Group Administrator Manual How to administer your group s health coverage

Transcription

1 Group Administrator Manual How to administer your group s health coverage 16430CTEENABS 09/14

2 Section 1 Introduction... 4 Welcome... 4 Employer responsibilities Section 2 Important addresses and telephone numbers... 6 General correspondence General claims Specialty Anthem Blue View Vision SM... 6 Section 3 Eligibility... 8 Eligible employees Section 4 Effective dates... 9 Open enrollment Employee benefit conversion Employer group benefit conversions New hires... 9 Newly eligible dependents Section 5 Enrollment procedures How to enroll an employee and eligible dependents Medicare secondary payer (MSP) Enrollment changes Addition or deletion of members Removal of a dependent Changing contact information Correcting dates of birth Changing primary care physicians Moving out of the service area Flexible benefits plans (Section 125 plans) Special enrollment considerations When to send enrollment forms Open enrollment Section 6 Electronic enrollment Electronic enrollment advantages Electronic enrollment options Online tools and resources for employers Online tools and resources for members

3 Section 7 Coordination of Benefits (COB) Section 8 Claim filing Hospital claims Medical/surgical claims BlueCard : the out-of-area program BlueCard Worldwide program Anthem Dental Prescription drug claims Home delivery pharmacy prescription Section 9 Billing Quick reference guide Fully insured groups Notification of new employees Waiting period Effective dates Notification of left employees Medical Loss Ratio Disclosure Common Membership Change messages Administrative Services Only (ASO) Groups Section 10 Accounting and terminations Payment Reinstatement Retroactive coverage changes Employee contract termination Transfer privileges Section 11 Federal law Medicare Medicare Secondary Payer (MSP) regulations Medicare and group coverage: Who is the primary carrier? Dual Medicare eligibility Family Medical Leave Act (FMLA) Summaries of Benefits and Coverage (SBC) Health Insurance Portability and Accountability Act of 1996 (HIPAA)

4 Section 1 Introduction Welcome Thank you for selecting Anthem Blue Cross and Blue Shield! You are important to us, and our number one priority is to provide you with the prompt, efficient service that you deserve. To help you manage your group s benefit program, we ve developed this benefit administrator manual. The manual includes summary information on eligibility, enrollment procedures and other important information about your plan. It also gives you step-by-step instructions on how to enroll employees and fill out the appropriate forms. You ll find information such as: Employer responsibilities As an employer, your responsibilities include: Giving notice of eligibility to each employee who is or will become eligible for enrollment. Obtaining and submitting complete enrollment information for eligible employees wishing to enroll. Note: Incomplete enrollment information will delay enrollment. Sending Anthem Blue Cross and Blue Shield all applications, notices, or other written information or inquiries received from eligible employees. Distributing Anthem Blue Cross and Blue Shield notices to covered employees. Paying premiums on or before their due dates, even though the group requires a contribution toward the premium from covered employees. Maintaining a benefits record file of employee applications for each employee. It should include any changes of classification, benefit amounts and other relevant details when applicable. We may periodically request information that would be contained in the benefits record file. Reporting to Anthem Blue Cross and Blue Shield the following changes and their effective dates: - Change in classification - Change in earnings (if benefit amounts are affected) - Change in dependent status - Change of employee name - Change of employee address - Termination of coverage and the reason - Change of employer information Assisting covered employees in filing claims, if applicable. Notifying employees of COBRA or continuation coverage eligibility, if applicable. - If Anthem Administered COBRA, the employer is responsible for logging in to Benefit Admin Solutions website, and enter the employee entering the Qualifying Event (QE). Reporting to Anthem Blue Cross and Blue Shield any of its Qualified Medical Child Support Order (QMCSO) determinations, and providing Anthem Blue Cross and Blue Shield with copies of such QMCSOs. Notifying employees of any conversion eligibility upon termination of employment, or when coverage is lost due to other events as stated in your Certificate, if applicable. Notifying Anthem Blue Cross and Blue Shield of changes in group size. Note: State and federal legislation will alter the administration of different aspects of your group health plan depending on the number of employees in your group. It is important that Anthem Blue Cross and Blue Shield receive notification of changes in groupsize from 2-19, and 51+.

5 Notifying Anthem Blue Cross and Blue Shield if an employee ceases to meet the eligibility requirements set forth in the Eligibility Requirements section of this manual. Notifying Anthem Blue Cross and Blue Shield if an employee is not actively at work (as defined in the Certificate) on the date coverage would otherwise be effective. Tracking who is on COBRA, establishing who is no longer eligible for (has used up their time on) COBRA, and notifying Anthem Blue Cross and Blue Shield s Billing Department about the status of these individuals, if applicable. Group participation and contribution requirements To avoid cancellation of your group s coverage, group participation requirements must be met and consistently maintained. Small group s (2-50 eligible employees) minimum participation requires enrollment of at least 75 % of net eligible employees for groups of eligible employees. Groups under 10 eligible employees require 100 % participation (minus spousal waivers). If the small group enrolls at least 50 % of the total eligible employees, then only enrolling employees and enrolling dependents need to fill out the medical portion of the initial application; for small groups enrolling less than 50 % of the total eligible employees, both waiving and enrolling employees and dependents must fill out the medical portion of the initial application. A minimum of two must be enrolled in health coverage (including husband and wife-only groups). For dual choice plans, a large group employer must have a minimum of 10 employees enrolled between the two plans with at least two covered in the plan with the lowest enrollment, and a small group employer must have a minimum of 2 employees enrolled with at least 1 employee enrolling in each plan being offered. Please note: This manual is not a legal policy or contract. It is designed to familiarize you with Anthem Blue Cross and Blue Shield administrative procedures. While the information in this manual covers topics that affect your group s benefit program, the information in this manual is not intended to modify, interpret, replace or govern the terms of the Certificate of Coverage Group Health Care Benefits Contract (GHCBC). This manual does not constitute legal advice or counsel. You should always consult your own legal counsel whenever you have specific legal questions concerning any of the provisions of your group s benefit program. The procedures followed by Anthem Blue Cross and Blue Shield and outlined in this manual may be changed without notice. If you have any questions about your group s benefit program, please refer to the GHCBC, Certificate of Coverage or Subscriber Agreement. If you still have questions concerning a specific problem, please contact your sales representative, account service representative or member services department. 5

6 Section 2 Important addresses and telephone numbers General correspondence General correspondence: Commercial Accounts Anthem Blue Cross and Blue Shield P.O. Box 1044 North Haven, CT State of Connecticut Anthem Blue Cross and Blue Shield P.O. Box 554 North Haven, CT Public Sector Accounts Anthem Blue Cross and Blue Shield P.O. Box 1026 North Haven, CT General claims General claims: General Customer Service: Commercial Accounts Anthem Blue Cross and Blue Shield P.O. Box 533 North Haven, CT State of Connecticut Anthem Blue Cross and Blue Shield P.O. Box 583 North Haven, CT Public Sector Accounts Anthem Blue Cross and Blue Shield P.O. Box 533 North Haven, CT Specialty: Anthem Life and Disability Customer service number: LifeandDisabilityClaims@anthem.com Life claims Fax: P.O. Box Atlanta, GA Disability claims: Fax: P.O. Box Atlanta, GA Anthem Vision Customer service number: In-network claims: Anthem Vision P.O. Box 8504 Mason, OH Out-of-network claims: Anthem Vision 555 Middle Creek Parkway Colorado Springs, CO

7 Anthem Blue View Vision Customer service number: In-network claims: Blue View Vision Claim P.O. Box 8504 Mason, OH Out-of-network claims: Blue View Vision Claim P.O. Box 8504 Mason, OH Online services anthem.com (integrated with health online administration) Anthem Dental Prime and Complete Customer service number: Dental claims: P.O. Box 1115 Minneapolis, MN Online services: anthem.com/mydentalvision Dental claims: Anthem Dental P.O. Box San Antonio, TX Online services: anthem.com (integrated with health online administration) Pharmacy claims In or out of state: Anthem Blue Cross and Blue Shield P.O. Box St. Louis, MO

8 Section 3 Eligibility Eligible employees To be eligible, an employee must be: Full-time employee working at least 30 hours per week and paid by W-2. Full-time working owner or partner employee may be eligible if working 30 or more hours per week (unless another hourly requirement has been mutually agreed upon),and work exclusively for the company with which they are applying, and at least 50 % of the group and at least two covered employees are paid by W-2. An eligible dependent may be: The employee s spouse. The employee s or spouse s child(ren). The child(ren) for whom the employee or employee s spouse is the legal guardian. The child(ren) must qualify as an eligible dependent as defined in your certificate. For health coverage only, child(ren) who the group has determined are covered under a QMCSO (Qualified Medical Child Support Order). Newborns of an enrolled dependent child (third generation). These newborns are covered for the first 61 days following birth only if and when the certificate holder/subscriber or spouse is appointed legal guardian by the court, and all other eligibility criteria for a dependent child are met. Note: Any child(ren) must be within the age limit and criteria defined in the group Certificate and Schedule of Benefits. Appropriate documentation is needed to confirm legal guardianship. 8

9 Section 4 Effective dates Open enrollment Coverage for eligible employees and their dependents who select an Anthem Blue Cross and Blue Shield benefit program during a company s open enrollment period will begin on the designated effective date following the open enrollment period. Retroactive effective dates will not be allowed. Open enrollment periods must be held annually, and are typically no less than 10 working days, and are usually 30 (31) days, unless otherwise specified, and must be held at the same time for all plans. We require equal access, and we must be offered as a choice to all eligible employees when open enrollments are required. We also must be offered as a choice to all new hires upon eligibility. Some exceptions may include adding new benefits plans or significant changes to employer contribution off anniversary. An employer may be allowed an election period for currently enrolled members if the employer is introducing or revising an HRA or HSA product off anniversary, subject to Underwriting approval. Underwriting reserves the right to change rates that may be needed due to enrollment changes. Employee benefit conversion We will allow employees of employer groups with multiple health benefit plans to convert coverage only at the end of the renewal term, or during the open enrollment period, whichever is applicable. Employees can convert coverage only once every 12 months. Employer group benefit conversions Employer groups will be allowed to convert to upgrade benefits only at the end of the renewal term. Employer groups will be allowed to convert to downgrade benefits during the term of the group health care benefits contract with our approval. Anthem Blue Cross and Blue Shield will continue the benefit programs at employer group rates to striking employees, either through the union strike fund or under the provisions of COBRA, as amended, provided premium payments are paid to us when due. The employer group must notify us immediately of the actual or anticipated date of the strike, specific classification of employees and unions involved, expected duration of the strike and information relative to discontinuance of premium payments. New hires New hires and their dependents will be eligible to enroll following completion of the waiting period, unless another exception has been mutually agreed upon. The standard waiting period allows new hires to be eligible to enroll for coverage following 30 days of continuous actively-at-work employment. New hire applications for coverage that are signed and received more than 31 days (unless 60 days is specified in your plan documents) from the date first eligible will be considered late entrants. New hires and their dependents will be effective following the first of the month following 30 days of employment, unless other guidelines are determined. 9

10 Newly eligible dependents New spouse A new spouse is eligible for coverage the first of the month following the date of marriage unless otherwise specified. The effective date of coverage will not be prior to the date of marriage. A marriage certificate may be required as proof of eligibility. Newly adopted children and children legally placed for adoption Adopted children are eligible for coverage when they are legally placed for adoption. If an Enrollment and Membership Change Form is not signed and received within 31 days, (unless 60 days is specified in your plan documents) coverage will be contingent upon approval as a late entrant. Applicable legal placement papers, as well as the appropriate Anthem Blue Cross and Blue Shield enrollment forms, must accompany the appropriate premiums. New stepchildren Coverage will be effective the first of the month following the date of marriage, provided we are notified by the end of the marriage month and the Enrollment and Membership Change Form and Family Health Statement* have been signed and received. If these conditions are not met, coverage will be contingent upon approval as a late entrant. Legal proof of the dependent relationship may be required. Legal guardianship Qualified children are eligible for coverage on the date of the guardianship order, provided an Enrollment and Membership Change Form and Family Health Statement* are signed and received by us within 31 days of the start of the parent/child relationship. If an Enrollment and Membership Change Form and Family Health Statement are signed and received by us after 31 days, (unless 60 days is specified in your plan documents) coverage will be contingent upon approval as a late entrant. Applicable legal placement papers and our required enrollment forms must accompany the appropriate premiums. *Applies to Small groups (2-50 eligible employees).

11 Section 5 Enrollment procedures How to enroll an employee and eligible dependents When an employee and his or her dependents are eligible to apply for membership, they must complete and sign the Enrollment and Membership Change Form and Family Health Statement, if applicable. They can get the form from you or obtain one online. The instructions attached to the Enrollment and Membership Change Form will help employees complete these forms. After an employee has completed the Enrollment and Membership Change Form and Family Health Statement form, if applicable, please make sure the forms are accurate and have been signed and dated. Medicare secondary payer (MSP) Federal law requires insurers and third-party administrators to gather and report information about Medicare recipients who have other group coverage.* This helps the Centers for Medicare & Medicaid Services (CMS) and health insurers coordinate benefit payments so claims can be paid promptly and correctly. As part of this process, members are asked to provide their Social Security numbers. If any covered members are unable or unwilling to do so, they must fill out an exception form each year. If a group member does not either provide a Social Security number or complete the enclosed form annually, both Anthem Blue Cross and Blue Shield and the group may be penalized. *Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA), effective Jan. 1,

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13 Enrollment changes There may be changes in a subscriber s life that require changes to his or her enrollment. This section explains when and how the subscriber can change the members on his or her contract, change his or her contact information, or change a primary care physician. Addition or deletion of members Marriage To add a new spouse (and eligible children, if applicable) to the contract, the subscriber needs to complete a Member Enrollment/Member Change Form and Family Health Statement, if applicable. A Marriage Certificate is also required for all Small Groups and some Large Groups. The date of marriage must be noted on the application. If we receive the Member Enrollment/Member Change Form: Within 31 days (unless 60 days is specified in your plan documents) from the date of the marriage, coverage is effective the first of the month following the marriage date, unless otherwise noted in the group contract. After 31 days (unless 60 days is specified in your plan documents) from the date of the marriage, the spouse s application may be submitted during the annual enrollment period or considered a late entrant subject to penalty depending on type of coverage added. To end the coverage of a dependent who has married, the subscriber needs to complete a Member Enrollment/Member Change Form. The married dependent is removed from coverage on the first of the month after the marriage occurs. Note: A dependent reaching age 26 or divorced spouse is no longer eligible for coverage under the subscriber s contract and must be removed from coverage. If your company is required to comply with COBRA, please see Section 10 (Terminations) for information about continuation rights. If your company does not have to comply with COBRA, the dependent reaching age 26 or divorced spouse may have the option of purchasing individual coverage, subject to the eligibility requirements of that coverage. Domestic partner (if domestic partnership benefits are offered) To add a domestic partner (and eligible children, if applicable) to the contract, the subscriber needs to complete a Member Enrollment/Member Change Form and the Affidavit of Domestic Partnership as well as a Family Health Statement, if applicable. The date that the domestic partnership began must be noted on the forms along with a visible notary stamp or seal. If we receive the Member Enrollment/Member Change Form Within 31 days (unless 60 days is specified in your plan documents) from the date of initial eligibility (12 months from when domestic partnership began, as a general rule), coverage is effective on the first of the month following the date of initial eligibility. After 31 days (unless 60 days is specified in your plan documents) from the date of initial eligibility (12 months from when the domestic partnership began, as a general rule), the forms may be submitted during the annual enrollment period and coverage will be effective on your annual review date or considered a late entrant subject to penalty depending upon type of coverage selected. To end the coverage of a domestic partner, the subscriber needs to complete a Member Enrollment/Member Change Form. The subscriber is required to submit a Member Enrollment/Member Change Form within 31 days of the termination of the domestic partnership. Domestic Partners are not eligible for COBRA continuation coverage.

14 Birth To add a newborn dependent to the subscriber s contract, the subscriber needs to complete a Member Enrollment/ Member Change Form. If we receive the Member Enrollment/Member Change Form within 61 days from the date of birth, coverage is continuous from the moment of birth, unless otherwise noted in the group contract. Adoption/placement for adoption To add a newly adopted dependent or a dependent placed for adoption to the subscriber s contract, the subscriber needs to complete a Member Enrollment/Member Change Form. If we receive the Member Enrollment/Member Change Form and adoption paperwork: Within 31 days (unless 60 days is specified in your plan documents) from the date of adoption/placement for adoption with the subscriber and/or spouse, coverage begins on the date of adoption/placement or considered a late entrant subject to penalty depending upon type of coverage selected. After 31 days (unless 60 days is specified in your plan documents) from the date of adoption/placement for adoption with the subscriber and/or spouse, the Member Enrollment/Member Change Form may be submitted during the annual enrollment period. Court orders and support orders To add a dependent child due to a court order or a support order, the subscriber needs to complete a Member Enrollment/ Member Change Form and Family Health Statement, if applicable. With a support order for a child, the Member Enrollment/Member Change Form may be received any time following issuance of the support order. Coverage is effective on the first of the month following receipt of the Member Enrollment/Member Change Form and appropriate support order documents. With a legal court order changing custody of a dependent child, the Member Enrollment/Member Change Form must be received within 31 days (unless 60 days is specified in your plan documents) of the date of the court order changing custody. Appropriate court order documents required. Coverage is effective on the date of the court order. To add a spouse due to a court order of coverage for the spouse, the subscriber needs to complete a Member Enrollment/ Member Change Form and Family Health Statement if applicable within 31 days (unless 60 days is specified in your plan documents) of the date of the court order. Coverage is effective on the first of the month following the date of the court order. Health care reform age mandate Dependent Age Mandate for Connecticut According to the Dependent to Age 26 federal mandate, eligible dependents are to be covered up to age 26. The Connecticut State Legislature has changed the age 26 mandate for fully insured groups. Connecticut Public Act says that dependent children who turn 26 can stay on their parents health plan until the end of the policy year, after the dependent turns age 26. For ASO groups, a dependent child would be off their parents plan on the last day of the month following the month the dependent child turned 26 unless they have a different arrangement. 14

15 Divorce and legal separation A divorced spouse is no longer eligible for coverage under the subscriber s contract and must be removed. A legally separated spouse is eligible for coverage under the subscriber s contract and may remain on the contract until they are divorced and he or she is no longer a legal spouse. To delete a divorced or legally separated spouse from the subscriber s contract, the subscriber needs to complete a Member Enrollment/Member Change Form. Eligibility for Medicaid or state assistance programs To delete a spouse, domestic partner or dependent(s) because they have become eligible for Medicaid or other state assistance, the subscriber needs to complete a Member Enrollment/Member Change Form. The spouse and/or dependent(s) are removed from the subscriber s contract for the requested date as long as enrollment forms are received within 31 days (unless 60 days is specified in your plan documents). Death To delete a deceased subscriber, spouse, dependent or domestic pa rtner, please complete a Member Enrollment/Member Change form. Coverage will end first of the month following date of death unless the group s exception states otherwise. If the request is received within 31 days of death, no death certificate is required (unless 60 days is specified in your plan documents). If the date of death is being reported after 31 or 60 days, a copy of the death certificate is required. Involuntary loss of existing coverage (portability) Portability is the transfer of membership when previous coverage ends involuntarily. Portability applies for reasons such as: Termination of employment Termination (without replacement) of the firm contract or policy Divorce/legal separation Termination of domestic partnership Exhaustion of COBRA benefits Death To add a spouse, domestic partner or eligible dependent(s) due to a portability event, the subscriber needs to complete a Member Enrollment/Member Change Form. We will require proof of the involuntary loss of coverage. If we receive the Member Enrollment/Member Change Form and Family Health Statement, if applicable: Within 31 days (unless 60 days is specified in your plan documents) of the loss of firm coverage, coverage will be effective on the first of the month following the loss of coverage or the first day following loss of coverage, unless otherwise noted in the group s contract. After 31 days (unless 60 days is specified in your plan documents) from the loss of firm coverage, the Member Enrollment/Member Change Form and Family Health statement if applicable may be submitted during the annual enrollment period or considered a late entrant and subject to penalty depending upon type of coverage selected. The subscriber needs to write the name of the previous insurance carrier, contract number, the date and reason for the loss of coverage on the Member Enrollment/Member Change Form and/or on a copy of the Certification of Creditable Coverage form from the previous carrier. We may contact the previous carrier to verify loss of coverage.

16 Involuntary loss of Medicaid or state assistance programs To add a spouse, domestic partner or dependent(s) because he or she involuntarily lost Medicaid/MediCare or other state assistance coverage, the subscriber needs to complete a Member Enrollment/Member Change Form and Family Health Statement if applicable and include a copy of the letter from Medicaid or the applicable state assistance program that states the date Medicaid or state assistance program coverage ended, and the reason for the loss. If we receive the Member Enrollment/Member Change Form and Family Health Statement if applicable to add a spouse or dependent(s) who involuntarily lost Medicaid or other state assistance coverage: Within 31 days (unless 60 days is specified in your plan documents) from the loss of assistance, coverage is effective on the first of the month following the loss of assistance or the first day following loss of coverage, unless otherwise noted in the group s contract. A copy of the letter stating that coverage has ended, the reason coverage ended, and the effective date of the loss must accompany the Member Enrollment/Member Change Form and Family Health Statement, if applicable. After 31 days (unless 60 days is specified in your plan documents) from the loss of assistance, the Member Enrollment/Member Change Form and Family Health Statement, if applicable, may be submitted during the annual enrollment period or considered a late entrant subject to penalty depending upon type of coverage selected. A copy of the letter stating that coverage has ended, the reason coverage ended, and the effective date of the loss must accompany the Member Enrollment/Member Change Form. Entrance to or discharge from military service To add a spouse, domestic partner or dependent because of discharge from the military, the subscriber needs to complete a Member Enrollment/Member Change Form and Family Health Statement, if applicable. If we receive the Member Enrollment/Member Change Form and Family Health Statement, if applicable: Within 31 days (unless 60 days is specified in your plan documents) of the date of discharge, coverage is effective on the day following the date of discharge. After 31 days (unless 60 days is specified in your plan documents) from the date of discharge, the Member Enrollment/Member Change Form and Family Health Statement, if applicable, may be submitted during the annual enrollment period or considered a late entrant subject to penalty depending upon type of coverage selected. To cancel coverage, or to delete a spouse, domestic partner or dependent due to entrance in the military service, the subscriber needs to complete a Member Enrollment/Member Change Form. The coverage will be canceled as of the effective date of the military coverage if we are notified within 31 days (unless 60 days is specified in your plan documents) of the effective date of the military coverage. Removal of a dependent To delete a spouse, domestic partner or dependent(s) from coverage, the subscriber needs to complete a Member Enrollment/ Member Change Form within 31 days of termination date (unless 60 days is specified in your plan documents). We do not allow retro terminations. 65+ coverage Three months before a member s 65th birthday, we send the group a 65+ questionnaire. The group needs to complete and return this questionnaire to help us determine what benefits we should offer 65-year-old members.

17 For groups that do not have to comply with TEFRA: Once we have received the completed 65+ Questionnaire, an eligible employee or eligible employee s spouse/domestic partner will have the option to: Remain enrolled in the group s coverage, with the same coverage as members under age 65. The employer- sponsored plan is the secondary payer, and Medicare Parts A and B are the primary payers. Cancel firm coverage and purchase an individual Medicare supplement policy, such as the Companion Plan (Anthem Blue Cross and Blue Shield s individual Medigap plan). The individual must be enrolled in both Medicare Part A and Part B to enroll in the Companion Plan. For groups that do have to comply with TEFRA: Once we have received the completed 65+ Questionnaire, an eligible employee or eligible employee s spouse/domestic partner will have the option to: Remain enrolled in the group s coverage, with the same coverage as members under age 65. The employer- sponsored plan is the primary payer, and Medicare is the secondary payer. Choose Medicare as primary coverage, cancel the group s coverage, and purchase an individual Medicare supplement policy, such as the Companion Plan (Anthem Blue Cross and Blue Shield s individual Medigap plan). Also, the individual must be enrolled in both Medicare Part A and Part B to enroll in the Companion Plan. Note: You must notify us when an employee who has continued on the firm coverage after age 65 retires or reduces hours below your firm s minimum. Retirees and employees who no longer work minimum hours are not eligible to remain on the firm primary coverage. Your company may offer retiree coverage. This information is in your plan documents. Retiree benefits Please refer to your plan documents or contact your account service team for information about benefits available for retirees. Changing contact information A subscriber needs to notify us of the following: Name changes Address changes Telephone number changes (both work and home) One way to notify us is by submitting a Member Enrollment/Member Change Form. A subscriber can also call customer service or use the information change form available at anthem.com. Correcting dates of birth To correct a member s date of birth, the subscriber needs to complete a Member Enrollment/Member Change Form. Subscribers should notify us of birth date corrections as soon as possible to avoid potential problems caused by inconsistency in membership records. We may require a copy of the birth certificate for verification.

18 Changing primary care physicians Members can change primary care physicians at any time. To notify us, members can: Fill out a Member Enrollment/Member Change Form. Call our customer service representatives. Use the information change form available at anthem.com. The change will be made effective on the first of the month following the date the application is accepted. Moving out of the service area If a member of a managed care product (lock-in or choice) moves out of the service area, he or she may transfer to another type of health plan offered by the group or keep the current coverage. Flexible benefits plans (Section 125 plans) The Internal Revenue Code Section 125 allows employers to provide flexible benefits plans to their employees. The three types of plans are: Premium-only plans or premium conversion plans: Permits employees to pay the employee contributions to employer-provided health and welfare benefit plans on a pretax basis. Flexible spending accounts and flexible reimbursement accounts: Reimburses employees on a tax-free basis for eligible child care and health care expenses that are not otherwise covered by the employer-sponsored benefit plan. Cafeteria plans: Allows employees to choose between certain nontaxable benefits and cash. Section 125 of the Internal Revenue Code and regulations define situations when an employee can make off-anniversary changes. Situations when employees can make flexible benefits election changes do not always entitle the subscriber to make a related change to his or her health coverage. For example, the birth of a child entitles the subscriber to enroll the child and spouse in the health plan and change the flexible reimbursement account, but not to enroll other dependents in the health plan or to change their coverage series/benefits. Those changes can only be done at the firm s renewal time. A Section 125 plan does not create enrollment opportunities that do not exist without a 125 plan. Work with your Section 125 processor if you have any questions. Special enrollment considerations Additional forms are required for: Dependent child, 26, overage: A Dependent Certification Form Dependent child, incapacitated, incapable of self-support: A Request for Coverage for a Mentally or Physically Incapacitated Dependent Child Form An adopted child: Proof of adoption or placement Medicare eligible: A copy of the Medicare health insurance card Adding a child, court order: A copy of the court order Proof of prior group coverage: A Certificate of Health Plan Coverage from the previous health insurance carrier, or if a certificate cannot be obtained, other proof of coverage as described by HIPAA. Anthem Blue Cross and Blue Shield requires a letter from the former carrier stating the loss of coverage date. Small groups also need to complete the Standardized Health Form (SHF). 18

19 When to send enrollment forms The submission deadline depends on the specific enrollment circumstance: Open enrollment The Enrollment and Change Form must be received by the last day of the open enrollment month to be effective on the first day of the anniversary month. Late enrollees A late enrollee is an employee who signs an application more than 31 days after the Qualifying Event date (unless 60 days is specified in your plan documents). The effective date is contingent upon the type of coverage. Qualifying event special enrollment For special enrollments, all Enrollment and Change Forms must be received by Anthem Blue Cross and Blue Shield during the first 31 days of the special enrollment period (unless 60 days is specified in your plan document). Newly hired employees Anthem Blue Cross and Blue Shield recommends you submit the Enrollment and Change Form within 31 days of the qualifying event date or as specified by your contract. The date you submit an Enrollment and Change Form impacts the effective date for the employee s medical coverage. Family status change The following rules apply to membership enrollments as a result of marriage, birth or adoption. Marriage: Anthem Blue Cross and Blue Shield recommends that you submit the Enrollment and Change Form within 31 days of the qualifying event date as specified by your contract. The date you submit an Enrollment and Change Form impacts the effective date for the spouse s medical coverage. Birth: Benefits are provided for the newborn child for up to 61 days following birth. Submit the membership Enrollment and Change Form within 61 days following the child s date of birth to ensure uninterrupted coverage. The date you submit an Enrollment and Change Form impacts the effective date for the child s medical coverage. On a family membership: A newborn child is a member from the date of birth. The birth must be reported to Anthem Blue Cross and Blue Shield within 61 days by submitting an Enrollment and Change Form for the new dependent to be added to the family records and for claim payments to be made appropriately. Adoption: Benefits are provided for an adopted child for up to 31 days following the placement or adoption. Copies of placement or adoption papers are required, if applicable. Submit the membership Enrollment and Change Form within 31 days following the child s date of placement or adoption to ensure uninterrupted coverage. The date you submit an Enrollment and Change Form impacts the effective date for the child s medical coverage. On a family membership: An adopted child is a member from the date of placement. The placement must be reported to Anthem Blue Cross and Blue Shield within 31 days by submitting an Enrollment and Change Form for the new dependent to be added to the family records and for claim payments to be made appropriately. 19

20 Section 6 Electronic Enrollment Electronic enrollment advantages Electronic Enrollment is a quicker, easier way to maintain enrollment-related data and manage the enrollment process. Time saving: Electronic enrollment is a faster, more convenient way to enroll new members and make changes to existing accounts 24/7. It eliminates paperwork, reduces postage and may require fewer follow-up phone calls. Best of all, the information is processed on an average of two to four days faster than paper forms. Safe, secure, accurate: To help protect against unauthorized access to employees private information, Electronic enrollment is enhanced with the latest technical safeguards. In addition, employees receive a user ID and password that can be personalized during the registration process. For more information about Electronic enrollment, contact your Anthem Blue Cross and Blue Shield Account Manager. Electronic enrollment options With Electronic enrollment, you have two options: file-based transfer and web enrollment. Here are descriptions of both: Description Web enrollment The same process on paper, but online. Complete enrollment applications through online forms. File-based transfer Ideal for high volumes of enrollment transactions when a group prefers to send an enrollment file. Platform Web-based, accessed through a browser. Site-specific, PC-based, Mainframe Allows enrollment by Benefit Administrator Allows enrollment by employees Yes Yes Features New employee enrollment Open enrollment management Membership maintenance (add, change, delete, reinstatement, firm division transfers) 128-bit encryption for safe, secure transfer of information 24/7 access Automated member set up 2 to 4 days faster processing than paper forms, on average Quicker ID turnaround and member benefit realization Yes No New employee enrollment Open enrollment management Membership maintenance (add, change, delete) Secure 24/7 access Quicker ID turnaround and member benefit realization Groups should review the file-based legal agreement to evaluate its advantages and disadvantages. 20