Q & A for the IEEE Comprehensive HealthCare Plan Transition

Transcription

1 Q & A for the IEEE Comprehensive HealthCare Plan Transition It is important for the insured to make an informed decision and enroll in the alternative medical coverage that will best meet his or her medical and financial needs to ensure he or she has uninterrupted medical coverage in I. GENERAL 1. Q: Why is the medical insurance being discontinued? The news said, under the Patient Protection and Affordable Care Act (PPACA) that insureds would be able to keep their medical group insurance. So, how come they can t? A: The new healthcare reform laws do not recognize CIGNA's type of non-employer based Association Medical insurance plans as group insurance. Today Cigna offers Association coverage as group insurance, which allows an Association policy to cover individual members nationwide, with plan designs and cost customized to each Association. However the new laws consider these types of health care plans to be Individual Insurance, which removes these features. This is a very significant change and would require CIGNA to become a very different type of insurer and to comply with varying coverage and rate requirements on a state by state basis. Therefore, after much review, CIGNA determined it is unable to continue to offer to associations of individuals a product that will be competitive in the evolving insurance market conditions and regulatory requirements. 2. Q: Even though Cigna is not able to provide the type of coverage that we currently have, why didn t the Association just move the plan to another insurance company? A: Since PPACA does not consider non-employer based group Association coverage to be group insurance, this type of coverage will have to comply with individual insurance rules. It is not feasible for most health insurers to offer a nationwide, cost customized plan with all the state specific rules on a cost-competitive basis. In other words, effective 1 January 2014, most nonemployer based group association health plans will cease to exist. Instead most of those plans will become individual plans, if they are to be still offered. 3. Q: Is CIGNA going to provide information on other medical options? A: Yes. CIGNA has a website that provides information for Healthcare exchanges. The website provides information on the insurance plans that are available to an individual and how the insurance exchanges will work. 1

2 Additionally, beginning on 01 October 2013, we urge you to visit learn more about Marsh U.S. Consumer s Healthcare Exchange solution. NOTE Contac t these resourc es for informa tion a nd c omparison of the med ic a l insuranc e op tions a va ila b le, a nd when to enroll to ensure uninterrup ted med ic a l c overa ge. 4. Q: What is an Exchange? * A: An Exchange, also known as the Health Insurance Marketplace or Marketplace, is an online site where an individual, family, or small business can shop for health insurance. Open enrollment starts in October 2013 for coverage that can become effective, as of 1 January Starting in October 2013, an individual can go on-line at the Marketplace and get information about all the qualified health plans available in a state, compare the benefits and costs, and enroll directly through the website, or call a toll-free phone hotline. Each state can choose how its Marketplace will operate: A state can create and run their own Marketplace; have a Marketplace supported by the Department of Health and Human Services (HHS); or choose to partner with HHS to run some functions of their Marketplace. HHS already has granted conditional approval to some states. This means they are on track to have a Marketplace starting in October Regardless of how the state s Marketplace is operated, the same underlying Essential Benefits and use of the Standard Benefit Comparison (SBC) form mandated by PPACA will apply. The links below take you to websites that describe a state s Marketplace efforts. The Marketplaces themselves won t begin accepting enrollments until October NOTE Also visit Dep a rtment of Insura nc e (DOI) for your sta te, a nd / or lthc a re.gov, c lic k on the ta b for Prep are for the Hea lth Insuranc e Marketp la c e. An eligib le ind ivid ua l is gua ra nteed c overage in the p la n selec ted for their geogra p hic a l a rea, a s c overa ge c annot b e refused b ec a use of a c hronic or p re - existing c ond ition. * Per 5. Q: Who can use the Marketplace (Exchange)? 2

3 A: Anyone can use the Marketplace to explore their health insurance options, even if they already have insurance. The only requirements to get insurance through the Marketplace are you must: live in the U.S., be a U.S. citizen or national (or lawfully present), and can t be currently incarcerated. 6. Q: Is an insured guaranteed medical insurance coverage in 2014, even if there is a preexisting medical condition? A: Yes. An insured is guaranteed medical coverage if they apply for an individual insurance plan, or employer group insurance plan in the Health Insurance Marketplace. Applicants must be accepted regardless of their pre-existing conditions. 7. Q. Will an insured need to change physicians? A: This will depend on the alternative medical coverage the insured enrolls in and the network, if any, which is used by the alternative medical plan. When an insured evaluates a potential alternative option, it is important for them to check how the providers in that network compare to the providers the insured uses. 8. Q. Does this affect insureds residing outside of the United States too? A. Yes. CIGNA s medical insurance coverage will be terminating for all insureds regardless of where they reside. If an individual lives in a US Territory (e.g., US Virgin Islands, Puerto Rico, Guam) he or she will need to contact the local insurance department and insurance carriers as soon as possible to evaluate the available alternative options. To find information on the plans, you can also direct insureds to: 9. Q: Is CIGNA still providing medical insurance today to IEEE members? A: Yes. Although CIGNA is no longer accepting new applications, if an individual is already insured under a CIGNA medical insurance plan for IEEE members, the coverage will continue throughout 2013, provided the applicable premium is paid in a timely manner. 10. Q: Is this going to impact other CIGNA insurance coverage that a member may have through the association? A: No. Any life, AD&D, disability income plan, business overhead, hospital indemnity, or other non-medical coverage an insured may have through the Association will not be affected by this change. 3

4 11. Q: When is the insureds last premium Due Date? A: Insureds cannot be billed for coverage beyond 31 December 2013 no matter what premium mode the insured has been paying on in the past. 12. Q: Will the insured get a Certificate of Creditable Coverage (CCC) when the coverage is terminated on 31 December 2013? A: You can provide the insured with a CCC if requested, but if the insured is under the age of 65, it is unnecessary since PPACA requires all plans offered on the Health Insurance Marketplace (Marketplace) and elsewhere to accept all applicants regardless of whether there is existing or prior medical insurance. However, members 65 years of age or older will automatically receive a CCC since some MediGap (also called Medicare supplemental coverage) insurance companies may require proof of termination of prior coverage to enroll in a plan, without medical underwriting. II. MEDICARE-AGE 65 & OVER 1. Q: Does this termination affect medical insureds ages 65 and over too? A: Yes. We recommend insureds age 65 or older, or those who will become Medicare eligible on or before 1 January 2014 to contact Medicare for information on Medicare, MediGap (also known as Medicare supplemental coverage), or Medicare Advantage plans to determine the best alternative to your current CIGNA medical insurance coverage. Log onto or call MEDICARE for information about options that are available to you. Personalized health insurance counseling is also available at no cost at your local State Health Insurance Program (SHIP). It is important these insureds to become familiar with the Medicare enrollment rules that apply to them, as failure to enroll on a timely basis may permanently increase the cost of the coverage. 2. Q: If an insured is already enrolled in Medicare Parts A & B but not in Medicare D since the prescription coverage is through the CIGNA medical plan, what happens now? A: The answer depends on whether the insured s Association group prescription drug coverage is Creditable or non-creditable. 1. If the prescription coverage under the CIGNA plan is Creditable: 4

5 Since the CIGNA plan is terminating at the end of this year, the individual must enroll in Medicare D during the Open Enrollment Period from 15 October 2013 to 7 December 2013 to obtain prescription drug insurance. Each individual will receive a Notice of Creditable Coverage in September to be able to enroll in a Medicare D Plan of his or her choice without penalty. The notice will also provide the Medicare website link and toll-free number for information on the prescription plans available. 2. If the prescription coverage under CIGNA plan is Non-Creditable: If the prescription coverage is under CIGNA s plan and an individual did not enroll for Medicare D when first eligible, he or she may now enroll for Medicare D, subject to a late enrollment penalty. 3. Q. How would a member who is currently Medicare eligible know (now) if their prescription drug medical coverage is considered Creditable? A: The insured would have received a notice in Every year in September or October, the Administrator sends out either a Creditable or Non-Creditable notice to each member who is Medicare eligible, or who will become Medicare eligible, and has group medical coverage. III. CLAIMS 1. Q: How will this coverage termination affect an insured who is in the middle of acute medical treatment that was started prior to midnight 31 December 2013, or taking prescription drugs? A: Medical services provided in 2014 will be the insured s financial responsibility unless the individual has obtained alternative health insurance that is effective on/before 1 January Association medical health benefits are terminated as of 1 January Under PPACA, all individuals will be eligible for insurance through the Exchanges beginning on 1 January They should be strongly encouraged to enroll in an Exchange or obtain other alternative coverage of their choice prior to that date. Here are a few examples of situations that may be encountered if acute services were started in 2013 and continue in In each situation, if an insured has not elected alternative medical coverage to be in effect on 1 January 2014, as of this date, payment of the medical care costs will be the insured s responsibility. 5

6 A prescription for a covered drug presented to the pharmacy in 2013, will be considered subject to policy provisions. A prescription presented to the pharmacy on, or after, January is ineligible for benefits. Ongoing inpatient care. For example, if an insured is admitted to a facility on December 28, 2013 and remains hospitalized on 1 January 2014 and later, the charges in 2014 are ineligible for benefits. If an insured is receiving radiation therapy or chemotherapy, that extends into 2014, only the services incurred prior to 1 January 2014 would be covered. Any services provided on 1 January 2014 and later is the insured s responsibility. An insured who is pregnant as of 31 December 2013 will be covered for only the services incurred prior to 1, January The delivery, hospitalization and other services provided on 1 January 2014 or later will be the insured s responsibility. 2. Q: The member s spouse is pregnant and they have already paid the physician upfront for maternity care. Will the insured s Cigna coverage continue until delivery? A: No. Benefits will be based on the date of service. Covered services provided in 2013 will be considered. However, services in 2014 are ineligible for benefits. If the physician has billed one all inclusive charge, upon receipt of the bill, we will request the physician to re-submit a bill by date of service to allow us to determine the care eligible for benefits. 3. Q: What if an insured received approval of a requested medical service by the TPA or Utilization Review Agency and the care extends into 2014? A: Authorization of a covered service will only apply to care that is provided in Services in 2014 are subject to the rules of any alternative medical plan that is selected by the insured. To avoid a gap in medical insurance, it is important to urge the insured to enroll in a plan that meets their needs and will provide coverage as of 1 January Q: How long does a member have in 2014 to still send in claims for 2013 charges? A: Claims are to be submitted within 90 days of the date of service. 5. Q: What happens if an insured is in case management and the treatment is ongoing into 2014? A: Case management services will discontinue on 31 December Prior to this, the case manager is available to answer the insured s questions on how this may impact on them. 6

7 6. Q. Where does an individual call for questions about eligibility, claims, PPO Network, or Utilization Review for services provided in 2013? A: Refer to the contact information on your medical ID card. The phone number to call for any question on eligibility, claims, PPO Network, or utilization review remains unchanged. Once the designated number is reached, the caller is to follow any prompt that may apply. NOTE Ad d itiona lly, the insured s ma y look for inp ut on wha t should b e their next steps. Visit lthc a re.gov web site, whic h ha s useful informa tion to help guid e you through this p roc ess. For exa mp le, the next step inc ludes tha t the ind ivid ua l eva lua te the b elow. Learn a b out the a va ilable med ic a l c a re op tions (through Insura nc e Ma rketp lac e web site a nd b y visiting the web site of ma jor c a rriers in a sta te provided to ea c h Ad ministra tor. Ma ke a list of q uestions tha t a re imp orta nt to a ssist in the d ec ision (i.e., a re the p rovid ers I use in the new network, wha t will b e my out-of-p oc ket c osts, etc.). Und ersta nd how the insuranc e c overage works, inc lud ing d ed uc tib les, out-ofp oc ket ma ximums, exc lud ed servic es, etc., Determine wha t b est meets b oth the fina nc ia l a nd med ic a l c overa ge need s 7