A Broker s Guide to Working with HealthSpan SUMMER 2014 VERSION 2

Transcription

1 A Broker s Guide to Working with HealthSpan SUMMER 2014 VERSION 2

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3 Welcome! We re excited to work with you to introduce HealthSpan s redefined model of care and coverage that delivers real value to your clients. We ve created this guide as a quick reference tool to help you, our valued broker partners, work with us as efficiently as possible. It covers contacts, guidelines, and commission across all lines of business. If you don t find what you need, please don t hesitate to contact your HealthSpan representative or any of the folks listed in this booklet. We appreciate your partnership. Thank you.

4 Contents 5 About Us and Capabilities 6 Contacts 10 Commercial Service Area 11 Medicare Advantage Service Area 12 Guidelines for Individuals and Families 15 General Requirements for Employer Groups 21 Small Group Guidelines 23 Small Group Quote/Sold Case Checklist 25 Large Group Guidelines 27 Large Group Quote/Sold Case Checklist 28 Resources

5 About Us HealthSpan is an Ohio company with a long and proud heritage of serving Ohio families, and includes both HealthSpan Inc. and HealthSpan Integrated Care. Since 1991, Cincinnati-based HealthSpan Inc. has helped self-insured employers manage claim costs and improve employee wellness through proven Benefit Plan Design, PPO Networks, Care Management, Wellness and Employee Assistance Programs. HealthSpan Inc. began offering fully funded insurance products on January 1, Our Northeast Ohio operation, serving the Cleveland and Akron areas as HealthSpan Integrated Care, was established in 1969 and has been offering integrated care and coverage for more than four decades. Our organization also includes HealthSpan Physicians. National leaders in integrating care to control costs and deliver better health, these 265 physicians serve 80,000 members in 15 care locations in Northeast Ohio. Today, in addition to our services for self-insured employers, HealthSpan brings the right care at the right time to over 200,000 members across Ohio through our affordable health insurance plans. We team a statewide network of more than 25,000 affiliated primary care and specialty physicians and 1200 Ohio-based employees with quality leaders Catholic Health Partners and University Hospitals to deliver a You First healthcare experience. Capabilities We offer a variety of plans to serve individuals and companies throughout Ohio: Individual and Family plans Plans for small businesses Plans for large employers, unions, and trusts Medicare plans In addition to fully insured plans, HealthSpan offers self-funded products; competitive, cost-effective provider networks; population health solutions including wellness and health coaching; supportive care management with accredited Utilization and Case Management services; and employee assistance programs. ABOUT US AND CAPABILITIES 5

6 Contacts Broker Assistance Licensing, appointment, commission, etc Medicare Jaime Lebron Manager, Medicare Sales (Individual) Jaime Rosado Consultant, Group Medicare Sales Individual and Family New Sales Patricia T. Horvath, RN, MSN VP Sales and Business Development Luke Boemker, MBA Director, Individual and Small Group Sales Maria Dawe Account Executive (Northeast OH, West of I-77) Matthew Dieter Account Executive (Southwest OH) Julie Pantello Account Executive (Northwest OH) Timothy P. Krenn Senior Sales Executive (Northeast OH, East of I-77) Melissa Murphy Account Executive (statewide) Quotes, questions Connector (On Exchange) BROKER S GUIDE

7 Existing Business / Renewals Lisa Flanagan Director, Client Services llflanagan@healthspan.org, Client Managers Unit CMU@healthspan.org, Hope Watkins Sales Support Specialist hrwatkins@mercy.com, Premium Payments For plans in the greater Cincinnati, Springfield, Lima, Toledo, and Youngstown areas, please have your customers use the methods below. For these plans, the ID on the member s HealthSpan ID card begins with HS and is followed by nine digits, for example HS Pay online: Pay by mail: HealthSpan Inc., P.O. Box Cincinnati, OH Pay over the phone: For plans in the greater Cleveland, Lorain, Medina, Akron, and Canton areas, please have your clients use the methods below. For these plans, the medical record number (MRN) on the member s HealthSpan ID card is made up of seven digits, for example Pay online: Pay over the phone: Pay by mail: Exchange plans: Kaiser Permanente, P.O. Box 7192, Pasadena, CA Off-Exchange plans: HealthSpan, P.O. Box 94759, Cleveland, OH Small Group (2-99 eligible employees) New Sales Patricia T. Horvath, RN, MSN VP Sales and Business Development pthorvath@mercy.com, Luke Boemker, MBA Director, Individual and Small Group Sales lwboemker@mercy.com, Maria Dawe Account Executive (Northeast OH, West of I-77) mldawe@mercy.com, Matthew Dieter Account Executive (Southwest OH) msdieter@mercy.com, Julie Pantello Account Executive (Northwest OH) japantello@mercy.com, Timothy P. Krenn Senior Sales Executive (Northeast OH, East of I-77) tpkrenn@healthspan.org, Melissa Murphy Account Executive (statewide) mamurphy1@healthspan.org, Quotes and prescreens HS-smallgroup@healthspan.org Existing Business/Renewals Lisa Flanagan Director, Client Services llflanagan@healthspan.org, Client Managers Unit CMU@healthspan.org, Hope Watkins Sales Support Specialist hrwatkins@mercy.com, CONTACTS 7

8 Large Group (100+ eligible employees) New Sales Patricia T. Horvath, RN, MSN VP Sales and Business Development Kim Lawson Manager, Operations & Sales John King Senior Account Executive Theresa Pedone Sales Associate Holly Cooney Sales Associate Quote requests Existing Business / Renewals Patricia T. Horvath, RN, MSN VP Sales and Business Development pthorvath@mercy.com, Lisa Flanagan Director, Client Services llflanagan@healthspan.org, Tom Riley Senior Benefit Consultant tmriley1@healthspan.org, Donna Crowe Senior Benefit Consultant dkcrowe@mercy.com, Brad Petrella Senior Account Manager bwpetrella@healthspan.org, Jeff Lewis Senior Benefit Consultant jjlewis@healthspan.org, Pamela May Associate Account Manager pamay@healthspan.org, Terri Rinder Associate Account Manager tarinder@healthspan.org, Stephanie Patton Implementation Consultant scpatton@healthspan.org, Barb Leiden Enrollment Specialist baleiden@healthspan.org, Client Managers Unit CMU@healthspan.org, BROKER S GUIDE

9 Other Helpful Contacts Cincinnati, Springfield, Lima, Toledo, and Youngstown Customer Service Claims address HealthSpan P.O. Box 3630 Akron, OH Electronic Claim Payer ID: Membership Administration (enrollment and eligibility processing, billing and account reconciliation) Fax: Mailing address: Apex P.O. Box 3670 Akron, OH Overnight mail address: Apex 10 N. Main Street Akron, OH Cleveland and Akron Customer Service or 711 TTY Monday Thursday, 8:15 a.m. 5 p.m. Friday, 9 a.m. 5 p.m. Medicare Customer Service or 711 TTY 7 days a week, 8 a.m. 8 p.m. Claims address HealthSpan P.O. Box 5316 Cleveland, OH Membership Administration (enrollment and eligibility processing, billing and account reconciliation) CSC-DEN-ROC-Group@kp.org Fax: Mailing address: Kaiser Permanente Consolidated Service Center P.O. Box Denver, CO Overnight mail address: Kaiser Permanente Consolidated Service Center 7901 E. Lowry, 4th Floor Denver, CO CONTACTS 9

10 Commercial Service Area Individuals and Employer Groups LAKE FULTON LUCAS Toledo OTTAWA Lorain Cleveland CUYAHOGA GEAUGA DEFIANCE HENRY WOOD LORAIN TRUMBULL PUTNAM HANCOCK SENECA HURON MEDINA SUMMIT Akron PORTAGE MAHONING Youngstown VAN WERT ALLEN WAYNE STARK Canton Lima MERCER AUGLAIZE SHELBY DARKE MIAMI CHAMPAIGN CLARK Springfield PREBLE MONTGOMERY GREENE BUTLER WARREN CLINTON HAMILTON Cincinnati HIGHLAND CLERMONT BROWN ADAMS Counties in our service area 10 BROKER S GUIDE

11 Medicare Advantage Service Area LAKE FULTON LUCAS Toledo OTTAWA Lorain Cleveland CUYAHOGA GEAUGA HENRY WOOD LORAIN TRUMBULL PUTNAM MEDINA SUMMIT Akron PORTAGE MAHONING Youngstown VAN WERT ALLEN Lima STARK Canton MERCER AUGLAIZE SHELBY CHAMPAIGN CLARK Springfield PREBLE BUTLER CLINTON HAMILTON Cincinnati HIGHLAND CLERMONT BROWN ADAMS Counties in our Non-Rural service area Counties in our Rural service area Both service areas apply for Group Medicare Advantage; Group Medicare rating reflects all 31 counties. SERVICE AREAS 11

12 Guidelines for Individuals and Families HealthSpan in Ohio s Health Insurance Marketplace (aka Exchange) HealthSpan offers a variety of plans for individuals and small groups on the Health Insurance Marketplace. Our Individual plans are called HealthSpanOne and include Gold, Silver and Bronze HMO and HSA-qualified HMO options. Open Enrollment / Special Enrollment The next Open Enrollment period both on and off the Marketplace is November 15, 2014 February 15, Outside of the open enrollment period, individuals can enroll or change their coverage only if they experience a situation known as a triggering, or qualifying, event. For example, if they get married, have a baby, or lose coverage because they lose their job all qualifying events they will have a special enrollment period. A special enrollment period lasts 60 days after the qualifying event occurs; individuals have 60 days from the day of the qualifying event to change or apply for health care coverage for themselves and / or their dependent. 12 BROKER S GUIDE

13 If individuals lose health plan coverage because they didn t pay their premiums or contributions or because their plan was rescinded, these do not qualify as qualifying events. Individuals must lose minimum essential coverage in order to have a qualifying event. Qualifying events: 1. Loss of health care (minimum essential) coverage. a) The individual loses employer health plan coverage (other than COBRA) for the following reasons: They lose their job. Their work hours are reduced so they no longer qualify for health coverage. The person who covers them on his / her employer health plan dies. They are a dependent on the employer s health plan and their marital status changes due to a legal separation or divorce, so their eligibility as a dependent ends. They lose eligibility for coverage through their employer because they no longer live or work in the service area, and no other group health coverage is available to them. They or their dependent meets or exceeds the maximum lifetime benefits of their health plan because of one specific claim. They are part of a group of employees who are no longer offered coverage from their employer. A dependent child has a birthday and no longer qualifies as a dependent on his / her parent s health plan. Their employer stops contributing premium payments for their group health coverage. Their COBRA coverage ends. Their retiree coverage is terminated or substantially eliminated when their employer declares bankruptcy (Chapter 11). They lose their eligibility for coverage because the person who covered them on the employer health plan becomes entitled to Medicare. b) Their individual plan, Medicaid, Medicare, or other governmental coverage (but not special Medicaid programs) ends. 2. Gaining or becoming a dependent. They have a baby, adopt a child, or get married. 3. Permanent relocation. They move to a new location and have a different choice of health plans, or they were recently released from incarceration. 4. Change in eligibility for federal financial assistance through healthspan.org/quote. Their income level changes and, as a result, they qualify or no longer qualify for federal tax credits; their eligibility to enroll in a health plan with reduced costs (cost-share reduction) changes. 5. Employer health coverage changes. Their employer discontinues or changes their current coverage options so that they become newly eligible for federal financial assistance. Healthspan.org/quote may determine that their special enrollment period begins before their current coverage ends or changes. 6. Immigration status change. They were not previously entitled to enroll in health plan coverage through healthspan.org/quote because they were not lawfully present in the United States. 7. Determination by healthcare.gov. The Health Insurance Marketplace in Ohio determines that they are entitled to a special enrollment period. INDIVIDUAL GUIDELINES 13

14 Qualifying Events: Confirmation Required If an individual has experienced a qualifying event, we ll need a letter from them that confirms the qualifying event. The letter should state their name and address as submitted on the application, explain the qualifying event that occurred, and include the date of the event. If the individual is completing a paper application, they can send the letter along with the application and their first month s premium. We must receive the qualifying-event-confirmation letter within 10 calendar days of when the individual s application was submitted or before the end of their special enrollment period, whichever comes first. If we don t receive a letter within 10 calendar days, we will cancel the individual s application. They may reapply and submit the letter regarding the qualifying event, but they must do so within their 60-day special enrollment period. By submitting a signed application and a letter, the individual is confirming that a qualifying event occurred. It s important that we receive their letter because we will rely on it to establish that they are eligible to enroll during a special enrollment period. If we determine that the qualifying event did not occur, we may take legal action, including but not limited to canceling the individual s coverage retroactively. Qualifying Events: Effective Dates The date the individual s coverage will start depends on the triggering event that they experience. QUALIFYING EVENT DATE WE RECEIVE APPLICATION EFFECTIVE DATE OF COVERAGE Loss of health care coverage Any day of the month First day of the month following the loss of coverage Marriage Any day of the month First day of the month following the event Birth, adoption, or placement for adoption Permanent relocation, change in eligibility for federal financial assistance, change in employer coverage, change in immigration status Determination by the Health Insurance Marketplace Any day of the month Between the 1st and 15th of the month Between the 16th and the last day of the month Any day of the month Date of birth, adoption, or placement for adoption First day of the month following the event First day of the second month following the event Any day of the month as determined by the Health Insurance Marketplace, including a retroactive date 14 BROKER S GUIDE

15 General Requirements for Employer Groups Carve Outs Groups must make coverage available to all full-time employees (those working 25 or more hours per week). Per the Taft-Hartley Act, the employer can elect whether or not to cover union employees. Employers cannot class out by job title, such as offering coverage to management only. Child-Only Enrollment We accept child-only enrollments. For these accounts, the child is listed as the subscriber. COBRA / State Continuation Any group with 20 or more eligible employees is subject to the Consolidated Omnibus Budget Reconciliation Act (COBRA). Employers must allow an employee who has left employment to continue their health coverage with the same benefits they had when active. The employee is responsible for the cost of coverage at the group rate. The employer can charge 1-2 percent of the active rate for administration purposes. The employee has 60 days to enroll in COBRA, retroactive to the first day of lost coverage. The employer must offer each employee the opportunity to enroll, and notify them of the benefits and rates along with the last date of enrollment. Some acceptable COBRA-qualifying events are: voluntary or involuntary termination of employment; reduction in hours to a part-time status; death of a covered employee (offering coverage for spouse and dependents); divorce or legal separation; ceasing to be a dependent child under the terms of the plan; or an employee becoming eligible for Medicare. Employer groups with fewer than 20 eligible employees are subject to State continuation law instead of COBRA. Employees who leave the organization may continue under the ex-employer s group coverage. Please call your account manager for assistance, or contact the Ohio Department of Insurance at or visit EMPLOYER GROUP GUIDELINES 15

16 Domestic Partners HealthSpan provides domestic partner coverage to employer groups of any size upon request. Multiple versions of the Domestic Partner Rider are available, including: coverage for domestic partners; coverage for domestic partners and their dependents; coverage for same-sex domestic partners; and coverage for same-sex domestic partners and their dependents. Employee (Subscriber) Application Lifespan Underwriting will accept applications that were signed within 90 days from the effective date, judged from the signature date to the effective date. If you have applications that were signed more than 90 days prior to the effective date, you can have the employee review the application to make any applicable changes. Each change must be initialed by the employee, who must then sign the end of the form again and date it with the current date. This new signature can be placed above or below the original. Group Size Here is the calculation to determine if a group is large or small: Total number of employees working 25 hours or more per week (including waivers) Subtract the number of COBRA employees, 1099 employees, and retirees Total If the total is between 1 and 50, the group is a small group. If the total is 51 or more, the group is a large group. Large groups can determine the number of hours needed to work for eligibility. If the number of employees is 50 or fewer based on the eligibility, it is still a large group. (If the eligibility is less than 20 hours, approval from Underwriting is required.) With common ownership groups, i.e., more than one entity with the same owner(s), all entities, regardless of tax ID numbers, must be included when determining if the group should be classified and underwritten as a large group or a small group. Under ERISA and the IRS code section 414, the employer-employee relationship is the same regardless of the businesses being unique. For example, if an employer owns two companies that have different tax ID numbers and different SIC codes, the number of employees from both companies would be added together to see if it constitutes a large group or small group. If one company is in our service area and one is out of our service area, the numbers of employees would still be added together to classify the group as large or small. The employer can opt to write only the company that is located within our service area. 16 BROKER S GUIDE

17 Military Personnel HealthSpan follows the Uniform Services Employment and Reemployment Rights Act. This means that if subscribers leave their jobs to perform military service, they have the right to elect to continue existing employer-based health plan coverage for themselves and their dependents for up to 24 months while in the military. If the members do not elect to continue the coverage during their military service, they have the right to be reinstated in the employer s health plan when they are reemployed, generally without any waiting periods or exclusions, such as pre-existing conditions exclusions, except for service-connected illnesses or injuries. Notice of Group Termination HealthSpan is a prepaid health plan, which means that group premiums are due on the last day of the month prior to the month of coverage. We don t want to lose any customers for non-payment. So we advise customers follow industry best practices and provide at least 30 days notice of termination. Advance notice can help a group avoid the delinquency process and the obligation to pay additional months of coverage and incurred claims. Here s how the notification process works: If we don t receive a group s premium by 15 days after the due date, we send a warning letter to the group. If the premium is not paid by the 10th of the following month the 40th day after the due date we send a second and final warning letter. If we do not receive the premium, the group s coverage terminates on the 60th day after the due date. At that time, premium is due and payable through the termination date and unpaid balances are sent for collection. EMPLOYER GROUP GUIDELINES 17

18 Open Enrollment Each group may have at least one open enrollment period per year. In addition, each group is also eligible for a special, one-time open enrollment period each year. Please call your account manager with questions. Overage Dependents The Affordable Care Act (ACA) permits dependent coverage up to age 26. Ohio law permits dependents to stay on a parent s plan up to age 28. Federal dependent coverage until age 26: The ACA requires group health plans to extend eligibility for child dependents until they turn 26, whether or not they re in school. The provision applies to commercial (non-medicare) coverage other than retiree plans if that coverage covers child dependents. State dependent coverage until age 28: Under Ohio law, dependent children can stay on their family s plan until they turn 28 under the eligibility criteria indicated below: The dependent is: Under the age of 28 and unmarried A natural child, stepchild, or adopted child A resident of Ohio or a full-time student at an accredited public or private institution of higher education Not employed by an employer who offers any health plan benefit under which the child is eligible for coverage Not eligible for coverage under any Medicare or Medicaid program

19 In addition: Employee will provide HealthSpan with certification of continuing eligibility annually, if requested by HealthSpan. Employee understands that HealthSpan will automatically terminate any overage dependents on this plan if response is not received within 60 calendar days of the date of the request Employee understands that coverage terminates when the dependent no longer meets the criteria specified above, but no later than the end of the month in which the dependent reaches the age of 28. Employee agrees to notify HealthSpan immediately when the dependent no longer meets the criteria specified above. HealthSpan will adjust monthly premiums to reflect the additional dependent coverage as applicable and that premium will not be calculated separately. Employee understands that any monthly plan premium increase may be his or her responsibility to pay, subject to the group s policy, and that any questions about such arrangements are to be directed to the group contact. EMPLOYER GROUP GUIDELINES 19

20 Reinstatement of group coverage Groups that have been terminated by HealthSpan for non-payment of premium must wait six months after the termination before they can re-enroll with HealthSpan. This time period starts from the termination date. These groups will be re-rated as new business and may or may not have the same rate that they had prior to termination. Please note that all financial obligations from the prior contract must be paid. This includes back premium and repayment of claims that should not have been paid due to the non-payment of premium. If a group has recently filed for bankruptcy protection, it will be eligible to apply for coverage with HealthSpan six months after the bankruptcy has been resolved. Waiting periods At the time of initial group enrollment, an employer can make coverage available to all eligible employees without a service waiting period the decision about a service waiting period belongs to the employer. The ACA prohibits waiting periods in excess of 90 days for group health plan coverage for plan years beginning on or after January 1, BROKER S GUIDE

21 Small Group Guidelines Employee Eligibility Per section (G) of the Ohio Revised Code, an eligible employee is an employee who works a minimum of 25 hours per week. The definition of eligible employee does not include temporary or seasonal employees, nor does it include substitute employees. A seasonal employee is anyone working less than 40 weeks per calendar year. (Example: a landscaper who works 38 weeks per calendar year would be considered seasonal, and therefore not eligible.) 1099 employees are eligible providing that they do not make up more than 10 percent of the eligible employees. Minor employees may apply for coverage as an employee provided they meet the definition of a full-time employee (25 or more hours per week, 40 or more weeks per year). Legal aliens are eligible to apply for coverage. A Social Security number is not required. Per the ACA, a small group may have only one subscriber. The enrollee cannot be anyone the business owner can claim as a dependent on his or her taxes (e.g., a spouse or family member). The ACA permits dependent coverage up to age 26. Ohio law permits dependents to stay on a parent s plan up to age 28. If the employer has 20 or fewer eligible employees, active employees who are eligible for Medicare will receive coverage through our group Medicare Plus product. Please note that for employees covered through the group Medicare Plus product, a separate rate will apply, and there is a separate application and solicitation packet that must be provided for that subscriber and his or her dependents. SMALL GROUP GUIDELINES 21

22 Plan Design Changes If a small group wishes to make a plan design change at the time of renewal, HealthSpan must receive the group s required materials no later than five business days after the effective date to make any changes retroactive to the first of the month. Otherwise, any changes will become effective on the first of the following month. If a small group requests a plan design change anytime other than at renewal, it is considered a mid-year contract change and will become effective on the first of the month following the request (e.g., if a change is requested on March 20th, it will become effective on April 1st). Renewals Small group renewals are all issued as guaranteed renewal under Ohio state statutes. Consistent with Ohio law, we deliver renewal notices to clients no later than 30 days prior to the effective date of the renewal change in rates. We send copies of the renewal notices to the broker or the general agent (if there is one). Small Employer Tax Credit Requirements Employers must have an average of fewer than 25 FTE employees (based on a 40-hour work week and excluding owners, owners family members, and seasonal employees). Average annual employee wages must be below $50,000. Employers must pay a uniform percentage (at least 50 percent) of the cost of each employee s health insurance. Small Group Validation Matrix ACCEPTABLE DOCUMENTATION FOR SMALL GROUP VALIDATION OWNER REGULAR EMPLOYEE NEW HIRE GROUP SIZE 1-50 ELIGIBLES** Sole Proprietor OBES* and Owner Attestation and 1040 (w / Schedule C) OBES* Most recent pay stubs Partnership, LLC OBES* and 1040 (w / Schedule K) or 1065 (w / Schedule K) S, C Corporation OBES* or 1040 (w / Schedule E) or 1120 (w / Schedule K) Incorporated OBES* or 1040 (w / Schedule E) or 1120 (w / Schedule K) OBES* OBES* OBES* Most recent pay stubs Most recent pay stubs Most recent pay stubs Churches N/A W-2 Most recent pay stubs * Accepted substitutions for Ohio Bureau of Employment Services (OBES) statement: 1. Third party quarterly wage and tax submission or third party payroll submission. 2. Tax Form 941 with roster equaling reported wages. 3. Third party payroll submissions for brand new group; OBES sent first available quarter. ** May be supplied after the effective date as long as at least one subscriber passes validation. Newly Formed Group Agreement is acceptable. 22 BROKER S GUIDE

23 Small Group Quote/ Sold Case Checklist Information Required for a Quote Group name Effective date Census including name, date of birth, sex, zip code, eligibility designation (active/waiving/not eligible) and tobacco status of each employee and dependent Information Required for a Sale: Off Exchange Business Requirements Employers must contribute at minimum 50% of the single employee premium. Employers must meet 50% gross employee participation to be enrolled in a HealthSpan Small Group employer plan. HealthSpan must be the sole health insurance carrier for a Small Group employer to be eligible for enrollment. Employers may select up to three (3) of HealthSpan s plan options for their employees. Required Documents Completed employer group application signed by the employer Completed employee applications or waivers for all eligible employees Signed plan/rate elections Updated census (roster of all benefit-eligible employees and their spouses and dependents, including name, birth date and tobacco status for each) Copy of employer s Unemployment Compensation Quarterly Tax Return ( OBES ) for the most recent quarterly filing or comparable documentation (see Small Group Validation Matrix on page 13) Check/copy of check for first month s premium Group Eligibility form (number of employees/eligibles for CMS reporting) Newly Formed Group Agreement (if applicable; for new companies only) Please scan and the documents to your local HealthSpan Sales Account Executive or to HS-smallgroup@healthspan.org. SMALL GROUP GUIDELINES 23

24 Information Required for a Sale: SHOP Eligibility Requirements for SHOP Employer s business must: Have no more than 50 full-time equivalent (FTE)* employees on payroll Offer coverage to all full-time** employees Have 70% of the eligible employees enroll in the plan(s) offered *Part-time workers must be counted as fractions of an FTE when determining employer size, even if part-time workers are not offered coverage. **Full-time is defined as working an average of 30 or more hours per week. Eligibility Requirements for the Small Business Tax Credit Employer s business must: Have an average of fewer than 25 FTE employees (based on a 40-hour work week and excluding owners, owners family members, and seasonal employees) Have average annual employee wages below $50,000 Contribute a uniform percentage (at least 50%) of the cost of each employee s health insurance Required Documents Completed employer group application signed by the employer Completed employee applications or waivers for all eligible employees Signed plan/rate elections Updated census (roster of all benefit-eligible employees and their spouses and dependents, including name, birth date and tobacco status for each) Copy of employer s Unemployment Compensation Quarterly Tax Return ( OBES ) for the most recent quarterly filing or comparable documentation (see Small Group Validation Matrix on page 13) Check/copy of check for first month s premium Group Eligibility form (number of employees/eligibles for CMS reporting) Newly Formed Group Agreement (if applicable; for new companies only) Please scan and the documents to your local HealthSpan Sales Account Executive or to HS-smallgroup@healthspan.org. 24 BROKER S GUIDE

25 Large Group Guidelines Employee Eligibility The employer may determine the number of hours needed to be eligible for benefits. If fewer than 20 hours per week, Underwriting approval is needed. The definition of eligible employee does not include temporary or seasonal employees, nor does it include substitute employees. A seasonal employee is anyone working fewer than 40 weeks per calendar year employees may be eligible for coverage; please contact your account executive. Minor employees must meet the eligibility criteria determined by the employer. Legal aliens are eligible to apply for coverage. A Social Security number is not required. The ACA permits dependent coverage up to age 26. Ohio law permits dependents to stay on a parent s plan up to age 28. If the employer has more than 20 eligible employees, active employees who are eligible for Medicare may select the same benefits as any other non-medicare eligible employee (these members are not eligible for any POS plans). Please note that we do not cover prior employees who have retired from the company; we cover active employees who are of retirement age. An employer s pre-65 retirees may not be more than 10 percent of the eligible employees. Employer Contribution / Employee Participation Employers must contribute at least 50 percent of the single premium for the core plan. Employers may develop their contribution as they like as long as it meets this minimum standard. When offering two or more products, the employer must contribute the same flat dollar contribution to all plans offered. For large (51+) groups, HealthSpan requires that employers have at least 75 percent of the net eligible employees taking coverage. LARGE GROUP GUIDELINES 25

26 Plan Design Changes If a large group wishes to make a plan design change at the time of renewal, HealthSpan must receive the group s required materials by the 15th of the month prior to the effective date for the change to be made by the effective date. Otherwise, any changes will be implemented on the first of the month following the effective date (e.g., if a group renews on January 1st and all required materials don t arrive until December 20th, the change becomes effective on February 1st). Retroactive contract changes are not allowed. If a large group requests a plan design change anytime other than at renewal, this is considered a mid-year contract change and the change will become effective on the first of the month following the request. 26 BROKER S GUIDE

27 Large Group Quote/Sold Case Checklist Information Required for a Quote Group name Effective date Census including zip code, gender, date of birth, dependent status, and other indicators such as COBRA, waivers, retirees, etc. Current benefits Current and renewal rates Completed Employer Risk Assessment form (ERAF), including nature of business and employer contribution. (We will accept individual medical applications in lieu of a completed ERAF.) For groups of more than 100, we need at least one year s experience Information Required for a Sale Completed employer group application signed by the employer Completed employee applications or waivers for all eligible employees Signed benefit/rate pages Updated census (roster of all benefit-eligible employees and their spouses and dependents) Group Eligibility form (number of employees/eligibles for CMS reporting) Letter of Indemnification or Letter of Agreement regarding HIPAA certificates of creditable coverage Grandfathered Status Tracking form (if applicable) Single Case Agreement ( Non-Standard Broker Commission Schedule ) to document broker s commission Binder check/copy of check LARGE GROUP GUIDELINES 27

28 Resources HealthSpan.org Healthspan.org is a one-stop resource for plan information, health resources, access to our member portals, access to our broker portal and much more. With input from members and patients, employers, and members of our broker community, we are continuously improving the site to better serve everyone s needs. Please bookmark healthspan.org and visit often to check out the enhancements coming over the next couple months. Quick links to remember: Shop Health Plans: healthspan.org/shop-health-plans Member information and resources: healthspan.org/members Medicare information and resources: healthspan.org/medicare Employer information and resources: healthspan.org/employers Broker information and resources: healthspan.org/brokers Find a Provider: healthspan.org/findaprovider Find a Medication: healthspan.org/formulary Log in and / or start a quote: healthspan.org/quote 28 BROKER S GUIDE

29 HealthSpan Broker Portal Our broker website is available 24/7 to give you support and the answers you need for all of your small group and individual business. Our online features were designed with you in mind to make it easier to sell and service our products and meet the needs of your clients. View and compare HealthSpan plans Calculate individual subsidies Quote individuals both on and off the Exchange Enroll individuals directly through healthcare.gov Quote small groups by entering employee data or uploading Excel census Track enrollment status Edit saved quotes your clients recommended plans, quotes, and links to enroll Update agent / agency contact information and add new agents Look up in-network providers and covered medications Download commonly used marketing materials, forms, Schedules of Benefits, Summaries of Benefits and Coverage, and Evidences of Coverage Access healthcare reform training, tools and calculators To register on or to access our broker site, please visit healthspan.org and click on the Broker Login button in the top right corner of the page. If you are a Northeast Ohio broker who was appointed with Kaiser Permanente, please visit broker-span for quick and easy registration. RESOURCES 29

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31 Join us on Facebook, Twitter and at healthspan.org. #140826_823HSPBRO (8/14)