Administrative How to Read Your Premium Invoice Guide How to Read Your Explanation of Benefits Medical Loss Ratio Summary of Benefits and Coverage

Transcription

1 Administrative Guide

2 Process... 4 Delinquent Payments... 5 New Hires and Newly Eligible Employees... 5 The Open Enrollment Process... 6 Employee Transfers Outside of Coventry Health Care s Service Area... 6 Dependent Coverage to Age Change in Enrollment Status... 7 Disenrolling a Member... 7 Who Is Eligible to Enroll Table of Contents In-Network Out-of-Area Services Prior Authorization Primary Payor Secondary Payor COBRA (for groups with 20 or more employees) State (for groups with fewer than 20 employees) Medicare Certificate of Group Health Coverage Conversion Policies To use this interactive guide, click on a topic to go to the page. You may also click on a section in the sidebar on the following pages to go to a different section What Is My Responsibility as the Employer? Who Is Required to Receive an SBC and When Does My Company Need to Give it to Them? Can SBCs be Distributed Electronically? Online Account Management SM My Online Services SM Provider Search Coventry Mobile chcga.com 2 Fully Insured :

3 Table of Contents QUICK REFERENCE GUIDE Marketing Department Coventry Health Care of Georgia 1100 Circle 75 Parkway, Suite 1400 Atlanta, GA Broker Service Line (for brokers) Group inquiries Member inquiries Commission Department (for clients) Coventry Health Care of Georgia Department P.O. Box 6473 Carol Stream, IL Enrollment Department (for clients) Coventry Health Care of Georgia Attn: Georgia Enrollment P.O. Box 7743 London, KY (for members) /benefits Member verification Provider status Member appeals Address Coventry Health Care of Georgia P.O. Box 7711 London, KY Coventry Dental Member services Coventry Consumer Choice SM (C3) Client or broker inquiries Product/benefit information Ordering forms/supplies invoices and premium payments Reconciliation questions Payment history Status of enrollment forms Terminations, additions, changes and corrections Questions about COBRA, HIPAA and qualifying events Requests for Spanish materials Member ID cards Deductible information Coventry Consumer Choice (C3) inquiries Prescription Drug Benefits (provided by Express Scripts ) or x (fax) HMOmarketing@cvty.com CHCGeorgia@cvty.com (fax) careteambrokerhbg@cvty.com cvtydental.com (client/broker) Questions about specific prescriptions Behavioral Health Line (provided by MHNet) Behavioral health and substance abuse information available 24 hours a day Avesis (visit chcga.com to locate an in-network vision provider) Prior Authorization Inpatient hospitalizations Out-of-network benefits Other services : chcga.com Provider status Plan and benefit information Health information Access to Online Account Management SM and My Online Services SM Tech support for Online Account Management Net support for general website assistance chcga.com (general) (web support) This manual represents processes utilized for standard fully insured commercial business. Large self-funded clients may have customized processes in place for enrollment/eligibility, coordination of benefits, medical management, behavioral health, pharmacy and vision coverage. For those self-funded groups, the information within these sections may not reflect the appropriate processes. Additionally, phone numbers and addresses (i.e., IVR, claims phone and address, enrollment phone and address) have been established for certain self-funded clients that are not reflected in this manual. chcga.com 3 Fully Insured :

4 Welcome to Coventry Health Care of Georgia, Inc. ( Coventry Health Care ). We are happy to provide this manual to assist you in the administration of your employee health benefits program. As always, we are committed to delivering exceptional service to our clients and members. Your account manager serves as your primary contact and stands ready to assist you in whatever your needs may be from answering claims and benefit questions to collaborating with you on your health benefit program. Our wide variety of cost-effective benefit plans, extensive provider network and hassle-free administration ensure that you can focus on your business while we focus on the health and wellness of your employees. Process Coventry Health Care creates your monthly invoice on or about the fifth business day of the month for the following month s premium. The invoice includes an Employer Group/Subscriber Summary report that lists the premium for each subscriber and a Group Statement that summarizes the amount billed and any adjustments that were applied to the charges. The premium is due and payable on the first day of the covered month. For example, November premiums are due by November 1. Please remit payment to the billing address and be sure to include a copy of the statement with any necessary additions or deletions with your remittance. Our billing address is located in Key Contact Information on page 3. We follow the 15th of the month rule, which means you are charged a full month s premium for enrollments and additions that are effective between the first and the 15th of the month. You are not charged a monthly premium for enrollments and additions that are effective between the 16th and the 31st of the month. Conversely, you are not charged a monthly premium for terminations and deletions that are effective between the first and the 15th of the month, but you are charged a premium for terminations and deletions effective between the 16th and the 31st of the month. Account activity (e.g., late or new enrollments, terminations, additional dependents, etc.) that occurs after the billing cycle will be recorded as a retroactive adjustment on the next month s statement. IMPORTANT FACTS Make your billing process easier by using Online Account Management (OAM). Make billing adjustments, pay your bill electronically and more. Talk to your account manager for more information. is generated on or about the fifth business day of the month. Premiums are due by the first day of the month. We follow the 15th of the month rule. If your group s premium is not paid by the first of the month, we will grant your group a 31-day grace period without charging interest. If payment is not received upon expiration of the grace period, we reserve the right to charge your group interest at the rate of 1.5 percent for each 31-day grace period that your account is delinquent retroactive to the initial date of delinquency. chcga.com 4 Fully Insured :

5 Continued Delinquent Payments If your group s premium is not paid by the first of the month, Coventry Health Care grants your group a 31-day grace period without charging interest. If payment is not received upon expiration of the grace period, we reserve the right to charge your group interest at the rate of 1.5 percent for each 31-day period that your account is delinquent, retroactive to the initial date of delinquency. For example, if your group s premium was delinquent as of July 1, your grace period ends on August 1. If payment is not received by that date, your group is charged interest on its premium retroactively from July 1 thereafter until the premium payment is received. If payment is not received upon expiration of the grace period, we have the right to terminate our agreement with your group. In the case of termination, any costs that we incur in the care of your group s members from the initial date of delinquency to the date of termination are charged back to the members in your group. Termination for nonpayment is effective on the last date of premium payment. For further information on delinquent payments and termination, please refer to your group s agreement with Coventry Health Care. For further information on reading and paying your premium invoice, please refer to the section. New Hires and Newly Eligible Employees Newly hired or newly eligible employees selecting coverage must enroll within 31 days from their eligibility date. If you have a large group of new hires, your account manager is happy to hold an informational presentation and help new employees complete their enrollment forms. New hires should be given an informational packet to review. This packet usually includes the enrollment/change form*, benefit summary and other information about Coventry Health Care. When the employee returns the enrollment/change form*, be sure it is completely filled out (including date of hire, group number and dependent Social Security number) and signed by the employee. Incomplete forms may delay enrollment and member ID cards, so please review thoroughly prior to submission. The enrollment/change form* must be completely filled out, signed and dated in ink by each enrollee; you may also enroll your new employees via our Online Account Management system (see page 20). Some members may be required to designate their primary care provider (PCP) on the form. We will return forms with blank fields to the employer for completion, which causes delays in members receiving their member ID cards. If an entry must be changed, please initial the change. It is very important to complete the Other Insurance section. This information allows us to coordinate benefits with other carriers. Coventry Health Care follows the regulations developed by the National Association of Insurance Commissioners to determine which insurer is primary and which is secondary. If this information does not apply, please write N/A in this section. will deny if this section is incomplete. *The appropriate enrollment/change form varies by group size. Our website provides our various enrollment/change forms for your selection. chcga.com 5 Fully Insured :

6 Continued An authorized Employee Benefits Administrator for your group must sign before submitting enrollment/change forms* to us for processing. Please mail or fax the enrollment/change form* to: Coventry Health Care of Georgia Attn: Georgia Enrollment P.O. Box 7743 London, KY Fax: (877) (medical enrollments) Fax: (240) (dental enrollments) The Open Enrollment Process We assist in planning open enrollment activities prior to your group s annual renewal. Your account manager can provide you with literature, hold informational meetings and coordinate the processing of enrollment forms. IMPORTANT FACTS The enrollee s signature and the authorized Employee Benefits Administrator s signature are required on all enrollment/change forms* submitted to Coventry Health Care. Employees or dependents with insurance from another carrier must complete the Other Insurance section or indicate N/A on the enrollment form. will deny until complete. Employees who are not covered by an out-of-area plan and are permanently transferred outside our service area are no longer eligible to participate with us. Enrollment/change forms* must be submitted to us within 31 days of the qualifying event. The effective date of coverage begins the first day of the renewal month. To ensure the timely issuance of member ID cards by the effective date, please forward all completed applications to an enrollment representative by the 15th of the preceding month. Employee Transfers Outside of Coventry Health Care s Service Area If your group does not offer an out-of-area plan, employees who transfer outside of our service area on a permanent basis are not eligible to participate with Coventry Health Care. Employees who work outside our service area on a temporary assignment retain coverage for health emergencies only. Employee Benefits Administrators must authorize the termination of employees who have permanently transferred outside our service area by submitting an enrollment/change form* to Coventry Health Care that indicates termination. Dependent Coverage to Age 26 Health insurers offering group coverage that provides dependent coverage of children are required to cover an adult child until age 26. Dependents do not have to be full-time students to receive extended benefits. Benefit plans will cover dependents age 26 and younger. *The appropriate enrollment/change form varies by group size. Our website provides our various enrollment/change forms for your selection. chcga.com 6 Fully Insured :

7 Continued Change in Enrollment Status An enrollment/change form* must be completed for an enrollee within 31 days when any of the following events occur: Addition of a dependent through marriage, birth, adoption or legal guardianship Termination of a dependent through divorce, death or age cutoff Change of address, if out of area Change in employment status through retirement, layoff or other form of termination Coverage for new dependents usually becomes effective on the date of a life-changing event. Life-changing events include marriage, birth, adoption and legal guardianship. Refer to the Certificate of Coverage for further details. If the Coventry Health Care plans offered to your employees require a selection of a primary care provider (PCP), employees who wish to change their PCP must do so by the 15th of the month for the change to be effective by the first day of the following month. Each family member may choose a different PCP. Your group s authorized Employee Benefit Administrator and the affected employee must sign the enrollment/ change form*. The Employee Benefit Administrator mails or faxes the form to our Enrollment department. Please note Newborns are not automatically covered Newborn coverage must be added within 31 days of the birth of the newborn for benefits to be paid, even if a family agreement is in place. Disenrolling a Member As your company s benefits administrator, you are responsible for notifying our Enrollment department when you disenroll an employee or family dependent. To do this, simply complete Sections A, B and D on the enrollment/ change form* for processing. It is important that you understand and follow this disenrollment process. Coventry will not accept any retroactive disenrollments beyond 31 days of the date of the member s disenrollment. Coventry Health Care may generally disenroll employees and family dependents when the employee and/or dependents: Fail to pay all copays, coinsurance, deductibles, penalties, and premium contributions and bills for unauthorized or uncovered services Misuse the member ID card Fail to cooperate with the coordination of benefits Do not maintain a satisfactory physician/patient relationship Become ineligible for benefits Provisions related to member disenrollment are detailed in your contractual agreement(s) and/or the Group Membership Agreement. Who Is Eligible to Enroll Please review this section of your agreement or Certificate of Coverage carefully. Failure to abide by eligibility provisions may result in loss of coverage for an employee and his or her family dependents. This section of the Certificate of Coverage includes information on who is eligible to enroll in your company s health care benefit plan and when coverage begins for enrolled employees and their family dependents. *The appropriate enrollment/change form varies by group size. Our website provides our various enrollment/change forms for your selection. chcga.com 7 Fully Insured :

8 We mail member ID cards to your employees and retirees shortly after they enroll with us. If members have any concerns or questions about our services or providers, they should call our department at the number listed on their member ID card. Employees will be assigned a system-generated ID number. Example: The spouse s ID number will be the same as the employee s ID except for the last two digits. Example: Each child s ID number is the same as the employee s ID except for the last two digits. Example: (first child), (second child), etc. chcga.com 8 Fully Insured :

9 Our department is available Monday through Friday, 7:00 a.m. to 6:00 p.m., at the number on the member ID card. The department is ready to assist members with any questions they may have about their health benefits. Customer service representatives can answer questions on our HMO, POS and PPO products. They can also: Change PCP assignments at the member s request Respond to service-related issues Verify a provider s participation status Handle claim problems Answer benefit questions Assist in selecting providers IMPORTANT FACTS Whenever members have questions about their coverage or other concerns, they can call the department. This number is listed on their member ID card. Members are also welcome to write to us. Refer to the section of this guide for the appropriate address or visit our website at chcga.com. chcga.com 9 Fully Insured :

10 In-Network Your employees should not be billed or charged for in-network medical care other than the deductible, copays or coinsurance indicated in your group plan design. If an employee is billed inappropriately, please call the Customer Service department at the number listed on the member ID card. Out-of-Area Services If members are out of their service area and receive medical treatment, they must complete a health care benefits claim form for reimbursement. Members are also responsible for filing claims if they visit a nonparticipating provider. Instructions for completing the health care benefits claim form are included on the first page of the form. Coventry Health Care needs the following information to pay claims for health care provider services: Member s name and identification number Date of service Services provided Name of provider rendering service Provider s billing address We need the following information to pay claims for facility services (e.g., hospitalization, outpatient procedures, etc.): Member s name and identification number Date of service Services provided Name of facility rendering services Facility s billing address Prior Authorization IMPORTANT FACTS Members should never be balance-billed for covered in-network services. Members always have the right to appeal a medical, benefit or claim payment decision. To appeal, they should call the department at the number listed on their member ID card. More information on the appeals process can be found on our website. chcga.com, in the Member section. Members with coverage questions should contact the department at the number listed on their member ID card. Members should mail out-of-network claims for covered services to the claims address on the back of their member ID card. Some medical services, supplies, durable medical equipment products and prescription drugs require prior authorization before members can receive them. In most cases, participating providers will obtain prior authorization for the member. However, members are responsible for ensuring that prior authorization has been obtained. Please note that if members use nonparticipating providers or are outside Georgia, they are responsible for obtaining prior authorization. To obtain prior authorization, members should call the Prior Authorization department at the number listed on the back of their member ID card. A list of services requiring prior authorization can be found in the Group Medical Agreement, on My Online Services or on our website, chcga.com, in the Member section. chcga.com 10 Fully Insured :

11 Coordination of benefits is a method of integrating benefits payable under more than one health insurance plan so that the insured person s benefits from all sources do not exceed 100 percent of allowable medical expenses or eliminate incentives to contain costs. Primary Payor When Coventry Health Care is identified as the primary plan, we are the first plan to make payment. The primary plan must pay or provide its benefits as if the secondary plan or plans did not exist. Secondary Payor When one of our members has medical coverage with another carrier that has been determined to be the primary payor, Coventry Health Care is considered the secondary payor. We take the allowed amount, less the member copay, deductible and coinsurance to determine the amount we would pay if we were primary. The difference between the benefit payments we would have paid as the primary plan and the benefit payments we actually paid or provided is recorded as a benefit reserve for the member or his/her covered dependent. This benefit reserve is used to pay any allowable expenses not otherwise paid during the claim determination period. As each claim is submitted, we will determine: 1. Our obligation to pay or provide benefits under our contract 2. Whether a benefit reserve was recorded for the member or his/her covered dependent 3. Whether there are any unpaid allowable expenses during that claim determination period If there is a benefit reserve, the secondary plan uses the member s benefit reserve to pay up to 100 percent of Coventry Health Care s total allowable expenses incurred during the claim determination period. At the end of the claim determination period, the benefit reserve returns to zero. A new benefit reserve must be created for each new claim determination period. For a more detailed description of our coordination of benefits process, please refer to the Coordination of Benefits section of the Certificate of Coverage. chcga.com 11 Fully Insured :

12 HOW TO READ YOUR PREMIUM INVOICE CONTACT NAME 1234 MAIN STREET ANYTOWN USA Prior Account Payments Health Plan Current Month Retro Premium * Account Balance Received Adjustments Premium (+/-) Balance $129, $129, $0.00 $164, $10, $175, Account Summary Prior Month Transactions Date Totals Prior Month s Statement Balance 05/09/06 $ 129, Payment Received Since Last Statement 05/09/06 $ 64, Payment Received Since Last Statement 05/14/06 $ 65, Health Plan Adjustments $ 0.00 Unpaid Balance From Prior Periods $ New Charges for Coverage Period Premium Detail 16 E3 $ 35, FAM $ 37, E1 $ 48, EMP $ 23, E&SP $ 19, Total Contracts $ 164, Retro Active Charges for Prior Period $ 10, Current Monthly Charges $ 175, *Account Balance Payment Due $ 175, *This is the balance of your account. Payments remitted, adjustments made or enrollment changes not reflected on this invoice will be reflected on your next statement. Please verify the date of your last payment to determine if you should pay the Account Balance or Current Month Premium Due. Complete the attached A/R Transmittal form to submit terminations. Credits for those terminations will be applied against your next statement amount. Come visit our website at CUSTOMER COPY Group Number: Invoice Number: Invoice Date: 06/01/ Due Date: 07/01/2006 Coverage Period: 07/01/2006 to 7/31/2006 Please make check payable to: Health Plan PO BOX CITY ST We are also here 24 hours a day to service you at where in a personalized, secure environment you can: View and Print Your Invoice Review Your Covered Employees/Dependents Add, Remove or Change Covered Employees/Dependents So, come check us out soon! Page 3 of 6 1 This is an example of your group number & pertinent invoice information that should be referenced when making payments if you choose to not use the coupon provided. 2 The lockbox address you should use to mail in premium payments. 3 Account Summary A summary of payments and/or adjustments applied to your account since the last invoice period. 4 New Charges for Coverage Period Premium charges for the CURRENT coverage period. 5 Retro Active Charges for Coverage Period Premium charges/credits for PRIOR periods that have not been billed to you on previous invoices. 6 Current Monthly Charges This amount represents the total monthly charges for this particular coverage period (Items 4 & 5 combined). 7 Account Balance- Payment Due This is the amount you owe, less any payments not reflected in Item 3 above. You can also download this flyer for future reference. chcga.com 12 Fully Insured :

13 HOW TO READ YOUR EXPLANATION OF BENEFITS (EOB) how your medical claim(s) are processed (including a payment adjustment or denial). If you have questions, call the customer service number printed on your ID card. No, the health plans of Coventry Health Care do not bill members for medical services. Rather, the health plans process and pay the claims submitted from your provider, facility or hospital. 1 2 P Page 1 of 1 1 Address address to which the EOB was mailed. Payments made on behalf of The Coventry subsidiary paying your medical claim. If your employer is a self-funded group, their name will appear here. Insured The person who holds the policy with the insurer. Patient The person who received medical services. Group Name The policy holder s employer group. ID Number assigned by your health plan. Date the date(s) of your medical service(s). 3 Insured: ID Number: Date: Payments made on behalf of: Coventry Health Plan Member, John D **Payments made at the time services were rendered are not reflected on this statement.** Our organization processes the claims submitted from your health care provider(s). You have received this (EOB) as our notification to you explaining how your claim(s), including payments or denials, are being processed. Patient: Group Name: THIS IS NOT A BILL EXPLANATION OF BENEFITS Member, Jane D XYZ Group 99XXXXXXX0 2 10/19/2011 Your Health Is Important. Preventive care services include flu and pneumonia vaccines, mammograms, colorectal screenings and spirometry (if you have COPD). Talk with your doctor to schedule needed services. Claim Number: 8XXXXXX2 2 Pa id to Provider: Paid to Member: Paid to Other: Total Plan Paid: Member Responsibility: P COVENTRY HEALTH CARE, INC. Administered by Coventry Health Care, Inc 6705 ROCKLEDGE DRIVE, SUITE 900 BETHESDA, MD Electronic Service Requested TFATADATFADFAFTDFTDAFFTFADTADTFTDTDATFATDATDTFADFT Member, Jane D 123 ANYWHERE ST. ANYWHERE, MO $0.00 $0.00 $0.00 $0.00 $ WHITE STOCK IO Provider: Provider Address: CURE U FAMILY CARE PC 1 MEDICAL DR SOMEWHERE, MO Patient Account #: **Provider billing address may differ from physical office location** Important messages from your health plan. If there is no message this area will be blank. Claim Number Document control number generated by Coventry Health Care. Please reference this number when calling a member service representative to discuss the claim. Paid to Provider, Paid to Member & Paid to Other Entities to which the Coventry Health Care plan paid dollars. Total Plan Paid the Coventry Health Care plan for services rendered. 4 5 ENV 1 1 OF Member Responsibility The amount the member may be responsible to pay the provider. This amount is not payable to the Coventry Health Care plan. If payment was made at the time of service, this may not be applicable. Provider The name and billing address of the health care provider that rendered your medical service. This could be an individual practice or facility. Patient Account # assigned by your health care provider. Date The date(s) of your medical service(s). Procedure Code/Description The health care industry code and description of services performed and billed by your health care provider. Billed Amount The total dollar amount billed to your Health Plan by your health care provider for the services they rendered. Contractual Adjustment Reductions in payment due to contracts with your health care provider, coordination of responsibility. Approved Amount The amount Coventry agrees to pay the provider for services rendered. This amount your other health care insurance plan considered for payment. Copay Dollar amount member is responsible to pay. Coins. Member s shared expenses for eligible charges on a percentage basis. The member is responsible to pay this to the health care provider. Deduct. Amount of eligible charges which the member responsible to pay this to the health care provider Service Date From - To Proc Code / Description 10/13/11-10/13/ /OFFICE VISIT - F/U : Contractual Remarks: Billed Amount Contractual Adjustment Approved Amount Member's Responsibility to Provider Copay Coins Deduct. $ $0.00 $0.00 $0.00 $ $0.00 $0.00 $ TOTALS: $ $0.00 $0.00 $0.00 $0.00 $0.00 $ $0.00 Other Carrier Allowed: $ CHARGE EXCEEDS THE CONTRACTUAL ALLOWANCE PER THE CONTRACT Other Remarks: PATIENT HAS REFUSED TO ASSIGN BENEFITS Other Carrier Paid: Grievance Review Process: PLEASE CONTACT A CUSTOMER SERVICE REPRESENTATIVE AT WITH ANY QUESTIONS OR CONCERNS. To ensure that your health plan was properly billed, please review the services listed on your explanation of benefits. If you believe any of the services were incorrectly billed, contact a customer service representative using the toll free number listed on your insurance card. For diagnosis and treatment codes, the meanings of such codes, and questions regarding this notice, please call the number listed on your card. If you have a HRA/HSA/FSA with Coventry Consumer Choice (C3), or you have a medical plan with the Coventry Fund, you may be eligible for additional reimbursement on this claim. Check your fund or account on My Online Services at the website listed on your medical ID card for options. Deductible Dollars $0.00 Other The amounts below include claims processed as of 10/19/2011. The information does not reflect any claims received or adjusted after the above mentioned date. Member Medical Benefit Usage for Dates of Service January 01, December 31, 2011 This may include deductible carry over dollars. Plan Paid Out of Pocket Dollars Year-To-Date Maximum Remaining Year-To-Date Maximum Remaining Type Satisfied $ $ Satisfied $ $ OVERALL-Family $ $ 6, $ 6, $ $ 6, $ 6, Cont./ Rmk Other Rmk Other Descriptions of these codes are displayed in the Other Remarks section below this section. This amount paid by your other health care insurance plan. Plan Paid The amount paid by your plan. Cont. Rmk/Other Rmk A Coventry Health Care code that Brief explanation of Cont. Rmk and/or Other Rmk codes, plus any optional detail text for the Remarks code. Other information and/or alerts from the plan. If your plan has deductibles and/or out-of-pocket maximums, the usage table will display. CVTY.EOB.0112 You can also download this flyer for future reference. chcga.com 13 Fully Insured :

14 COBRA (for groups with 20 or more employees) When an employee no longer qualifies for health care coverage through your company, his/her present coverage may be extended under the COBRA law (Consolidated Omnibus Budget Reconciliation Act Public Law ). The COBRA law applies to any commercial organization that employed 20 or more people on a typical business day during the preceding year. COBRA coverage is available to both employees and any dependents formerly covered by an employer s group policy. It is the responsibility of the employer to notify the employee of COBRA eligibility within 30 days of the qualifying event. The qualifying event affecting enrollees or their dependents can be any one of the following: Termination of employment (other than for gross misconduct) or reduction of work hours Death of the employee Divorce or legal separation from the employee Employee becomes eligible for Medicare A dependent child or ward no longer qualifies as a dependent Retirees (not Medicare-eligible) affected by a company s filing or bankruptcy Employees who elect COBRA coverage must enroll within 60 days from the date of the qualifying event (for dependents, within 60 days from the date notice is received from the employer). The COBRA participant must pay the full premium, not just the portion he/she previously contributed. As the employer, you are responsible for collecting the premium and sending it to Coventry Health Care. However, the employer has the right to charge the COBRA participant up to an additional 2 percent of the full premium to cover your administrative costs for this service. To help identify members on COBRA, we use a separate group number for your company s COBRA participants. COBRA participation for termination or reduction in hours usually lasts for 18 months. However, if the qualified beneficiary is also disabled, he/she is entitled to an additional 11 months, making the continuation period 29 months. For all other qualifying events, the continuation period is 36 months. State (for groups with fewer than 20 employees) While the COBRA law protects members of the commercial groups of 20 or more employees, members affiliated with a church or commercial group having fewer employees are protected by state continuation laws. Any state-mandated coverage applicable to your employees and their families is explained in the Group Membership Agreement. chcga.com 14 Fully Insured :

15 Continued Medicare Medicare is the federal program that provides health insurance to the elderly and disabled. Within the three months prior to an American citizen s 65th birthday, the Social Security Office will send the individual information concerning enrollment in Medicare. Companies with 20 or More Employees If you are an employer with 20 or more employees, the actively working Medicare-eligible employee or his or her spouse is required to choose either Medicare or your company s group health care benefit plan as the primary payor. No additional coverage needs to be provided by your company s benefit plan. As your company s benefit administrator, you are responsible for notifying your account manager of any Medicare-eligible employees or spouses who choose Medicare as the primary payor and disenrolling the individual(s) from your company s benefit plan. To do either, complete the group enrollment/change form* and submit to the Enrollment department. Companies with 19 or Fewer Employees If you are an employer with 19 or fewer employees, Medicare is the primary payor of the covered health care services for an actively working Medicare-eligible employee or spouse. The Medicare-eligible employee or spouse may have secondary coverage through your company s benefit plan. If your company is to provide secondary coverage, it is your responsibility as your company s benefits administrator to complete the group enrollment/change form* and submit it to the Enrollment department. It is also your responsibility to disenroll any Medicare-eligible employees or spouses who do not choose secondary coverage under your company s benefit plan. To disenroll an employee or spouse, complete the group enrollment/ change form* and submit it to the Enrollment department. Certificate of Group Health Coverage In compliance with the federal Health Insurance Portability and Accountability Act (HIPAA), Coventry Health Care sends terminated members a Certificate of Group Health Coverage. This certificate is mailed when the member is disenrolled in our system. If your company prefers to send this document to disenrolled members, please advise your account manager. Conversion Policies Once COBRA or continuation coverage expires, members who reside in our service area may apply to Coventry Health Care for coverage under a conversion contract without furnishing evidence of insurability. Application and payment of the initial premium must be made within 31 days after termination of COBRA or continuation coverage. The level of benefits offered to conversion members may be substantially different than the benefits offered by the employer group. To request a conversion policy, submit an enrollment/change form* indicating Conversion on the Other line in the Reason for Enrollment section of the form. *The appropriate enrollment/change form varies by group size. Our website provides our various enrollment/change forms for your selection. chcga.com 15 Fully Insured :

16 On March 23, 2010, the Affordable Care Act (ACA) was signed into law. The law, which is commonly referred to as health care reform, contains mandates that must be implemented at specific times. One requirement of the law relates to provisions regarding potential rebates from insurers and health maintenance organizations (HMOs) to employers and individuals if certain minimum standards regarding medical claims payment, also known as the (MLR), are not met. The MLR is defined as the percentage of premiums insurers/hmos spend on medical care, less federal and state taxes and licensing and regulatory fees. The MLR is used to determine if a refund is due in any of the market segments in which Coventry Health Care operates. Individual, small group and large group are examples of market segments. Rebates are calculated by legal entity, by state and then at the market segment level. It is a complex calculation. For instance, an insurer/hmo may owe rebates for one market segment but not for others, even within the same state. The questions and answers below are provided to help you learn more about the process. Question What is the MLR? What are the minimum MLR thresholds that insurers must meet regarding premium rebates? Answers The MLR is the percentage of premiums, less federal and state taxes and licensing fees, that insurers/hmos spend on medical care. Inpatient hospitalizations, doctor visits, preventive care and prescription drugs are examples of just some of the medical services that are considered in the calculation. The minimum threshold varies based on group size. The ACA defines a small group as having one to 100 subscribers. Some states, however, can currently define a small group as having one to 50 subscribers. Groups that are not defined as small are considered large groups. The minimum MLR thresholds for large and small groups are listed below: Large group 85 percent Small group 80 percent If the MLR is below the percentage shown above, the insurer/hmo owes a rebate payment to group policyholders in that market segment (i.e., small group) in that state. Note: Minimum MLR thresholds may vary in some states. Any state-specific variations would be shared with you. When does Coventry Health Care report its MLR to the government? When will Coventry Health Care issue the rebates? Where can I obtain the calculations used to determine if my group qualifies for a rebate? Insurers/HMOs are required to provide MLR data to the federal government by June 1 of each year. Rebates must by issued by August 1 of each year. Rebates will be issued to your group policyholder, who is required to use the rebates as outlined in the December 2011 guidance by the U.S. Department of Labor. This information is intended to inform you about the MLR process and how it may affect you. Coventry Health Care follows federal guidelines to calculate the MLR, and we submit the results to the appropriate federal agency. Details about specific MLR calculations will not be shared with our customers because the outcomes are based on the experience of an entire segment of similar policyholders, not individual clients. chcga.com 16 Fully Insured :

17 Continued Question Why is the credit issued to my group policyholder, and what are his or her obligations as an employer group? What if the group or subscriber terminated prior to the rebate being issued? What if the group or subscriber was terminated for nonpayment of premium? Answers This depends on a number of things. In most cases, the regulations allow insurers/hmos to distribute the rebates to the policyholder (employer). The requirements differ, however, depending on whether the group 1) is subject to the Employee Retirement Income Security Act (ERISA); 2) is a nonfederal government plan; or 3) is not subject to ERISA and not a nonfederal government plan (i.e., church plan). Plans subject to ERISA: With a few rare exceptions, nongovernmental and non-church plans are subject to ERISA. Rebates for plans subject to ERISA should be paid to the group policyholder (employer). Nonfederal government plan (state and local government): Rebates should be paid to the group policyholder. Rebates must be used in the following manner: The group must use the amount of the rebate that is in proportion to the total amount of premiums contributed by subscribers as follows: Reduce the subscribers part of the premium for the next policy year for all subscribers enrolled under any health benefit plan option offered by the group at the time the rebate is received, or Reduce the subscribers part of the premium for the next policy year for all subscribers enrolled under the health benefit plan option for which the rebate is being paid, or Issue a cash refund to subscribers enrolled under the health benefit plan option for which the rebate is being paid, or At the option of the group, divide the reduction in future premiums or cash refund evenly among such subscribers based on each subscriber s actual contributions to premium, or distribute the rebate in a manner that reasonably reflects each subscriber s actual contributions to premium. The portion of rebate based upon the former subscribers contributions to premiums must be aggregated and used for the benefit of current subscribers. Non-ERISA, nonfederal government plans (mostly church plans): In order to pay rebates to the group policyholder (employer), the insurer/hmo (such as Coventry Health Care) must receive written assurance from the policyholder that the rebates will be used to benefit members similar to the requirements for nonfederal government plans. Otherwise, the insurer/hmo must pay the rebates to the subscribers covered by the group policyholder during the MLR reporting year. If the rebates are paid to the subscribers, they are divided equally among the subscribers. The MLR calculation is based on the previous year s premium paid, so the group or member would still be due the rebate. The MLR calculation is based on the previous year s premium paid, not billed, so the group or member would still be due the rebate. The rebate would be calculated based on premiums paid. chcga.com 17 Fully Insured :

18 What Is My Responsibility as the Employer? As outlined in the Employer Acknowledgment you signed, we prepared a (SBC) by using a template provided by the government in compliance with ACA regulations. Regulations place the responsibility of providing SBCs on both Coventry Health Care and your company. Along with this guide, we are providing you with a copy of an SBC for each health plan option that is available for your eligible employees. The next step in complying with ACA regulations is to distribute these SBCs. As an employer who sponsors a group health plan, your company is required to provide SBCs, in a timely manner, to your group health plan s participants and beneficiaries (i.e., eligible employees and covered family members). Who Is Required to Receive an SBC and When Does My Company Need to Give it to Them? Who receives an SBC: Those who become members during open enrollment/new hires Renewing members Special enrollees Upon request When they receive it: At the same time you distribute written applications or open enrollment materials If the plan does not distribute written materials, then no later than the first date on which the employee is eligible to enroll With renewal materials If written application is not required for renewal, no later than 30 days prior to the first day of the new policy year Exception: If the policy is not renewed before the 30-day period, SBCs must be provided no later than seven business days after issuance of the policy or receipt of written confirmation of intent to renew, whichever is latest. No later than 90 days after enrollment No later than seven business days after the request for your plan years beginning on or after September 23, 2012 Can SBCs be Distributed Electronically? SBCs can be distributed electronically to employees and covered family members in accordance with U.S. Department of Labor regulations: If employees have the ability to effectively access documents in electronic form at any location where they work, and they can access the employer s electronic information system If other participants and beneficiaries (for example, retired employees, employees who don t have access to computers at work, etc.) give the employer permission to send SBCs electronically Employers can also distribute SBCs electronically to employees who are eligible but not currently covered by the plan under the following circumstances: The format is easily accessible (for example, PDF) The SBC is provided in paper form free of charge if requested If the SBC is posted on a website, employees are notified that the SBC is available and a web address is given. This notification can be sent as an . chcga.com 18 Fully Insured :

19 Coventry Health Care has designed our website with you and your employees in mind. We invite you to visit our website at chcga.com. It features items such as our company profile, contact information, current news and links to other health-related sites. At chcga.com, members can access their health care information and manage their personal health with our wellness tools at a time that is convenient for them. The Other Important Information page of the Members section contains important documents in PDF format for downloading and printing or reading online. Some of the documents available include: Certificates of Coverage and our Certificate of Insurance Complaints and appeals policies Notice of Privacy Practices Enrollment Guides The Document Library found in the Employers section also provides valuable information on our provider network, employer reports and valuable online tools, including Online Account Management and My Online Services. Visit chcga.com today to explore the information available at your fingertips. chcga.com 19 Fully Insured :

20 Online Account Management SM Useful Tools for Plan Administration At Coventry Health Care, we know administrative needs are different, so we give you a convenient way to manage your group health benefits online. Through a single, password-protected website, employers can perform a variety of functions and access a wealth of account information at no additional cost. Online Account Management is available 24 hours a day. It is easy to: View up to six months of billing statements and invoices View payment history View eligibility information for any employee and find invoices on which that employee appeared Access online bill payment Add and terminate employee or dependent coverage Update employee demographics Perform a wide variety of functions on behalf of any covered member, including viewing/requesting ID cards and updating address/phone, etc. Request Certificates of Creditable Coverage Ask questions Request quantities of literature View service request status chcga.com 20 Fully Insured :

21 Continued Access Online Account Management Employers can sign up to use Online Account Management through an easy four-step process detailed below. Log on to chcga.com and visit the Employers home page. Under Online Account Management, select Login or Register Now. Select Register Now. Complete the registration process. Once the request is processed, the Employer Administrator will receive an with a login ID and password to begin using Online Account Management. You will receive separate s for security purposes. The Employer Administrator can use Online Account Management to establish access for other employer users, including the insurance broker. Security can be limited for additional users to access specific functionality as deemed appropriate. Our dedicated Net Support team is available Monday Friday, 8 a.m. to 6 p.m., Eastern time, to help with problems or questions using Online Account Management. Simply call toll-free for personal assistance. chcga.com 21 Fully Insured :

22 Continued My Online Services SM Members have access to an electronic personal health assistant, putting them in control of their health and benefits. Within My Online Services, members can find complete, personalized information that is built around a personal health record (PHR). Personal Health Record View, store, track and maintain personal health information Share with a health care provider, family member or caregiver Transactions View medical and prescription claims View or print Explanations of Benefits (EOBs) View, request or print an image of an ID card Send a secure to Update personal information Health and Wellness Take a health risk assessment Request an reminder for screenings and tests Access Coventry WellBeing SM with a wealth of online wellness programs Cost and Quality Tools Search for network providers Find costs for procedures and services with My Cost of Care Save on prescription drugs If you or your employees need assistance accessing our website, call , Monday - Friday, 8:00 a.m. to 6:00 p.m., Eastern Time. Our Net Support Team will gladly assist you. chcga.com 22 Fully Insured :

23 Continued Provider Search It s easy for you and your members to find an in-network provider using our electronic provider search tool. It contains the names, addresses and phone numbers of our participating providers, hospitals, pharmacies, outpatient facilities and other ancillary providers in our network. We update the online search weekly. Logging in is not necessary. Search for Providers in Our Provider Networks Prior to seeking services, members are responsible for reviewing the provider directory on the website to ensure they seek care from network providers. To search for in-network physicians, hospitals and ancillary providers such as physical therapy and urgent care facilities on our website: Go to chcga.com and select Find a Doctor at the top of the page or at the button on the right Select your provider search. For HP and HP Premier plans, select Enter Provider Search HP and HP Premier. For all other plans, select Enter Provider Search. Select the product as listed on the member ID card Search by zip, name, facility, specialty or condition Or select the type of provider service For members who live outside the service area or are a dependent on the Passport Program, please select Coventry National Network from the product selection list. chcga.com 23 Fully Insured :

24 Continued Select a product from the drop-down list Members can search by location, health conditions, specialty or best match by their specifications Our Net Support Team is available weekdays from 8:00 a.m. until 6:00 p.m. Call for assistance. NOTE: If you need a printed paper copy of the provider directory, you can create your own by clicking on Create Directory in the provider search results. Or, you can call your account manager or. Because any paper directory is only as current as the date it was printed, we encourage our members to either call our department or log on to our website if they have any questions about whether a provider participates in our network. chcga.com 24 Fully Insured :