit.
}}
When to send enrollment forms
The submission deadline depends on which enrollment circumstance is taking place:
Open enrollment
The Enrollment and Change Forms must be received by the last day of the open enrollment month to be
effective on the first day of the anniversary month.
Late enrollees
A late enrollee is an employee who signs an application more than 31 days after the effective date. Unless a
qualifying event has occurred the late enrollee must wait until their group’s next open enrollment period.
(See ‘section 5: Membership changes’ for more information.)
Qualifying event special enrollment
For special enrollments, all Enrollment and Change Forms must be received by Anthem during the first 31
days of the special enrollment period.
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Newly hired employees
Anthem recommends that you submit the Enrollment and Change Forms as outlined below or as specified by
your contract. The date by which you submit an Enrollment and Change Forms impacts the effective date for the
employee’s medical coverage as follows:
Probationary period
Effective date
Date of hire
Within 31 days of date of hire (DOH)
Date of hire
from DOH
Within 31 days after completion of
probationary period
First of the month following the
completion of the probationary period
after completion of probationary period
Time period other than none
Family status change
The following rules apply to membership enrollments as a result of marriage, birth, adoption or a
domestic partnership:
Marriage: Anthem recommends that you submit the Enrollment and Change Forms as recommended below
or as specified by your contract. The date by which you submit an Enrollment and Change Forms impacts the
effective date for the spouse’s medical coverage as follows:
}}
Applying for coverage after
getting married
Enrollment and Change
Forms submitted
Effective date of the policy
Subscriber applying for new coverage
with dependents (new spouse, children,
spouse’s children)
Within 31 days of date of
marriage (DOM)
First of the month following receipt of
the paperwork
More than 31 days from DOM
The group’s next anniversary date unless
a qualifying event occurs
Dependents (new spouse, children,
spouse’s children) applying under
subscriber’s existing plan
Within 31 days of DOM
DOM
More than 31 days from DOM
The group’s next anniversary date unless
a qualifying event occurs
Birth or adoption: Benefits are provided for the newborn/adopted child for up to 31 days following birth/
placement/adoption. Copies of placement or adoption papers are required. Submit the membership
Enrollment and Change Forms within 31 days following the child’s date of birth/placement/adoption (DOB/
P/A) to ensure uninterrupted coverage. The date by which you submit an Enrollment and Change Forms
impacts the effective date for the child’s medical coverage as follows:
}}
Effective Date
Within 31 days of DOB/P/A
DOB/P/A
More than 31 days from DOB/P/A
Note: This means the child has no benefits from day 32 to the
effective date and must fulfill any waiting periods for
pre-existing conditions.
13
On a family membership: A newborn/adopted child is a member from the date of birth/placement.
The birth/placement must be reported to Anthem within 31 days by submitting an Enrollment and
Change Forms for the new dependent to be added to the family records and for claim payments to be
made appropriately. Copies of placement or adoption papers are required, if applicable.
}}
Domestic partner: Submit affidavit within 31 days from the date it is signed and date it is notarized. The
effective date is the date it is signed.
}}
Adding an employee or dependent during a special enrollment period
Employees and their dependents who fail to enroll when first eligible may be added to your group plan
during the year, following open enrollment, if certain qualifying events occur.
Qualifying events
Qualifying events for enrolling an employee or dependent include:
If a person was covered under another public or private health coverage when first eligible to enroll in
this plan and the other coverage ends due to termination of employment or eligibility, or termination of
the other plan’s coverage, the death of a spouse, or divorce.
}}
Marriage/domestic partnership. (Domestic partner rider must be offered by your group. See ‘section 3:
Eligibility’ for more information.)
}}
A child joining a family by birth, adoption/placement, or marriage of subscriber.
}}
Loss of health insurance coverage.
}}
Employees not otherwise covered are allowed to enroll due to marriage at the same time as the
new spouse.
}}
Employees not otherwise covered are allowed to enroll at the same time as a newborn or adopted child.
}}
All other employees who refuse initial enrollment rights are late enrollees. Late enrollees cannot enroll
until the group’s next open enrollment period.
Timeframe
When a qualifying event occurs you have 31 calendar days from the date of the event to add a dependent to
make sure there is uninterrupted coverage. In the event of loss of coverage, you have 60 days from the date
of the loss to enroll the employee and/or dependent to make sure there is uninterrupted coverage.
Effective date
The change will be effective as of the first of the month following receipt of the Enrollment and Change
Forms. In the case of adoption/placement, the effective date is the date of placement. In the case of loss of
coverage, the effective date is the day after the prior coverage is lost.
Retroactivity
Retroactivity will not be permitted.
14
Section 5: Membership changes
Employee actions
Employee completes the Enrollment and Change Forms in its entirety. To add a dependent, list all
individuals who should be covered by the policy.
}}
Employee selects a primary care provider (PCP) for BlueChoice®, HMO Blue New England, Access Blue New
England, Matthew Thornton BlueSM, Lumenos BlueChoice New England CDHP HSA and HRA products.
}}
Employee sees Special Enrollment Considerations for any additional forms that may be required.
}}
Employee keeps a copy and gives a copy to the benefits administrator.
}}
}}Mail the original or fax a copy to Anthem Blue Cross and Blue Shield. (See ‘section 1: Important phone
numbers and address.’) If you send your forms in by fax, do not mail the original paper copy.
}}
}}
Membership changes can also be submitted electronically, please see ‘section 4: Enrollment’ for
more information.
Removing a dependent
Dependents may be removed from your group plan during the year, following open enrollment.
Downgrade to a single person policy can be done at any time, no event required. A subscriber may adjust
his or her policy to a single person policy when removing a dependent, if applicable.
Domestic partnership
If a domestic partner relationship is terminated, the employee must sign a termination notice and an
Enrollment and Change Forms and cannot add a new domestic partner until 12 months after termination.
The employee may re-enroll the former partner if applying within 31 days of termination.
Re-enrolling
Dependents can only be re-enrolled if a subsequent qualifying event occurs (special enrollment) or if it is
the group’s open enrollment period.
Effective date
The effective date of change will usually be the first day of the month following receipt of the Enrollment
and Change Forms by Anthem.
Certificate of Health Plan Coverage
Provided that Anthem and the employer have agreed in writing, when termination paperwork is received,
Anthem will send the dependent a Certificate of Group Health Plan Coverage in compliance with
New Hampshire law (and HIPAA).
15
Employee actions
Employee completes the Enrollment and Change Forms in its entirety. To remove a dependent, please
list all individuals who should remain on the policy in the “who is to be covered” section.
}}
}}
Benefits Administrator actions
}}
}}
numbers and address’) If you send your forms by fax, do not mail the original paper copy.
}}
Membership changes can also be submitted electronically. (See ‘section 4: Enrollment’)
Changing a name or address
Name or address changes may be submitted at any time. Address changes may also be done by the
subscriber by calling Anthem Customer Service.
Legal documentation is required if a name is changed due to reasons other than marriage or divorce.
Employee actions
Employee completes the Enrollment and Change Forms, checks “change of name/address,” fills in the
new information, and signs it.
}}
For a name change, indicate “Name change” under section 3 ”Change Membership.”
}}
}}
}}
}}
numbers and address.’) If you send your forms by fax, do not mail the original paper copy.
}}
Membership changes can also be submitted electronically. (See ‘section 4: Enrollment.’)
Changing a primary care provider (PCP)
A PCP change may be made at any time over the phone or in writing. The change must be entered in the
member’s record by Anthem before the member sees a new PCP.
Effective date
For BlueChoice, Access Blue, HMO Blue New England, BlueChoice New England and Matthew Thornton Blue,
the change will be effective immediately upon request.
Customer Service
Your employees may call Anthem Customer Service to change a PCP.
16
Employee actions
Employee completes the Enrollment and Change Forms or calls Customer Service.
}}
The employee may need to consult the network directory or go to anthem.com to select a new PCP.
}}
}}
}}
}}
Mail the original or fax a copy to Anthem Blue Cross and Blue Shield (See ‘section 1: Important phone
}}
If a PCP terminates or moves
Occasionally, a network PCP will terminate their contract with Anthem or move the practice out of area.
If this happens, a default PCP will be posted to the member and a new ID card will be sent to the member
telling them they need to call Anthem. Members will need to call Anthem Member Services to choose a
new provider.
Removing a subscriber
Subscribers may be removed from your group plan either by the employee’s voluntary cancellation or by
employment termination.
Timeframe
The Enrollment and Change Forms must be received by Anthem within 31 days of the term date
being requested.
Effective date Certificate of Prior Coverage
The effective date is the date of termination for a DOT group and the last day of the month for an EOM
group, provided the request is received within 31 days of the effective date. When the Enrollment and
Change Forms is received, Anthem will send the subscriber a Certificate of Group Health Plan Coverage
Form (HIPAA letter), if applicable.
Important note
When an employee leaves, it is very important for billing purposes that you immediately send in the
necessary paperwork to cancel his or her coverage. If the employee later elects to exercise his or her right
to have coverage continued, the employee will be added back on the plan retroactively to the date of
termination (understanding that arrangements have been made between you and the former employee for
premium owed).
If the employee does not elect to continue coverage and you have not cancelled their coverage, Anthem will
not retroactively terminate the coverage and reimburse premium paid.
17
Employee actions
Employee who voluntarily cancels should complete the Enrollment and Change Forms.
}}
Employee who terminates employment does not need to complete any forms unless he or she elects
continuation of coverage. Benefits administrator should fill out Notice of Membership Change Form.
(See ‘section 8: Continuation of Coverage’ for further instructions.)
}}
}}
Check the Enrollment and Change Forms for accuracy and completeness, or complete the Notice
of Membership Change Form.
}}
}}
}}
Other insurance
On occasion, members will have more than one payer potentially liable for a payment of service. When this
happens, benefits need to be coordinated by determining which of the payers is fully and/or partially liable.
Other Party Liability (OPL)
The OPL team is responsible for recoveries and savings attributable to coordination of benefits, subrogation
and workers’ compensation.
What you can do to help
You can assist Anthem’s recovery efforts to help ensure claims are processed correctly by:
Making sure the “other insurance section” of the Enrollment and Change Forms is completely filled out.
}}
Making sure your employees advise Anthem when their insurance status changes. (i.e., divorce, Medicare
eligibility, etc.)
}}
Notifying Anthem of any work related injuries. You can either send us a copy of the First Report of Injury
Form or use the Workers’ Compensation postcard to let us know of the employees’ injuries.
}}
Notifying Anthem with any knowledge of an accident (motor vehicle, motorcycle, bicycle, chainsaw,
lawnmower, etc.)
}}
18
Section 6: Billing and reconciliation
An invoice is sent out monthly or, in some cases, quarterly. The invoice includes the billing period, due
date, subscriber names, subscriber ID, type of coverage, and premium amounts. Anthem is a prepaid health
plan. All premiums are due by the first of the month for which insurance benefits will be provided to your
employees and their dependents. Accounts are considered past due if payment has not been received by
the 20th day of the month in which premium is due, at which time, you will receive a late notice. If your
account is not paid prior to the end of the month it is due, cancellation may occur.
Please reconcile your statement on a regular basis to ensure submitted adds and terminations have been
processed as expected.
Payment
Enclose the tear-off portion (payment stub) from the last page of your invoice. Indicate the amount of
your payment that should be allocated to this invoice stub.
}}
Indicate the “customer number” on your check or check stub.
}}
Mail invoice stub and payment to:
Anthem Blue Cross and Blue Shield
PO Box 1168
Newark, NJ 07101-1168
}}
Written notification of past due premium will be mailed on the 20th of the month in which premium is due.
Non-payment of premiums by the end of the due month may cause cancellation of your health coverage.
Do not send membership changes with payments. (See ‘Section 5: Membership changes’ for instructions
on submitting membership changes.)
Return check fee
A $20 fee will be accessed for any returned checks.
}}
The $20 returned check fee must also be paid by the subsequent invoice to avoid termination.
}}
Reinstatement
When a group is terminated, all past due and current premiums must be paid at the time of request
for reinstatement.
}}
A $150 reinstatement fee must also be paid at the time of request for reinstatement.
}}
19
Section 7: Medicare eligible members
Medicare is a federal health insurance program created in 1965. Medicare consists of three health care
program components:
Hospital benefit plan (Part A): Covers usual expenses in hospitals and skilled nursing facilities, and
approved home health care expenses.
}}
Medical benefit plan (Part B): Helps pay for doctor’s services and medical items and services not covered
under the hospital insurance program.
}}
Prescription benefit plan (Part D): Helps pay for prescription costs.
}}
Eligibility
A person usually becomes eligible for Medicare coverage by:
turning age 65
}}
becoming disabled, as determined by the Social Security Administration
}}
When a member of your group becomes eligible for Medicare, this does not necessarily mean that
Medicare will become his or her primary payer. See the ‘Medicare and group coverage: who is the primary
carrier’ chart later in this section for more information.
Required actions
In all cases, the fact that a member is or becomes eligible for Medicare must be communicated
immediately to Anthem.
Whether or not Medicare is the primary plan is determined by:
The reason the member has become eligible for Medicare.
}}
The size of the group.
}}
The actively at work status of the subscriber.
}}
Medicare Supplementary coverage
Medicomp
Anthem administers Medicare Supplementary programs that are intended to fill the gaps in benefit
coverage not satisfied by Medicare. Medicare Supplementary coverage for individuals eligible for Medicare
will vary depending on the coverage option elected by the employer. The employer should make available
supplementary coverage for individuals who have Medicare as their primary plan. This selection should be
made at the time the group enrolls and at each renewal with Anthem.
20
Who initiates notification and when
Anthem
Anthem will notify you by mail three months prior to when an employee/spouse is turning 65. You will
receive a Notice of Medicare Eligibility Form. Please be sure to submit both a completed Notice of
Medicare Eligibility Form and a Medicare Supplemental Selection Form for employees who enroll in a
group Medicare Supplemental Plan.
The benefits administrator
You need to notify Anthem when an employee who is under 65 becomes eligible for Medicare coverage.
Determining primary coverage
General rules
The following chart contains general guidelines for determining primary coverage given your group’s size,
the active employees’ or dependents’ status and Medicare qualifying event. To define “active” employment
for your group, seek legal counsel.
If you have a question on determining primary coverage, contact the Centers for Medicare and Medicaid
Services (CMS) or visit cms.gov.
Important notes
Medicare Supplemental eligibility requirements: To qualify for Medicare Supplemental coverage, eligible
employees must enroll in Parts A and B of Medicare. Any individual considering a delay in Medicare
enrollment should be directed to the nearest Social Security Administration office for immediate guidance.
Membership changes individual coverage: Because Medicare Supplemental Plans are administered when
employees become Medicare eligible, and elect a Medicare Supplemental plan, the previous membership
type will need to be changed, for example, from “Applicant/Spouse” to “Individual.”
21
Medicare and group coverage: Who is the primary carrier?
Actively at work:
ACTIVELY AT WORK
Employees and their Dependents:
Medicare Eligible
Medicare Enrolled
Groups 19 or
fewer employees
Groups 20-99
employees
Groups 100 or
more employees
Member is 65 or over
and Medicare eligible
due to age
Part A
Medicare coverage
is primary
Group coverage is
primary
Group coverage is
primary
Parts A & B
Medicare coverage
is primary
(employee elects
the Group Medicare
Supplemental policy)
Group coverage is
primary Employee
may select:
}}Group coverage as
primary, or
Same requirements
as in Groups of 20
or more
Medicare as
primary. If this
option is chosen,
the beneficiary is
NOT eligible for
group coverage.
The employee may
purchase a nongroup supplement
policy at his or her
own expense. The
group cannot
contribute to the
non-group policy.
}}
Member is under 65
and Medicare eligible
due to disability
Member has ESRD
Part A
Medicare coverage
is primary
Medicare coverage
is primary
Group coverage
is primary
Parts A & B
**Medicare coverage
is primary
**Medicare coverage
is primary
Group coverage
is primary
Member has Medicare coverage for end stage renal disease (ESRD)
For all group health plans, group coverage is primary during the first 30 months of Medicare eligibility
if the member has Medicare solely due to ESRD. (Medicare becomes primary when the 30-month
coordination period ends.)
Exception: If a member already has Medicare primary due to age or disability (see above) and
then he or she also becomes an ESRD beneficiary, Medicare remains primary. There is no 30-month
coordination period.
**Complete a Medicare Supplemental Selection Form and return to Anthem.
Employee must have both Parts A & B of Medicare to be eligible for the Group Medicomp policy.
22
Not actively at work
For Anthem groups of two or more: Retiree plans may be made available to former employees at the option of
the employer and subject to Anthem underwriting guidelines.
When Medicare is primary. Medicare is primary for most ‘not actively at work’ employees, such as
retirees or employees covered on an employer’s disability segment for more than six months.
}}
Exception ESRD: If an employee had Medicare as secondary due to age or disability immediately before
he or she also becomes an ESRD beneficiary, Medicare remains secondary throughout a 30-month
coordination period, even if the employee becomes a ‘not actively at work’ employee covered under
retiree or disability. When the 30-month coordination period ends, Medicare becomes primary.
How Medicare works with COBRA. Under federal COBRA law, an employee may continue on COBRA if
he/she also has Medicare, provided that he or she was entitled to Medicare on the day of COBRA
election. Medicare is prime with one exception for ESRD (stated above). If Medicare entitlement occurs
after COBRA election, COBRA coverage may end if the groups’ plan documents so designate. Under New
Hampshire Continuation of Coverage law, an employee cannot continue group coverage if he/she is
entitled to Medicare before, on or after he or she elects the continuation. (Entitlement to Medicare means
that the member is actually enrolled in Medicare.)
}}
If your employee is on COBRA continuation, refer to the COBRA regulations for Medicare Secondary
Payer rules.
If you offer a retiree program, you should refer to ‘section 9: Retirees.’
The information provided here does not constitute legal advice. Please contact your attorney if you have any
questions regarding the application of state and federal laws to your employee benefits plan.
Retirees and their dependents
For more information on retirees and their dependents, please see ‘section 9: Retirees.’
An active employee or dependent is turning 65
Coverage continuation for dependents
When Medicare becomes primary for an active employee, dependents under the age of 65 are eligible to
continue group coverage because the employee is still actively employed. In this eligibility circumstance,
“dependent” refers to the employee’s spouse or a physically/mentally incapacitated “child” who has been
continuously covered. The following pages contain the steps to take when a member is turning 65 and is
Medicare eligible. Prior to the member’s birth date, Anthem will alert you that the member is about to turn 65
by sending a notice.
Employee actions
Employee enrolls in Medicare at the local Social Security Administration office.
}}
Employee completes the Enrollment and Change Forms and includes information for both the Medicare
eligible member and for dependents not Medicare eligible.
}}
Employee includes Notice of Medicare Eligibility Form.
}}
Employee includes Medicare Supplemental Selection Form.
}}
Employee includes OBRA Employee Certificate Form, if applicable.
}}
}}
23
Mail or fax the member’s completed form(s), along with a copy of the member’s Medicare Health Insurance
Card or other evidence of Medicare coverage, to Anthem Blue Cross and Blue Shield (See ‘section 1:
Important phone numbers and address.’):
For BlueChoice and Matthew Thornton Blue: Within 10 days of receiving the notification letter.
}}
For Indemnity: Within 30 days of the member’s 65th birthday.
}}
If you send your forms by fax, do not mail the original paper copy.
Employee is under age 65 and becomes Medicare eligible
What to do when Medicare is the primary plan
Please complete the following steps when Medicare is the primary plan and the member is eligible to
remain covered under your group.
Employee actions
}}
Employee completes the Enrollment and Change Forms indicating the reason for the status change as
“Other – Medicare Eligible.”
}}
Employee includes the Notice of Medicare Eligibility Form.
}}
}}
}}
}}
Mail or fax the member’s completed form along with a copy of the member’s Medicare Health Insurance
Card or other evidence of Medicare coverage to Anthem Blue Cross and Blue Shield. (See ‘Section 1:
Important phone numbers and address.’) If you send your forms by fax, do not mail the original paper copy.
}}
What to do when group coverage is the primary plan
Please complete the following steps if the member chooses to remain covered under your group.
Employee actions
}}
Employee completes the Enrollment and Change Forms indicating the reason for the status change as
“Other – Medicare Eligible.”
}}
Employee completes an OBRA Employee Certification Form.
}}
}}
}}
}}
Mail or fax the member’s completed form, along with a copy of the member’s Medicare Health Insurance
Card or other evidence of Medicare coverage, to Anthem Blue Cross and Blue Shield. (See ‘section 1:
Important phone numbers and address.’) If you send your forms by fax, do not mail the original paper copy.
}}
24
Section 8: Continuation of coverage
This section is meant to inform you of the administrative tasks you need to perform with Anthem related to
continuation of coverage. It is a general guide only and not meant to be legal advice. Please consult with
your legal counsel for further information about the application of the laws referenced.
Events giving rise to continuation of coverage rights include, but may not be limited to the following:
Death of an employee
}}
A reduction of work hours below the minimum required for group membership
}}
Job termination (other than by reason of employees gross misconduct)
}}
Job loss due to employer bankruptcy
}}
Layoff
}}
Voluntary resignation
}}
Divorce or legal separation
}}
A member is no longer eligible due to age/student status
}}
Laws that dictate the actions you, as an employer, are required to take may include:
Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985
}}
New Hampshire State Continuation of Coverage Law (NH C of C)
}}
Omnibus Budget Reconciliation Act (OBRA) of 1986
}}
Family and Medical Leave Act (FMLA)
}}
In some situations, more than one law may apply. If you have a question about which laws apply, contact
your legal counsel.
Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)
COBRA was established to provide continuing group health care coverage for those whose coverage would
otherwise be terminated.
This law applies to group health plans maintained by employers with 20 or more employees as long as the
employers are in the private sector, state or local government. For more information about COBRA contact:
U.S. Department of Labor
Pension and Welfare Benefits Administration
Division of Technical Assistance and Inquiries
200 Constitution Ave., NW, Room N-5658
Washington, DC 20210
Continuing Health Care Coverage is an employer’s guide to providing COBRA coverage to former employees
and their beneficiaries. For a copy, write to:
Charles D. Spencer & Associates, Inc.
250 S. Wacker Drive, Suite 600
Chicago, Illinois 60606-5834
25
The COBRA Handbook is a more detailed guide. For a copy, call 866-444-3272 or write to:
Aspen Publishers
1185 Avenue of the Americas
New York, NY 10036
NH State Continuation of Coverage Law (NH C of C)
This law was established by New Hampshire legislation to provide continuing group health coverage for
those whose coverage would otherwise be terminated.
It applies to all New Hampshire employers. NH C of C is not available to individuals covered under groups
of one.
For more information about NH C of C contact:
New Hampshire Insurance Department
21 South Fruit Street, Suite 14
Concord, New Hampshire 03301
603-271-2261
state.nh.us
Omnibus Budget Reconciliation Act of 1986 (OBRA)
OBRA legislation has two parts. One part concerns continuation for retirees, their spouses and dependents
of an employer who files for protection under Chapter 11 of the Federal Bankruptcy Act. The other concerns
Medicare eligibility for individuals under age 65 (see ‘Section 7: Medicare eligible members’).
It applies to most New Hampshire employers with 100 or more full- and part-time employees. Certain
employers are exempt from OBRA, such as religious entities.
For more information about OBRA contact:
Pension and Welfare Benefits Administration
Administrative information on COBRA, NH C of C, and OBRA
For COBRA, OBRA and NH C of C, coverage begins on the day after group coverage would otherwise end.
When an employee leaves, or a dependent becomes ineligible for membership it is very important that you
send the necessary paperwork to notify Anthem to cancel coverage and remove the employee and any
dependents from your premium billing. Anthem must receive your paperwork within 30 days of the
employee’s termination date. The former employee has up to 60 days under COBRA and OBRA, and up to 45
days under NH C of C, after the date of their notification, to decide whether to elect to continue coverage.
If prior to the end of the decision period, the employee elects to exercise his or her right to have coverage
continued, the employee will be added back on the plan retroactively to the date of termination
(understanding that arrangements have been made between you and the former employee for
premium owed).
26
When you and your legal counsel have determined that an individual is no longer eligible to continue
coverage, or if the member voluntarily cancels the continuation policy, you must notify Anthem by
following the appropriate instructions on the following pages.
If continuation of coverage ends, the continuing member may be eligible to convert to a non-group
Anthem policy. The member must have been covered under the group plan for at least 60 days and
must apply for non-group coverage within 31 days after termination from group coverage.
If prior to the end of the decision period, the employee elects to exercise his or her right to have coverage
continued, the employee will be added back on the plan retroactively to the date of termination
(understanding that arrangements have been made between you and the former employee for
premium owed).
When you and your legal counsel have determined that an individual is no longer eligible to continue
coverage, or if the member voluntarily cancels the continuation policy, you must notify Anthem by
following the appropriate instructions on the following pages.
If continuation of coverage ends, the continuing member may be eligible to convert to a non-group
Anthem policy. The member must have been covered under the group plan for at least 60 days and
must apply for non-group coverage within 31 days after termination from group coverage.
Family Medical Leave Act (FMLA)
This law entitles employees who have been employed for at least 12 months by the same employer, and
have worked 1,250 or more hours during the 12-month period immediately preceding the start of the leave
to take a total of 12 work weeks of leave during any 12-month period if one or more of the following occurs:
Birth or adoption of a child
}}
Placement with employee of a child for adoption or foster care
}}
Care for spouse, son, daughter or parent who has serious health condition
}}
Serious health condition of the employee
}}
The law applies to employers with 50 or more employees, including those employers with multiple
locations within a 75-mile radius of each other whose total employee count equals 50 or more.
An employee is entitled to a total of 12 work weeks of unpaid leave during any 12-month period. The
employer is required to maintain coverage under any group health plan for the duration of the leave as if
the employee were continuously employed. Coverage is paid for just as it was when the employee was
active, but you should consult legal counsel to determine any reimbursement rights that you may have.
For more information about FMLA contact:
Pension and Welfare Benefit Administration
27
Steps you take with Anthem to continue coverage
This section shows you how to continue coverage for employees and their dependents if such employees/
dependents elect to continue their coverage.
Former Employee actions
Employee completes the Enrollment and Change Forms.
}}
For COBRA: Employee indicates “COBRA continuation” under “Reason for completing form.”
}}
For NH C of C: Employee indicates “Other” under “Change in status due to:” and fill in the blank with
“State Continuation.”
}}
For OBRA: Employee indicates “Other” under “Change in status due to:” and fill in the blank with “OBRA
– Chapter 11.”
}}
}}
}}
}}
Mail the original or fax a copy to Anthem Blue Cross and Blue Shield. (See ‘Section 1: Important phone
numbers and address.’) If you send your forms by fax, do not mail the original paper copies.
}}
Steps you take with Anthem to remove a member from continuation of coverage
Former Employee actions
The former employee only needs to complete this step if voluntarily canceling:
Employee completes the Enrollment and Change Forms as follows:
}}
— Locate the “Reason For Completing Form” section and indicate “Voluntary cancellation”
— Locate the “Change in status due to:” section, check off “Other” and indicate the following:
For COBRA: Indicate “COBRA”
}}
For NH C of C: Indicate “State Continuation”
}}
For OBRA: Indicate “OBRA - Chapter 11”
}}
Employee keeps a copy for his or her records and gives a copy to the benefits administrator.
}}
If applicable, check the Enrollment and Change Forms for accuracy and completeness.
}}
}}
Mail the original or fax a copy to Anthem Blue Cross and Blue Shield. (See ‘Section 1: Important phone
numbers and address.’) If you send your forms by fax, do not mail the original paper copies.
}}
28
Section 9: Retirees
For a retiree of your company to be covered by Anthem, your group must have established a retiree or
pension section with Anthem. These special billing sections provide the information for former employees
and their dependents to access group health benefits upon retirement. Not every group chooses to provide
this level of benefit, and you are under no obligation to do so. Any employer with two or more employees is
eligible to establish a retiree section, subject to certain conditions. If someone in your group is retiring and
you are reading this section for guidance, more than likely one of the following situations is true for you:
You do not wish to provide coverage to retirees.
}}
You do not currently offer retiree coverage and wish to establish that benefit.
}}
You offer retiree coverage and need to send in the necessary paperwork.
}}
You are not sure if you have retiree coverage.
}}
Obtaining retiree coverage
Employer requirements
For an employer to obtain retiree coverage, the employer must meet three general requirements:
1. A Retirement plan: The employer must have a formally documented retiree plan in effect that outlines
eligibility guidelines such as:
— Class of employee eligible for retirement benefits
— Number of years worked
— Expected contribution
— Spouse or dependent eligibility (including survivors of a deceased retiree)
2. Administration: The employer must agree to assume all administrative responsibilities in conjunction
with the retiree group plan.
3. Size: The employer must employ two or more individuals.
Retiree eligibility guidelines
The following items are general eligibility requirements for both Medicare supplement coverage and full
group coverage. Employers may have other specific requirements within their own formal retiree
agreements which would be incorporated into Anthem’s final retiree eligibility criteria for that particular
group. The retiree must transfer to retiree coverage immediately upon retirement. He or she will not be
allowed into the group plan at a later date and cannot remain on the active group billing section, unless a
late entry is allowed under New Hampshire law.*
Employees who retire before the establishment of a retiree section may be eligible to enroll if:
1. They meet the eligibility criteria outlined within the retiree plan,
2. They enroll when the new retiree section for the group is established, and
3. Late enrollment is allowed under New Hampshire law.*
}}
Employers should establish the rules for dependent eligibility within their formal retiree document. If
dependents are eligible, a retiree may choose to include none or all dependents within the retiree
membership. In the case where a spouse has coverage elsewhere and has only one child, the retiree may
choose to:
}}
— Enroll as a single parent with one child, or
— Enroll just himself or herself under a single person policy.
A retiree may maintain a membership under the retiree group and also be covered by a spouse’s group
membership. However, dual membership, when either partner has a non-group membership, is
not permitted.
}}
* In general, New Hampshire law addresses late enrollment only for certain former employees of New Hampshire municipalities.
29
Section 9: Retirees
Setting up retiree coverage
To set up a retiree section within your Anthem agreement, simply read through the preceding employer
requirements and retiree eligibility guidelines, and then call your Anthem Account Manager.
What to do when an employee retires and your group has no retiree coverage
Your group has no retiree coverage for one of two reasons:
Your group has no formal retiree plan document; therefore, you are unable to obtain coverage.
}}
You have chosen not to establish a retiree section in your agreement with Anthem.
}}
In either case, one of the following applies:
Retiree is 65 or over
If the retiree is 65 or older, then Medicare usually becomes the primary payer. The retiree may elect
non-group Medicomp coverage. (To elect this, the retiree must have both Parts A and B of Medicare.) If your
group is COBRA compliant, the retiree may choose to continue group coverage on COBRA and Medicare is
usually prime. If your group is not COBRA complaint, the retiree is not eligible for NH C of C.
Refer to ‘Section 7: Medicare eligible members’ for more specific instructions.
Retiree is under 65
If the retiree is under age 65, and not eligible for Medicare, then COBRA or NH C of C is available.
If the retiree is under age 65 and eligible for Medicare,* he or she may elect COBRA, provided that your
group is COBRA compliant (20 or more employees) and all other criteria has been met. If the retiree
becomes eligible for Medicare after he or she elects COBRA, eligibility for continuation of group coverage
may end only if the group’s plan document so designates. If the retiree becomes eligible for Medicare after
he or she elects NH C of C, eligibility for continuation of group coverage ends.
Whether a retiree leaves the group directly, leaves a retiree plan or terminates COBRA, he or she may select
an available Anthem non-group plan.
Refer to ‘Section 8: Continuation of coverage.’ For more instructions, go to the ‘Removing a subscriber’
section under ‘Section 5: Membership changes.’
* “Eligible for Medicare” means “enrolled in Medicare.”
What to do when an employee retires and your group has retiree coverage
If your group has retiree coverage, follow these steps when an employee retires.
Employee actions
Employee completes the Enrollment and Change Forms indicating “Retirement” at the top of the form.
Be sure to include any Medicare coverage information that may apply.
}}
}}
30
Section 9: Retirees
}}
}}
Complete the Notice of Membership Change Form and keep a copy for your records. Indicate keyword
“OTHER” and specify the retiree firm/division number at the top of the form.
}}
Mail the original or fax a copy of the completed forms to Anthem Blue Cross and Blue Shield. (See
‘Section 1: Important phone numbers and address.’) If you send your forms by fax, do not mail the
original paper copy.
}}
Canceling group retiree coverage
Retiree Group coverage may be terminated under one of the following two circumstances:
1. No longer offering coverage
If an employer chooses to discontinue retiree coverage, retirees and their covered dependents may be
eligible to transfer to non-group Anthem coverage. You may also need to issue certain COBRA notices, if
your group is COBRA compliant. Seek legal counsel to determine if COBRA notice is required for retirees.
Provide each enrolled retiree and their dependents written notice that retiree benefits are ending, and
COBRA notice as required.
}}
Advise the member to contact Customer Service to discuss available non-group options.
}}
Provide your Anthem Account Manager with written notice of retiree benefit cancellation.
}}
2. Cancelling group coverage
When the group chooses to cancel its Anthem coverage for another health plan carrier, the retiree section
of the agreement must also be cancelled and transferred to the new carrier. Retirees and dependents are
not eligible for COBRA continuation or to transfer to non-group Anthem coverage in this circumstance.
Provide your Anthem Account Manager with written notice of cancellation prior to the desired
effective date.
}}
Specify the new carrier chosen.
}}
Indicate all group numbers appearing on your Anthem invoices.
}}
31
Section 10: Online tools and resources
With our secure, online business tools, Anthem Blue Cross and Blue Shield makes it easier to administer
your benefit package. See for yourself. Log on to anthem.com > Employers > New Hampshire > Take a
virtual tour of our online tools.
Online tools and resources for employers
Employer Group Inquiry
Through the Employer Group Inquiry (EGI) feature, you can efficiently manage day-to-day benefit
administration tasks like:
View contract and coverage information (e.g., current address, phone number, contract number, plan
details and more).
}}
View benefit details, including co-payments and deductibles.
}}
Update primary care physician (if applicable).
}}
Request replacement ID cards.
}}
Update member contract information, such as an address or phone number.
}}
View employee coverage choices from previous years.
}}
Online Group Billing
Online Group Billing allows you to view and pay your bills online. This easy and convenient tool lets you:
View and print detailed premium bills going back 13 months.
}}
Pay bills electronically in a secure online environment.
}}
Manage your bank accounts with privacy.
}}
Eliminate paper bills completely (optional).
}}
Web Enrollment
Online Web Enrollment helps reduce paperwork, so that you can focus on your core business. This
password-protected application lets you:
Enroll new employees.
}}
Perform enrollment maintenance.
}}
Add or cancel dependents.
}}
Cancel contracts.
}}
Update names and addresses.
}}
Perform self-service tasks for open or new group enrollments.
}}
Reinstate contracts.*
}}
Utilize powerful search functionality.
}}
* This feature is subject to Anthem’s underwriting guidelines and requires Anthem’s consent.
32
Section 10: Online tools and resources
File-Based Transfer
Filed-Based Transfer is a process that’s ideal for larger groups. File-Based Transfer can be used to perform
the same eligibility functions as Web Enrollment. Both File-Based Transfer and Web Enrollment are secure
and accessible 24/7. Refer to the Web Enrollment section to compare your options.
Online tools and resources for members
Instant access to our online tools makes it easier for your employees to perform a variety of self-service
functions, so that you can focus more on your daily business. The more your employees know about their
plan, the better they can use it to their advantage – without posing time consuming questions to you or your
office staff. Employees have access to programs and services designed to help them get the most from
their benefits.
anthem.com
The vast online health information resources available at anthem.com give your employees the tools they
need to help them make health care decisions. Safe and secure, members can log on to:
View benefit details, including copays and deductibles.
}}
Check claims status.
}}
Choose a new primary care physician (if applicable).
}}
Find a network doctor or hospital using the online Provider directory.
}}
Request a permanent or temporary member ID card.
}}
Change passwords.
}}
Update an email address.
}}
Sign up for email messages from Anthem Blue Cross and Blue Shield.
}}
Submit benefit questions to Anthem Blue Cross and Blue Shield.
}}
Find information on chronic and acute diseases, use interactive health assessment tools, store and
organize personal health information, drug information and more.
}}
Find discounts on a wide variety of healthy living products and services such as fitness club
memberships, weight loss programs, safety products, vision correction surgery and more.
}}
Members can also use:
LifeAfter50: This website, accessible through anthem.com, provides online information and tools tailored
to the unique health and wellness needs of baby boomers and seniors.
}}
Healthy Lifestyles® – An easy-to-use online fitness and nutrition program that “rewards” employees for
leading healthier lifestyles.
}}
33
Section 11: Glossary
Administrative fee
The dollar amount paid to an administrator by a self-insuring firm or member of that firm for administration
of the health benefit plan.
Account agreement
The agreement between a firm and Anthem that details the terms of the firm’s health care coverage with us.
Account service team
The account executive and account manager representative in the sales office who provide service to your
firm account.
Amendment
A provision added to a subscriber’s contract that modifies coverage specified in the plan documents.
Annual enrollment period
The one-month period prior to a firm’s annual review during which employees and their dependents that
declined to enroll in the firm’s health plan when they were initially eligible would be allowed to enroll in the
firm health plan. Certain restrictions may apply on benefits for the first year of coverage, depending on the
coverage option chosen.
Annual review
A review of a firm’s coverage that usually occurs on the anniversary date of the firm’s enrollment with us.
This is sometimes referred to as renewal.
Anthem Care Management
A department at Anthem that provides utilization management, including member consultation,
preadmission review, continued stay review, individual care management and second surgical
opinion assistance.
Arrears
An unpaid or past due premium or fee amount.
Benefits administrator
An individual appointed by a firm to administer the health benefit program. The benefits administrator is
the liaison between the firm’s member, the firm and us.
Certificate number
A number used to identify the subscriber’s and family members’ health benefit coverage. The certificate
number appears on the ID card. It is also called the contract number.
34
Certificate of coverage
A contractual document including the application for enrollment, certificate, any amendments or attached
papers containing membership and eligibility provisions, benefit provisions, limitations and exclusions and
other information about health benefit coverage.
Certification of Creditable Coverage Notice (HIPAA Notice)
A mandated notice under the Health Insurance Portability and Accountability Act of 1996 that we issue to
every terminated member of your firm health plan. The notice must contain information on the employee’s
and/or dependent’s length of coverage under the plan, activation and termination dates, waiting period
information, COBRA eligibility and exhausted COBRA benefits.
COBRA
The Consolidated Omnibus Budget Reconciliation Act of 1985, as amended. COBRA applies to firms who
sponsor a health benefit plan and have 20 or more employees on at least 50% of their working days during
the preceding calendar year. Churches, the federal government, state governments and employers that
employ fewer than 20 employees are excluded. The definition of employee includes full- and part-time
employees, partners, independent contractors and directors who are eligible to participate in the
employer’s health benefit plan. COBRA requires that employers provide an option to continue firm health
benefits at up to 102% of the firm rate or fee for employees or their dependents that would otherwise lose
coverage upon the occurrence of a qualifying event. (For certain disabled individuals the limit is 150% of
the firm rate or fee for months 19-29 of continued coverage.) The beneficiary is responsible for paying the
premium or fee.
Continuation coverage
A coverage that beneficiaries can choose upon the occurrence of a qualifying event. The coverage is the
same as that of active firm members and is paid for by the beneficiary to the group. The length of
entitlement to continuation coverage depends on the qualifying event.
Contract number
See ‘Certificate number.’
Coordination of Benefits (COB)
A contract provision that limits benefits from multiple health care coverages to no more than 100% of the
allowance for covered services. The COB contract provision also designates the order in which multiple
payers pay health care benefits. See your plan documents for detailed information.
Customer service representative
An associate who answers firm members’ questions about benefits, claims or membership.
35
Dependent
A person other than the subscriber who meets the eligibility requirements for health benefit coverage
under the subscriber’s certificate or contract. Examples include the spouse or unmarried child of the
subscriber who is age 26 or under.
Domestic partner
A person in a relationship with the subscriber that meets the requirements of the affidavit of domestic
partnership and the firm’s eligibility requirement.
Effective date
The date when health benefit coverage under a policy begins.
Enrollment and billing representative
An associate who handles membership, eligibility and billing for your firm account.
Enrollment and Change Application
Completed by an applicant to enroll himself or herself and eligible family members. The form may also
be completed by a subscriber to add or delete family members, change an address or change a primary
care physician.
Explanation of Benefits (EOB)
A statement issued to a subscriber when we process a claim for health care benefits resulting in member
liability other than the copay. The EOB explains the action taken on the claim when a balance is due from
the member. An EOB may include the amount to be paid, the benefits available, and the reasons for
denying payment.
Firm
The employer.
Firm members
The eligible subscribers and dependents accepted for coverage under a firm contract.
Firm number
The number that identifies a firm.
FMLA
Please refer to ‘Section 8: Continuation of coverage’ for details about the federal Family and Medical Leave Acts.
ID card
The card we issue that contains information about members’ health care coverage with us.
36
Individual coverage
Other than a firm plan. Individual coverage is also called non-group coverage.
Large employer
An employer that employed, on average, at least 51 persons on business days, during the previous calendar year.
Late enrollee
A person who does not enroll in the firm health benefit plan when initially eligible and later applies for
coverage without an involuntary loss of other coverage.
Medicaid
A federal program administered and operated by the states that provide medical benefits to low income
people. The states and federal government share the costs of the program.
Medicare
A federal program that provides hospital, physician and prescription drug benefits for people aged 65 and
older and disabled people of any age. Medicare Part A provides hospital benefits, Medicare Part B provides
benefits for professional services, and Medicare Part D provides prescription drug benefits.
Member
The eligible subscriber and family members who are covered under your firm’s health plan contract.
Minimum hours
The minimum number of hours an employee must regularly work to establish and maintain eligibility
for coverage. The number of your firm’s minimum hours for eligibility is listed on your Application for
Firm Insurance.
New hire probationary period
The period of time specified in the contract during which eligible people can enroll themselves and their
dependents under the health plan, without waiting for the firm’s annual enrollment period.
OBRA
Omnibus Budget Reconciliation Act of 1986. OBRA applies to large firm health plans that cover at least one
employer or employee organization that normally employed at least 100 employees on 50% or more of its
regular business days during the previous calendar year. OBRA provides that when an employer of 100 or
more full- and/or part-time employees offers a firm health plan, the firm health plan is the primary
coverage for disabled employees, spouses or dependents who have Medicare because of a disability.
Medicare is the secondary payer to the firm health plan if the disabled individual is covered under the firm
plan as either a subscriber or dependent on the basis of current employment status with the employer. The
disabled person can choose Medicare as primary coverage but would have to cancel firm coverage and
could purchase Medigap coverage. Special rules apply to members with end-stage renal disease.
37
Portability
An enrollment policy allowing a subscriber and/or spouse and dependent(s) to apply within 31 days of the
date of the involuntary loss of coverage. Portability events include:
Termination of employment
}}
Termination (not replacement) of the firm contract or policy
}}
Divorce/Legal Separation
}}
Death
}}
Premium
The dollar amount required to be paid to an insurer by an individual or firm for enrollment in the health
benefit plan. Also called a rate.
Pre-existing condition
Any disease, ailment, or condition for which a person received care or incurred medical expense at any
time during the three-month period before the effective date of coverage.
Primary care physician (PCP)
Each member of Matthew Thornton Blue, HMO Blue New England, BlueChoice, BlueChoice New England or
Access Blue New England chooses a PCP who provides all of the member’s preventive care, provides or
arranges coverage 24 hours a day, can refer members to specialists when necessary and can arrange for
any needed inpatient hospitalizations. The PCP works with the member to manage the member’s health
care. PCP’s are generally family practitioners, general practitioners, internist or pediatricians. They are
independent contractors and not our agents or employees.
Probationary period
See ‘waiting period.’
Qualifying event
For companies that must comply with COBRA or state law a qualifying event obligates the employer to
offer continued health care coverage at the member’s expense to a firm member whose coverage is
ending. Qualifying events include death, termination from employment, reduction of hours, divorce or
legal separation and losing dependent status.
Rate
See ‘Premium.’
Small employer
A business or organization which employed, on average, two and up to 50 employees, including owners and
self-employed persons, on business days during the previous calendar year. A small employer is subject to
this chapter whether or not it becomes part of an association, multi-employer plan, trust, or any other
entity cited in RSA 420-G:3 provided it meets this definition.
38
Subrogation
Process by which we recover payment for claims identified as the responsibility of another party because
of that other person’s action. For instance, when we pay claims for health care benefits and our member’s
injury was sustained in a car accident that is another party’s fault, we can recover from the other party (or
the other party’s liability insurer) any benefits paid on behalf of our member.
Subscriber
The employee who is properly enrolled and accepted for coverage under the plan and to whom the
certificate is issued.
TEFRA/DEFRA
Tax Equity and Fiscal Responsibility Act of 1982 and Deficit Reduction Act of 1984. Companies who sponsor
firm health plans (including tax exempt and government entities) with 20 or more employees in each of 20
or more weeks in the current or preceding year must comply with TEFRA/DEFRA. The definition of
employee includes full- and part-time employees and self-employed people such as consultants, business
owners, directors and clergy. TEFRA/DEFRA requires employers to offer currently employed workers and
their spouses who are age 65 and older the same health care coverage offered to younger workers. The
employee can elect Medicare as either the primary or secondary coverage. If the employee chooses to stay
on the firm plan, the Medicare coverage is secondary to the employer-sponsored plan. The employee or
spouse can reject the employer-sponsored coverage in writing, be removed from the firm coverage, choose
Medicare as the primary payer, and purchase Medigap coverage at his or her own expense.
Waiting period
The length of time an applicant must wait for health care coverage to become effective (sometimes called a
probationary period). Your firm’s waiting period is listed in the eligibility section of your plan documents.
The waiting period begins when the employee regularly works the minimum hours required for eligibility as
defined in your plan documents. The employee must regularly work the minimum hours required for
eligibility throughout the entire waiting period.
Workers’ Compensation
State laws that require certain employers to provide medical and income benefits to employees who incur
injuries or illnesses arising out of and in the course of employment. We exclude coverage of work-related
illnesses and injuries. See your plan documents for detailed information.
39
Life and Disability products underwritten by Anthem Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. ®Anthem Blue Cross and Blue Shield is the tradename of Anthem Health Plans of New Hampshire, Inc.
Independent licensee of the Blue Cross and Blue Shield Association. ®Anthem is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
SM
“SpecialOffers@Anthem” is a service mark of Anthem Insurance Companies, Inc. All of the offerings in the SpecialOffers@Anthem program are continually being evaluated and expanded so the offerings may change. Any additions or changes will be communicated on our Web site,
anthem.com. These arrangements have been made to add value for our members. Value-added services and products are not covered by your health plan benefit. Available discount percentages may change or be discontinued from time to time without notice. Discount is applicable to the
items referenced.
Addendum
Renewal changes for Small Groups
There have been some changes to the invoice and ID card generation for Small Group plans renewing on or after
January 1, 2014.
Before the changes
Currently, invoices are suspended or put on hold 45 days before the group’s renewal date and the invoice for the
month they renew isn’t generated until the renewal has been processed and completed.
}}
ID cards are triggered for the group once the renewal has been processed and completed.
}}
After the changes
As of January 1, 2014, invoices and ID cards will be generated and triggered 30 days before the group’s renewal
date, whether we’ve received their signed renewal or not.
}}
Invoices and ID cards will be triggered based on the default (or mapped) plan if we haven’t received their
signed renewal.
}}
If the group selects a different plan, ID cards will be reissued and the premium change goes into effect on future
invoices with any needed premium adjustments.
}}
Life and Disability products underwritten by Anthem Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. ®Anthem Blue Cross and Blue Shield is the tradename of Anthem Health Plans of New Hampshire, Inc. Independent
licensee of the Blue Cross and Blue Shield Association. ®Anthem is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
SM
“SpecialOffers@Anthem” is a service mark of Anthem Insurance Companies, Inc. All of the offerings in the SpecialOffers@Anthem program are continually being evaluated and expanded so the offerings may change. Any additions or changes will be
communicated on our Web site, anthem.com. These arrangements have been made to add value for our members. Value-added services and products are not covered by your health plan benefit. Available discount percentages may change or be discontinued from
time to time without notice. Discount is applicable to the items referenced.
42014NHEENABS 11/13

Benefit Administrator’s Manual - 2014

Transcription

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