2016 Producer QUICK REFERENCE GUIDE Group Market Segment Two-50. Local Toll Free

Transcription

1 2016 Producer QUICK REFERENCE GUIDE Group Market Segment Two-50 Local Toll Free Group Size and Proposal Rating: All BusinessADVANTAGE and BusinessADVANTAGE Select Upstate I Plans: Two 50 eligible employees Adjusted Community Rates o Tobacco Surcharge 20 percent on tobacco users 18 years or older (if participating in a tobacco cessation program, surcharge can be removed by completing and submitting the Tobacco Usage form). The size of the group is determined by the number of full-time, eligible employees, not the number of enrolled subscribers. If a business has 50 or fewer full-time employees, the health care law considers it a small business, and subject to ACA requirements. Family dependent rates are based on the three oldest children under age 21 and all children 21 through 26. A rate will only be applied to the three oldest dependents under age 21. Dependents age 21 and over will be rated individually. Affordable Care Act (ACA) Fees All applicable ACA fees are included in new and renewal rates for all groups. Open Enrollment All groups will have an open enrollment period 30 days prior to their renewal/effective date. Any member changes outside of that open enrollment period must be subject to a qualifying event Page 1

2 New Group Submission Requirements: Refer to the 2016 Producer New Group Check List which lists all required documentation needed for submission of new groups. Key Reminders of required documents: 1. Group Request for Coverage Form 2. Master Group Application 3. Copy of Accel-A-Rate sm (AAR) proposal that matches enrollment to include full legal names and correct dates of birth. 4. Enrollment Application or Census Enrollment Spreadsheet (preferred) 5. Quarterly Wage and Tax Report (UCE 101 and 120) Group Size Review Form two pages 7. Tobacco Usage Form- only required for tobacco users if currently enrolled in tobacco cessation program. 8. Companion Life Master Application (if elected optional) Life insurance offered by Companion Life. Because Companion Life is a separate company from BlueChoice HealthPlan, Companion Life will be responsible for all services related to life insurance. NOTE: Receipt of signed rates is required for the processing of group coverage. Failure to submit will delay the group and could impact requested effective dates and rates. BusinessADVANTAGE Select Upstate I: BusinessADVANTAGE Select Upstate I offers six comprehensive health plans designed for employers who are located in six exclusive counties. It uses a SELECT group of providers and hospitals affiliated with the My Health First Network affiliated with Greenville Hospital System (EPO network). It is only offered in Abbeville, Greenville, Greenwood, Laurens, Oconee and Pickens. Members can use any CVS Minute Clinic throughout the state at the primary care physician benefit level. Members can use Doctors Care for Urgent Care Services in all South Carolina counties except for the six in the EPO network and Newberry County due to network adequacy. Emergency Services are the only covered services outside the Select network for both in and out of state. There is a specific Group Request for Coverage form for this product. All other group paperwork is the same as Business Advantage products Page 2

3 Group Criteria: Plan Effective Date: Groups may select effective dates on the first of the month (preferred) or 15 th of the month. Proposals must be run in AAR at least seven days prior to the effective date. Cases should be submitted a minimum of two weeks prior to the effective date. This will ensure groups are loaded into the system, and members receive ID cards in a timely fashion. Plan Year: Calendar or Contract Year Waiting Periods: First of the month following 30 days First of the month following 60 days 90 days (exact) If a group does not elect a waiting period, the default will be the first of the month following 60 days. Employer Contribution: Employer Contribution Requirement: 50 percent of the single medical premium rate. Employer contribution does not include tobacco surcharges. Employee Eligibility: All eligible employees (working a minimum of 30 hours a week, 48 weeks of the year) are eligible to enroll after meeting the waiting period. New hires must enroll within 31 days of their eligibility dates. We exclude late enrollees until the group s open enrollment period at renewal and enrollees must submit by the renewal date. Member s enrolled on exchange individual plans CANNOT be added to the group plan until they have been terminated off the exchange plan. Members MUST contact healthcare.gov for this service if coverage was purchased on exchange. We will cover dependent children up to age 26. Coverage ends at the end of the birthday month. Contract (1099), leased employees and management (class) carve-outs of any kind are not eligible. Participation Requirements: Eligible Employees: Two 50 Minimum Participation Requirement 70% of total full-time, eligible employees after excluding valid waivers Valid waivers include Medicare, Medicaid, other employer-sponsored group insurance coverage and military/veterans programs. Individual coverage is not a valid waiver Page 3

4 Dual Option Coverage: Groups can elect a dual option from any BusinessADVANTAGE plan options. Groups cannot select one option from BusinessADVANTAGE and one option from BusinessADVANTAGE Select Upstate I. There can be no mixing between these two products. Minimum group size for dual option is two employees, with at least one employee on each option. Two - Three-Person Groups: If a husband and wife are the only two employees in a valid group, they must enroll on separately. They may only enroll children under one parent. If the group has three or more employees and two of those are a husband and wife, they may enroll together with employee/spouse or family coverage. The employee covered as a spouse must complete a waiver enrollment form for medical/dental. The employee covered as a spouse must complete a waiver enrollment form for life insurance, offered by Companion Life Insurance Company. The covered spouse still has the option of electing the employee life insurance. If elected, the life section on the enrollment form must be complete. SHOP Criteria: All new group enrollments through the SHOP have to be quoted and enrolled through All adds and terms must also be completed through BlueChoice HealthPlan CANNOT make eligibility changes on SHOP groups. First of the month effective date only option. Employer Contribution requirement is not applicable only during open enrollment. Participation requirement is not applicable only during open enrollment. Dual Options are not available. Comprehensive Dental and Companion Life products are not available. BusinessADVANTAGE Select Upstate I products are NOT available on SHOP Page 4

5 Additional Guidelines and helpful hints: Pediatric Vision is considered a standard benefit on all BusinessADVANTAGE and BusinessADVANTAGE Select Upstate I plans. This benefit utilizes the VSP network for children up to age 19. The adult Routine Vision benefit is also a standard benefit utilizing the Physicians Eye Care Network (PEN). Neither benefit can be removed. All BusinessADVANTAGE groups have an Employee Assistance Program (EAP) through First Sun EAP. Because First Sun is a separate company from BlueChoice HealthPlan, First Sun will be responsible for all services related to the employee assistance program All plans include an embedded deductible and MOOP. Six- tier drug benefit is effective January 1, 2016 for new groups and upon renewal for existing groups during All groups switching to BusinessADVANTAGE and BusinessADVANTAGE Select Upstate I plans will receive a new group number and new member ID cards. Below are the id card prefixes: BusinessADVANTAGE and Carolina Advantage ZCL BusinessADVANTAGE through the SHOP ZCG BusinessADVANTAGE Select Upstate I ZCI BusinessADVANTAGE/Carolina Advantage (legacy business) utilizes the full Open Access Network. BusinessADVANTAGE Select Upstate I utilizes a separate, exclusive network in six counties ONLY. BusinessADVANTAGE utilizes a closed formulary, prescription drug list. The Covered Drug List is on our website under Products and Services/Business Advantage/Prescription Drug Information/Covered Drug List. Comprehensive Dental Coverage (Optional): If the group elects Comprehensive Dental coverage, the employee s dental election must match the medical election. Example: E/S medical = E/S dental Employees cannot elect dental only. Life Insurance from Companion Life (Optional): A minimum of $10,000 group life and accidental death and dismemberment insurance is optional. Companion Life requires a Personal Health Statement for amounts greater than $15,000. Eligible Employees: Increments: Two 19 $10,000 $15,000 $20,000 $30,000 $40,000 $50,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40, $45,000 $50,000 Companion Life will underwrite and bill for all amounts over $50,000. If a group elects life, all enrolled in medical will be enrolled in life. If the employee elects only life insurance, he or she must complete the life section of the enrollment form/census spreadsheet. Companion Life may sell Dependent Life with Basic Life. The dependent life amounts are flat amounts based on group size Page 5

6 Eligible Employees: Covered Spouse Amount: Per Covered Child Amount: Two 19 $2,000 $1, $5,000 $5,000 The life insurance election does not have to match the medical/dental election. The employee can elect to have dependent life (if the employer offers it), and only elect single medical/dental coverage. Also, the employee can waive the dependent life, but elect to cover the family under the medical/dental plan Page 6

7 Group Renewals-Form Requirements: Grandfathered CarolinaADVANTAGE Plans 1. Group Attestation form Group Size Review form 3. Revised signed rate sheet if group renews with rate concession. Non-Grandfathered CarolinaADVANTAGE Plans Group Size Review form 2. Signed rate sheet (if switching to another CarolinaADVANTAGE plan) 3. Revised signed rate sheet if group renews with rate concessions. Moving to 2016 BusinessADVANTAGE and BusinessADVANTAGE Select Upstate I Plans (ACA metal plans) On Renewal Date 1. Signed metallic rate sheet Group Size Review form Off Renewal Plan changes All New Group Paperwork including census spreadsheet or enrollment applications with tobacco usage questions answered. Important Reminder If any group currently has optional life or comprehensive dental coverage; it MUST be reflected on the group renewal proposal if the group plans to continue with this coverage. If it is not reflected, the coverage will be dropped. Agent of Record (AOR) Changes: AOR requests should be submitted on company letterhead and signed by an officer of the company. First Year Groups AOR change will be approved upon the first year renewal. After the renewal, all AOR requests will be approved the first of the month following the date of the request. Group Termination Requests: All group termination requests should be submitted PRIOR to the requested termination date for approval. Failure to provide timely requests will result in the request being approved the first of the following month of the request. Retro-termination requests will ONLY be granted if claims have not been paid on members, and the request is within days of the request. This Quick Reference Guide is designed to assist our producers with useful information that will result in faster service and implementation of groups and renewals. Contents are subject to change anytime at the discretion of BlueChoice HealthPlan. Please contact your BlueChoice HealthPlan Marketing Representative if you have questions. We are your primary resource for all of your small group business. Make the right choice BlueChoice Page 7