Benefits Administrator Guide

Benefits Administrator Guide

Welcome Thank you for selecting Independence Blue Cross (IBC) for your organization s health care coverage needs. We strive to exceed our customers expectations every day by delivering innovative health and wellness solutions. Your satisfaction is our top priority, and we are committed to providing you and your employees with an excellent customer experience. As the benefits administrator of your IBC insured or administered plan, you have the important job of understanding your program and assisting your employees with their questions and concerns. We have prepared this Benefits Administrator Guide to help you manage the day-to-day administration of your organization s IBC health benefits program. Using this guide/obtaining forms This guide explains IBC processes and procedures related to enrollment, billing, invoices, and coordination with Medicare. An electronic version of this guide and the related forms are available to download at www.ibxpress.com. Registration is required to access our secure employer website. ID cards Each employee selecting an IBC plan will receive benefits information and an ID card. While we process the member s Enrollment/Change Form, a copy of the form may be used as a temporary ID card until the member receives a permanent card in the mail. More information about enrollment procedures is available on page 3. Members can also print a temporary ID card at our secure member website, ibxpress.com, once their enrollment has been processed. More information about using the Enrollment/Change Form as a temporary ID is available on page 6. Please review this guide in its entirety. If you require more information, or if you have any questions about your IBC coverage, please contact your IBC account executive, consultant, or broker. Thank you for choosing Independence Blue Cross!

Contents Managing benefits online......................... 2 Enrollment.................................... 3 Billing........................................ 7 Understanding your invoice....................... 10 Continuation of Coverage and Conversion Privilege..... 17 Medicare Secondary Payer....................... 19 Important contact information.................... 21 1

Managing benefits online As a group administrator or business owner offering IBC insurance plans, you can use our employer website, ibxpress.com, to conveniently manage your group s account. With ibxpress.com, transactions are quick, easy, and secure. Account management view benefits information for your covered employees; add, terminate, or change a member s health benefits; view coverage history for active and terminated members; request ID cards for members and their covered dependents; print temporary ID cards for members and their covered dependents; view previously submitted transactions via the Transaction History feature; assign access to other users within your company; utilize a variety of membership reports. ebilling/ereconciliation * access your current and prior invoices; view a summary of individual health plan costs; view billing and payment history; get monthly billing reminders; receive and pay invoices online; update enrollment activity directly from your roster; reconcile your group s bill online so you only pay the amount owed. *Note: The ebilling and ereconciliation features are available to fully insured customers only. Get started Register at www.ibxpress.com to begin taking advantage of many time-saving features that will help you simplify your benefits administration tasks. To complete the registration process at ibxpress.com, you need to enter the numeric characters of an Active Group/ Account number and an Active Member number from the same Group/Account number. Please contact your IBC account executive, consultant, or broker to obtain this information. 2

Enrollment We recommend that you manage your group s account through our secure employer website, ibxpress.com. The following information regarding the Enrollment/Change Form and Enrollment Report is provided for those instances when you do not use ibxpress.com. For more information about communicating enrollment information electronically, refer to our Guide to Your Electronic Options. A copy of the EDI Enrollment guide is available under Quick Links at www.ibx.com/employers. Open enrollments Open enrollments are held at least once a year. During the open enrollment period, any eligible employee of the group may enroll in any applicable IBC plans you ve selected. The effective date of coverage is listed on the face sheet of your Group Master Contract or may be confirmed by your IBC account executive, consultant, or broker. Each newly eligible person who enrolls during the open enrollment must complete an Enrollment/Change Form. Employees currently enrolled in an IBC plan who wish to continue the same coverage do not have to complete a new Enrollment/ Change Form during the group s open enrollment period. However, a form must be completed if the employee is changing coverage (e.g., an employee switches from a Keystone Health Plan East HMO copay plan to a Keystone Health Plan East HMO deductible plan). Your account executive, consultant, or broker will assist you in planning and determining the appropriate way to conduct your group s open enrollment, which could include employee meetings, posting information on your company s intranet, and/or payroll announcements. Employers that routinely require mandatory attendance at open enrollment meetings often experience fewer difficulties and higher employee satisfaction with their choice of health plans. Enrollment procedures Each new IBC member, whether joining as a new hire or through open enrollment, must complete an Enrollment/Change Form. All information must be provided to avoid processing delays. You may enroll new hires and their dependents within 30 days of their becoming eligible for health benefits. Under federal law, unmarried and married dependents up to the age of 26 are eligible for coverage under their parents health insurance plan. Pennsylvania employers can also opt to extend health care coverage for dependents up to age 30. This provision applies to fully insured and self-funded customers. Talk to your IBC account executive, consultant, or broker for additional information about dependent coverage. Your company establishes the eligibility date for health care benefits for new hires. In most cases, if employees are not enrolled within 30 days, they cannot enroll until your company s next open enrollment or until a life event occurs. 3

Enrollment forms Use the IBC Enrollment/Change Form to add members to IBC s medical programs. IBC offers the following medical programs: Keystone Health Plan East HMO, Keystone Point-of-Service (POS), Keystone Direct POS (DPOS), Personal Choice PPO, Traditional, and Comprehensive Major Medical (CMM). Be sure your employees carefully read the instructions for completing this form because specific information is required of HMO, POS, and DPOS members. Any time you add a new employee or propose a change, you must submit both the Enrollment/Change Form and an Enrollment Report. The Enrollment/Change Form records the change for each individual employee, while the Enrollment Report summarizes all the changes being submitted at one time. Both forms need to be completed each time a change is made, even if only one change is being submitted. Adding a new employee using the Enrollment/Change Form To ensure that we process a new employee s information accurately, please verify the following information before submitting the Enrollment/Change Form: all questions in the employee information section are answered; the dependent information section is complete for eligible dependents; a valid primary care physician (PCP) is selected*; the portion of the form that requires the employee to list any other health coverage is complete, if applicable; the employee has signed and dated the form. As the benefits administrator, it is your responsibility to complete the required group information. Please see the detailed instruction sheet attached to the Enrollment/Change Form. Remember to include your account or group number. If your organization has more than one account or group number, be sure to indicate the correct account or group number on each Enrollment/Change Form. Remember to sign and date the form. * PCP information is required for employees enrolled in HMO, POS, or DPOS plans. If a PCP is not selected, the member ID card will indicate that the member must select one. Reduce your paperwork Add or update employee information with the click of mouse at ibxpress.com. Our employer website makes managing your group s account quick and secure. 4

Changing information for an employee using the Enrollment/Change Form Any updates to an employee s personal information should be made on the Enrollment/Change Form. The employee must specify on the form what type of change is being requested. If the employee is adding a dependent, he or she must also complete the section on individuals covered. The form must be signed and dated. As the benefits administrator, it is your responsibility to complete the required group information. Please see the detailed instruction sheet attached to the Enrollment/Change Form. Remember to include your account or group number. If your organization has more than one account or group number, be sure to indicate the correct account or group number on each Enrollment/Change Form. Remember to sign and date the form. Any time you change information for an existing member, we ll ask you to send us both the Enrollment/Change Form and an Enrollment Report. The Enrollment/Change Form records the change for each individual member, while the Enrollment Report summarizes all the changes being submitted at one time. Both forms need to be completed each time a change is made, even if only one change is being submitted. Special information for Keystone Health Plan East HMO, POS, and DPOS members Each family member must select a primary care physician (PCP) from the Keystone Health Plan East physician network. Female members do not have to preselect a Keystone Health Plan East OB/GYN. Members can go to www.ibx.com and access the Find a Provider tab to search for a participating PCP by last name or location. Once they locate a physician in the IBC Provider Directory, they can click on the name for more information, including the physician s HMO ID number, hospital affiliations, and whether or not the physician is accepting new patients. If an HMO, POS, or DPOS member does not select a PCP, or if he or she selects a physician who is not accepting new patients or one who no longer participates with Keystone Health Plan East, the member s ID card will indicate that the member must select a valid PCP. It is important that the member chooses a valid PCP during the enrollment process so IBC does not have to reissue the member ID card. Members may change their PCP up to two times per calendar year; members wishing to do so should make their selection through ibxpress.com or by calling 1-800-ASK-BLUE (1-800-275-2583). The change will go into effect on the first day of the following month. 5

Using the Enrollment/Change Form as a temporary ID It is important that you retain a copy of the completed Enrollment/Change Form for your records and provide each employee with a copy for use as his or her temporary ID card. If any enrolled member requires care before he or she receives a permanent ID card, this form may be presented at the physician s office and will allow the member to receive all the benefits to which he or she is entitled. A member can also register at ibxpress.com to print out a temporary ID card anytime. Completing the Enrollment Report The Enrollment Report summarizes all the additions and changes you submit to IBC. A completed Enrollment Report must be included any time you request a change, even if you are submitting only one Enrollment/Change Form. The Enrollment Report must be filled out in its entirety, including the group number, group name, current effective date, address, and phone number so we can contact you if there are any questions about the report. To communicate this information to IBC quickly, we recommend that you complete the Enrollment Report online at ibxpress.com. If you fill out a paper copy of the report, each numbered line should reflect the information on one of the enrollment forms included in the submission. Be sure to include the member s identification number and the effective date of the change, and also indicate whether the transaction is an addition, a change, or a removal. If the change is a removal, be sure to include the removal code number, which can be found on the bottom of the form, and include the terminated member s address in the Remarks section. Once you ve completed all the necessary lines, simply total the number of transactions by type, and enter the grand total of all transactions in the designated box. Keep copies for your records, and mail the original documents to the address at the top of the form, or fax it to 215-761-9176. Because insurance bills are prepared in advance of the coverage date, changes may not appear on your bill for one or two monthly billing cycles. To avoid any potential payment problems, you should always pay the billed amount. Any credits or additional premium due will be applied on subsequent bills. 6

Billing IBC sends itemized invoices monthly, approximately 15 days before the month of coverage. Invoices for a given month of coverage are based on the actual group enrollment for the prior month. This enables billing and payment to occur in advance of the covered month. To avoid payment problems, it is important to always pay the amount billed, even though it may not reflect your most recent additions and terminations. ebilling To make bill payment as easy as possible, you may establish electronic payments through ibxpress.com or your financial institution s electronic bill payer service. Paper format You also have the option of receiving and paying invoices via mail. To ensure prompt and accurate updating of future payments and to help avoid any interruption in your coverage, all payments, along with the payment coupon and check, should be mailed to: Independence Blue Cross P.O. Box 70250 Philadelphia, PA 19176-0250 Please include one check per coupon, and indicate the dollars paid on the coupon. More information about ebilling and paper invoices is available on page 10. Using the Enrollment Report When submitting payment to IBC via mail, do not write membership or plan changes on your invoice. These changes will not be made. Submit enrollment changes by mail using the Enrollment/Change Form and Enrollment Report. You can also report enrollment changes electronically via ibxpress.com. The Enrollment Report should be mailed to the Enrollment Department along with the Enrollment/Change Forms indicating the desired action. This could include adding dependents to a contract (due to birth, adoption, or marriage) or making any changes to an individual s coverage (i.e., marriage, divorce, legal separation, death of a spouse or dependent, loss of eligibility for coverage, or moving out of the IBC service area). 7

If you are terminating an individual s coverage or deleting dependents, use the Enrollment Report Form, but continue to remit the billed amount. Do not delete billed premium amounts or add the additional premium due in your remittance. The next invoice will reflect those changes retroactively along with any corresponding change to your premium balance. Adjustments made will appear in the Retroactive Adjustments section of the invoice. Simply detach the remittance coupon from the bottom of the first page of your invoice and return it with your payment to the address indicated on your bill. If you are including multiple payments in one envelope, please be sure to indicate on each coupon the amount to be applied to each account/group. The sum of all coupons must equal the full amount of the check you are remitting. This will ensure that your payment is credited to the proper account. More information about ebilling and paper invoices is available on page 10. Notes on coverage and billing cycle for HMO/POS/DPOS groups IBC uses the following steps when processing invoices for groups offering Keystone Health Plan East HMO, POS, or DPOS plans. If your group s effective date is the 1st of the month: If members are added between the 1st and the 15th day of the month, you are billed for that month. If members are added between the 16th and the last day of the month, you are not billed for that month. If members are dropped between the 1st and the 15th day of the month, you are not billed for coverage for that month. If members are dropped between the 16th and the last day of the month, you will be billed for coverage for that month. If your group s effective date is the 15th of the month: If members are added between the 15th and the last day of the month, you are billed for that month. If members are added between the 1st and 14th day of the month, you are not billed for that month. If members are dropped between the 15th and the last day of the month, you are not billed for coverage for that month. If members are dropped between the 1st and 14th day of the month, you will be billed for coverage for that month. For assistance with billing reconciliations, please call the telephone number that appears on your bill. 8

Notes on coverage and billing cycle for PPO, Traditional, and CMM groups When IBC processes invoices for groups offering Personal Choice PPO, Traditional or Comprehensive Major Medical (CMM) plans, enrollment activity is prorated. For example, if your group s effective date is the first day of the month and a member is added on the 16th day of the month, we will charge the applicable premium for days 16 through 30 or 31. This means you are billed for the actual number of days a member has coverage during the month. Payment reminders When paying your group s invoice, please keep the following points in mind. They will help us credit your account promptly and accurately, by reducing the chances of any record-keeping confusion. Submit all payments using the coupon included with your invoice. If you have more than one account, please be sure to submit all required coupons with your payment(s). Submit all payments to the Post Office box noted on the invoice. Do not send enrollment activity (member additions, changes, deletions) with your premium payments. Send them with the appropriate forms to the Enrollment Department. Review/verify all additions, changes, and deletions processed since the last invoice, whether you submit payments via ibxpress.com or send them to IBC via mail. If they are incorrect or incomplete, contact the Enrollment Department at the telephone number listed on the invoice. Verify with your bank that your checks have been cashed before making a call regarding payments not yet posted on an invoice. Please note: Payments received after the due date noted on invoices can cause claim processing delays or rejections. Making partial payments can also result in claim processing delays or rejections. If the number of members listed on your bill is incorrect, contact our Enrollment Department using the telephone number listed on the invoice to have the adjustments noted on your next premium statement. Always pay the amount noted on the invoice to prevent claims problems. 9

Understanding your invoice Each month, your group receives a statement and invoice from Independence Blue Cross. It s important to make sure the information on the statement is accurate and that the amount enclosed with the invoice is correct. Simply click on an invoice number to view detailed information. You can receive your invoices electronically at ibxpress.com (registration is required) or on paper. The following information details some of the features of ebilling. More information about paper invoices is available on page 12. Our service team is available to answer your questions from 8 a.m. to 5 p.m. EST, Monday through Friday. If you access your invoice via ibxpress.com, click the Invoice Summary tab for contact information. On the paper version, contact information is printed on the invoice page. ebilling features receive an email when your ebill is ready to view; check prior balances and current total due amounts on one page; download your current enrollment roster in comma delimited text, XML, or HTML format; (ebilling features continued on the next page) 10

Tabs allow navigation through all pages of the invoice. ebilling features (continued) view billing and payment history; - view up to 24 months of all historical payments, invoices, and adjustments on specific Group/Billing Accounts. stop sending paper checks; - pay invoices online via Automated Clearing House payments*; - pay multiple invoices from one screen; - register your bank account, then authorize payment; - modify any payments you are advancing to IBC within two business days of the scheduled payment date. assign billing/payment specific roles; - the primary administrator, also known as the super user, determines who has access to view invoices and make payments by assigning unique role access; - this function is scalable to fit small Accounts Payable Departments and larger, more complex organizations. *Automated Clearing House Payments work just like checks but without paper. You authorize the amount that is withdrawn from your group s account. The money is transferred via the Federal Reserve Bank. Any payments you are advancing to IBC can be modified up to 48 hours prior to the scheduled payment date. 11

Paper Format The coupon page Your coupon page has two parts. The top is for your records; the bottom part should be carefully torn off at the perforation and returned with your payment. If you have submitted enrollment changes with your group change form and they are not reflected on this statement, they should be included with the next bill. Please do not adjust the bill or statement. 1. Bill to account: This is the number that identifies your account. 2. Invoice number: For billing purposes only, this number is a combination of your Bill To Account number and the premium month. Please refer to it when you have inquiries regarding this bill. 3. Due date: The latest date we should receive your payment. 4. Total due: The full amount you should pay. 5. Special message area: When we have special information to communicate to you, you ll find it in the special message area in the middle of the page. Additional instructions: The bottom portion of the coupon page should be torn off and submitted with your payment. Indicate the amount you are paying in the space provided. 1 2 3 BILL TO ACCOUNT: 123456 INVOICE: 123456110401-01 REF #: PREM 0411 DUE DATE: TOTAL DUE: 04/01/11 $5,000.00 4 *********************************************** * FOR INTERNAL USE ONLY * *********************************************** * SPECIALIST - A * ABC COMPANY * COMPANY - 500 0000 * JOHN DOE * SPECIAL - * 123 NOWHERE *********************************************** LANE PHILADELPHIA, PA 19100 TO ENSURE THE TIMELY APPLICATION OF YOUR PREMIUM PAYMENT, PLEASE RETURN THE COUPON PORTION OF THIS BILL. 5 ************************************************************************************************ * MAKE CHECK PAYABLE TO: * * INDEPENDENCE BLUE CROSS * * AND NOTE BILL TO ACCOUNT NUMBER ON YOUR CHECK. PLEASE DETACH THE * * BOTTOM PORTION AND RETURN WITH YOUR REMITTANCE TO: * * INDEPENDENCE BLUE CROSS * * P.O. BOX XXXXX * * PHILADELPHIA, PA XXXXX-XXXX * * IF PAYMENT HAS BEEN MADE, RETAIN THIS BILL FOR YOUR RECORDS. * * PAYMENTS CAN BE MADE ELECTRONICALLY AT WWW.IBXPRESS.COM * ************************************************************************************************ PLEASE REMOVE INVOICE BY CAREFULLY TEARING ALONG PERFORATION DO NOT FOLD INVOICE Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Ins. Co., and with Highmark Blue Shield -- indpendent licensees of the Blue Cross and Blue Shield Association. BILL TO ACCOUNT: 123456 INVOICE: 123456110401-01 SPEC: A CUSTOMER NAME: A B C COMPANY REF: PREM 0411 ENTER AMOUNT PAID CO: 500 0000 ACC: 111100000 DUE DATE 04/01/11 TOTAL DUE: $5,000.00 ******************************************************************************************************************************************************* REMITTANCE TO: INDEPENDENCE BLUE CROSS P.O. BOX XXXXX PHILADELPHIA, PA XXXXX-XXXX DO NOT WRITE BELOW THIS LINE ******************************************************************************************************************************************************* 70250 500 1234560000000001 20110401 43470000 0000 00000000000000 Make your checks payable to Independence Blue Cross, and mail to the address indicated on the coupon page. Please do not write on or near the scan line along the bottom of the page. This is used to electronically record payment. 12

Invoice page The invoice page explains how Independence Blue Cross calculates the Total Premium Due. 1. Amount of last bill: The total amount of the last billing. 2. Payment received: Payments received since the last billing, including the amount paid and the date received. 3. Balance due: Your outstanding balance due from the prior billing. 4. Retroactive enrollment changes: Credit or debit amount for retroactive changes appearing on this invoice. 5. Current charges: The amount of premium due for the current billing period. 6. Important notice: A section with instructions for submitting enrollment activity. 1 2 4 5 PHILA. AREA CALL: 215-XXX-XXXX BILL TO ACCOUNT: 123456 OUTSIDE PHILA. ABC COMPANY CALL: JOHN DOE 1-800-XXX-XXXX 123 NOWHERE LANE PHILADELPHIA, PA 19100 INVOICE INVOICE #: 123456110401-01 AS OF: 03/28/11 ACCOUNT SUMMARY: AMOUNT OF LAST BILL $ 3,500.00 PAYMENT RECEIVED 03/15/11 $ -3,500.00 - THANK YOU 3 BALANCE DUE $.00 $ 1,500.00 RETROACTIVE ENROLLMENT CHANGES (NO CHANGES FOR THIS BILLING PERIOD) CURRENT CHARGES $ 5,000.00 $ 6,500.00 TOTAL PREMIUM DUE TOTAL DUE BY: 04/01/11 PLEASE PAY PROMPTLY THE DUE DATE APPLIES TO CURRENT CHARGES ONLY AND DOES NOT EXTEND THE DUE DATE FOR PAYMENT OF PAST DUE AMOUNTS 6 ************************************************************************************************************************************* * I M P O R T A N T N O T I C E * * * * PAYMENTS CAN BE MADE ELECTRONICALLY AT WWW.IBXPRESS.COM OR MAILED TO THE PO BOX * * LISTED ON PAGE ONE OF THIS INVOICE. PLEASE DO NOT SUBMIT ENROLLMENT ACTIVITY * * WITH YOUR PAYMENT. SUBMIT ENROLLMENT ACTIVITY THROUGH THE GROUP PORTAL AT * * WWW.IBXPRESS.COM OR SEND ALL ENROLLMENT CHANGES TO: * * * * KEYSTONE HEALTH PLAN EAST * * P.O. BOX XXXX * * PHILADELPHIA, PA XXXXX-XXXX * * * ************************************************************************************************************************************* 13

Summary of retroactive charges This page of your bill will list only enrollment or rate changes that we have processed with an earlier effective date than the current billing period. 1. Member #: Member s ID number. 2. Name: Member s name. 3. BPKG items (Benefits Package including Items): The code used to describe the benefits you purchased. 4. Tier: A code that identifies the member s family status. 5. Bill For: The month and year for the period that the activity represents. 6. Amount: The premium for the period represented in the Bill For column. 7. Total retroactive enrollment charges: The total amount of the retroactive enrollment charges. BILL TO ACCOUNT: 123456 ABC COMPANY JOHN DOE 123 NOWHERE LANE PHILADELPHIA, PA 19100 SUMMARY OF RETROACTIVE CHANGES SINCE LAST BILLING PAGE 1 PHILA. AREA CALL: 215-XXX-XXXX OUTSIDE PHILA. CALL: 1-800-XXX-XXXX 1 2 3 4 5 6 MEMBER # NAME BPKG ITEMS TIER BILL FOR AMOUNT XXXXX234500 DOE JOHN B NEBP PPE PPM PPR PP1 S991 02/11.00 XXXXX234500 DOE JOHN B NEBP PPE PPM PPR PP1 S991 03/11 1000.00 ADDED TO ACCOUNT EFFECTIVE 03/01/11 XXXXX432100 SOMEBODY BOB B IMBP PPD PPM PPR PPV S991 02/11.00 XXXXX432100 SOMEBODY BOB B IMBP PPD PPM PPR PPV N991 03/11 500.00 CHANGE IN STATUS EFFECTIVE 03/01/11 7 TOTAL RETROACTIVE ENROLLMENT CHARGES: CHARGES: 1,500.00 1,500.00 14

Roster page The roster page lists each active member of your account. 1. Member #: Member s ID number. 2. Name: Member s name. 3. BPKG items (Benefits Package including Items): The code used to describe the benefits package you purchased. 4. Tier: A code that identifies the member s family status. 5. Bill For: The billing period month and year. 6. Amount: The current premium amount for each member. 7. Invoice total: The total amount of current premiums billed. CID: INVOICE: 000001234 123456110401-01 ABC COMPANY REF # PREM 0411 JOHN DOE BILL TO ACCOUNT: 123456 123 NOWHERE LANE CUSTOMER NAME: ABC COMPANY PHILADELPHIA, PA 19100 BILLING PERIOD: 04/11 DETAIL ENROLLMENT ROSTER AS OF: 03/10/11 PAYMENT OF CURRENT CHARGES DUE BY: 04/01/11 CURRENT PERIOD : 04/01/11 THROUGH 04/30/11 1 2 3 4 5 6 MEMBER # NAME BPKG ITEMS TIER BILL FOR AMOUNT XXXXX123400 DOE JANE A. NEBP PPE PPM PPR PP1 S991 04/11 1000.00 XXXXX234500 DOE JOHN B. NEBP PPE PPM PPR PP1 S991 04/11 1000.00 XXXXX432100 SOMEBODY BOB B. NEBP PPD PPM PPR PP1 N991 04/11 1500.00 XXXXX543200 SOMEBODY JOE I. NEBP PPD PPM PPR PP1 N991 04/11 1500.00 7 INVOICE TOTAL: 5000.00 15

Rate summary page The rate summary page is designed to help you keep track of how much your company spends on health care coverage for your employees. It details what benefits plans you offer, how many members are enrolled in each plan, and how much your company pays per plan. 1. Tier code: The code and description of the family status categories available in the group. 2. Package/item: The benefits plan and code that describes each plan. 3. Date/rate: The effective date and rates of the benefits plan. 4. Contracts: Indicates how many members based on family status are receiving each benefits plan. 5. Total number of contracts: Indicates the total number of members covered under each benefits plan. 6. Package item total: Represents the dollar amount for members covered under each benefits package. 7. Total package items: The total amount of premium billed for all benefits packages. 1 2 3 4 ACCOUNT: 123456 ABC COMPANY JOHN DOE 123 NOWHERE LANE PHILADELPHIA, PA 19100 RATE SUMMARY AS OF 03/10/11 *************************************************************************************************************************************************** TIER CODE -> S H N F P E TWO PARENT PARENT INDIV. PERSON & CHLDRN FAMILY N/A N/A & CHILD N/A OTHER PACKAGE/ITEM GRP# 123456/ACCT# 123456 NEBP/PPE 991 PPO/ POS+ BENEFITS EXCEPTION 04/01/11.00.00.00.00.00 CONTRACTS 2 2 TOTAL NUMBER OF CONTRACTS: 2 PACKAGE ITEM TOTAL: $.00 PACKAGE/ITEM GRP# 123456/ACCT# 123456 NEBP/PPM 991 PPO/ POS+ MEDICAL 04/01/11 700.00 800.00 900.00 1000.00 900.00 CONTRACTS 2 2 TOTAL NUMBER OF CONTRACTS: 2 PACKAGE ITEM TOTAL: $ 1400.00 PACKAGE/ITEM GRP# 123456/ACCT# 123456 NEBP/PPR 991 PPO/ POS+ DRUG 04/01/11 300.00 400.00 500.00 600.00 500.00 CONTRACTS 2 2 TOTAL NUMBER OF CONTRACTS: 2 PACKAGE ITEM TOTAL: $ 600.00 PACKAGE/ITEM GRP# 123456/ACCT# 123456 NEBP/PP1 991 PPO/ POS+ BENEFITS EXCEPTION 1 04/01/11.00 50.00 100.00 150.00 100.00 CONTRACTS 2 2 5 PHILA. AREA CALL: 215-XXX-XXXX OUTSIDE PHILA. CALL: 1-800-XXX-XXXX TOTAL NUMBER OF CONTRACTS: 2 PACKAGE ITEM TOTAL: $.00 7 6 TOTAL PACKAGE ITEMS: $ 2,000.00 16

Continuation of Coverage and Conversion Privilege IBC provides extended coverage through COBRA, which is required by federal law for groups employing 20 or more, and through Mini-COBRA, which is a Pennsylvania law that extends benefits for groups with 2 19 employees. COBRA COBRA provides certain former employees, retirees, spouses, former spouses, and dependent children the right to temporary continuation of health coverage at group rates. COBRA continuation coverage is available upon the occurrence of a qualifying event that would, except for the COBRA continuation coverage, cause an individual to lose his or her health care coverage. To be eligible for COBRA coverage, former employees must have been enrolled in their employer s health plan when they worked, and the health plan must continue to be in effect for active employees. More information about COBRA benefits is available in the IBC COBRA Manual. Go to www.ibx.com/employers, and click on Manuals and Guides under Quick Links to download a copy of the IBC COBRA Manual. Mini-COBRA In Pennsylvania, small employers (2 19 employees) must offer employees the option to continue their group health coverage, at the employee s expense, when an employee is terminated for reasons other than cause, when he or she goes to part-time status, or if an employee voluntarily ends employment. Individuals eligible for other group health coverage, such as a spouse s plan or Medicare, cannot receive continuation coverage through Mini-COBRA. An employee on continuation would pay his or her premium to you, which you would remit as part of your regular premium payment. Mini-COBRA is modeled after the federal COBRA law. However, there are some differences. For example, Pennsylvania s Mini-COBRA extends coverage for nine months, while the federal COBRA law allows an extension of 18 months or more. More information about Mini-COBRA benefits is available from the Pennsylvania Insurance Department at www.insurance.pa.gov. Use the search term Mini-COBRA. Notifying employees about continuation of coverage Employers have a legal obligation to notify their employees of the right to continue coverage at the time of termination or at the time the employee assumes part-time status. The decision to continue coverage may be made by the employee only. In most instances, dependents do not have an independent right to elect continuation. The policy or contract issued to you and the certificate or evidence of coverage issued to the covered employees outlines the procedures that the employer and employee must follow for continuation of coverage. You should consult with your own legal counsel to determine your obligations under COBRA or Mini-COBRA. 17

Termination or cancellation of memberships Termination of membership occurs when an employee terminates his or her employment and loses group eligibility in such instances. Cancellation of membership may occur when a member who remains eligible for group health benefits chooses to cancel IBC membership. The conversion privilege (see below) is not offered in this situation. The employer should either complete an Enrollment Report or use ibxpress.com in order to terminate an employee s coverage. The employer is responsible for submitting to IBC the Enrollment Report or processing requests via ibxpress.com within 60 days of the employee s termination date. Conversion privilege An employee s coverage, or the coverage of an employee s eligible dependent, could be terminated for several reasons: the employee s death, a change in employment status, divorce from a spouse, or a change in a dependent s eligibility status. If eligible, the conversion privilege allows an individual to maintain health care coverage after termination, with certain limitations. The terminated person will be eligible to apply for and buy individual conversion coverage within the required time period, or following termination of continuation privilege under COBRA or Mini-COBRA. Conversion coverage is subject to the terms and conditions of the applicable group contract. State regulations require that conversion coverage must include minimum standards for health care benefits. However, conversion coverage is not required to include the same level of benefits an employee received under his or her employer s group coverage. Representatives are available at 1-800-ASK-BLUE (1-800-275-2583) to answer any questions you or your employees have about the conversion privilege requirements. 18

Medicare Secondary Payer Your company must follow the requirements of Medicare Secondary Payer (MSP) in order to avoid potentially costly penalties and litigation. MSP requirements determine when Medicare is the primary insurance payer. For example, if your company has 19 or fewer full- and part-time employees, Medicare is almost always primary. If your company is larger, various rules apply to determine whether your group plan is the primary or secondary payer. MSP requirements also apply for Medicare-eligible employees who are disabled or have end-stage renal disease. IBC s Medicare Secondary Payer Guide provides you with an overview of the MSP requirements. Go to www.ibx.com/employers, and click on Manuals and Guides under Quick Links to download a copy of the Medicare Secondary Payer Guide. More information is also available from the Centers for Medicare & Medicaid Services (CMS) at www.cms.gov/home/medicare.asp. We also encourage you to refer to the actual laws and regulations with the assistance of your own legal counsel. Reporting requirements In 2007, the Medicare, Medicaid and SCHIP Extension Act of 2007 (the Act ) was signed into law. The Act included modifications to the MSP laws and imposed significant new obligations on insurers, third party administrators ( TPAs ), and plan administrators of group health plans that are both self-insured and self-administered ( Plan Administrators ). Specifically, it requires that these entities ( Responsible Reporting Entities, or RREs ): secure certain information from group health plan sponsors and plan participants; share such information with CMS to assist in determining who should be the primary payer for claims (i.e., IBC or Medicare). TPAs and Plan Administrators are required to collect certain information and provide it to the United States Department of Health and Human Services in order to identify situations where the group health plan is or has been a primary plan to the Medicare program. RREs must provide the following information to CMS: Medicare health insurance claim numbers (HICNs) for members of a certain age and older. This allows CMS to determine if members of group health plans also have Medicare coverage. If the HICN is not available, the social security number (SSN) may be provided to determine if the individual is a Medicare beneficiary. IBC has elected to obtain HICNs/SSNs for all subscribers, dependents, and domestic partners (if applicable) regardless of age. Requiring HICNs/SSNs for all ages now will hopefully prevent future follow-up with you. Group size. The MSP laws and regulations contain specific guidelines for determining group size (the number of fulland part-time employees) for the purposes of determining whether the group health plan or Medicare is the primary payer. Employer s tax identification numbers (TINs). 19

In order to determine whether Medicare is the primary or secondary payer, there are group size thresholds (number of employees measured over a period of time) that determine primacy. For example: For members and/or their spouses who are age 65 or older and employed by a company with fewer than 20 employees, Medicare is the primary payer. For members and/or their spouses who are age 65 or older and employed by a company with 20 or more employees, Medicare is the secondary payer. This includes multiple and multi-employer health plans. Medicare is the secondary payer for individuals under 55 who have Medicare because of a disability and who are covered under a group health plan based on the individual s (or a family member s) current employment status if the employer has 100 or more employees. CMS has clarified that the term multi-employer health plan means any trust, plan, association, or any other arrangement made by one or more employees to contribute, sponsor, directly provide health benefits, facilitate directly or indirectly the acquisition of health insurance by an employer member. If such facilitation exists, the employer is considered to be a participant in a multi-employer group health plan even if it has a separate contract with the insurer. For details on multi-employer health plans and exceptions, visit the CMS website at www.cms.gov/home/medicare.asp. Our goal is to obtain the identified information with as little inconvenience and burden to you and your employees as possible. Your participation is important Our ability to report to CMS and to make accurate primary/secondary determinations involving individuals enrolled in your group health plan, and thus to assist CMS in processing MSP claims properly in the first instance, depends entirely on the breadth and accuracy of our files concerning individuals covered by your group health plan. We depend on you to provide us with this information. Accordingly, it is important that you respond promptly and accurately to our requests for information. Moreover, to ensure the continuing accuracy of our files, it is your responsibility to notify us promptly of any changes in the size of your workforce or the status of your employees that might affect the order of payment under the MSP statute, such as information regarding working-aged persons who retire (and thus for whom Medicare makes primary payment) and changes in the size of your workforce that place you in, or take you out of, the scope of the MSP statute. We will be using the information you provide us to update our files, and will also forward this information to CMS on a quarterly basis so that CMS can revise its file to reflect relevant changes in primary/secondary status. MSP statute and regulations are frequently amended. As a result, it is important that you and your counsel continue to monitor changes in the law and assess the impact of such changes on your company. While we can assist you by providing general information about the statute, it is ultimately your responsibility to ensure your company s compliance with the MSP statute. 20

Important contact information We value our relationship with our customers. If you have any questions regarding the administration of your group health insurance plans, please call IBC at the appropriate number: Customer/Employer Services 1-800-ASK-BLUE (1-800-275-2583) Website Support (ibxpress.com) 215-587-0360 Pre-Certification 1-800-ASK-BLUE (1-800-275-2583) Baby BluePrints Maternity Program 1-800-598-BABY (1-800-598-2229) Health Resource Center 1-800-ASK-BLUE (1-800-275-2583) Magellan Health Services (Mental Health) 1-800-688-1911 FutureScripts 1-888-678-7012 More information is available anytime at www.ibx.com/employers. You can access a variety of online resources, including a direct link to ibxpress.com, our secure employer website. Register at www.ibxpress.com to submit enrollment changes, view coverage history, view and pay invoices, and complete additional administrative functions quickly, easily, and securely. You can also contact IBC by mail: Independence Blue Cross 1901 Market Street Philadelphia, PA 19103 1480 21

We re here for you every step of the way. www.ibx.com Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield. Independent Licensees of the Blue Cross and Blue Shield Association. Produced by the Independence Blue Cross Business Services Center, Philadelphia, PA 08031 2011-0144 (9/11) Benefits Administrator Guide