Group Administration Manual For groups with two to 50 eligible employees

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1 Group Administration Manual For groups with two to 50 eligible employees

2 Horizon Blue Cross Blue Shield of New Jersey Three Penn Plaza East Newark, New Jersey July 2008 Dear Group Administrator: Thank you for choosing Horizon Blue Cross Blue Shield of New Jersey as your health insurer. This Group Administration Manual will help you administer your group s health benefits plan(s). As your group s administrator, you are the liaison between Horizon BCBSNJ and your group. What s more, you are responsible for the initial enrollment, changes (including deletions) and payment of premiums. Federal regulations, underwriting rules and state regulations govern your enrollment responsibilities and the Group Administration Manual explains them in detail to ensure accurate enrollment of your employees and their dependents. Please call us if you have a special situation that needs further explanation. The Group Administration Manual does not discuss the benefits purchased for your employees. Those benefits are explained in detail in the employees Benefit Booklets or their Member Handbooks. We send these booklets and/or handbooks to newly enrolled employees along with their ID cards. This educational publication presents information as an aid to independent research. It does not provide legal opinion or advice for any individual case. Consult the appropriate professional for any such services or advice. Again, thank you for choosing Horizon Blue Cross Blue Shield of New Jersey. An independent licensee of the Blue Cross and Blue Shield Association.

3 TABLE OF CONTENTS ELIGIBILITY - EMPLOYEES Who is eligible ELIGIBILITY - DEPENDENTS Who is an eligible dependent Reasons for which coverage cannot be denied Noneligible dependents PROOF OF CHILD DEPENDENT ELIGIBILITY Legal adoption Court appointed guardianship Full-time student status Disabled dependent status UNITS OF COVERAGE Types of coverage When carve-out units of coverage apply PRE-EXISTING CONDITION LIMITATION WAITING PERIOD Waiting period election Changing the waiting period EFFECTIVE DATE OF ENROLLMENT EMPLOYEES Eligibility date Timely enrollment Late enrollment OPEN ENROLLMENT EFFECTIVE DATE OF ENROLLMENT DEPENDENTS Effective date of enrollment Eligibility date for spouse/civil union partner/domestic partner Adding a spouse/civil union partner/domestic partner timely enrollment Adding a spouse/civil union partner/domestic partner late enrollment Adding a newborn Selecting a PCP for a newborn Adding a child other than a newborn timely enrollment Adding a child other than a newborn late enrollment Eligibility date GROUP S ELIGIBILITY EXCEPTIONS TO THE LATE ENROLLEE RULES Enrolling under an exception to the late enrollee rules Loss of Coverage Special Enrollment Period Dependent Special Enrollment Period Dependent Special Enrollment Period employee is not currently enrolled Dependent Special Enrollment Period employee is currently enrolled Enrolling a dependent due to a court order PRE-EXISTING CONDITION LIMITATION What is a pre-existing condition What is the enrollment date When does the pre-existing condition limitation apply When the pre-existing condition limitation does not apply Length of pre-existing limitation and when it starts being counted Impact of waiting period on pre-existing condition limitation

4 TABLE OF CONTENTS Crediting previous creditable coverage What is creditable coverage Certificates of creditable coverage WHEN EMPLOYEES MAY CHANGE BETWEEN THE SMALL EMPLOYER S PLANS Annual open enrollment Employer opens a new plan offering HIPAA special enrollment period Employee is changing from Horizon HMO coverage CONTINUATION RIGHTS ANNUAL VERIFICATION OF EXISTING GROUP S ELIGIBILITY When to certify group qualification TERMINATION OF ENROLLMENT EMPLOYEE Mandatory termination Voluntary termination Coverage options for terminated employees TERMINATION OF ENROLLMENT DEPENDENT Dependent coverage termination Reasons a child is no longer eligible Coverage options for ineligible dependents TERMINATION OF ENROLLMENT SPOUSE/CIVIL UNION PARTNER/ DOMESTIC PARTNER Divorced spouse termination Coverage options for a divorced spouse or former civil union partner/ domestic partner TERMINATION OF ENROLLMENT DECEASED DEPENDENT Deceased spouse termination TERMINATION OF A DEPENDENT FOR CAUSE (APPLIES TO HORIZON HMO) Effective date of termination CONTINUATION RIGHTS Coordinating continuation rights CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT (COBRA) Employers who must comply with COBRA Employers who are exempt from COBRA Who is a qualified beneficiary Who is a covered employee Qualifying events and maximum coverage periods Medicare entitlement Qualifying events Election period Coverage under another group health plan Amount of premium employers may charge When premium payments are due Terminating qualified beneficiaries

5 TABLE OF CONTENTS OTHER CONTINUATION RIGHTS New Jersey Group Continuation (NJGC) New Jersey Total Disability Surviving Dependent Continuation New Jersey Continuation Rights for Over-Age Dependents (NJCROD) S A Uniformed Services Employment and Reemployment Rights Act (USERRA) MEDICARE ENTITLEMENT DUE TO AGE TEFRA/DEFRA TEFRA/DEFRA APPLIES If TEFRA/DEFRA applies (groups with at least 20 employees) Group coverage as primary How to select group coverage as primary Medicare coverage as primary When an employee retires TEFRA/DEFRA DOES NOT APPLY Groups with less than 20 employees How to select Medicare as primary Coordination of Benefits MEDICARE ENTITLEMENT DUE TO DISABILITY Medicare-eligible due to disability (other than ESRD) Medicare-eligible due to ESRD Determining the primary payer Coordination period DUAL MEDICARE ENTITLEMENT Dual Medicare eligibility Dual entitlement chart BILLING Statement and summary of account Detail bill Timely paperwork USEFUL TERMINOLOGY MANAGED CARE HORIZON HMO HORIZON HMO COINSURANCE OPTIONS HORIZON POS HORIZON DIRECT ACCESS HORIZON PPO BLUECARD PPO PROGRAM

6 TABLE OF CONTENTS BLUECARD WORLDWIDE INDEMNITY PLANS Horizon Basic Health Plan A Horizon Comprehensive Health Plans B, C, D and E UTILIZATION REVIEW Pre-facility review Emergency admission notification Medical appropriateness review Procedures requiring preapproval CLAIM FILING Guidelines Horizon POS claims Horizon Direct Access and BlueCard PPO claims Horizon PPO claims Explanation of Benefits (EOB) HEALTH CLAIM FORMS AND MAILING ADDRESSES Horizon HMO Horizon POS Horizon Direct Access Horizon PPO Horizon Basic Health Plan A and Horizon Comprehensive B, C, D and E COORDINATION OF BENEFITS Which insurance pays first How to file a COB claim PRESCRIPTION DRUG PROGRAMS Deductible and copayment options How to use the Prescription Card Program Using nonparticipating pharmacies MAGELLAN BEHAVIORAL HEALTH T Benefits of managed mental health care Utilization Management Pre-Admission Review Program HORIZON BCBSNJ DENTAL PROGRAMS USEFUL FORMS HORIZON BCBSNJ DENTAL PROGRAMS HIPAA NOTICES GENERAL NOTICES OF SPECIAL ENROLLMENT RIGHTS GENERAL NOTICES OF PRE-EXISTING CONDITIONS EXCLUSIONS CONTACT US BY TELEPHONE CONTACT US ON THE WEB

7 Eligibility Employees Employees When an employee joins your organization, it is important to follow proper enrollment procedures to ensure that the employee s enrollment is accurate and takes effect on the correct day. After an employee s coverage is in effect, he/she becomes a subscriber of Horizon Blue Cross Blue Shield of New Jersey. Who is eligible? To be eligible for small employer group coverage as an employee, a person must be: In an eligible class of employees (e.g., salaried, hourly) to whom a small employer is offering coverage; and Actively at work on the effective date of his/her coverage. If the employee is not actively at work due to a health status-related factor, the actively at work requirement does not apply. A person must also be one of the following: A bonafide full-time employee who works a normal work week of 25 hours or more for you or any of your affiliated companies. An employee who works on a temporary or substitute basis is not eligible for coverage. A proprietor or partner if he/she is a full-time employee as specified above. An independent contractor who meets these requirements: Performs a service for the employer pursuant to a written contract; Works exclusively for the employer; Works 25 or more hours per week for the employer; Works on other than a temporary or substitute basis; and The relationship is established to serve a substantial business need of the employer, not intended primarily to obtain insurance coverage. If the employer does not offer coverage to independent contractors, independent contractors do not count toward group size and are not used when calculating participation. For Horizon HMO, an eligible employee must also reside in the Horizon HMO service area. 1

8 Other eligible subscribers Persons who do not qualify as eligible employees as defined on page 1 may also be eligible as follows: A small employer who is replacing his/her health benefits plan may choose to offer coverage to permanent part-timers (work less than 25 hours per week, but at least 20 hours per week) and/or pensioners who were already enrolled on the prior Small Group Non-Reform or Small Group Non-Standard group health benefits plan at the time the small employer s coverage is converted to a Reform health benefits plan. Future permanent, part-time employees and/or pensioners would also be eligible. Former employees may have the right to continue group coverage in certain situations (e.g., total disability, COBRA and New Jersey Group Continuation). Eligibility Dependents Who is an eligible dependent? To be eligible for coverage, a dependent must be the employee s spouse, civil union partner or domestic partner (if the employer extends coverage to domestic partners) or child as defined in this section. Spouse A spouse is an individual legally married to the employee. For Horizon HMO, an eligible spouse must reside in the Horizon HMO service area. If the spouse s last name is different than the employee s last name, we must receive a copy of the marriage certificate. Civil Union Partner A civil union partner is an individual who is the same sex as the employee and has legally entered into a civil union with the employee. It requires both individuals to: Not be a party in another civil union, domestic partnership or marriage; Be of the same-sex; Be at least 18 years of age (parental consent required for minors); and Obtain a civil union license/certificate from their local or state registrar. For Horizon HMO, the civil union partner must reside in the Horizon HMO service area. Note: If the civil union partner s last name is different than the employee s last name, the employee must submit a copy of his/her civil union license/certificate. 2

9 Domestic partner (if the employer extends coverage to domestic partners) A domestic partner must meet the following requirements: Is in a same-sex relationship with the employee where both the employee and domestic partner are at least 18 years of age. Has established a domestic partnership with the employee by jointly filing an Affidavit of Domestic Partnership and obtaining a New Jersey Certificate of Domestic Partnership from their local registrar. For Horizon HMO, the domestic partner must reside in the Horizon HMO service area. Note: If the domestic partner s last name is different than the employee s last name, the employee must submit a copy of his/her Certificate of Domestic Partnership. Child A child is an individual who meets all the requirements listed below. He/she is the: Employee s own child; Employee s stepchild, if he/she depends on the employee for most of his/her support and maintenance; Employee s legally adopted child (proof is required); Child for whom the employee has court-appointed guardianship (proof is required); Child of the employee s civil union partner if he/she depends on the employee for most of his/her support and maintenance; or Child of the employee s domestic partner if he/she depends on the employee for most of his/her support and maintenance (if the employer extends coverage to children of domestic partners); He/she is unmarried; and He/she is under age 19, unless he/she: Is enrolled as a full-time student at an accredited school and is under age 23 (proof is required); or Has a mental or physical incapacity or developmental disability (proof is required) and he/she: Remains unmarried and is incapable of earning a living; Depends on the employee for most of his/her support and maintenance; Had the condition before age 19 or while covered as a full-time student; and 3

10 Initially enrolled under the employee s policy or any other policy before reaching the age limit and stayed continuously covered after reaching the age limit. We may request proof of dependent eligibility at our discretion. Reasons for which coverage cannot be be denied An employee s child cannot be denied coverage on the grounds that the child: Was born out of wedlock. However, proof of parentage, such as a birth certificate, may be required. Is not claimed as a dependent on the employee s federal tax return. Does not reside with the employee or reside in our service area (any applicable physician, health care professional and hospital use restrictions must be adhered to). Noneligible dependents A noneligible dependent is: An employee s dependent who is on active duty in any armed forces of any country. An employee s dependent, if he/she is eligible for coverage under the small employer s health plan as an employee, is offered a health benefits plan and has chosen to enroll under a separate contract. A foster child or grandchild of either the employee or his/her spouse unless the child meets the requirements specified for an eligible dependent child. An employee s opposite-sex domestic partner. An employee s same-sex domestic partner unless the employer offers coverage to same-sex domestic partners. Proof of Child Dependent Eligibility Overview This section details what is considered satisfactory proof of: Legal adoption; Court-appointed guardianship; Full-time student status; and Disabled dependent status. 4

11 Legal adoption Satisfactory proof of adoption consists of one of the following: A copy of the adopted child s birth certificate in the name of the adopting parents together with a certificate by the parents of the date of adoption; A notarized statement by an adoption agency (which is approved and accredited by the appropriate State authority) stating that adoption proceedings have been initiated in a court of competent jurisdiction and that the named child has been formally placed for adoption with the prospective parents (who are also named on the statement); or A notarized legal document from the attorney representing the employee, which clearly defines the parties involved and the terms of the custody appointment. The document should include a statement indicating that the employee is responsible for the medical care of the child. A child is considered legally adopted from the time he/she is placed for the purpose of adoption, whether a final adoption order is ever issued. Court appointed guardianship Satisfactory proof of court-appointed guardianship consists of: A document issued by a court of competent jurisdiction naming the employee or spouse/civil union partner/domestic partner as the legal guardian; and A statement by the employee certifying that the child is principally dependent upon the employee or spouse/civil union partner/ domestic partner for support and maintenance. Full-time student status Annually each fall, Horizon BCBSNJ partners with various vendors to validate full-time student status. Children who cannot be verified through these vendors will receive a Student Verification Questionnaire. If the child meets the definition of a full-time student, the employee must complete and return the questionnaire and provide acceptable documentation of full-time student status in order to enroll his/her child. Full-time is 12 or more credit hours, or as defined by the accredited school. The documentation must contain: The child s name; The name of the school the child is attending; Whether or not the child is a full-time student; and The academic period for which the child is enrolled. 5

12 We will only accept the following documents as proof of full-time student status: A signed letter from the school s Registrar on the school s letterhead; A signed letter from the employee with a stamp or signature from the school; A current course schedule; A current paid tuition receipt; or Documentation from the National Student Clearinghouse. Disabled dependent status The employee must provide written proof that the child is incapacitated and depends on the employee for most of his/her support and maintenance. Horizon BCBSNJ must receive the notification within 31 days from the date the child reaches the policy age limit. Please use the Request for Continuance of Enrollment for a Disabled Dependent form (#2407) to supply the required information. We may request periodic proof that the child s condition continues. Units of Coverage Types of coverage The units of coverage are: Single Covers the employee only. Two Adults Covers the employee and eligible spouse/civil union partner/domestic partner. Parent and child(ren) Covers the employee and eligible child(ren). Family Covers the employee, eligible spouse/civil union partner/domestic partner and eligible child(ren). When carve-out units of coverage apply An employee may be enrolled in a carve-out unit of coverage for his/her health benefits plan when the employee and/or his/her eligible dependent is eligible for Medicare for any reason and Medicare is the primary plan and the group health plan is the secondary plan. Carve-out units of coverage do not apply to freestanding prescription drug riders or to dental coverage. Refer to pages for information on when Medicare is the primary plan. 6

13 Waiting Period Waiting period election You may elect to have your employees become eligible for coverage on the date of employment or at the completion of a specified waiting period. The length of the waiting period, measured in monthly increments, can range from zero to six months. You may vary the waiting period among classes of employees. Example ABC Company has a Horizon HMO plan for all its eligible employees. The waiting period chosen by ABC Company varies between classes of employees: The salaried employees have a one-month waiting period. The hourly employees have a three-month waiting period. Changing the waiting period You may change the length of the waiting period for a class of employees effective upon the group s next anniversary date. The change only applies to employees who are hired on or after the effective date of the new waiting period. Effective Date of Enrollment Employees Eligibility date An employee s eligibility date for medical coverage is the later of two dates: The date of employment; or The day after any applicable waiting period ends. Note: Freestanding dental programs have different effective dates and waiting period requirements. Please refer to the Dental Group Administration Manual for information on freestanding dental program effective dates and waiting periods. 7

14 Required form The Enrollment/Change Request form is required for enrollment. This form must be completed and signed by the employee and the employer. The employees ID card and certificate are sent to the group. You must submit this form to Horizon BCBSNJ. Keep a copy of the form for your files. Timely enrollment For coverage to start on the employee s eligibility date, Horizon BCBSNJ must receive the completed enrollment form within 30 days of the employee s eligibility date. To determine whether the pre-existing condition limitation applies, please refer to the Pre-existing Condition Limitation section on page 16. The effective date of an employee s coverage will not be postponed if an employee is not actively at work due to his/her own health status-related factor. Examples The group does not have a waiting period. Reed begins working on timely enrollment February 7, Horizon BCBSNJ receives the enrollment form on February 11, Reed s coverage is effective February 7, 2008, the date of employment. The group s waiting period is two months. Anthony s start date is January 12, 2008 and Horizon BCBSNJ receives the enrollment form on January 21, Anthony s coverage is effective on March 12, 2008, the day after the waiting period ends. Late enrollment If Horizon BCBSNJ receives the completed enrollment form more than 30 days after an employee s eligibility date, the employee is considered a late enrollee. Coverage for late enrollees becomes effective no earlier than the date Horizon BCBSNJ receives the completed application. Late enrollees are subject to the pre-existing condition limitation, which may be reduced by prior creditable coverage. Examples Craig begins active full-time work on March 7, There is no late enrollment waiting period. The enrollment form is received on April 15, The effective date of coverage is April 15, 2008, since the enrollment form was received more than 30 days after his eligibility date. Craig is a late enrollee and is subject to the pre-existing condition limitation. 8

15 The group imposes a two-month waiting period. Laura s date of hire is September 1, On December 15, 2008 we receive her enrollment form. Since we received her enrollment form more than 30 days after her November 1 eligibility date, she is a late enrollee and is subject to the pre-existing condition limitation. Effective Date of Enrollment Dependents Effective date of enrollment An employee must be enrolled for his/her eligible dependent(s) to be added. If coverage is made available to dependents, your employee may elect to enroll his/her eligible dependents when his/her own coverage becomes effective. An employee may also add eligible dependents at any time after the employee s effective date of coverage. Any eligible dependent who is confined to a hospital or other health care facility or is confined at home on the date his/her coverage is to start is still eligible for coverage on that date. Required form The Enrollment/Change Request form is required for any change in enrollment. This form must be completed and signed by the employee and the employer. You must submit this form to Horizon BCBSNJ. Keep a copy of the form for your files. Eligibility date for spouse/civil union partner/domestic partner The eligibility date is as follows: For a spouse, the date of marriage; For a civil union partner, the date of the civil union; and For a domestic partner, the date the Certificate of Domestic Partnership was issued. Adding a spouse/civil union partner/domestic partner timely enrollment If Horizon BCBSNJ receives the completed enrollment form to add an eligible spouse/civil union partner/domestic partner within 30 days of eligibility, his/her coverage becomes effective on the date of eligibility. To determine whether the pre-existing condition limitation applies, please refer to the Pre-existing Condition Limitation section on page 16. 9

16 Examples Stephanie is an enrolled employee in a group of six or more timely enrollment eligible employees. She marries on May 21, 2008, and the enrollment form to add her spouse arrives at Horizon BCBSNJ on May 27, Since the required paperwork was received within 30 days of the marriage, the effective date of the spouse s coverage is May 21, The spouse is not subject to a pre-existing condition limitation since the group has six or more eligible employees. As of the last anniversary date, the group has four eligible employees. Ashley marries on June 4, 2008, and the enrollment form to add her spouse arrives at Horizon BCBSNJ on June 10, The effective date of the spouse s coverage is June 4, The spouse is subject to a pre-existing condition limitation since there are two to five eligible employees in the group. Adding a spouse/ civil union partner/ domestic partner late enrollment If we receive the completed enrollment form to add an eligible spouse/civil union partner/domestic partner more than 30 days after eligibility, he/she is a late enrollee and is subject to the pre-existing condition limitation. Coverage becomes effective no earlier than the date Horizon BCBSNJ receives the completed enrollment form. Example Bill marries on January 8, 2008, and the required paperwork to late enrollment add his spouse arrives at Horizon BCBSNJ on July 14, Bill s spouse is a late enrollee, so her coverage is effective July 14, The spouse is subject to a pre-existing condition limitation. Adding a newborn An employee s newborn child is automatically covered for 31 days from the date of birth, subject to the terms of his/her health benefits plan. When the employee is enrolled in a Single or a Two Adults unit of coverage and we receive the application for Parent and Child(ren) or Family coverage: Within 31 days of the newborn s birth, the newborn will be covered from the moment of birth and is considered to have enrolled timely. More than 31 days after the newborn s birth, the newborn is automatically covered for the first 31 days from the date of birth. However, coverage will be interrupted after the first 31 days. Coverage will become effective again no earlier than the date we receive the completed enrollment form. To determine whether the pre-existing condition limitation applies, please refer to the Pre-existing Condition Limitation section on page

17 An employee who already has Parent and Child(ren) or Family coverage must also submit an enrollment form to continue coverage for the newborn. Regardless of when we receive the enrollment form, there is no lapse in coverage for the newborn. Coverage for the newborn will be provided from the date of birth. Note: If the employer does not offer coverage to dependents, the newborn child is not covered after the initial birthing confinement (the joint eligible hospital stay with the newborn s mother). Selecting a PCP for a newborn If required by plan design, a Horizon HMO member must select a Primary Care Physician (PCP) for his/her dependent newborn so that rendered services and supplies are covered. If a PCP is not selected, all services for the newborn are not covered. A Horizon POS member must select a PCP for his/her dependent newborn so that incurred services and supplies are covered at the highest level of benefits. If the member does not select a PCP, all services for the newborn are paid at a lower level of benefits, except for medical emergencies. Example The employee is enrolled in a Two Adults unit of coverage. The timely enrollment newborn s date of birth is August 18, We receive the enrollment form to convert from Two Adults to Family on August 26, The effective date of change to Family coverage is the newborn s date of birth since the enrollment form was received within 31 days of the date of birth. The newborn has continuous coverage from the date of birth and is not subject to the pre-existing condition limitation. Example The employee is enrolled in a Single unit of coverage. The late enrollment newborn s date of birth is March 1, We receive the enrollment form to convert from a Single to a Parent and Child(ren) unit of coverage on April 15, The newborn is covered for the first 31 days from the date of birth (from March 1 through March 31, 2008) and then has a lapse in coverage. The newborn s coverage becomes effective again on his/her enrollment date, which is April 15, Although the application was received more than 31 days after the newborn s date of birth, whether the pre-existing condition limitation applies depends on whether the break in coverage is more than 90 days. For details, please refer to the Pre-existing Condition Limitation section on page

18 Adding a child other than a newborn timely enrollment The child s coverage becomes effective on his/her eligibility date, if we receive the completed enrollment form to enroll the child within 30 days of the child s eligibility date. To determine whether the pre-existing condition limitation applies, please refer to the Pre-existing Condition Limitation section on page 16. Adding a child other than a newborn late enrollment If the completed enrollment form is received more than 30 days after the child s eligibility date, the child is a late enrollee and coverage becomes effective no earlier than the date we receive the enrollment form. The child is subject to the pre-existing condition limitation. Eligibility date For adopted children, the eligibility date is the date of adoption or the date the child is placed in the home for adoption. Proof of adoption is required. If your employee becomes a legal guardian, the eligibility date is the date your employee assumes the legal guardianship of the child. Proof of court-appointed guardianship is required. Exceptions to the Late Enrollee Rules Enrolling under an exception to the late enrollee rules When a person enrolls during one of the time frames described below, he/she is not considered a late enrollee because he/she is enrolling under an exception to the late enrollee rules: HIPAA Special Enrollment Period. Loss of Coverage Special Enrollment Period. Dependent Special Enrollment Period. Enrolling a dependent due to a Court Order. Loss of Coverage Special Enrollment Period An eligible employee or eligible dependent is not considered a Late Coverage Special Enrollee if he/she was covered under any group health plan or health insurance coverage when coverage was previously offered and lost coverage is due to one of the following qualifying reasons: Loss of eligibility which includes but is not limited to: Termination of employment or eligibility; Reduction in the number of hours of employment; Divorce, legal separation, dissolution of civil union, civil union separation, termination of domestic partnership; or Death of an employee. 12

19 Exhaustion of COBRA continuation coverage, which occurs when an individual s COBRA coverage ends for any reason other than failure of the employee or dependent to pay premium timely or termination of coverage for cause. Termination of the employer s contribution toward coverage, which occurs when the employer stops contributing toward the employee s or the dependent s coverage so long as it is not COBRA continuation coverage. For this to apply, we must receive the completed enrollment form within 90 days after the event and documentation that states the reason and the date the previous coverage ended. Coverage begins when the other coverage ends and the person is not a late enrollee. Examples Maria becomes an active full-time employee in a group with six or more eligible employees on January 10, She initially waives coverage since she s covered under her spouse s group coverage, and she states this reason on the Waiver form. Coverage with her spouse s health benefits plan terminates on May 27, 2008 due to divorce. Horizon BCBSNJ receives Maria s application on July 15, The effective date of coverage is May 28, 2008, since the enrollment form was received within 90 days after the previous group health benefits plan ended. Maria is enrolling under an exception to the late enrollee rules and is not subject to the pre-existing condition limitation, since she is enrolled in a group of six or more eligible employees. Erica becomes an active full-time employee in a group with six or more eligible employees on January 10, She initially waives coverage since she s covered under her spouse s group coverage and states this reason on the Waiver form. Coverage with her spouse s health benefits plan terminates on May 27, 2008 due to divorce. Horizon BCBSNJ receives Erica s enrollment form on September 20, The effective date of coverage is September 20, 2008, since we did not receive the enrollment form within 90 days after the previous group health benefits plan ended. Erica is a late enrollee and is subject to the pre-existing condition limitation. Jim marries on June 14, His new spouse initially waives coverage in a group of six or more eligible employees since she s covered under her own employer s group health benefits plan and states this reason on the Waiver form. Her coverage ends on June 30, 2008, due to termination of employment, and the enrollment form to enroll her as Jim s dependent arrives on July 15, The effective date of her group coverage is July 1, 2008, since the required enrollment form was received within 90 days of the date of termination of the other employer s health benefits plan. She is enrolling under an exception to the late enrollee rules and is not subject to the pre-existing condition limitation since she is enrolled in a group of six or more eligible employees. 13

20 Dependent Special Enrollment Period The Dependent Special Enrollment Period allows an eligible employee to enroll new dependents he/she obtains through marriage/civil union/domestic partnership, birth or adoption. This applies whether the employee is currently enrolled or not. Dependent Special Enrollment Period employee is not currently enrolled If an eligible employee is not currently enrolled and an individual becomes the employee s dependent through: Marriage/civil union/domestic partnership, the employee may enroll the following persons without being considered late enrollees if we receive the enrollment form within 30 days of marriage/civil union/ domestic partnership: Himself/herself; His/her new spouse/civil union partner/domestic partner; and/or New child dependents he/she obtains as a result of the marriage/civil union/domestic partnership. Birth, adoption or placement for adoption, the employee may enroll the following persons without being considered a late enrollee if we receive the enrollment form within 31 days of birth, adoption or placement for adoption: Himself/herself; The newborn or newly adopted child; and/or His/her spouse/civil union partner/domestic partner (if not already enrolled). Coverage becomes effective on the date of marriage/civil union/ domestic partnership, birth, adoption or placement for adoption. Dependent Special Enrollment Period employee is currently enrolled If an eligible employee is currently enrolled and an individual becomes the employee s dependent through: Marriage/civil union/domestic partnership, the employee may enroll the following persons without being considered late enrollees if we receive the enrollment form within 30 days of marriage/civil union/ domestic partnership: His/her new spouse/civil union partner/domestic partner; and/or New child dependents he/she obtains as a result of the marriage/ civil union/domestic partnership. Birth, adoption or placement for adoption, the employee may enroll the following persons without being considered a late enrollee if we receive the enrollment form within 31 days of birth, adoption or placement for adoption: 14

21 The newborn or newly adopted child; and/or His/her spouse/civil union partner/domestic partner (if not already enrolled). Coverage becomes effective on the date of marriage/civil union/ domestic partnership, birth, adoption or placement for adoption. Note: If the employee is adding his/her dependent during a Dependent Special Enrollment Period, the employee may change to another offering of the employer without having to wait until the group s next open enrollment period. Example Lee previously waived coverage when she was first eligible. She marries on November 20, We receive her enrollment form on November 30, 2008, enrolling herself and her new spouse in a Two Adults contract. The effective date is November 20, Due to this special dependent enrollment period, they are enrolling under an exception to the late enrollee rules and are not subject to a pre-existing condition limitation since they are enrolled in a group of six or more eligible employees. Had the group size been between two and five eligible employees, the pre-existing condition limitation would apply. Enrolling a dependent due to a court order When an employee is under legal obligation to provide health coverage for his/her eligible dependent due to a court or administrative order, the dependent is not considered a late enrollee if we receive: The completed enrollment form within 30 days of the issuance of the order; and A copy of the order. Coverage becomes effective as of the date required pursuant to the order. 15

22 Pre-existing Condition Limitation What is a pre-existing condition? A pre-existing condition is an illness or injury, whether physical or mental, which manifests itself in the six months before a covered person s enrollment date and for which medical advice, diagnosis, care or treatment was recommended or received from a practitioner in the six months before his/her enrollment date. Taking a prescribed drug is considered medical care or treatment. Genetic information cannot be treated as a pre-existing condition in the absence of a diagnosis. A pre-existing condition limitation can never apply to pregnancy. What is the enrollment date? For persons who enroll timely, the enrollment date is the earlier of: The effective date of the person s coverage; or If there is a waiting period, the first day of the waiting period, which is typically the first day of full-time employment. For late enrollees and for persons who enroll under an exception to the late enrollee rules, the enrollment date is the effective date of the person s coverage. When does the pre-existing condition limitation apply? For groups of two to five eligible employees, the pre-existing condition limitation applies to: Persons who enroll timely; Late enrollees; and Persons who enroll under an exception to the late enrollee rules. For groups of six or more eligible employees, the pre-existing condition limitation only applies to late enrollees. In addition, late enrollees get credit for coverage within the past 90 days. The determination of a group s size and whether the pre-existing condition limitation applies to your health benefits plan is made on the initial effective date of the small employer s coverage and each subsequent policy anniversary date. If a change is made as to whether the pre-existing condition limitation applies to your group, it will not affect employees and dependents already enrolled in your health benefits plan. 16

23 When the The pre-existing condition limitation does not apply in the following pre-existing condition situations regardless of group size: limitation does not apply A newborn child: When the employee is enrolled in a Single or Two Adults unit of coverage and we receive the enrollment form: Within 30 days of the newborn s birth; or More than 31 days from birth but the newborn was covered under any creditable coverage within 30 days of birth and there is not a significant break in coverage of more than 90 consecutive days prior to the newborn s enrollment date. When the employee is enrolled in a Parent and Child(ren) or Family unit of coverage and we receive the enrollment form at any time. An adopted child or a child placed for adoption, if we receive the enrollment form: Within 31 days of the date of adoption or placement for adoption; or More than 31 days from the date of adoption or placement of adoption and the child was covered under any creditable coverage within 30 days of adoption or placement for adoption and there is not a significant break in coverage of more than 90 consecutive days prior to the child s enrollment date. To late enrollees, unless 10 or more late enrollees request enrollment during any 30-day enrollment period. Example Newborn The employee is enrolled in a Single unit of coverage. The and no break in newborn s date of birth is March 1, We receive the coverage of more enrollment form to convert to a Parent & Child(ren) unit of than 90 days coverage on April 15, The newborn is covered for the first 31 days from the date of birth (from March 1 through March 31, 2008) and then has a lapse in coverage. The newborn s coverage becomes effective again on his/her enrollment date, which is April 15, Since the newborn was covered under creditable coverage within 30 days of birth and did not have a significant break in coverage of more than 90 consecutive days prior to his/her April 15th enrollment date, the newborn is not subject to the pre-existing condition limitation. 17

24 Example Newborn and break in coverage of more than 90 days The employee is enrolled in a Single unit of coverage. The newborn s date of birth is March 1, We receive the enrollment form to convert to a Parent & Child(ren) unit of coverage on July 15, The newborn is covered for the first 31 days from the date of birth (from March 1 through March 31, 2008). The newborn s coverage becomes effective again on his/her enrollment date, which is July 15, Although the newborn was covered under creditable coverage within 30 days of birth, he/she had a significant break in coverage of more than 90 consecutive days prior to his/her July 15th enrollment date. Therefore, the newborn is subject to the pre-existing condition limitation from his/her July 15, 2008 enrollment date. Length of pre-existing limitation and when it starts being counted If the pre-existing condition limitation applies, we do not cover services or pay benefits for charges for pre-existing conditions for a look-forward period of 180 days starting on the person s enrollment date. Impact of waiting period on pre-existing condition limitation When a person enrolls timely in a group of five or fewer eligible employees and the group imposes a waiting period, the waiting period and pre-existing condition limitation periods are counted concurrently. Examples ABC Company has seven eligible employees on the last anniversary date. The pre-existing condition limitation does not apply except for late enrollees. On the group s next anniversary date, it has five eligible employees, and the pre-existing condition limitation applies to anyone who subsequently enrolls. It will not impact employees and dependents who were enrolled prior to the anniversary date. Norma is hired June 7, 2008, into a group of two to five eligible employees and has a three-month waiting period. Horizon BCBSNJ receives her enrollment form within 30 days of her eligibility date. Her enrollment date is June 7, 2008 (the first day of her waiting period); the effective date of coverage is September 7, Norma has a look-forward period that starts on June 7, 2008, and continues for 180 days through December 4, As of December 5, 2008, the pre-existing condition limitation no longer applies. Karen is hired March 1, 2008, in a group of six or more eligible employees and has a one-month waiting period. Horizon BCBSNJ receives her enrollment form on June 21, 2008, which is more than 30 days after her eligibility date. Karen is a late enrollee and her enrollment date is June 21, 2008 (her effective date of coverage). Her look-forward period starts June 21, 2008, and continues for 180 days through December 18, As of December 19, 2008, the pre-existing condition limitation no longer applies. 18

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