Administratin Manual fr Emplyers Grup Plans GROUP PLANS 6/13 Page 1
Table f Cntents HOW TO USE THIS MANUAL... 3 HOW TO GET HELP... 5 ADMINISTRATIVE RESPONSIBILITIES... 9 GENERAL ADMINISTRATIVE GUIDELINES... 11 MINIMUM PARTICIPATION REQUIREMENTS... 11 WAITING PERIOD... 13 IMPORTANT TERMS... 17 HOW TO PROCESS MONTHLY BILLING STATEMENTS... 30 HOW TO PROCESS ENROLLMENTS... 39 HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)... 47 HOW TO PROCESS EVIDENCE OF GOOD HEALTH APPLICATION... 52 HOW TO PROCESS CHANGES... 57 HOW TO PROCESS A CHANGE OF BENEFICIARY... 67 HOW TO PROCESS TERMINATIONS... 70 LEAVING ACTIVE EMPLOYMENT... 87 LIFE, PERSONAL ACCIDENT AND DISABILITY CLAIMS... 93 HOW TO PROCESS MEDICAL AND DENTAL CLAIMS... 94 BASIC MEDICARE INFORMATION... 104 EMPLOYER ACCESS... 112 FLEXIBLE SPENDING ACCOUNT... 116 ADMINISTRATIVE FORMS... 117 GROUP PLANS 6/13 Page 2
HOW TO USE THIS MANUAL HOW TO USE THIS MANUAL Purpse This manual is intended t help each Emplyer participating in the Grup Plans effectively and efficiently administer the benefit plans ffered t its Emplyees. Specific plans and cverage may vary by Emplyer. This manual describes the imprtant Administrative prvisins f these plans and sets frth the step-bystep prcedures that each Emplyer must fllw in rder fr GuideStne Financial Resurces t prperly recrd new Emplyees, make subsequent changes t master recrds and accunt fr Emplyer payments. This manual serves as a training tl fr new Administrative persnnel wh becme respnsible fr the administratin f the plans. The manual als serves as a reference guide fr persnnel wh are already familiar with the peratin f the plans. This manual des nt cntain prcedures which are specific fr each Emplyer such as an Emplyer s internal prcedures fr recnciling payments against payrll recrds. We recmmend that each Emplyer maintain a set f detailed internal prcedures that perate in cnjunctin with the prcedures utlined in this manual t effectively administer these plans. Organizatin and cntents Many f the chapters cntained in this manual are rganized t present infrmatin n an events basis. Fr example, HOW TO PROCESS ENROLLMENTS describes what must be dne t handle the enrllment event. The HOW TO PROCESS TERMINATIONS chapter explains the infrmatin yu shuld give an Emplyee leaving yur emplyment, as well as hw and when yu must cmmunicate this infrmatin t GuideStne. Other chapters deal with medical claims and ther claims events. We think yu will find this rganizatin helpful in explaining what yu must d when a particular event ccurs. A few f the chapters in the manual are nt event-riented, but cntain imprtant infrmatin abut the plans and hw they perate. Fr example, the manual cntains a glssary f defined terms which are capitalized and used thrughut this manual. It is imprtant t be familiar with these terms and their definitins. Als in this manual is a chapter titled HOW TO GET HELP. This chapter lists infrmatin yu may require fr administratin f the plan and enables yu t identify a cntact wh can supply this infrmatin. GROUP PLANS 6/13 Page 3
HOW TO USE THIS MANUAL Anther chapter includes instructins fr rerdering frms by mail r dwnlading them thrugh GuideStne Financial Resurces internet website. Revisins GuideStne Financial Resurces reviews and makes revisins t this manual frm time t time. The effective date f each page is in the lwer left crner f the page, after the cde GROUP PLANS. While every effrt is made t maintain accurate infrmatin in the manual, changes in plicy that ccur between revisins will nt be reflected until the next revisin date. Emplyers are typically ntified by mail r email f changes in plicy in the interim and are respnsible fr administering their plans in accrdance with the new plicies. Since this manual is maintained n the GuideStne Financial Resurces website, hard cpies are nt prvided. As situatins arise that are nt cvered by this manual, it is imprtant t knw where t get help. As a general rule, yur questins r prblems shuld be directed t the department at GuideStne Financial Resurces respnsible fr handling that aspect f the Prgram, r yu may call the Insurance Slutins and Services department. Sme questins will need t be directed t an utside agency, such as Highmark Blue Crss Blue Shield fr medical plan benefit infrmatin r Express Scripts fr prescriptin drug infrmatin. GROUP PLANS 6/13 Page 4
HOW TO GET HELP HOW TO GET HELP This sectin helps yu direct yur questins and prblems t the apprpriate agency r individual. The fllwing pages cntain a listing f sme areas where these questins can be addressed and a list f imprtant phne numbers. Since persnnel assignments may change, yu may print the Imprtant Numbers page in this sectin and use the blank lines t list the names f yur usual cntacts. Fr infrmatin r questins n: Age reductin and retirement effect n benefits Cntact: Insurance Operatins, Grup Plans Appeal f denied Medical benefits claims Insurance Operatins, Claims Unit Highmark BCBS Appeal f denied Dental claims Cigna Dental Beneficiary designatin Insurance Operatins, Claims Unit Benefit interpretatin fr Medical Highmark BCBS Billing Statements Insurance Operatins, Grup Plans Claim submissin prcedures fr Dental benefits Cigna Dental Claim submissin prcedures fr PPO Medical Plans, Senir Plan r Senir Plus Plan, Care Basic Plan, Care Plus Plan r Care Tday Plan Highmark BCBS GROUP PLANS 6/13 Page 5
HOW TO GET HELP Fr infrmatin r questins n: Cntact: Claim submissin prcedures fr Term Life, Disability, Accidental Death and Dismemberment r Persnal Accident benefits Insurance Operatins, Claims Unit Cnversin f Term Life cverage Insurance Operatins, Grup Plans Crdinatin f Benefits prcedures fr Medical Highmark BCBS Eligibility f Emplyees r dependents fr benefits Insurance Operatins, Grup Plans Enhanced Benefits prvider verificatin PPO Member Services number listed n the ID card Enrllment prcedures Insurance Operatins, Grup Plans ID cards Request new Dental ID cards Cigna Dental ID cards Request new Medical/prescriptin drug ID cards fr PPO Highmark BCBS (fr Medical) Express Scripts (fr prescriptins) Leave f absence infrmatin Insurance Operatins, Grup Plans Plan Administratin Insurance Operatins, Grup Plans Prtability f Term Life cverage Insurance Operatins, Grup Plans GROUP PLANS 6/13 Page 6
HOW TO GET HELP Fr infrmatin r questins n: Cntact: Preauthrizatin fr PPO Medical Plans Highmark BCBS Prescriptin drug infrmatin fr PPO Medical Plans Express Scripts Upgrading Emplyer cverage r adding new Emplyer benefits Insurance Slutins and Services GROUP PLANS 6/13 Page 7
HOW TO GET HELP Imprtant numbers GuideStne Financial Resurces phne numbers: Main number: 1-888-98-GUIDE (1-888-984-8433) Internet address: www.guidestne.rg Department Cntact Email address Phne number Insurance Operatins, Grup Plans Insurance Operatins, Claims Insurance Slutins and Services Outside agencies: Agency Internet address Phne number Highmark BCBS Prvider Search Explanatin f Benefits and Claims www.highmarkbcbs.cm 1-866-472-0924 Express Scripts www.express-scripts.cm 1-800-555-3432 Cigna Dental Premier Dental Care Plan www.mycigna.cm 1-800-244-6224 Chice Dental Care Plan Guided Dental HMO Plan GROUP PLANS 6/13 Page 8
ADMINISTRATIVE RESPONSIBILITIES ADMINISTRATIVE RESPONSIBILITIES Emplyer respnsibilities Explaining the Grup Plans t new Emplyees Offering new Emplyees wh are eligible fr Participatin in Grup Plans the pprtunity t enrll in the Prgram s Plan(s) within 31 days f initial eligibility Verifying that all Emplyees and dependents enrlled in Grup Plans meet the eligibility rules fr the Plan(s). Failure t adhere t the eligibility rules will result in the terminatin f cverage fr the affected enrllee(s) and reimbursement t GuideStne, at its sle discretin, may be required fr claims paid n behalf f ineligible enrllees Offering enrllment in Cntributry medical plans t Emplyees wh previusly declined cverage fr themselves and/r their Eligible Dependents when they becme eligible as Special r Late Enrllees Enrlling Emplyees and submitting their enrllment frms t GuideStne Financial Resurces Distributing apprpriate benefit materials t new participating Emplyees Maintaining mnthly earnings recrds fr each participating Emplyee Maintaining cpies f enrllment frms, Beneficiary designatin frms and ther imprtant papers relating t an Emplyee s Participatin in the Prgram Verifying the mnthly billing statement and remitting the mnthly payments due t GuideStne Financial Resurces. Nn-payment culd result in terminatin f cverage Submitting changes t GuideStne Financial Resurces in a timely manner Initial filing f Term Life, Persnal Accident and Disability claims Instructing Emplyees and Retirees abut Medical and Dental claim filing prcedures Reprting changes that affect an Emplyee s r Retiree s grup benefits r cverage status t GuideStne Financial Resurces Cunseling Emplyees wh are appraching retirement cncerning the effect retirement will have n their cverage Registering with and reprting t gvernment agencies, when and if required Prviding GuideStne Financial Resurces with Emplyee and Retiree infrmatin and any statistical data needed fr GuideStne Financial Resurces t prperly administer the Prgram Ntifying Emplyees and Retirees f their rights and bligatins under the Prgram Maintaining the minimum Participatin requirements f the Grup Plans. If these requirements are n lnger met, it must be reprted t the Grup Plans Accunt Administratr GROUP PLANS 6/13 Page 9
ADMINISTRATIVE RESPONSIBILITIES Distributing Summaries f Benefits and Cverage (SBCs) yu currently ffer t all eligible Emplyees, including emplyees wh have waived ut f Medical cverage, new emplyees and enrlled Emplyees. Yu may find SBCs fr all GuideStne health plans at www.guidestne.rg/summaries Distributing the Cntraceptives Ntice and Certificatin t currently enrlled Emplyees GuideStne Financial Resurces respnsibilities Establishing and maintaining Emplyee and Retiree cverage recrds Submitting the Grup Plans Administrative payments t the Claims Administratrs Prviding Emplyers with technical Administrative assistance and benefit plan infrmatin Interpreting plan prvisins Serving as liaisn n escalated claim situatins Preparing and distributing cmmunicatin materials cvering Prgram benefits and claim prcedures Crdinating the verall administratin f the Prgram between participating Emplyers and the Claims Administratrs Designing and instituting Prgram benefits and Administrative changes Reviewing Prgram renewal terms and mdifying rates, when applicable Cntrlling all accunting, statistical and csting functins as they pertain t the financial success f the Prgram GROUP PLANS 6/13 Page 10
GENERAL ADMINISTRATIVE GUIDELINES GENERAL ADMINISTRATIVE GUIDELINES General infrmatin This chapter f the manual discusses many f the general plan prvisins and Administrative guidelines that apply t an Emplyer s Participatin in Grup Plans. This chapter des nt discuss specific benefit prvisins r cverage since this infrmatin will vary depending n plan electins made by each participating Emplyer. Fr specific benefit and cverage infrmatin, cnsult the crrespnding Emplyee Bklet. Plan Participatin requirements Minimum Participatin requirements An Emplyer eligible t participate in Grup Plans is: Any church, cnventin, bard, agency, cmmissin, rganizatin r unit affiliated with the Suthern Baptist Cnventin. Or, Nn-Suthern Baptist Cnventin churches and evangelical ministries wh are nt in cnflict with the Suthern Baptist Cnventin and wh, n an n-ging basis, maintains a minimum Participatin requirement f 10 r mre full-time Emplyees. Nte: The minimum Participatin requirement applies t any new Emplyer effective n r after January 1, 1994, fr all churches regardless f their effective date. An Emplyer falling belw the minimum Participatin requirement shwn abve will be given until January 1, fllwing the end f a 12-mnth perid t achieve the necessary Participatin levels. The 12- mnth perid begins n the first mnth the Emplyer falls belw the minimum Participatin requirement. If the Participatin requirement is nt met, cverage will autmatically terminate fr all Emplyees participating in Grup Plans. If a Grup Plan s Emplyer lses eligibility t participate in Grup Plans and cverage is terminated, participating Emplyees may have the ptin f transferring their Term Life, Accident, Medical, Dental, Shrt-Term Disability and Lng-Term Disability cverage int GuideStne Financial Resurces Persnal Plans. Emplyees wh transfer int Persnal Plans will receive benefits and rates accrding t plan prvisins f the Persnal Plans. An Emplyer falling belw the minimum Participatin requirement shwn abve will nt be eligible t upgrade r add cverage until the Participatin requirement has again been met. In rder t transfer back t Grup Plans frm Persnal Plans at a future date, an Emplyer must maintain a minimum f 10 fulltime emplyees in Persnal Plans fr six mnths. The Emplyer wuld then need t g thrugh the grup underwriting prcess and be apprved in rder t be eligible t transfer back t Grup Plans. GROUP PLANS 6/13 Page 11
GENERAL ADMINISTRATIVE GUIDELINES Nn-cntributry plans When the full cst f a plan is paid by an Emplyer (Nn-cntributry plans), the same cverage must be prvided t all eligible Emplyees with n individual selectin with regard t any plans. 100% f all eligible Emplyees and dependents must participate in Nn-cntributry plans. If Emplyee and/r dependent cverages are prvided by an Emplyer n a Nn-cntributry basis, and a new Emplyee and/r Eligible Dependent is nt enrlled at the time f his r her initial eligibility, it will be treated as an Administrative errr. The Emplyee and/r Eligible Dependent will be enrlled as f the date f eligibility with the apprpriate back charges. Waiver f Medical and Dental An Emplyee may waive ut f Medical r Dental cverage when the cverage is paid 100% by the Emplyer. A Grup Plans Waiver f Medical/Dental Cverage Frm must be cmpleted, which can be lcated n the website at www.guidestneinsurance.rg. The waiver allws the Emplyee t pt ut f Nn-cntributry Medical and Dental cverage. The fllwing criteria apply in rder fr the waiver t be apprved: A waiver may be used fr the Emplyee, all dependents r the entire family. An Emplyee may waive cverage nly if the Emplyee/dependent has Medical/Dental cverage elsewhere. If the Emplyee waives cverage, the Emplyee s dependents are nt eligible fr cverage. Emplyers may nt ffer any financial r ther incentives in exchange fr the Emplyee waiving cverage. The Emplyee wh waives cverage des nt cunt fr the 10 Emplyee minimum that the Emplyer must maintain t participate in Grup Plans. The Emplyee/dependent may enrll in the Medical plan later if the requirements fr a Special r Late Enrllee f the plan are met. See the Special and Late Enrllment sectin f this manual. The Emplyee/dependent may enrll in the Dental Plan at any time accrding t the guidelines fr the effective date. The Dental Plan limits benefits fr sme initial perids f cverage. When a waiver frm is submitted t GuideStne and apprved, the date cverage will end will be determined accrding t the Rescissin rules. Refer t the HOW TO PROCESS TERMINATIONS chapter. GROUP PLANS 6/13 Page 12
GENERAL ADMINISTRATIVE GUIDELINES Cntributry Plans If the Emplyer s Grup Plans require Emplyees t pay a prtin f the cst (Cntributry plans), 75% f all eligible Emplyees must participate in the plans. The Emplyer must pay at least 50% f the cst f any Cntributry Emplyee cverage. (Participatin requirements and Emplyer cntributin requirements d nt apply t Emplyee and Spuse Persnal Accident Insurance.) If the Emplyer ffers Medical r Dental benefits t Emplyees, the Emplyer must ffer dependent cverage as well. At least 50% f all Eligible Dependents must participate in the Medical and Dental plans. The Emplyer is nt required t pay any f the cst f dependent cverage. If Emplyee and/r dependent cverage is prvided by an Emplyer n a Cntributry basis, and a new Emplyee and/r Eligible Dependent is nt enrlled within 31 days f the Eligibility Date, that Emplyee and/r Eligible Dependent must prvide satisfactry Evidence f Gd Health befre Term Life r Disability cverage will becme effective. The Emplyee and/r Eligible Dependent will nt be able t enrll in a Medical plan until the fllwing January 1 unless Special Enrllment Requirements are met. (See the Special and Late Enrllment sectin f this manual.) Emplyees and Eligible Dependents can enrll in Premier Dental Care Plan, Chice Dental Care Plan r the Guided Dental HMO Plan at any time. Eligible Emplyees All Salaried, full-time Emplyees, (as defined by the Emplyer), that wrk at least the number f hurs that the Emplyer requires t be cnsidered a full-time Emplyee, but nt less than 20 hurs a week, are cnsidered eligible t participate in the Grup Plans. The fllwing classes f Emplyees are nt eligible fr cverage under the plans: Temprary Emplyees Emplyees wh wrk less than 20 hurs per week Waiting Perid This is the perid f time an Emplyee must cmplete t be eligible fr Grup Plans cverage. An Emplyer may elect t have n Waiting Perid. If an Emplyer elects t have a Waiting Perid, the usual Waiting Perid is ne t three mnths f emplyment. The Waiting Perid may be different fr separate Classificatins f Emplyees. (See the Emplyee Classificatins sectin f this chapter.) The Waiting Perid may be waived in cases f a rehired Emplyee if he r she returns t wrk within ne year f his r her riginal terminatin date r fr an Emplyee transferring frm anther Emplyer where the Emplyee had GuideStne Financial Resurces cverage. GROUP PLANS 6/13 Page 13
GENERAL ADMINISTRATIVE GUIDELINES Emplyee Classificatins An Emplyer may designate Classificatins f Emplyees. Cntributin arrangements, benefits and Waiting Perids may vary amng these Classificatins. Fr example, an Emplyer may divide Emplyees int Administrative and Nn-administrative Classificatins. The Emplyer may elect t ffer dependent Medical cverage n a Nn-cntributry basis fr Administrative Emplyees and n a Cntributry basis fr Nn-administrative Emplyees. The Emplyer may als elect t have n Waiting Perid fr Administrative Emplyees and a ne mnth Waiting Perid befre cverage becmes effective fr Nnadministrative Emplyees. In rder t prtect against discriminatin n the plans ffered, the Waiting Perid and any cntributin requirements under the Emplyer s Prgram must be applied cnsistently and unifrmly t all Emplyees within the same Emplyee Classificatin. Emplyers with 10 t 24 Emplyees are requested t limit the number f Emplyee Classificatins t tw. Dependent cverage An Emplyee is eligible fr dependent cverage if ne f these is true: The Emplyee has Emplyee cverage under this Plan. The Emplyee used t have Emplyee cverage under this Plan but is nw cvered under ne f GuideStne Financial Resurces plans fr Medicare-eligible Emplyees, Retirees and dependents. Eligible Dependents under the Grup Plans are: The spuse f the Emplyee The Emplyee s Child under age 26 The Emplyee s Child wh was cvered under the Plan and is incapacitated, prvided the fllwing requirements are met: The Child must be develpmentally disabled r physically handicapped and incapable f earning a living. The Child must have been incapacitated when his r her Plan cverage wuld have ended because f age. Prf f incapacitatin must be sent t GuideStne Financial Resurces at least 31 days befre the Child s Plan cverage is scheduled t end. Additinal prf must be sent whenever asked t shw that the Child is still incapacitated under this prvisin. GROUP PLANS 6/13 Page 14
GENERAL ADMINISTRATIVE GUIDELINES Children under GuideStne Grup Plans can be any f the fllwing: An Emplyee s r spuse s natural (bilgical) child An Emplyee s r spuse s legally adpted child r a child placed in the hme fr adptin An Emplyee s r spuse s stepchild r fster child An Emplyee s r spuse s unmarried grandchild wh resides with the Emplyee and is dependent n the Emplyee fr supprt and maintenance A child fr whm the Emplyee r spuse must prvide health care by curt rder r rder f a state agency authrized t issue Natinal Medical Supprt Ntices under federal law A child fr whm the Emplyee r spuse is a legal guardian r managing cnservatr The Emplyee s spuse r child is nt an Eligible Dependent while: On active duty in the armed frces f any cuntry Cvered fr health care expenses under the Emplyer s Plan as an Emplyee (N ne can have bth Emplyee cverage and dependent cverage under the Plan thrugh the same Emplyer.) Eligible fr Medicare, and Medicare pays benefits befre this Plan Incapacitated children The Term Life, Medical and Dental benefits f a child apprved as fully incapacitated will nt be terminated when the child reaches the maximum age fr dependent cverage if the child cntinues t be incapacitated and prvided cverage des nt terminate fr any ther reasn. Generally, a child is cnsidered fully incapacitated if he r she is unable t earn a living because f a develpmental disability r physical handicap. Prf that a child is fully incapacitated must be submitted t the Claims Administratr fr apprval 31 days prir t the date the child reaches age 26. The Claims Administratr may peridically request the Emplyee t submit subsequent prf f a child s incapacitating cnditin. GROUP PLANS 6/13 Page 15
GENERAL ADMINISTRATIVE GUIDELINES Plan Administrative changes Certain plan administratin infrmatin and recrds n the peratin f an Emplyer s Prgram must be accurately maintained by GuideStne Financial Resurces Insurance Operatins, Grup Plans. This infrmatin includes: Emplyee Classificatins Waiting Perid Cntributins required fr Participatin This infrmatin is determined by the Emplyer when they elect t participate in Grup Plans and is maintained by GuideStne Financial Resurces Insurance Operatins, Grup Plans. T change any f the infrmatin listed abve, cntact GuideStne Financial Resurces Insurance Operatins, Grup Plans, in advance f the change. Yu will be sent an Emplyer Acceptance Agreement n which t recrd the changes and the effective date f change. The cmpleted Emplyer Acceptance Agreement shuld then be returned t GuideStne Financial Resurces fr the change t be prcessed and recrded in the Prgram s master recrds. Refer all questins cncerning Emplyee Classificatins, Waiting Perids and cntributin amunt changes t GuideStne Financial Resurces Insurance Operatins, Grup Plans. GROUP PLANS 6/13 Page 16
IMPORTANT TERMS IMPORTANT TERMS This chapter cntains sme f the imprtant terms that are used in cnnectin with the Grup Plans administratin. These terms have a particular and definite meaning. It is imprtant t becme familiar with these terms and t knw hw t use them in cnnectin with the Prgram peratin. Terms Active Disabled An Emplyee wh is disabled but is cnsidered t have current emplyment status. See the Disabled Medicare Beneficiaries sectin f the BASIC MEDICARE INFORMATION chapter f this manual fr mre details. Allwable Expenses The necessary and reasnable Medical and Dental benefits, part r all f which are cvered by the benefit plans cvering the claimant under the Prgram. Annual Re-enrllment Perid The perid each year when participating Emplyees and their Eligible Dependents may transfer between Medical plans ffered by the Emplyer. Or, fr eligible Emplyees and their Eligible Dependents wh did nt elect t enrll in a GuideStne Financial Resurces Medical plan when they first became eligible, the perid when the Emplyee r Eligible Dependent(s) may enrll as a Late Enrllee in a Medical plan. Cverage becmes effective the January 1 fllwing the request fr Emplyers wh have a standard renewal perid. Assignment With respect t Medical and Dental benefits an electin by an Emplyee t have benefits payable frm the plan made directly t the prvider f a service (the hspital, dctr, dentist, etc.). With respect t Term Life and Persnal Accident benefits the right exercised by an Emplyee, in which he r she delivers ver t anther individual all incidents f wnership f cverage, including the right t name r change a Beneficiary. GROUP PLANS 6/13 Page 17
IMPORTANT TERMS Beneficiary The persn r persns named by a participating Emplyee t receive the prceeds frm the Term Life, Accidental Death and Dismemberment r Persnal Accident benefit plans in the event f the Emplyee s death. If an Emplyee dies and des nt have a valid Beneficiary designatin(s) n file with GuideStne Financial Resurces, payment will be made in the fllwing rder: The estate f the deceased Emplyee The surviving Spuse The surviving children, in equal shares The surviving parents, in equal shares Care Basic Plan Care Plus Plan Care Tday Plan Certificate f Creditable Cverage The surviving sibling(s), in equal shares A Medicare-crdinating plan ffered t Emplyees, Retirees r cvered dependents fr whm Medicare is the primary payer f claims. The plan prvides benefits fr Medicare Part A services nly and includes Part D prescriptin drug cverage with generic c-pays in the Medicare-designed cverage gap. A Medicare-crdinating plan ffered t Emplyees, Retirees r cvered dependents fr whm Medicare is the primary payer f claims. The plan prvides benefits fr Medicare Part A and B services and includes Part D prescriptin drug cverage with generic c-pays in the Medicare-designed cverage gap. A Medicare-crdinating plan ffered t Emplyees, Retirees r cvered dependents fr whm Medicare is the primary payer f claims. The plan prvides benefits fr bth Medicare Part A and Part B services and Part D prescriptin drug cverage with a Medicare-designed cverage gap. Certificatin prvided t a Participant f a Medical plan by the Medical plan prvider when cverage ends. The certificate may be used by the individual when enrlling int a new Medical plan t reduce the Pre-existing Cnditin Limitatin perid f the new plan. GROUP PLANS 6/13 Page 18
IMPORTANT TERMS Claims Administratr Highmark Blue Crss Blue Shield fr the PPO Medical plans Cigna Dental fr the Premier Dental Care Plan, Chice Dental Care Plan and Guided Dental HMO Plan Prvident Life and Accident Insurance Cmpany, a part f Unum Prvident Crpratin fr the Persnal Accident Plan Unum Life Insurance Cmpany f America fr the Term Life, Accidental Death and Dismemberment plans, and Lng- and Shrt-Term Disability Plans Cnversin Privilege An Emplyee s right t cnvert terminated grup Term Life t individual direct payment plicies administered by the Claims Administratr withut being required t furnish Evidence f Gd Health. Plan benefits must be cnverted and paid fr within 31 days after grup cverage stps. Crdinatin f Benefits (COBs) Cntraceptives Ntice and Certificatin The prvisin that guarantees that Emplyees receive all the benefits they shuld, but nt mre than the actual csts f the Medical care received. If tw r mre grup Medical plans cver expenses, ne f the plans is called Primary and the ther(s) Secndary, the primary plan will pay first and will pay the maximum benefit prvided by the plan. The rules fr determining the Primary and Secndary Medical plan may be fund in the Emplyee Bklet. Specifically, ur Medical and Dental benefit plans will pay either benefit in full, r a reduced amunt, which, when added t the benefit paid by anther plan, will equal 100% f the Allwable Expenses incurred by the claimant. GuideStne is wrking with legislatrs and regulatrs t determine hw the cntraceptives part f the wmen s preventive health expansin mandate des and shuld apply t church plans. The White Huse has issued an exemptin fr religius rganizatins that bject t the cntraceptives mandate n religius grunds. GuideStne is invking the Religius Organizatin Temprary Enfrcement Safe Harbr while we wrk with the U.S. Department f Health and Human Services and legislatrs t gain additinal clarity n GROUP PLANS 6/13 Page 19
IMPORTANT TERMS hw this t-narrwly defined exemptin applies t church plans. A Ntice and Certificatin is evidence f ur qualificatin fr the Temprary Enfrcement Safe Harbr. C-payment Under the Medical and Dental benefit plans, the part f the Allwable Expenses paid by the participating Emplyee. Cvered Dental Expenses Cvered Medical Expenses The usual charges f a dentist. Supplies which are necessary fr treatment f a Dental cnditin, but nly t the extent that such charges are within reasnable and custmary fees fr services and supplies custmarily emplyed fr treatment f that cnditin, and nly if rendered in accrdance with accepted standards f Dental practice. The expenses fr certain hspital and ther Medical services and supplies incurred by a claimant in cnnectin with treatment f an injury r disease. Creditable Cverage Fr Medical cverage, the amunt f previus cverage (measured in mnths) used t reduce the Pre-existing Cnditin Limitatin perid. Deductible Dental Health Maintenance Organizatin (DHMO) The amunt an Emplyee must pay each calendar year befre benefits are payable under the PPO Medical Plans, the Premier Dental Care Plan r Chice Dental Care Plan. A managed Dental Care Plan ffered by Emplyers t Emplyees wh reside in a service area established by the Dental insurance prvider. Netwrk prviders must be used t receive benefits frm the plan. The Guided Dental HMO Plan ffered thrugh Cigna Dental ffers Dental cverage thrugh a Dental HMO Plan. GROUP PLANS 6/13 Page 20
IMPORTANT TERMS Disability Shrt-Term Any sickness r injury that limits a cvered Emplyee frm perfrming the material and substantial duties f his/her regular ccupatin fr a perid f time established by the plan, and the Emplyee has a 20% r mre lss in weekly earnings. Sme disabilities may nt be cvered. Lng-Term Fr the initial perid defined by the plan, any sickness r injury that limits a cvered Emplyee frm perfrming the material and substantial duties f his/her regular ccupatin and results in a 20% r mre lss in mnthly earnings. After the initial perid, due t the same sickness r injury, the Emplyee is unable t perfrm the material and substantial duties f any gainful ccupatin fr which he r she is reasnably fitted by educatin, training r experience. Sme disabilities may nt be cvered. Effective Date The date the Emplyer enters the Grup Plans and the date an Emplyee s cverage begins under the Prgram. Eligible Dependents Emplyee s spuse: A spuse is a persn f the ppsite sex t whm the Emplyee is married at the relevant time by a religius r civil ceremny effective under the laws f the state in which the marriage was cntracted. Emplyee s Child under age 26 fr Medical and Dental cverage. Fr Child life cverage, the dependent must be at least 14 days ld. A Child is defined as: An Emplyee s r spuse s natural (bilgical) Child An Emplyee s r spuse s legally adpted Child r a Child placed in the hme fr adptin An Emplyee s r spuse s stepchild r fster Child An Emplyee s r spuse s unmarried grandchild wh resides with the Emplyee and is dependent n the Emplyee fr supprt GROUP PLANS 6/13 Page 21