A Small Employer Group Eligibility tool for CareFirst of Columbia and Virginia
DC / VIRGINIA GROUP ELIGIBILTY A Small Employer Group Eligibility tool for CareFirst products sold in the District of Columbia and Virginia Broker Manual > Welcome This manual was last revised on April 1, 2014. To: CareFirst Distributors This Small Employer Group Eligibility Manual was developed to educate and assist you in selling all CareFirst products sold in the State of Virginia and the District of Columbia. Many of you who have participated in previous training sessions may be familiar with this document; for some of you, this may be your first exposure to CareFirst’s Small Group Eligibility Manual. Regardless of which category you fall into, this reference manual should be utilized by you on an ongoing basis to assist you in both new business and renewal sales; grandfathered and ACA compliant products. Additionally, changes and additions have been shaded to assist you. This manual was originally released in September 1997 and has now been revised to include many new sections and to incorporate the guidelines associated with selling all of our small group products in Virginia and the District of Columbia. We hope that the additional information will be of value to you and will help facilitate more efficient writing of both new business and renewal sales. With the 2014 implementation of the Affordable Care Act, additional State and Federal legislation has been implemented that has modified the original document. CareFirst has also implemented internal changes regarding our small group business policies. Lastly, some of our groups elected to remain “grandfathered,” in their pre ACA benefits and rating structure; therefore, you will see sections of the manual identified as such to assist you as you address your clients’ questions. Note that all new groups may not be sold “grandfathered” products and must adhere to the ACA rules and rating methodology. Every effort has been made to ensure that the information is complete and accurate. The information provided in this manual is based on the CareFirst interpretation of State and Federal legislation in addition to CareFirst Sales and Underwriting policies and guidelines. Further detail on any section of the Manual can be found in the Sales Flash communications that we have relied on for many years or from your assigned CareFirst Broker Sales Representative. Because so much information is being released based on the implementation for ACA, policy may change during the year; when this occurs we will make every effort to keep this document current. We believe that the information here will provide you with the basics to successfully prospect and sell any small group account in Virginia and the District of Columbia and to then retain and renew that business. Please review all sections carefully, as our guidelines will vary at times, based on the product sold. As our appointed and contracted Distributors, your continued support and adherence to our policies and guidelines is appreciated. Any questions regarding the information contained within this manual should be directed to your assigned General/Full Service Producer or your CareFirst Broker Representative. i / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Table of Contents If you are viewing this file online (PDF format), BOOKMARKS have been added which link to the page being referenced. ■■ Click on the BOOKMARKS tab in the left-hand navigator pane to view. ■■ Click the plus sign (+) to expand sub-categories. ■■ Click the topic to be linked to the page referenced. CareFirst Product Offerings................................... 1 Continuation of Coverage.................................... 32 Defined Geographic Regions................................. 3 COBRA (Consolidated Omnibus Budget Reconciliation Act of 1986)................................. 33 DC Market Rules.................................................... 4 Doing Business with CareFirst.............................. 5 Keeping You Informed........................................... 7 Connecting with CareFirst..................................... 8 Contacts................................................................ 9 Calendar Year vs. Contract Year Benefit Periods............................. 11 Enrolling Eligible Dependents............................. 34 Multiple Option Offerings................................... 37 Movement Between Products............................. 38 Consumer Driven Health Products (CDH)............ 39 Small Group Rating............................................. 40 New Business...................................................... 42 Deductible Credit................................................. 12 Requesting a Quote............................................. 43 Deductible Carryover........................................... 13 New Group Paperwork........................................ 44 Determination of Group Size ACA-Compliant...... 14 Renewal Business............................................... 45 Determination of Group Size Grandfathered....... 15 Existing Groups that Move Their Headquarters Outside of MD, DC, N. VA.................................... 47 Group Eligibility for ACA-Compliant Small Group Benefits............................................................... 16 Group Eligibility For Grandfathered Small Group Benefits............................................................... 17 Retirees, Part-time Employees and Full-time Employees with Other Coverage: Grandfathered Products Only...................................................... 19 Request for Anniversary Date Change................ 48 Contract Issuance................................................ 49 Matrix: Eligibility, Rating & Participation........... 50 Medicare Eligibility, Rating And Participation for “Grandfathered” Products Only.......................... 52 Medicare Retirees and Eligibles: ACA-Compliant Products.............................................................. 20 Dental Benefits.................................................... 55 Segment Eligibility Effective 1/1/14................... 21 DC/VA Product Portfolio...................................... 59 Affiliated Companies........................................... 22 DC and VA Group Contract Application Matrices........................................... 60 Account Eligibility Verification............................ 25 Tax Documentation.............................................. 26 Husband/Wife Businesses.................................. 28 Enrolling Eligible Employees............................... 29 ii / DC/VA GROUP ELIGIBILITY / BROKER MANUAL Vision Benefits.................................................... 58 Highlights of Small Group Legislation— DC, VA, Federal.................................................... 64 District of Columbia......................................... 64 Virginia............................................................ 65 Federal............................................................. 67 CONTENTS > > CareFirst Product Offerings CareFirst, Inc. is made-up of several subsidiaries that are licensed separately and as such are viewed as separate carriers by the Insurance Divisions. However, for new sales bonus and Broker of Record transfer requirement purposes, any business in these subsidiaries is considered “existing CareFirst business.” Various products are offered through each CareFirst carrier as shown in the chart below: Medical/Dental/Vision Products Effective 1/1/14 Group Hospitalization and Medical Services, Inc. (GHMSI) CareFirst BlueChoice, Inc. BluePreferred PPO BlueChoice HMO Referral BluePreferred PPO HSA/HRA BlueChoice HMO Select Preferred Provider Plan (SPPP)* BlueChoice HMO Opt-Out Open Access* BlueChoice Opt-Out Plus Open Access* BlueChoice HMO HSA/HRA BlueChoice Plus BlueChoice Plus BlueChoice Plus HSA/HRA BlueChoice Plus HSA/HRA BlueChoice Advantage BlueChoice Advantage BlueChoice Advantage HSA/HRA BlueChoice Advantage HSA/HRA HealthyBlue HMO HealthyBlue HMO HSA/HRA HealthyBlue PPO HealthyBlue PPO HSA/HRA 1 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > CareFirst Product Offerings (continued) Group Hospitalization and Medical Services, Inc. (GHMSI) CareFirst BlueChoice, Inc. HealthyBlue Plus HealthyBlue Plus HealthyBlue Plus HSA/HRA HealthyBlue Plus HSA/HRA HealthyBlue Advantage HealthyBlue Advantage HealthyBlue Advantage HSA/HRA HealthyBlue Advantage HSA/HRA DHMO Ridered Parallel Dental* Traditional Ridered Parallel Dental* Preferred Ridered Parallel Dental* BlueVision Plus Ridered Parallel Vision *Available to “grandfathered” groups only. Note that: HealthyBlue Advantage CDH cannot be offered with BlueChoice Plus, Blue Choice Plus CDH HealthyBlue Advantage non-CDH cannot be offered with BlueChoice Plus, BlueChoice Plus CDH BlueChoice Advantage CDH cannot be offered with BlueChoice Plus, BlueChoice Plus CDH BlueChoice Advantage non-CDH cannot be offered with BlueChoice Plus, BlueChoice Plus CDH A broker can determine in which Legal Entity a prospect/group is being quoted by the Plan Code noted on the proposal (listed under the product name) ■■ ■■ B in the 5th position = GHMSI C in the 5th position = BlueChoice 2 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Defined Geographic Regions CareFirst Marketing Sales Area District of Columbia, Maryland and the Commonwealth of Virginia, the cities of Alexandria and Falls Church, the counties of Arlington and the portion of Fairfax east of Route 123 including the incorporated limits of Fairfax City and the town of Vienna in their entirety. (Helpful hint: use the BCBS website (www.bcbs.com) to determine the appropriate BlueCross BlueShield plan.) The zip codes that are split by Route 123 are (refer to map): ■■ Fairfax County: 22030, 22039, 22079, 22101, 22102, 22124, 22180, 22181, 22182, 22191, 22192 ■■ Prince William County: 22125, 22191, 22192 3 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > DC Market Rules Beginning January 1, 2014 any District of Columbia small employer group not currently offering group health benefits that then elects to offer group health benefits must purchase those benefits through the DC Health Link (SHOP). Beginning January 1, 2015 any small employer group offering group health benefits must purchase or renew on the DC Health Link (SHOP). Any new small group sale or small group renewal effective 1/1/15 must go through the DCHL. 4 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Doing Business with CareFirst CareFirst products are sold through brokers who are contracted with us directly and/or through a General Producer (GP)/Full-Service Producer (FSP). It is important for all distributors selling CareFirst products to understand their role in the sales process in order to efficiently service our members. Please use the following details as a guideline for selling CareFirst products: The role of the CareFirst Broker Sales Representative is to educate the General Producer (GP) and their staff on CareFirst products and procedures. The role of the Full-Service Producer (FSP): ■■ ■■ The role of the General Producer (GP): ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ Establish and maintain compliance with all regulatory requirements Assist with contracting and appointment of brokers Provide brokers with rate quotes for new groups and alternative options for existing groups Gather, review, and submit all paperwork required for new group enrollment, off-cycle benefit changes and renewals Provide brokers with marketing/sales materials and literature Distribute renewals to brokers and groups Submit/upload complete and accurate paperwork to CareFirst via Broker Express by the deadlines established in the Account Installation (AI) Calendar (Broker/Agent Administrative Manual) Assist brokers with benefits and eligibility questions Assist with the Quote to Bill Process: customer service, CareFirst Connect, enrollment and billing issues Distribute CareFirst Broker Sales Flashes to their brokers The General Producer (GP) is also responsible for educating brokers and their staff on the requirements for new group and benefit change submissions. In addition, the General Producer (GP) is expected to hold broker training sessions on CareFirst products, enrollment eligibility requirements and other important topics. CareFirst Representatives also attend these sessions to assist and answer questions. 5 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ Establish and maintain compliance with all regulatory requirements Assist with contracting and appointment of brokers Provide brokers with rate quotes for new groups and alternative options for existing groups Gather, review, and submit all paperwork required for new group enrollment, off-cycle benefit changes and renewals Provide brokers with marketing/sales materials and literature Distribute renewals to brokers and groups Submit complete and accurate paperwork to CareFirst via Broker Express by the deadlines established in the Account Installation Calendar (Broker/Agent Administrative Manual) Assist brokers with benefits and eligibility questions Distribute CareFirst Broker Sales Flashes to their brokers Bill and collect premiums for groups Send termination notices to groups and brokers Update and maintain enrollment records, service accounts and members regarding billing, enrollment and customer service issues The CareFirst Broker Sales Representative is responsible for assisting the Full-Service Producer with broker training sessions. In addition, they are responsible for training and educating the Full-Service Producer on all changes and updates related to doing business with CareFirst. CONTENTS > > Doing Business with CareFirst (continued) The role of the CareFirst Representative for the Direct Broker is: ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ Establish and maintain compliance with all regulatory requirements Provide training on CareFirst Products and policies Provide training on the CareFirst Quote to Bill process Assist in new sales and renewals Assist with enrollment meetings (groups with 25 or more enrollees) Provide materials necessary to sell and renew CareFirst products Maintain a positive relationship with all brokers Assist with benefit and eligibility questions 6 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Keeping You Informed CareFirst BlueCross BlueShield strives to keep our broker community informed. Timely updates result in better service to our accounts and members. Information and product updates are available as described below. Broker Sales Flash The CareFirst Sales Flash covers a variety of sales-related topics including product updates, administrative matters, application and form changes, among many other subjects. The Sales Flash is market-specific and is distributed on a weekly basis via email. In addition, Sales Flashes are available on www.carefirst.com via the Broker & Agents portal. General/Full Service Producers are responsible for providing brokers with Sales Flash information. Direct Brokers can contact their Broker Sales Representative to be added to the distribution list to receive the Sales Flash directly from CareFirst. Broker Forums Broker forums are held to keep brokers informed of CareFirst product initiatives and enhancements, pricing updates and other sales related information. These forums are generally held on an annual basis and brokers are notified in advance by invitation. Broker Council The CareFirst Broker Council is comprised of approximately twenty experienced health insurance brokers representing Maryland, DC and Northern Virginia. New members are appointed to the Council each year. The Council meets quarterly and provides the opportunity for members of the Council to discuss issues and concerns in the broker community. The Broker Council represents CareFirst’s entire distributor networks. We strongly encourage brokers to contact any member of the Broker Council with any questions, comments or concerns. To request a copy of the list of Council members, please contact your Broker Sales Representative. 7 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Connecting with CareFirst General Producer(s) (GP), Full-Service Producer(s) (FSP) or Direct Brokers doing business with our DC location, may contact our Sales Associates at 202-479-8595 or toll-free at 877-315-2254. The Broker Sales email address is: [email protected] and the DC fax number is 301-470-8049. Brokers working with a General/Full-Service Producer should not use this email address or RightFax number; instead, they should contact their General/Full-Service Producer directly. Direct Brokers only: As part of the workflow process, all paperwork should be submitted via Broker Express for new and renewing business. Please send the following requests to the above-stated email address or the DC fax number: ■■ ■■ ■■ ■■ Signed renewals Benefit booklet & group contract requests for existing groups (please allow 6–8 weeks for shipment) Group updates (i.e. address change, group administrator, enrollment eligibility) Group cancellation letters 8 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Contacts Broker Customer Service [email protected] 1-888-4CF-BRKRS (423-2757) Consumer Driven Health (CDH): [email protected] 1-888-755-2656 Billing Enrollment and ID Card Inquiries Group Enrollment: Group Enrollment Fax (including subsidy paperwork): Billing & Collections (Invoices) Group Conversion 202-479-2730 301-470-7604 1-888-232-2335 1-888-567-9155 BluePreferred Member Services Monday-Friday 7:00am – 7:00pm Pre-Authorization Toll Free (800) 321-3497 TTY 202-479-3546 1-866-773-2884 Bluechoice Member Services Monday-Friday 7:00am – 7:00pm Pre-Authorization Toll Free (866) 520-6099 TTY 1-800-828-3196 1-866-773-2884 HealthyBlue Member Services Monday-Friday 7:00am – 7:00pm 1-866-452-2217 When writing to CareFirst BlueCross BlueShield, always include the Member Identification Number and group number. Please address your correspondence to: CareFirst BlueCross BlueShield P.O. Box 14114 Lexington, KY 40512-4114 HealthFitness Monday-Friday 8:00am – 8:00pm 1-866-454-5375 Additional Contacts CareFirst Connect Command Center [email protected] 1-888-323-4595 CareFirst Connect Retroactive Enrollment Requests [email protected] BlueVision (Davis Vision) 9 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL 1-800-783-5602 CONTENTS > > Contacts (continued) FirstHelp (24 hour Emergency Assistance) 1-800-535-9700 CVS CareMark (Rx Services) 1-800-241-3371 Dental Benefits 1-866-891-2802 The Dental Network 410-847-9060 / 1-888-833-8464 CareFirst Switchboard (DC location) 202-479-8000 Individual Sales 410-356-8000 / 1-800-544-8703 Commission Information / Broker Accounting Group Individual 410-998-6718 410-998-7187 Broker Contracting and Compliance [email protected] 410-998-6919 Contract and Evidence of Coverage Booklets requests [email protected] BlueCard® Provider Information 1-800-810-BLUE (2583) Magellan Mental Health Services 1-800-245-7013 PayFlex 301-530-9400 / 1-866-208-8587 HFS Benefits www.hfsbenefits.com 410-771-1331 / 1-888-460-8005 Broker Portal and Broker Express Help Desk [email protected] 877-526-8390 My Account Members have the capability to check the status of their medical claims history, covered members, eligibility, benefits and e-mail questions to customer service through “My Account” located in the Members & Visitors section of www.carefirst.com. Members will need their ID number or SSN to register for “My Account.” Due to changes in state and federal privacy rules, adult dependents will only have access to claims information about themselves. 10 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Calendar Year vs. Contract Year Benefit Periods ■■ ■■ ■■ ■■ BluePreferred/BlueChoice sold for first of the month effective dates normally have contract year benefit periods with deductible/maximum beginning/renewing on the effective date. Groups may request a calendar year benefit period. Under a calendar year benefit period, the deductible and maximums reset each year on January 1. BluePreferred/BlueChoice groups sold on a 15th of the month effective date have calendar year benefit periods. Under the calendar year benefit period, the deductible and maximums reset each year on January 1 even if the group changes its benefits upon renewal during the year. Groups have the option to change benefit periods at their renewal or in conjunction with an approved off-cycle benefit change. 11 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Deductible Credit For ACA compliant products, deductible credit is only available for those products where language has been filed and approved to allow the benefit. CareFirst BlueCross BlueShield has implemented the following changes to the business rules around deductible credit. ■■ ■■ The following is currently in effect for groups in the 1-200 market for CDH products and Blue Selections that include a CDH product: ■■ ■■ Deductible Credit For New Business ●● For 15th of the month—no deductible credit and remains calendar year ●● Contract year—no deductible credit ●● Calendar year—(except for 15th of the month effective dates) provide deductible credit as long as they are currently in a calendar year plan with a competitor. This ensures that we are not extending their deductible period longer than 12 months, thus making the plan out of compliance with the IRS. Deductible Credit for Renewals ●● Off-cycle renewals—no deductible credit for contract year; deductible credit DOES apply for calendar year. For ACA-compliant products, deductible credit is only available for those products where language has been filed and approved to allow the benefit. ●● Moving from calendar year to contract year or vice versa—no deductible credit. ●● Remaining on calendar year but changing benefits on renewal—deductible credit applies. The following business rules have been in effect for non-CDH products sold as standalone or not offered with CDH as part of Blue Selections: ■■ products where language has been filed and approved to allow the benefit. ●● For new business—manual process ●● For existing business—manual process when a group changes benefits Deductible credit is not permitted when a group changes benefit effective periods Rx deductible credit is not a CareFirst business or industry practice Please refer to the following charts that outline the business rules for both new and renewing business. Deductible Credit Business Rules— New Groups Calendar Yes* Contract No 15th of Month (Calendar)+ No Deductible Credit Business Rules— Renewing Groups Off Cycle Change Calendar—Yes Contract—No Moving Calendar to Contract (vice versa) No Remaining Calendar Year— changing benefits Yes * Must currently be calendar year plan with competitor -- ensures we are not extending their deductible period longer than 12 months, thus making the plan out of compliance with the IRS. + 15th of the Month Contract Year Not Available. Non-CDH products sold stand alone or not offered with CDH as part of Blue Selections: Existing Deductible Credit Rules Apply. When a CDH product is offered standalone or as part of Blue Selections, deductible credit is ONLY ALLOWED on calendar year new or renewing business. Medical deductible and out-of-pocket credit is available. For ACA-compliant products, deductible credit is only available for those 12 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Deductible Carryover For ACA-compliant products, deductible carryover is only available for those products where language has been filed and approved to allow the benefit. Deductible carryover is available as a benefit enhancement to all medical options as well as all RX options that have an in-network deductible and a calendar year benefit period. ■■ Not available with any HSA or HRA BlueFund or Compatible options 13 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Determination of Group Size ACA-Compliant ACA Compliant Small Group: Effective 1/1/14, product eligibility and group size will be determined based on the Full Time Equivalent (FTE) calculation that uses a 30-hour work week and 120-hour work month. This calculation not only includes full-time employees working 30 or more hours per week, but also includes seasonal and aggregates the part time employees. If an employer was not in existence throughout the preceding calendar year, the determination of whether the employer is a small employer shall be based on the average number of employees that the employer is reasonably expected to employ on business days in the current calendar year. Employers are encouraged to use Federal guidance in conjunction with accountants and/or legal counsel when determining their group size. Please access our “Full-Time Equivalent Calculation” form on the Broker Portal. This calculation is used to determine the average number of all employees, not just the number of covered lives, who worked for your company in the calendar year prior to your new sale or renewal effective date. Included in FTE Calculation for Group Size Not Included in FTE Calculation for Group Size All F/T employees (including those in probationary period). However, employee must complete their contractual probationary period prior to enrolling in the plan even if the Open Enrollment occurs during the probationary period. F/T independent contractor—1099 employees Seasonal employee COBRA ex-employee or dependent Part-time employee (less than 30 hrs) Retiree or dependent F/T owners Board Members 14 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Determination of Group Size Grandfathered Grandfathered Small Group: Existing small group accounts which were enrolled under the pre ACA guidelines (either prior calendar year or prior quarter) are able to remain in their current grandfathered product. However, if they choose to make a benefit change, they must move to an ACA-compliant plan and they must meet the group eligibility requirements under ACA. to actually be moved from one TEFRA/Non-TEFRA designation to another. Centers for Medicare and Medicaid Services (CMS) has put this in place to avoid groups moving between designations repeatedly. Groups are responsible for determining their designation and should enlist assistance from their accountant if there is confusion. Employee Eligibility Requirements Board members of accounts are not considered eligible for coverage under an employer group plan because they are not employees. The following employees (and their dependents) are eligible for coverage, as long as they meet the additional eligibility requirements set forth in the Certificate of Coverage or Group Enrollment Agreement, and any attachments thereto. All employees (including owners and partners) who are regularly employed on a full-time basis working at least 30 hours a week. (Seasonal employees, subcontractors, consultants or other persons issued 1099’s by the Group are not eligible.) All former employees and their dependents whose eligibility for group coverage has been extended due to COBRA requirements. Note: No individual is eligible under your Group coverage both as a Subscriber and as a Dependent. If your Group employs both a husband and wife (or Domestic Partner, if applicable), they may not both have Individual + Adult Coverage or Family Coverage. TEFRA vs. Non-TEFRA TEFRA only applies to a group health plan sponsored by or contributed to by an employer that has 20 or more employees for each working day in each of 20 or more calendar weeks in the current or preceding calendar year. Segments of employees (i.e.: union members) not eligible for plan benefits are not included in the calculation to determine TEFRA/Non-TEFRA designation. Groups should also note that there is a period of time that a group must maintain the required number of employees 15 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL Board Members Terminated Employees in COBRA Election Period If an employee is within their 60 day COBRA election period, they should not be included in the group census. If the employee then elects coverage, they will be provided coverage retroactive to their termination date and the group will be re-rated. Retirees, Part-time Employees and Fulltime Employees with Other Coverage The group can elect to provide coverage for the following: ■■ Part-time employees working at least 17.5 hours a week for more than six months each year. (Those working less than these required time periods are not eligible.) ■■ Retirees who have retired prior to the effective date of this coverage. (Available only if covered under the Group’s prior health coverage.) Proof will be required which may include a copy of prior carrier’s contract and most recent billing statement. ■■ Retirees who retire on or after the effective date of this coverage. (Available only if covered under the Group’s prior health coverage.) ■■ All employees who terminated employment due to disability prior to the effective date of this coverage for a period of not more than two years. If for a shorter period of time, please indicate . (Available only if covered under the Group’s prior health coverage.) CONTENTS > > Group Eligibility for ACA-Compliant Small Group Benefits “Small Employer” means an employer headquartered in VA or DC that, during the preceding calendar year, employed an average of not more than fifty employees during the preceding calendar year. The group must be defined as a single and employer under IRS code 414(b), (c), (m), or (o). At least one full time currently employed Eligible Employee must be enrolled under the Group’s coverage or have a valid waiver at all times who is not the owner or the owner’s spouse. 16 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Group Eligibility For Grandfathered Small Group Benefits There must be at least one contract in the service area and the group must be headquartered and physically located (a P.O. Box is not sufficient) in DC, MD or Northern Virginia East of Route 123 including the city of Fairfax and town of Vienna to be covered under a small group product. Enrolled groups that drop to less than two full-time employees should contact their Broker, General Producer (GP), Full-Service Producer (FSP) or Sales Representative to obtain information. Minimum Participation Requirements: ACA Compliant Products: The group must enroll and maintain enrollment of at least 75% of all eligible employees for medical coverage and for each ancillary product purchased, if offered (or 100% if the employer pays the entire Individual coverage premium). The ancillary products are dental and vision benefits. If at any time there are less than 75% enrolled in any of the medical or ancillary products, CareFirst reserves the right to rescind the proposal, revise the rates, or terminate the product that does not meet the 75% requirement. The Group cannot enroll in their HMO programs (other than CareFirst BlueChoice) more than 25% of the total number of employees enrolled in all health programs offered through the Group. The Group cannot continue to enroll new employees in their staff model HMO. For participation purposes, all eligible employees are included in the participation calculation except for: ■■ Those with spousal coverage under a public or private plan of health insurance or another employer’s health benefit arrangement, including Medicare, Medicaid, and CHAMPUS, that provides benefits similar to or exceeding the benefits provided under the Group Contract. ■■ Those who are under the age of 26 years who are covered under their parent’s health benefit plan. 17 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL ■■ ■■ Those who neither live nor work in the CareFirst BlueChoice service area when that is the only CareFirst affiliate being offered by the Group. Those who are able to obtain a federal subsidy through enrollment on the public Exchange. These requirements are waived for a small employer enrolling between November 15 and December 15 of any calendar year with an effective date of January 1. Minimum Participation Requirements: “Grandfathered” Products: The requirements in this section do not apply to Virginia small groups electing coverage under Virginia Essential or Standard Health Benefit Plans. The Group must enroll and maintain enrollment (unless otherwise approved by CareFirst/CareFirst BlueCross BlueShield) as stated below: If Point of Enrollment or BlueChoice Opt-Out Plus Open Access is selected, this must be the sole health plan offered by the Group to its employees. Groups must enroll and maintain enrollment of 75% of all employees eligible for medical coverage and for each ancillary product purchased, if offered (or 100% if the employer pays the entire Individual Coverage premium). The ancillary products are dental and vision benefits. If at any time there are less than 75% enrolled in any of the medical or ancillary products, CareFirst reserves the right to rescind the proposal, revise the rates, terminate the product that does not meet the 75% requirement, or refuse to renew the product that does not meet the 75% requirement. Voluntary Dental requires 35% participation or 10 enrolled whichever is less. Voluntary Vision has no participation requirement. The Group cannot enroll in their HMO programs (other than CareFirst BlueChoice) more than 25% of the total number of employees enrolled in all health programs offered through the Group. The CONTENTS > > Group Eligibility For Grandfathered Small Group Benefits (continued) Group cannot continue to enroll new employees in their staff model HMO. The following employees should be excluded from the above counts: 1. Those employees who have coverage under their spouse’s or parent’s group coverage, CHAMPUS, Medicare as primary under TEFRA, or their prior employer’s plan under COBRA. 2. Those employees enrolled in other Company coverage or covered under any Company affiliate. At least two employees must be employed fulltime and enrolled under the Group’s coverage at all times. (Note: Those employees with complementary to Medicare coverage do not count toward the two employee minimum enrollment requirement.) Enrolled Groups that drop to less than two full-time employees should contact their Sales Representative to arrange for individual direct pay coverage. a valid waiver, not an owner or their spouse. Any existing groups of this nature will be migrated to an ACA compliant product and may not make a benefit change. For “grandfathered” business: will be renewed with no benefit change. A company insured with CareFirst must be an active entity with a Federal Tax I.D., engaged in a trade or business, consisting of at least 2 eligible employees. Employer Contribution: To be eligible for Group coverage, the employer must contribute an amount equal to at least 50% of the cost of the Individual Coverage for enrolled employees. If at any time total enrollment increases or decreases by 10% or more, the Company reserves the right to rescind the proposal, revise the rates, terminate this contract, or refuse to renew this contract. The basis for determining whether an enrollment increase or decrease has occurred will be the total enrollment: 1. On the effective date or contract renewal date versus the total enrollment proposed at the time the rates were developed; and 2. On the first day of any month during the contract period versus the total enrollment proposed at the time the rates were developed. The Company may change the applicable premium rates at any time by giving no less than thirty (30) days prior written notice to the Group. If, however, the proposed premium rate increase exceeds thirty-five percent (35%) of the annual premium charged, the Company will give the Group prior written notice of no less than sixty (60) days. Sole Proprietorships, Partnerships or Corporations: Under ACA requirements, there must be at least one full time “common law” employee enrolled or with 18 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Retirees, Part-time Employees and Fulltime Employees with Other Coverage: Grandfathered Products Only Note that the Group Contract Application allows groups the option only to cover part-time employees effective 1/1/14. The group can elect to provide coverage for the following: ■■ Part-time employees working at least 17.5 hours a week for more than six months each year. (Those working less than these required time periods are not eligible.) ■■ Retirees who have retired prior to the effective date of this coverage. (Available only if covered under the Group’s prior health coverage.) Proof will be required which may include a copy of prior carrier’s contract and most recent billing statement. ■■ Retirees who retire on or after the effective date of this coverage. (Available only if covered under the Group’s prior health coverage.) ■■ All employees who terminated employment due to disability prior to the effective date of this coverage for a period of not more than two years. If for a shorter period of time, please indicate . (Available only if covered under the Group’s prior health coverage.) 19 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Medicare Retirees and Eligibles: ACA-Compliant Products For ACA-compliant products, any active employee with Medicare must enroll as an active employee under the member level rating methodology. Under ACA-compliant products, retirees currently enrolled may remain enrolled on the group plan as long as the group does not make a benefit change that requires a new Group Contract Application. Coverage will not be extended to retirees not currently enrolled and seeking group benefits. TEFRA vs. Non-TEFRA: TEFRA only applies to a group health plan sponsored by or contributed to by an employer that has 20 or more employees for each working day in each of 20 or more calendar weeks in the current or preceding calendar year. All active members are included in the calculation to determine TEFRA/Non-TEFRA designation. Groups should also note that there is a period of time that a group must maintain the required number of employees to actually be moved from one TEFRA/ Non-TEFRA designation to another. CMS has put this in place to avoid groups moving between designations repeatedly. Groups are responsible for determining their designation and should enlist assistance from their accountant if there is confusion. 20 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Segment Eligibility Effective 1/1/14 Existing groups that have chosen to designate product(s) as “grandfathered” may renew in the current product and segment. However, if a benefit change is made, the ability to “grandfather” ends. Then based on their Full-Time Equivalent calculation, they must move into an ACA-compliant product if their FTE is 50 or less, or to a product offered in the 51–199 market if the FTE calculation is over 50. 21 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Affiliated Companies Under ACA regulations, certain affiliated employers with common ownership or who are part of a controlled group must aggregate their employees for determining group size and specifically for the Full-Time Equivalency (FTE) calculation. CareFirst looks to the employer and their counsel for this certification. In determining the number of eligible employees, companies which are affiliated companies or which are eligible to file a consolidated federal income tax return shall be considered one employer. The key phrase here is “eligible to file;” the type of affiliation between the parent company and the others will determine whether or not they are eligible to file a consolidated tax return or separate returns. 22 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Affiliated Companies (continued) “Parent Company” Tax Filing Method Corporations If corporation has 80% Ownership or more in the other businesses, they have a choice of filing separate returns OR a consolidated tax return. If corporation has less than 80% ownership in the other businesses, they must file separate tax returns. Sole Proprietors Must file separate tax returns Legislative Interpretation Either way they choose, they are eligible to file consolidated returns. Therefore, they are considered one employer. Since they are not eligible to file consolidated tax returns, then under there must be sufficient proof that they are affiliated companies under common ownership and common control in order to be written as one group. “Common ownership” is shown by one person or entity having more than 50% ownership in both companies. When there is proof that one entity owns another in excess of 50% but less than 80%, thus establishing ownership, CareFirst may request that the company provide additional information including a certification in order to determine whether or not the owner exerts control over the owned entity or entities. Corporations, LLC’s, Partnerships, and Sole Proprietorships are all subject to this rule. Since they are not eligible to file consolidated tax returns, there must be sufficient proof that they are affiliated companies under common ownership and common control in order to be written as one group. “Common ownership” is shown by one person or entity having more than 50% ownership in both companies. When there is proof that one entity owns another in excess of 50% but less than 80%, thus establishing ownership, CareFirst may request that the company provide additional information including a certification in order to determine whether or not the owner exerts control over the owned entity or entities. Corporations, LLC’s, Partnerships, and Sole Proprietorships are all subject to this rule. Partnerships Must file separate tax returns Since they are not eligible to file consolidated tax returns, there must be sufficient proof that they are affiliated companies under common ownership and common control in order to be written as one group. “Common ownership” is shown by one person or entity having more than 50% ownership in both companies. When there is proof that one entity owns another in excess of 50% but less than 80%, thus establishing ownership, CareFirst may request that the company provide additional information including a certification in order to determine whether or not the owner exerts control over the owned entity or entities. Corporations, LLC’s, Partnerships, and Sole Proprietorships are all subject to this rule. 23 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Affiliated Companies (continued) ■■ ■■ ■■ Just because two companies have different names and different employer tax ID numbers does not necessarily mean that they are Small Group eligible as two separate employers! YOU NEED TO CHECK ON THE AMOUNT OF OWNERSHIP BETWEEN THE COMPANIES AND HOW THE COMPANIES INTERACT WITH EACH OTHER! The “Affiliated Companies/Common Ownership Certification” form should be completed by any group that is applying for coverage that has Affiliated Companies, Subsidiaries, or enough Common Ownership to apply for coverage under one entity. The form can be obtained from the Broker Sales Representative. 24 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Account Eligibility Verification As a requirement for all new business and upon request at renewal, an account must provide a copy of their most recent quarterly Wage and Tax Statement. This quarterly document, filed with the State of Maryland, Virginia and the District of Columbia lists all compensated employees for unemployment tax purposes. It is via this document that CareFirst will be able to determine the total number of eligible employees. When the Wage and Tax is submitted, the account should note eligibility status next to each employee. For example: Mary Peters no insurance John Smith group spousal waiver Steve Meyers part-time Susan Jones probationary/waiting period whether the employer is a small employer shall be based on the average number of employees that the employer is reasonably expected to employ on business days in the current calendar year. Group must have at least one common law employee who is not the owner or spouse in order to be a viable small group. Note that the most current Wage and Tax statement filed with the State of Maryland, Virginia or the District of Columbia is required on all new accounts including those transferring from one company within CareFirst to another (GHMSI, BlueChoice). CareFirst requires a duplicate copy of the Wage and Tax sent to the state or District. W-4’s are required for those employees not appearing on the Wage and Tax, unless they are an owner. The owner’s name and social security number should be written on the bottom of the Wage and Tax and identified as such with the number of hours worked per week and eligibility status. Segment Migrations between small group and 50+: Payroll Registers in Lieu of a Wage and Tax: Payroll registers will be accepted in lieu of the Maryland Wage and Tax when the payroll register is filed as an amendment. This option should only be exercised on an exception basis when the Wage & Tax Statement is not available. If a payroll register is provided, it must be generated by a payroll service (EasyPay, ADP, etc.) and must not be generated by software via desktop computers. Newly Formed Companies: If an employer was not in existence throughout the preceding calendar year, the determination of 25 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL If the newly formed company does not have a Wage and Tax, they should submit a notarized letter on company letterhead listing their employees, the number of hours per week and their eligibility status. W-4’s must be submitted for each employee as well as the business formation documents. The application for the Wage and Tax should be submitted as well, if available. Renewals will be released 60–120 days in advance of the effective date using the group’s FTE calculation based on the prior calendar year. Groups are required to keep this number current with CareFirst so that we can accurately apply rating calculations required for the number of FullTime Equivalents in the group. Groups with New Federal Tax ID Numbers: A new Fed tax ID number is generally consistent with a change of entity for the group (i.e.: sole proprietorship shifting to a partnership or new ownership) and requires that the original group be termed and the new entity written as a new group. This may be of concern for existing groups currently offering a high deductible plan. Annual Enrollment Certification: CareFirst and/or CareFirst BlueChoice, Inc. reserve the right to inspect the records of the Group after sixty (60) days from the effective date of the Group coverage in order to verify the eligibility of employees and their dependents. In addition, the Group may be required to complete and return to CareFirst and/or CareFirst BlueChoice an eligibility audit and/or census report annually. CONTENTS > > Tax Documentation The following information was either provided by State legislation (as in the case of a selfemployed individual), or by the Maryland Office of Type Of Business Wage and Tax Required If Employees Are Unemployment Insurance to determine which tax documents are available to verify eligibility of an employer group and its employees: Wage and Tax Not Required If Employees Are If No Wage and Tax Required, Submit Instead Self-Employed Individuals Signed Form 1040 or 1040EZ and any one of the following: Schedule C, C-EZ, F, SE, Form 1120, 1120-S or Form 1065 with K-1, Form 7004, and Form 4868. Self-Employed “Licensed Professionals” such as attorneys, physicians (LLP “Limited Liability Partnership” excluded) Articles of (Professional) Incorporation and “Letter of Good Standing” from licensing group Non-Profit Organization IRS Form 501(c)(3) a.k.a. “Letter of Determination” w/ notarized letter on company letter-head, listing employees, hours per week/eligibility status* (1 sole eligible employee working 20 hrs/wk) NOTE THAT THE ABOVE TYPES ARE NO LONGER ELIGIBLE FOR COVERAGE UNDER ACA REGULATIONS; IF THEY HAVE “GRANDFATHERED” AND CONTINUE TO MEET THE “GRANDFATHERING” REQUIREMENTS THEY MAY RENEW WITH NO BENEFIT CHANGE. 26 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Tax Documentation (continued) Type Of Business Wage and Tax Required If Employees Are Wage and Tax Not Required If Employees Are Corporation If No Wage and Tax Required, Submit Instead Form 1120, Form 1120-S or Articles of Incorporation showing owners of business Must have at least 1 FT common law employee, not the owner or spouse Note: In most cases, corporations will have a formal Wage & Tax** Non-Profit Organization IRS Form 501(c)(3) a.k.a. “Letter of Determination” w/ notarized letter on company letter-head, listing employees, hours per week/ eligibility status; in lieu of 501(c), Charter Document w/ notarized letter 1 FT common law employee, not the owner or spouse Sole Proprietorship Must have at least 1 FT common law Employee, not the owner or spouse Partnership Must have at least 1 FT common law employee, not the owner or spouse Signed Schedule C/F showing at least Husband and wife as Owners** Owner’s children (over age 21) working full time Other employees working full or part time Spouse, owner’s children, other employees Partners Form 1065 and signed K-1 forms for each Partner Note that for Corporations, Sole Proprietorships, and Partnerships, there must be 1 full time common law employee who is not the owner/spouse. Note that a current Wage and Tax Statement is required on all accounts including those migrating between CareFirst companies. Stock certificates are not accepted as proof of ownership. 27 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Husband/Wife Businesses Under ACA regulations, groups of only a husband and a wife are not eligible for coverage. There must be one common law employee other than the owner and their spouse. Husband/Wife groups currently enrolled can remain on group benefits as long as they do not make a benefit change. 28 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Enrolling Eligible Employees Eligible Employees in ACA-Compliant Groups: ■■ ■■ ■■ ■■ ■■ ■■ ■■ A full-time employee (including owners and partners) who works, on average, at least 30 hours per week. Seasonal employees and independent contractors, such as subcontractors, who receive a 1099 are not eligible employees. The IRS has issued guidance on when individuals are to be treated as either an employee or independent contractor and the group should consult with their tax advisor if they have questions relative to offering coverage to this classification. Former employees and their dependents that fall under COBRA or Continuation provisions are eligible for coverage. Groups may also choose to offer benefits to part time employees as long as the part time employee has a normal workweek of at least 17.5 hours and are not full time employees. If the part time employee works less than 17.5 hours in a normal workweek, they are not eligible for coverage. Groups may also offer coverage to Domestic Partners of eligible employees. Groups must offer benefits to all eligible employees or to all employees in an additional designated class (part time, Domestic Partners). No individual is eligible under the Group’s coverage both as a Subscriber and as a Dependent. For a 1–50 group headquartered in DC/VA or a 1–50 group headquartered in DC/VA with an office in another state that is NOT a “separate purchasing entity” location, all employees should be underwritten in DC/VA. For a 1–50 group headquartered Out-of-State can buy an HMO product only for those employees working in the CareFirst Service area if the branch office is not a “separate purchasing entity.” For a 1–50 group headquartered Out-of-State can buy an HMO or Indemnity product if the branch office is a “separate purchasing entity.” Eligible Employees in “Grandfathered” products: A full-time employee of a company who works on a full-time basis and has a “normal” work week of 30 or more hours, even though the employee may not be actively at work during the open enrollment. State law requires that the health benefits be offered to all employees who work at least 30 hours per week. Groups may not elect to limit their coverage of employees to only those who work a greater number of hours than the legislated 30 hours per week (i.e., only offer benefits to employees working 40 hours per week or more). An eligible employee must be a person who is compensated by the company for work/services performed in accordance with applicable Federal and State wage and hour laws. This includes those employees who are not United States citizens but meet the standard eligibility criteria noted above. Note: All employees working in excess of 30 hours per week and who otherwise meet the requirements of “eligible employee”, as well as their eligible dependents, must be offered all product options; excluding certain classes of employees or offering certain products to specific employees or classes of employees is not allowed. For a 1–50 group headquartered in DC/VA with an office in another state that is a “separate purchasing entity” location, employees working in DC/VA can be underwritten in DC/VA and employees in the other State can be underwritten in that State. 29 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Enrolling Eligible Employees (continued) For both “grandfathered” and “ACA-compliant” business, eligible employees may enroll: ■■ As a new hire, after satisfying any employer waiting period. ■■ During small employer’s annual open enrollment. ■■ Within 31 days of lifestyle change as defined by the Health Insurance Portability & Accountability (HIPAA) special enrollment period; this applies to those who initially declined coverage. ■■ Within 31 days of loss of spouse’s employment (voluntary or involuntary) that results in loss of insurance (except gross misconduct). ■■ Within 31 days of significant change in employment status (i.e. reduction in hours). ■■ Within 31 days of the expiration of COBRA coverage under another group plan. ■■ If they are full-time employees and are under the age of 18 as long as they provide proof of employment and hours worked via a current Wage and Tax. If a Wage and Tax is not available, a payroll statement or notarized letter indicating the number of hours the employee works must be submitted. Uniformed Services Employment and Reemployment Rights Act (“USERRA”): ■■ ■■ The Uniformed Services Employment and Reemployment Rights Act (“USERRA”) protects the job rights of individuals who voluntarily or involuntarily leave employment positions to undertake military service or certain types of service in the Natural Disaster Medical System. USERRA also prohibits employers, and insurers, from discriminating against past and present members of the uniformed services, and applicants to the uniformed services. If an eligible employee leaves his or her job to perform military service, the eligible employee has the right to elect to continue their group coverage including any dependents for up to 24 months while in the military. Even if continuation of coverage was not elected during the eligible employee’s military service, the eligible employee has the right to be reinstated in their group coverage when re-employed, without any waiting periods or preexisting condition exclusions except for service connected illnesses or injuries. If an eligible employee has any questions regarding USERRA, the eligible employee should contact 30 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL the Plan administrator. The Plan administrator determines eligible employees and provides that information to CareFirst. Enrollment in BlueChoice Products: All enrolling members must work or reside in the BlueChoice service area at the time of enrollment in order to enroll in a BlueChoice product. All members must choose a primary care provider no matter what product they are choosing including HMO, HMO Referral, and HMO Plus. This does not apply to BlueChoice Advantage or HealthyBlue Advantage. Part-time Employees: Part-time employees may not be enrolled on an employer’s small group policy if they are eligible to be enrolled as a dependent child on another group policy. Waiting Period for New Employees: ACA requires that all groups, including those offering “grandfathered” products have no more than a 90 day waiting period. For this reason, groups are contractually offered one of the following waiting period options: ■■ On the day of employment ■■ On the first day of the month following the date of employment ■■ First day of the month following 30 days of employment or eligibility ■■ First day of the month following 60 days of employment or eligibility ■■ Other specify (note this date cannot exceed a total of 90 days and must comply with federal and state law and regulation) Note that the waiting period options are stated in a specific number of days rather than months, actual calendar days must be counted. ■■ Waiting period may not be discriminatory or involve health related matters. ■■ Once defined in Group Application or Group Contract, a new Group Application/Contract must be submitted to change the waiting period. ■■ If the group elects to change their new hire waiting period current employees who have not completed their waiting period will be affected as follows: ●● If the new waiting period is longer than the prior one, the new waiting period is applied to the employee’s original hire date. CONTENTS > > Enrolling Eligible Employees (continued) If the new waiting period is shorter than the prior one, the employee is effective on the effective date of the waiting period change. Day 1 of a waiting period begins the day of hire. Employees whose employment is terminated for any reason but are then reinstated must fulfill a new waiting period and complete a new enrollment application unless the employer chooses to waive the waiting period based on the nature of the reinstatement and applies that decision to all similar reinstatements. New employees must fulfill their waiting period prior to enrolling even if the group’s annual open enrollment occurs during the waiting period; the group’s annual open enrollment does not override the waiting period. If a group is not offering benefits to P/T employees; however, a P/T employee moves to F/T status and is eligible for benefits, the employer can allow the time worked as a P/T employee to apply to the new hire waiting period as long as the employer applies that decision to all similar situations. ●● ■■ ■■ ■■ ■■ Open Enrollment Period: ■■ ■■ Subscriber Terminations: ■■ ■■ ■■ Termination and Rehire: ■■ ■■ If an employee is rehired within 30 days of their termination date, benefits will be reinstated without a wait period. Benefits will become effective using the appropriate effective date rule following the rehire date. If an employee is rehired more than 30 days after their termination date, benefits will be reinstated with a wait period. Benefits will become effective using the group’s wait period and effective date rule following the rehire date. The following provides examples assuming the group maintains a 30-day wait period: ■■ Termination Date 1/15/14; Rehire date 2/1/14; Rehire Category Less than 30 days; Benefit Eff. Date 2/1/14 ■■ Termination Date 1/15/14; Rehire date 2/16/14; Rehire Category Greater than 30 days; Benefit Eff. Date 4/1/14 31 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL When the Group first offers coverage; there will be an Open Enrollment Period for Eligible Employees. During the Open Enrollment Period, the employee and their dependents may apply for coverage. The Group will have an annual Open Enrollment Period that is the 31-day period immediately preceding the Open Enrollment Effective Date set forth in the Group Schedule. ■■ ■■ Termination occurs on the last day of the month in which the Subscriber’s employment or eligibility ends or on the date on which the Subscriber’s employment or eligibility terminates. Spouse and dependents may not terminate from the group coverage during the contact period unless the Subscriber terminates. A subscriber may make a mid year reduction or termination of coverage due to: ●● A reduction or elimination of coverage during the contract year ●● Spouse’s annual open enrollment ●● Significant increase or decrease in subscriber’s cost without a less costly and similar alternative including a change in job classification (FT/PT) ●● Entitlement to Medicare by the subscriber, spouse or dependent A subscriber may make a mid-year change to reduce or terminate coverage of the subscriber or dependent if one of the following qualifying life events occur: ●● Legal marital status change ●● Employment status change ●● Dependent status change ●● Residence change for HMO members only Groups are responsible for disenrolling their employee under the following conditions: ●● Employee no longer meets the eligibility requirements for health benefits coverage. ●● Employee is no longer employed by the Group CONTENTS > > Continuation of Coverage DC MD The District of Columbia’s City Council passed an emergency act, “Continuation of Health Coverage Act of 2001,” extending health benefits for covered members of a small employer group with fewer than 20 employees for a period of three months beyond termination of coverage. Eligible employees will have to pay full cost of the policy during the extension, but the cost may not exceed 102% of the group rate. Eligible employees must elect the continuation of coverage benefit and provide payment to the employer within prescribed time frames. There are no additional forms to complete. Maryland Continuation of Coverage enables members to continue their group’s coverage for a limited period of time after they cease to be eligible in the group. There are additional forms to complete. Events that qualify for continuation of coverage include: ■■ Involuntary termination ■■ Surviving Spouse ■■ Voluntary termination ■■ Divorce VA Virginia continuation of health coverage extends health benefits for covered members of a small employer group with fewer than 20 employees for a period of 12 months beyond termination of coverage. Eligible employee will have to pay full cost of the policy during the extension, but the cost may not exceed 102% of the group rate. Eligible employees must elect the continuation of coverage benefit and provide payment to the employer within prescribed time frames. A Selection Form for Continuation of Group Coverage is required. 32 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL The above is a general summary in condensed form of Maryland continuation coverage laws. A person may be eligible under more than one coverage (i.e., continuation or COBRA). If a person is eligible for more than one continuation coverage, such person will receive the continuation coverage that is most favorable at the time of application. A person may receive only one coverage at a time. Duration Periods: DC VA MD 3 months 12 months 18 months CONTENTS > > COBRA (Consolidated Omnibus Budget Reconciliation Act of 1986) Federal legislation that includes a requirement for groups with 20 or more employees to offer extended health insurance coverage at the member’s expense to members and eligible dependents who leave the group or otherwise no longer eligible for the group’s coverage. All applicants eligible for COBRA should complete an individual enrollment application and a COBRA application. The COBRA application should be completed by the applicant and the group administrator. These forms are available in the “For Brokers” section on the CareFirst website. 33 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Enrolling Eligible Dependents Eligible dependents may include a lawful spouse, a same sex or opposite sex domestic partner, biological child, stepchild, legal dependent child of a domestic partner dependent, foster child or grandchild if legal custody has been appointed to the subscriber. Eligible dependents may enroll: ■■ ■■ ■■ ■■ ■■ ■■ Along with newly hired employee. During small employer’s annual open enrollment. Within 31 days of marriage, birth, adoption, obtaining legal custody or guardianship. Within 31 days of lifestyle change as defined by the Health Insurance Portability & Accountability (HIPAA) special enrollment period; this applies to those who initially declined coverage. Within 31 days of loss of employment (voluntary or involuntary) that results in loss of insurance (except gross misconduct). Within 31 days of the expiration of COBRA coverage under another Group plan. Dependent children who meet the definition of a “dependent child” under the Group Contract will now be covered to the last day of the month in which their 26th birthday occurs. Enrolling a newborn always requires an enrollment application, even if the subscriber already has Family coverage. An elderly parent does not meet the contractual definition of a dependent; therefore he/she may NOT be enrolled on the employee’s membership. Full-Time Students Over the Age of 26: Grandfathered Products Only ■■ ■■ ■■ ■■ ■■ Primary Care Dependent (DC- Based Groups); ■■ ■■ No individual is eligible under the Group’s coverage both as a Subscriber and as a Dependent. Full-Time Students: Beginning with renewals effective 10/1/10, Federal law allowed for dependent children, whether fulltime student or not, to be covered on the parents’ group policy until the end of the month in which their 26th birthday occurs. 34 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL Unmarried dependent students may remain eligible as long as they are enrolled as full-time students in an accredited institution and have a student certification form on file with CareFirst. The student will be covered until the end of the month of their graduation. A full-time student is defined as a child who attends a: ●● public or private high school ●● college or university ●● graduate school ●● trade school Attendance must meet the requirements of the institution for full-time status. If an enrolled, over-age student dis-enrolls from the subscriber’s coverage for a period of time and wishes to re-enroll, they may be reinstated onto the subscriber’s policy, providing they still meet the eligibility requirements of a full-time student dependent and are within the age limit. (A Confirmation of Enrollment Form is required.) CareFirst requires proof of full-time student status at the time of enrollment. Forms are available on www.carefirst.com under the Broker portal. ■■ The child must be the Subscriber’s grandchild, niece or nephew. The child must be under the Subscriber’s “Primary Care,” (Primary Care means that the subscriber provides food, clothing and shelter for the child on a regular and continuous basis during the time that the District of Columbia public schools are in regular session); and If the child’s legal guardian is someone other than the Subscriber, the child’s legal guardian may not be covered under an accident or sickness policy. CONTENTS > > Enrolling Eligible Dependents (continued) Disabled Dependents: ■■ ■■ ■■ ■■ ■■ Eligibility may continue past age 26 for unmarried dependents who are mentally or physically incapacitated while covered under the health benefit plan and became disabled prior to reaching the limiting age, or the person was covered as a disabled dependent immediately prior to applying for coverage. Certification of eligibility is required through the submission and acceptance of a Disability Certification For Overage Dependent form. The parent must sign the top portion of the form and the attending physician must complete the bottom portion of the form. Supporting documentation from the physician must be attached to the form when submitted to CareFirst. Once reviewed and accepted by CareFirst, the dependent will be coded as a “disabled dependent” on the subscriber’s policy. If found ineligible to remain enrolled as a disabled dependent, the child may select a Consumer Direct policy. CareFirst may request proof of mental or physical incapacity at any time. Domestic Partner Dependents: Requirements for Domestic Partner eligibility are as follows: ■■ ■■ ■■ ■■ ■■ ■■ Available at the employer’s discretion. Coverage may also be added off-cycle with no rate or renewal date impact. ■■ Suggested that the Subscriber consult with a tax advisor regarding the cost of coverage for a person who is not a spouse or a child through marriage, as payments made by the employer may be taxable income to them. ●● Requirements for eligibility are monitored by the employer and may be subject to audit by CareFirst subsequent to the initial enrollment. ■■ ■■ 35 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL If the couple resides in a jurisdiction that requires or permits registration with that jurisdiction’s government as a domestic partnership, the couple has registered in accordance with the law of that jurisdiction. The Subscriber and the Domestic Partner are the same sex or the opposite sex and both are at least eighteen years of age and have the legal capacity to enter into a contract. The Subscriber and Domestic Partner are not parties to a legally recognized marriage, either to each other or to anyone else. The Subscriber and Domestic Partner share no blood or familial relationship that would bar marriage under the laws of the jurisdiction in which the couple resides, and neither the Subscriber nor the Domestic Partner are a member of another Domestic Partnership or substantially similar relationship within the past 6 months. The Subscriber and Domestic Partner share a close, committed and exclusive personal relationship that is meant to be of lasting duration. The Subscriber and Domestic Partner have a shared common legal residence continuously for at least six months and have submitted documentary evidence of such cohabitation that is satisfactory to the Group. The Subscriber and Domestic Partner are financially interdependent for at least 6 consecutive months prior to application and submit documentary evidence of such interdependence that is satisfactory to the Group; have both signed the appropriate affidavit, enrollment form, or other document(s) required by the Group, confirming their Domestic Partnership and agree to notify the Group, in writing, within thirty (30) days of the date of the Domestic Partnership. Qualifying Life Events allowing the Subscriber to reduce or terminate coverage: Termination of a Domestic Partnership or the death of the Subscriber’s Domestic Partner. CONTENTS > > Enrolling Eligible Dependents (continued) Michelle’s Law: Continued Coverage for Dependents on Medical Leave Michelle’s Law, allows for continued coverage for dependent children who are certified as dependent students when they take a medical leave of absence from a college, university or vocational school (postsecondary educational institution) due to a serious illness or injury. Dependent children on a leave of absence will be covered for one year from the first day of the leave of absence, or until the date on which the coverage otherwise would end, whichever comes first. This law is effective for groups upon their renewal on and after October 9, 2009 and for new groups with effective dates on or after October 9, 2009. Michelle’s Law does not change any benefits. Dependent children on a leave of absence will continue to receive all plan benefits. If the plan changes, dependents will have continued coverage under the new plan until their coverage ends. This law applies to all fully insured, self-insured, and direct bill business; including medical, pharmacy, behavioral health and, when part of the health plan, dental and vision coverage. A dependent is eligible for Michelle’s Law if the following criteria are met: ■■ The policy is in effect ■■ The plan provides dependent coverage ■■ The serious illness or injury and medically necessary leave of absence begins during the plan year ■■ The child was enrolled in the plan, on the basis of being a student at a postsecondary educational institution immediately before the first day of the medically necessary leave of absence ■■ There is written certification from the treating physician reflecting that the leave of absence is medically necessary Subscribers with dependents will be notified of this change whenever a student certification is requested. The attached letter will be included with the student certification form. Additionally, new and renewing groups with effective dates after October 9, 2009 will be notified of these changes when they receive their group contract. 36 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Multiple Option Offerings For both “Grandfathered” and ACA-Compliant groups, up to 3 medical products can be offered to a small group. The following apply to “Grandfathered” groups: ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ New/renewal rates are calculated based on Small Group Rating guidelines. A 2% discount is provided to groups with a single option, if dual or triple option is selected the discount is removed. Participation requirements will be assessed on the total enrollment in the account and not on each option. Employer may apply up to two new hire eligibility periods to defined segments of employees within the same account (i.e. Managers vs. non-Managers, hourly vs. salary). All employee segments must be offered all product options; classing out of employees is not permitted. The options offered must be differentiated by the medical benefits offered, and may not be limited to an “Open Access” or prescription drug benefit differentiation. Dental: If two (2) or three (3) medical plans are offered, two (2) dental plans may be offered as long as the offering includes no more than one (1) option from a product type (Traditional, Preferred PPO or DHMO). If one (1) medical option is offered, a Traditional or Preferred PPO plan may be offered. Two (2) Rx options can be offered if two (2) medical options are offered; three (3) RX options can be offered if there are three (3) medical options offered. 37 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL The following apply to ACA-Compliant groups: ■■ ■■ ■■ ■■ ■■ ■■ ■■ New/renewal rates will be calculated based on the guidelines in the Small Group Rating portion of this manual. Participation requirements will be assessed on the total enrollment in the account and not on each option. All employee segments must be offered all product options; classing out of employees is not permitted. The options offered must be differentiated by the product offered, and may not be limited to a “referral” differential. Dental: If two (2) or three (3) options are offered, two (2) dental plans may be offered as long as the offering includes no more than one (1) option from a product type (Traditional, Preferred PPO or DHMO). If one (1) option is offered, a Traditional or Preferred PPO plan may be offered. “Referral” cannot be used as the only differentiation between the same option number under the same product. CONTENTS > > Movement Between Products CareFirst is made-up of several companies from which our various products originate. These include CFMI; GHMSI and BlueChoice. Although the products offered through these companies are all offered through CareFirst and are all included in our Administrative Manual for Broker of Record transfers and compensation, there are some legislated requirements that come into play when moving between our products. Legislatively, this product movement constitutes movement between carriers because of the way CareFirst is structured. These include, look-back periods for eligibility and paperwork/tax document requirements which would then apply when moving between our various companies. Note that although movement between these products/ companies may require new sales paperwork/ tax documentation, for purposes of broker compensation, movement between our family of products is considered migrated (existing) business and is therefore not applicable under our new sales bonus. Brokers should also be mindful of the Account Installation RENEWAL paperwork submission dates when moving business between our legal entities. 38 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Consumer Driven Health Products (CDH) In the fall of 2006 CareFirst launched the first of the line of products categorized as Consumer Driven Health Products to the MSGR market. The first were BluePreferred Options that combined with a Health Savings Account (HSA) fund or with a Health Reimbursement Account (HRA) fund administered by our vendor, PayFlex. These were launched under the banner of “BlueFund.” At the same time, products were also made available that employers could offer either with no fund or through another administrator referred to as “Compatible.” Then, in July 2006, HSA products were launched to the small group market for September 2006 effective dates based off of the BlueChoice Open Access HMO and the BlueChoice Opt-Out Plus Open Access products. In August 2009, BlueChoice HMO HRA products were introduced for effective dates of September 1, 2009. These included unique employee funding requirements new to the CareFirst portfolio. With the advent of the 2014 ACA pricing methodologies, HRA’s and HSA’s have been priced under one CDH category and no longer have variable rating. Although quite popular and cost competitive, these products require much understanding of IRS regulations and CareFirst business rules on the part of the broker. The CareFirst sales representative and the General/Full Service Producers provide ongoing training on these products and are able to provide additional training upon request as needed. 39 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL When selling CDH products, please keep the following in mind: ■■ Additional lead time is required with these products to ensure that employers and employees understand how the product works and to get the most out of the funding, if applicable. ■■ It is strongly recommended that CDH plans not be sold exclusively, but instead along with a second alternative or if “BlueFund” is sold, with the corresponding “Compatible” plan. By doing so, those ineligible for funding either as new hires or during the year will have an alternative option to accommodate them. ■■ Brokers should use the “accelerated funding” process for the set-up of BlueFund HSA bank accounts. The instructions and forms necessary for completion are available on the Broker Portal under “Broker Resources.” ■■ A 1st of the month effective date for groups electing a CDH product is recommended. This will allow the group to choose a Calendar or Contract year benefit period. A 15th of the month effective date automatically defaults to a Calendar year deductible which can negatively impact the group. Please refer to our HSA and HRA Reference Guides located at www.carefirst.com for basic business rules for this line of CDH products to be used as a quick reference to brokers selling these products. CONTENTS > > Small Group Rating All ACA rating is guarantee issue and medical underwriting of groups as well as the application of new group discounts is no longer applicable. The ACA has required that groups be rated based on a per member basis; that is, each member will be rated based on their age. This methodology will be used for all new group quotes and for any nongrandfathered renewals. For families, each member will be rated individually, and these rates will be combined to form a family premium. ■■ For children under the age of 21, only the rate for the 3 oldest children will be counted ■■ For dependents age 21–25, the rate for each dependent will be counted ■■ Rates for ages 0–20 are the same, and the rates for 21–24 are the same ■■ Rates vary each year beginning at age 25 Rates may only vary by the following factors: ■■ 3:1 for age ■■ 1.5:1 for tobacco use (note that CareFirst has chosen not to rate for tobacco use in 2014) ■■ Geography The Rx benefit will now be part of the medical option chosen and the rate will be combined with the Medical rate. No longer will the Group separately choose a medical option and a Rx option. Metal Level: The ACA has also introduced “metal levels” to the rating model. The metal levels represent a range of actuarial values or “AV’s” that reflect the percentage of expected health care costs, both medical and Rx, a specific health plan will cover for the “standard” population. All non-grandfathered health plans must fall into a metal level. ■■ Bronze (58%–62%) ■■ Silver (68%–72%) ■■ Gold (78%–82%) ■■ Platinum (88%–92%) 40 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL All standard CareFirst product offerings will have a .60AV or better. Dental, vision, and grandfathered products will continue to use tiered rating. Medicare rates have been eliminated; subscribers with both Medicare parts A&B will receive a per member rate based on their age. The Retiree Rider has been eliminated for renewal and sale to non-grandfathered groups and coverage will not be extended to newly enrolling retirees. Retirees currently enrolled may remain on the group plan as long as the group extends coverage to them. For “grandfathered” products: BluePreferred and BlueChoice use average age rating. Standard Group Over 65 ■■ ■■ Accounts that had a non-SEGO Standard Group over 65 product in place prior to July 1, 1999 with active enrollment will be allowed to continue to offer that product to their Medicareeligibles and retirees. If enrollment in this product drops to 0, the Standard Group Over 65 product will be terminated and will not be reinstated. Grandfathered BlueChoice and BluePreferred: ■■ ■■ ■■ Under the BluePreferred options, and at the employer’s election, retirees and their dependents may currently have been offered health benefits through the Retiree Rider by opting “yes” to the “retiree” HB8 question on the rating proposal. Retirees are not included in the group eligible count nor counted toward participation. Retirees (CFMI/GHMSI BluePreferred are included in the group census; >65 Retirees with Medicare Parts A & B are capped at age 48; <65 Retirees are rated using their current age.) CONTENTS > > Small Group Rating (continued) ■■ ■■ ■■ ■■ ■■ ■■ If a group currently offering the Retiree Rider ceases to exist, there is no COBRA benefit. Non-TEFRA: Employer can offer coverage to their active Medicare-eligible employees by opting “yes” to the “other insurance” HB8 question on the Group Application. Non-TEFRA: Active Medicare-eligibles must be included in the under 65 census along with their spouses. TEFRA: Active Medicare eligibles are always offered benefits and the HB8 election of “yes” to “other insurance” will not apply to them. TEFRA: Active Medicare-eligibles are included in the under 65 census at their actual age and billed the under 65 rate. Non-TEFRA: The Medicare-eligible’s age is currently capped at age 48 and the spouse’s age is currently capped at 48 if they have Parts A & B, and actual age if they have Part A only or are not Medicareeligible. Applicable to all Grandfathered products: If the active employee is under age 65 and the spouse is over 65 with Parts A & B of Medicare: ■■ The spouse should not be included in the under 65 census. ■■ The employee should be included in the under 65 census at their actual age. ■■ They should be enrolled as “Husband/Wife” or “Family,” if appropriate. Medicare Only Enrollment: ■■ ■■ ■■ ■■ New groups whose enrollment is based solely on enrollees with Medicare A & B will not be accepted. Groups with under 65 enrollment of “0” and at least 1 active Medicare Complementary enrollee cannot be termed. Groups should be terminated if the under 65 enrollment drops to “0” and the enrollment in Medicare Complementary consists only of retirees. Grandfathered Standard Group Over 65 products will remain in-force as long as enrollment remains in the product. 41 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > New Business Beginning January 1, 2014 any District of Columbia employer group not currently offering group health benefits that then elects to offer group health benefits must purchase those benefits through the DC Health Link (SHOP). Physical Address: All new accounts must provide their physical address on the new sales paperwork. The physical address allows us to verify the account eligibility and provides us with an address for priority deliveries including contracts. Likewise, the physical address of all subscribers is required prior to enrollment. County Code: The address and county code used for rating purposes must be the headquarters of the group, not a branch office location. If there is a question, CareFirst reserves the right to investigate the actual headquarters of the business through use of the internet and business listings. Point of Enrollment—Blue Selections: The “Referral” feature may not be the only variation between 2 options of the same plan. HealthyBlue Advantage CDH cannot be offered with BlueChoice Plus, BlueChoice Plus CDH HealthyBlue Advantage non-CDH cannot be offered with BlueChoice Plus, BlueChoice Plus CDH BlueChoice Advantage CDH cannot be offered with BlueChoice Plus, BlueChoice Plus CDH BlueChoice Advantage non-CDH cannot be offered with BlueChoice Plus, BlueChoice Plus CDH Effective Dates for new groups in DC and VA are available on the1st or 15th of the month. Please contact your General/Full-Service Producer, CareFirst Broker Sales Representative or refer to the Broker Administrative Manual for deadlines. 15th of Month Effective Dates: This initial effective date is available under all medical products. The account will then renew 12 and 1/2 months later. CareFirst strongly recommends this option not be used; as 15th of the month effective dates necessitate a calendar year benefit period. Initial Premium Requirement: For all non-FSP business, the first month’s premium is required in order for the new account to be processed. For accounts effective on the 15th of the month, premium will be prorated with the first 43–47 days required based on the number of days in the month. 42 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Requesting a Quote Brokers doing business with General or Full-Service Producer: When requesting a proposal, please provide your General/Full-Service Producer with the following information about the prospective group regardless of group size. ■■ Name of company ■■ Main location’s physical address and all other locations ■■ Census information including dates of birth for employees and covered spouse/dependents ■■ Product information ■■ Number, nature of business and SIC codes of employees located outside the service area ■■ Federal Employer Size ■■ Full-Time Equivalent (FTE) calculation CareFirst Direct Brokers: When requesting a proposal, please provide your Broker Representative with the following information about the prospective group regardless of group size. ■■ Name of company ■■ Main location’s physical address and all other locations ■■ Census information including dates of birth for employees and covered spouse/dependents ■■ Product information ■■ Number of employees located outside the service area ■■ Federal Employer Size ■■ Full-Time Equivalent (FTE) calculation 43 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > New Group Paperwork For a checklist of items needed for new and renewing groups click on the following link: http://www.carefirst.com/brokers/html/ BrokerChecklist.html Note: If any item is incomplete or not received by the cut-off date, the document will be returned, which may result in the Group changing its effective date. 44 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Renewal Business All CareFirst renewals are rated based on the sum of the combined actual enrollment in all the product(s) offered. New enrollment applications are required when a change to another product is made. Migrating Business: ■■ ■■ ■■ Business migrating between CFMI/GHMSI BluePreferred and BlueChoice is considered “existing” business even though new group paperwork may be required and as such is not considered “new” business for purposes of CareFirst’s new business bonus schedule. Business migrating between CFMI/GHMSI BluePreferred and BlueChoice is considered “existing” business even though new group paperwork may be required and as such follows the renewal paperwork deadlines. Broker of Record Transfer letters are required when the non-incumbent broker migrates any CareFirst account from one CareFirst company to another. Changing Subscriber to Younger Age: ●● If a husband and wife (working for the same employer) wish to switch the main policyholder to the younger of the two, they may submit an application and alter the membership during the annual open enrollment. The renewal is then re-rated based on this membership change. Remember, requests for census changes to renewals must be submitted directly to CareFirst Small Group Underwriting or through the General/ Full Service Producer and are limited to one request per group per renewal. ■■ Census change requests are not applicable to ACAcompliant products. County Code Changes: ■■ Census Change Only “Grandfathered” Products: ■■ ■■ ■■ Requests for census changes must be submitted directly to CareFirst Broker Sales or through the General/Full Service Producer using the “Request for Average Age/Average Factor Adjustment” form. Census change only requests for these products can be made through the end of the month prior to renewal. Note that a group wishing to make a benefit change to a “grandfathered” product will no longer be “grandfathered” for that product and must choose from an ACA compliant option. Changing from a H/W or Family Contract to 2 Individual Contracts: ●● If a husband and wife (working for the same employer) wish to change their membership category from Husband/Wife to two Individuals, they may submit two applications and alter their membership during the annual open enrollment. The renewal is then re-rated based on this membership change. 45 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL ■■ The address and county code used for rating purposes must be the headquarters of the group, not a branch office location. If there is a question, CareFirst reserves the right to investigate the actual headquarters of the business through use of the internet and business listings. The address and county code must be updated in FACETS either through Broker Sales or through the General/Full Service Producer prior to a request for a recalculation of rates being submitted; this may only be done in conjunction with the group’s renewal, and must be done at least 3 days in advance of the A/I cut-off so as to allow time for the renewal rate recalculation and the approval by the group. CONTENTS > > Renewal Business (continued) Benefit Changes During Contract Year (for contract year benefit periods): Note that a benefit change made to a “grandfathered” product may eliminate the ability for the group to remain “grandfathered”. A group is required to choose an ACA-compliant product if the change results in one of the following: 1. Elimination of all or substantially all benefits to diagnose or treat a particular condition. 2. Increase in a percentage cost-sharing requirement (e.g. raising an individual’s coinsurance requirement from 20% to 25%). 3. Increase in a deductible or out-of-pocket maximum by an amount that exceeds medical inflation plus 15 percentage points. 4. Increase in a copayment by an amount that exceeds medical inflation plus 15 percentage points (or, if greater, $5 plus medical inflation). 5. Decrease in an employer’s contribution rate towards the cost of coverage by more than 5 percentage points. 6. Imposition of annual limits on the dollar value of all benefits below specified amounts. ■■ ■■ ■■ ■■ Mid-contract year benefit changes are defined as any change initiated by the account to alter the non-grandfathered product selection and does not include CareFirst initiated product changes. Requests for benefit changes to existing products or movement between products offered by the same CareFirst entity will not be approved 90 days prior to the account’s current renewal date. Accounts wishing to make off-renewal benefit changes may do so on the first of the month after their renewal or new sale. The effective date of the medical benefit change will become the new renewal date. 46 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL ■■ ■■ ■■ Under a contract year benefit period, Preferred and Traditional dental products and vision products can be added to the group mid-contract year without affecting the medical renewal date. When adding or changing products during the contract year, a signed proposal as well as any contract and supporting documents must be provided. Termination of either medical or ancillary, but not both products must be done as a benefit change and not a termination to avoid termination of both products. Benefit Changes at Renewal: Note prior section: changes that affect “grandfathering” ■■ Termination of medical or ancillary, but not both products must be done as a benefit change and not a termination to avoid termination of both products. Benefit Changes with a Jurisdiction Change at Renewal: ■■ Benefit Changes must be received prior to deadline ●● If group is located in VA and moves to MD or DC, the group can keep their current VA benefits (regardless of medical product). The group cannot change their benefits unless they accept MD/DC benefits. ●● If group is located in DC and moves to VA, within our service area, or MD, the group can keep their current DC benefits (regardless of medical product). The group cannot change their benefits or make enrollment changes unless they accept VA/MD benefits. CONTENTS > > Existing Groups that Move Their Headquarters Outside of MD, DC, N. VA Unless “grandfathered”, these groups will be termed upon renewal. 47 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Request for Anniversary Date Change Written request (in letter format) must be provided to Small Group Underwriting for any change of group anniversary date including the following: ■■ Group name and number ■■ Statement to include: “the group would like to move to MM/DD/YYY renewal from a MM/DD/ YYYY renewal” ■■ Statement noting that the group understands that their rates will change effective MM/DD/ YYYY and this may result in an increase in premium ■■ Letter must be signed by Group Administrator 48 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Contract Issuance Group contracts are issued within 90 days of receipt of appropriate group contract application. The process for distributing group contracts has changed. Effective immediately, you will notice the following: ■■ A contract will be completed for each group that renews, even if no changes are made. ■■ Upon renewal, groups will receive one contract and two benefit booklets for each product they have. To request additional paper or electronic copies of the Group Contract or Member Benefit Booklet, an email can be sent to our Contracts Department at [email protected]. ■■ A new letter will be included in the package that’s sent to groups to provide additional information about this change. For those groups who choose multiple benefit options, any outstanding products that are not enclosed may be shipped separately. 49 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Matrix: Eligibility, Rating & Participation Included in FTE count for determination of group size? Eligible for Benefits? Valid Waiver? F/T emp enrolling w/ CareFirst/no other insurance product YES YES YES F/T emp w/ no ins coverage, not enrolling YES YES YES F/T emp w/ other health plan offered by their employer YES YES NO P/T emp, not enrolling ( including Independent Contractor/1099 emp**, ***) YES YES YES P/T emp (17 1/2 hrs, 4 consec months), enrolling for coverage* (including Independent Contractor/1099 emp**, ***) YES YES YES Seasonal emp YES NO NO F/T emp w/ other group sponsored coverage not enrolling YES YES NO FT emp w/ other group sponsored coverage enrolling for coverage* YES YES NO F/T emp w/ CD coverage, not enrolling YES YES YES F/T emp w/ CD coverage, enrolling for coverage* YES YES YES F/T new hire in probationary period (not yet enrolling) YES NO NO COBRA w/ current grp (no longer emp, enrolling for coverage) includes divorced dep or qualified beneficiary NO YES NO F/T emp. w/COBRA from previous employer (keeping previous group sponsored coverage, not enrolling) YES YES NO Employee Categories 50 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Matrix: Eligibility, Rating & Participation (continued) Included in FTE count for determination of group size? Eligible for Benefits? Valid Waiver? F/T Independent Contractor (1099 emp)**, * (with/without other group sponsored coverage enrolling) NO NO NO F/T Independent Contractor (1099 emp)**, * (with other group sponsored coverage not enrolling) NO NO NO F/T Independent Contractor (1099 emp)*** (without other group sponsored coverage not enrolling) NO NO NO F/T emp w/MSA enrolling YES YES YES F/T emp w/Medicare Parts A&B, enrolling for coverage YES YES YES F/T emp w/VA coverage, not enrolling YES YES NO F/T emp w Public Exchange Subsidy, not enrolling YES YES NO Employee Categories *For “grandfathered” products and at the option of the employer, part-time employees meeting the criteria, full-time employees with other group sponsored coverage and retirees (effective 3/1/11only filed for CFMI/GHMSI BluePreferred may be offered small group coverage. “Group sponsored” coverage includes Medicare and Medicaid, and all other competitors’ group products. **Under ACA-compliant groups, part time employees may be offered coverage; independent contractors (1099’s) and retirees may not. ***For “grandfathered” products only and at the option of the employer, full-time independent (1099) contractors may be offered the small group coverage. If so, all must be offered coverage and will be considered eligible. If enrolling, will be rated and applied towards the 75% participation requirement. Note: Reference to COBRA above also refers to Continuation 51 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Medicare Eligibility, Rating And Participation for “Grandfathered” Products Only Medicare Only Enrollment ■■ ■■ Groups whose enrollment is based solely on enrollees with Medicare A & B are not eligible for group coverage. Anyone enrolling in any of CareFirst’s Medicare Secondary products must have parts A & B of Medicare. ●● Benefits for retirees are only available if covered under the group’s prior coverage. ●● Non-TEFRA: Employer can offer coverage to their active Medicare-eligible employees. ●● Non-TEFRA: Active medicare-eligibles must be included in the census along with their spouses but not included in the average age. ●● TEFRA: Active Medicare-eligibles are included in the census at their actual age and billed the under 65 rate. Only the nonMedicare spouse would be included in the average age. ●● If the active employee is under age 65 and the spouse is over 65 with Parts A & B of Medicare: ›› The spouse should not be included in the census ›› The employee should be included in the census at their actual age and enrolled as “Husband/Wife” or “Family,” if appropriate 52 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL ●● ●● ●● ●● At the option of the employer, retirees (available only if covered under their prior plan) and full-time 65+ employees with other group-sponsored coverage including Medicare, may be offered the small group coverage. Active employees with Medicare A&B in a TEFRA group have the group coverage as primary and are counted towards the eligible employee and minimum participation counts. The Medicare rate has only the individual tier coverage level. Groups with only Medicare-eligible employees enrolling will not be accepted. CONTENTS > > Medicare Eligibility, Rating And Participation for “Grandfathered” Products Only (continued) GRANDFATHERED Renewal Rating: Medicare Eligibles BlueChoice/BluePreferred Rate EE (employee) Rate SP (spouse) Rate CH (child) 1 EE is Medicare Rate EE as Medicare if Non-TEFRA and enroll as Medicare; If TEFRA, use EE actual age, and enroll as Individual. N/A N/A 2 EE is Medicare + SP Rate EE as Medicare if Non-TEFRA and enroll as Medicare; If TEFRA, use EE actual age, and enroll as (Ind/Adult). Rate spouse as Individual using their real age if Non-TEFRA, and enroll as Individual; If TEFRA, spouse is not rated separately. N/A 3 EE + SP is Medicare Rate on Employee ONLY using their real age as EE is <65. Must enroll as (Ind/Adult). N/A N/A 4 EE is Medicare + SP is Medicare Rate EE as Medicare if Non-TEFRA and enroll as Medicare; If TEFRA, use EE actual age, and enroll as (Ind/Adult). Rate spouse as Medicare if Non-TEFRA, and enroll as Medicare; If TEFRA, spouse is not rated separately. N/A 5 EE is Medicare + CH Rate EE as Medicare if Non-TEFRA, and enroll as Medicare; If TEFRA, use EE actual age, and enroll as Individual/Child(ren). N/A Rate Child as Individual if Non-TEFRA, and enroll as Individual; If Child is <16, rate at age 16 as this is minimum age allowed for rating; If TEFRA, Child is not rated separately. 6 EE + CH is Medicare Rate on Employee ONLY using their real age as EE is <65. Must enroll as Individual/Child(ren). N/A N/A 53 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Medicare Eligibility, Rating And Participation for “Grandfathered” Products Only (continued) Rate EE (employee) Rate SP (spouse) Rate CH (child) 7 EE is Medicare + CH is Medicare Rate EE as Medicare if Non-TEFRA, and enroll as Medicare; If TEFRA, use EE actual age, and enroll as Individual/Child(ren). N/A Rate Child as Medicare if Non-TEFRA, and enroll as Individual; If TEFRA, Child is not rated separately. 8 EE is Medicare + SP + CH Rate on Employee ONLY using their real age; Must enroll as Family. N/A N/A 9 EE + SP is Medicare + CH Rate on Employee ONLY using their real age; Must enroll as Family. N/A N/A 10 EE is Medicare + SP is Medicare + CH Rate on Employee ONLY using their real age; Must enroll as Family. N/A N/A 11 EE + SP + CH is Medicare Rate on Employee ONLY using their real age; Must enroll as Family. N/A N/A 12 EE is Medicare + Two or more CH Rate on Employee ONLY using their real age; Must enroll as Family. N/A N/A 13 EE is Medicare + SP + CH is Medicare Rate on Employee ONLY using their real age; Must enroll as Family. N/A N/A 14 EE + SP is Medicare + CH is Medicare Rate on Employee ONLY using their real age; Must enroll as Family. N/A N/A 15 EE is Medicare + SP is Medicare + CH is Medicare Rate on Employee ONLY using their real age; Must enroll as Family. N/A N/A 54 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Dental Benefits CareFirst offers a varied line of dental products including voluntary and employer sponsored Traditional, Preferred (PPO) and DHMO. The ridered products are only available for “grandfathered” groups. There is also a core Discount Dental fee schedule for BlueChoice members. Each of these utilize different networks of providers and all can be accessed via the CareFirst.com website. Beginning 1/1/14, we no longer offer parallel dental benefits to medical unless the medical product is “grandfathered”. Dental Overview: Large provider network across Maryland, D.C. and Virginia. ■■ Members outside of CareFirst’s service area in Traditional and Preferred products have access to a national network of participating dentists. DentalGRID replaced DNoA for out of area providers in May 2012. ■■ Unified portfolio of Traditional, Preferred(PPO) and DHMO dental products. ■■ Ability to sell dental products with medical coverage, freestanding or as part of a POE/Blue Selections combination. ■■ Voluntary plans offer lower participation requirements and no employer contribution. ■■ Consistent underwriting methodology and business rules: ●● Comprehensive benefits—emphasis on preventive care ●● No balance billing for members when using in-network services ●● No claim forms for members to file when using in-network services ●● Ability to add orthodontics coverage (up to age 19) to Traditional and Preferred (PPO) plans. Orthodontia is included in the DHMO products. ●● Medically necessary orthodontia is included for members up to age 19 in BlueDental Preferred and BlueDental Traditional. ■■ 55 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL ●● ●● All dental products (Traditional, Preferred, and DHMO) combine for participation requirements. Pediatric dental is an “essential health benefit” and is included in all ACA medical plans. Business Rules: Employer sponsored: the employer contributes at least 50% of the cost of Individual coverage Voluntary: 100% employee paid ■■ Groups offering one medical plan can offer a DHMO plan combined with either a Traditional or Preferred plan. ■■ Groups offering two or three medical plans, can offer up to two dental plans. ●● Note: If group is offering two dental plans, the two dental offerings must be selected from different product types. ●● The three product types are: ›› Traditional ›› Preferred (PPO) ›› DHMO (HMO or Opt-out) ◆◆ Example: Group offering two dental plans could choose one Traditional plan and one Preferred dental plan. ■■ New and renewing employer sponsored groups must have 75% of eligible employees enrolling in the dental plans offered (Traditional, Preferred, and DHMO). ■■ Groups whose renewal is released with medical and a dental option, but choose to terminate the medical must re-write the dental on a Freestanding basis. Voluntary (above business rules apply): ■■ ■■ New and renewing voluntary Traditional and Preferred participation requirement: dental must have the lesser of 10 employees or 35% of eligibles. New voluntary Traditional and Preferred dental group: 12 month benefit waiting period for classes 3, 4, and 5 will apply if group did not have 12 months prior dental coverage with CONTENTS > > Dental Benefits (continued) ■■ ■■ another dental carrier. “Proof of Prior Group Dental Coverage for Voluntary Dental” waiver form should be used to verify prior coverage. If a group purchases more than 1 voluntary dental plan, the benefit waiting period must be the same for both products. New and renewing voluntary dental can be sold with either employer sponsored or voluntary vision and can be sold with a calendar or contract year benefit period. Parallel Group Enrollment “GRANDFATHERED”Medical Only: ■■ ■■ ■■ ■■ For groups that offer both medical and dental benefits, parallel group enrollment means that all eligible employees may choose either: ●● Medical & Dental OR ●● No coverage All employees must enroll in medical and dental under the same coverage level. (Example: Family Medical, Family Dental) Ridered DHMO dental is offered as parallel only. Voluntary Dental products may not be offered as parallel. ■■ ■■ ■■ ■■ For groups that offer both medical and dental benefits, non-parallel group enrollment means that all eligible employees may choose either: ●● Medical & Dental ●● Medical Only ●● Dental Only: Traditional, Preferred and DHMO ●● No coverage Employees may enroll differently in medical and dental. (Example: Family Medical, H/W Dental) Exception: Even though the employer has selected non-parallel group enrollment, anytime Ridered DHMO dental is offered and selected by someone enrolling in BlueChoice medical, the member must enroll in Ridered DHMO dental at the same coverage level that they selected for medical. For example, if a member chooses BlueChoice family medical coverage, they must choose family Ridered DHMO coverage. Exception: Retirees may not enroll in dental only; even if the group is set up as non-parallel. Retiree must be enrolled in BluePreferred or SPPP to enroll in dental. 56 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL BlueChoice BluePreferred DHMO Dental Traditional Dental Important Note: BlueChoice members can select Ridered DHMO or Traditional. If Ridered DHMO is selected, the member must enroll in the dental at the same coverage level selected for the medical. If member elects the Traditional they may enroll differently in the medical & dental as the employer has selected Non-Parallel group enrollment. BluePreferred members can only select Traditional, but may enroll differently in medical and dental. Ridered DHMO Enrollment: GRANDFATHERED PLANS ONLY ■■ Non-Parallel Group Enrollment: ■■ POE Example: POE existing of BlueChoice and BluePreferred. Group is offering both Traditional and DHMO dental. Non-Parallel Group Enrollment selected. ■■ ■■ Ridered DHMO enrollment will always be parallel to the medical enrollment even if the employer has chosen non-parallel group enrollment (i.e. BlueChoice family medical / Ridered DHMO family dental). In a POE/Blue Selections combination, BlueChoice members do not have to choose Ridered DHMO coverage if multiple dental products are offered. If they do choose Ridered DHMO, they must have parallel enrollment. Members enrolling in BluePreferred medical products cannot enroll in Ridered DHMO dental. Short Plan Year Dental ■■ ■■ ■■ Dental products or orthodontia benefits can be added to existing medical plans for a short plan year without affecting the medical renewal month. No changes can be made 90 days prior to the renewal date. You may not change, remove or add dental during this timeframe. A group can replace their current employer sponsored dental with voluntary dental (or the reverse) prior to renewal, as long as it is not within 90 days of the renewal date. CONTENTS > > Dental Benefits (continued) Freestanding DHMO (Provider Choice $5/$10/$20) ■■ ■■ ■■ ■■ ■■ ■■ ■■ Definition: DHMO underwritten by BlueChoice that can be offered alongside CareFirst Traditional and Preferred Dental products and/or medical products or without other CareFirst medical or dental products. Freestanding DHMO may be offered alongside a Freestanding Traditional or Preferred dental product. TDN’s “Provider Choice” products. Enrollment in these products is combined with Traditional and Preferred product enrollment to meet total participation requirement of 75%. There is no participation requirement for the Freestanding DHMO if offered with no other CareFirst dental product. Available to groups with 2 eligibles; 1 enrolling. Must be offered non-parallel. ■■ ■■ ■■ ■■ ■■ ■■ Freestanding Dental Business Rules ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ Definition: An account with CareFirst dental coverage and medical coverage with another carrier. Employer sponsored or voluntary Traditional and Preferred products as well as the employer sponsored Freestanding DHMO products can be sold as freestanding. 75% participation of eligible employees required for employer sponsored Traditional and Preferred products. No participation requirement on the Freestanding DHMO products; must have 2 enrolled. Group must prove medical coverage with another carrier by submitting current health carrier invoice. Freestanding dental groups may offer one Traditional or Preferred Dental plan plus a DHMO (Preferred Choice) plan. BlueVision Plus may be added “short plan year” to an existing Freestanding Dental product. Freestanding Dental may only be sold with first of the month effective dates. Freestanding Dental may not be sold 15th of the month. New and renewing groups with Freestanding Traditional and Preferred dental currently receive a 15% rate load. 57 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL ■■ There is no rate load on freestanding ACA compliant BlueDental Preferred and BlueDental Traditional. Freestanding Traditional and Preferred dental groups in DC and VA will be sold under a GHMSI contract. Freestanding Dental must be offered non-parallel. New and renewing voluntary Traditional and Preferred dental must have the lesser of 10 employees or 35% of eligibles. New voluntary Traditional and Preferred dental group: 12 month benefit waiting period for classes 3, 4, and 5 will apply if group did not have 12 months prior dental coverage with another dental carrier. “Proof of Prior Group Dental Coverage for Voluntary Dental” waiver form should be used to verify prior coverage (under “Miscellaneous Forms” section of Broker website). If a group purchases more than 1 voluntary dental plan, the benefit waiting period must be the same for both products. New and renewing voluntary dental can be sold with either employer sponsored or voluntary vision and can be sold with a calendar or contract year benefit period. BlueChoice Discount Dental: ■■ ■■ ■■ The BlueChoice Discount Dental is core to all BlueChoice medical products and is not available to any other CareFirst products. A fee schedule of discount fees rather than a percentage of discounts is used. The Discount Dental fee schedule is an added feature to the BlueChoice product line and is not a contractual benefit; nor can it be carved out of the benefit/rate package. CONTENTS > > Vision Benefits Overview: CareFirst offers an array of employer sponsored as well as voluntary BlueVision Plus options. BlueVision is not core to ACA-compliant medical plans. ■■ Vision is being offered by CareFirst BlueCross BlueShield through Davis Vision.* ■■ BlueVision is included as a core benefit TO “GRANDFATHERED” GROUPS ONLY EXCEPT in the following options: ●● BlueChoice HMO Open Access HRA Option 3 CORE ●● BlueChoice HMO Option 6 CORE (but may be purchased) ●● SPPP Option D CORE (but may be purchased) ■■ BlueVision offers a comprehensive eye exam for a $10 copay and discounts on eye ware including lenses, frames and contacts once per benefit period (12 month period) to “grandfathered” groups only. ■■ BlueVision Plus offers a comprehensive eye exam and the opportunity to receive one free pair of eyeglasses or a supply of contact lenses each benefit period (12 or 24 month period). ■■ 12/12/12, 24/24/24, or 12/12/24 (exam/lens/ frame) benefit periods are offered based on the option purchased under BlueVision Plus. ■■ The BlueVision Plus plan is installed on the same platform as the medical plan for the Account. ■■ Voluntary plans have no participation requirements and no employer contribution and are sold non-parallel only. ■■ Pediatric vision is an “essential health benefit” and is included in all ACA medical plans. Business Rules: Employer sponsored: the employer contributes at least 50% of the cost of Individual coverage Voluntary: 100% employee paid ■■ BlueVision (the core product) always has parallel enrollment to “grandfathered” groups only. ■■ Employer sponsored BlueVision Plus may be sold non-parallel. ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ New and renewing employer sponsored accounts must have 75% of eligible employees enrolling in the BlueVision Plus plan and must contribute at least 50% of the individual premium. Employer sponsored freestanding vision and vision offered with dental is available for accounts with 2 eligible, one enrolled. Voluntary BlueVision Plus will be sold as nonparallel. Voluntary freestanding BlueVision Plus and BlueVision Plus offered with dental has no participation requirement on the vision. Voluntary BlueVision Plus has no benefit waiting period. Short plan year changes to add BlueVision Plus or to change from employer sponsored to voluntary (or the reverse) can be made; except 90 days prior to the Account’s renewal and will not cause the entire account to be re-rated or the account to renew as a result. Groups whose renewal is released with medical and BlueVision Plus, but choose to terminate the medical may re-write the vision on a Freestanding basis. Groups can change their parallel/non-parallel enrollment status upon renewal. ●● if the group is changing their medical benefits; OR ●● if the group is adding Dental or BlueVision Plus. BlueVision Plus is not an age-rated product, therefore, enrollees with vision only will not be included in the average age. BlueVision Plus may be offered on a contract or calendar benefit year period. For all 1–50 groups (regardless of medical product), the BlueVision Plus tier rate structure must be consistent with the medical tier structure. Freestanding Vision must be offered non-parallel. Ridered Vision is only available to “grandfathered” groups that currently rider vision. All new business is non-ridered/nonparallel. * CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. contract with Davis Vision to offer an extensive national network of optometrists, ophthalmologists and opticians. Davis Vision is an independent company that provides administrative services for vision care to CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. members. Davis Vision is solely responsible for the services it provides. 58 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > DC/VA Product Portfolio Brokers have found our Product Portfolio to be a useful tool in quickly referencing all of the options offered under CareFirst’s varied product lines with a high level description of each option. The online Benefit Summaries available on the Broker website can then be used to reference detailed benefits for each option. Please visit CareFirst’s broker portal under Quick Links for the most recent product portfolio. 59 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > DC and VA Group Contract Application Matrices ACA District of Columbia OFF-SHOP Products Effective 1/1/2014 Note: No Retiree Coverage is available under ACA Medical Product(s) SOLD SOLD With or Without Traditional/Preferred Dental/BlueVision Plus Required Group Applications Employer Sponsored/ Voluntary Section A BlueChoice HMO Product(s) OFF-SHOP BlueChoice HMO Referral BlueChoice HMO Referral HSA/HRA BlueChoice HMO BlueChoice HMO HSA/HRA HealthyBlue HMO HealthyBlue HMO HSA/HRA BlueChoice Plus 100%/80%, $10/$20 NO – DC/CFBC/BCBCOO-OA/GCA/SG (1/14) DC/CFBC/BC-BCOO-OA/ GCA/SG (1/14) YES – Use DC Pointof-Enrollment (POE) Application listed below This is the ONLY application that you will need to complete BlueChoice Plus 100%/80%, $20/$30 BlueChoice Plus 100%/60% $20/$30 Section B District of Columbia Point-of-Service Product(s) OFF-SHOP BlueChoice Plus HSA/HRA $1500 BlueChoice Plus $2000 BlueChoice Plus HSA/HRA $2000 BlueChoice Plus HSA/HRA $3500 Yes or No – The DC POS Group Contract Application covers the Traditional/Preferred Dental and BlueVision Plus if sold DC/GHMSI/CFBC/POS/GCA/ SG (1/14) HealthyBlue Plus HealthyBlue Plus HRA/HRA BlueChoice Advantage BlueChoice Advantage HSA/HRA HealthyBlue Advantage HealthyBlue Advantage HSA/HRA 60 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > DC and VA Group Contract Application Matrices (continued) ACA District of Columbia OFF-SHOP Products Effective 1/1/2014 Note: No Retiree Coverage is available under ACA Medical Product(s) SOLD SOLD With or Without Traditional/Preferred Dental/BlueVision Plus Required Group Applications Employer Sponsored/ Voluntary Section C District of Columbia CareFirst BluePreferred Product(s) OFF-SHOP BluePreferred PPO BluePerfered PPO HSA/HRA HealthyBlue PPO HealthyBlue PPO HSA/HRA Yes or No – DC PPO Group Contract Application covers the Traditional/Preferred Dental and BlueVision Plus if sold DC/GHMSI/GCA/SG(1/14) (PPO) Point-of-Enrollment Group Contract Application (POE) Note: Any time you are selling multiple ACA medical products together from Sections A, B and C, with or without Traditional/Preferred Dental and/or BlueVision Plus, you can use one of the following POE Applications for all products sold. This is the ONLY application that you will need to complete. You will also use the POE Application when you are adding Traditional/Preferred Dental and/or BlueVision Plus to any Section A Product or combination of Section A Medical Products. Point-of-Enrollment (POE) – DC Section D DC/GHMSI/CFBC/POE/GCA/ SG (1/14) Freestanding Traditional/Preferred Dental, Blue Dental Traditional/Preferred, and/or BlueVision Plus Only use when there is no medical plan with CareFirst. Group Contract Application For Freestanding Dental and Freestanding Vision Products – DC 61 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL DC/GHMSI/GCA/SG (1/14) (D-V Only) CONTENTS > > DC and VA Group Contract Application Matrices (continued) ACA Virginia OFF-SHOP Products Effective 1/1/2014 Note: No Retiree Coverage is available under ACA Medical Product(s) SOLD SOLD With or Without Traditional/Preferred Dental/BlueVision Plus Required Group Applications Employer Sponsored/ Voluntary Section A BlueChoice HMO Product(s) OFF-SHOP BlueChoice HMO Referral BlueChoice HMO Referral HSA/HRA BlueChoice HMO BlueChoice HMO HSA/HRA HealthyBlue HMO HealthyBlue HMO HSA/HRA NO – VA/GRPAPP/HCR (1/14) (HMO) VA/GRPAPP/HCR (1/14) (HMO) YES – Use VA Pointof-Enrollment (POE) Application listed below This is the ONLY application that you will need to complete BlueChoice Plus 100%/80%, $10/$20 BlueChoice Plus 100%/80%, $20/$30 BlueChoice Plus 100%/60% $20/$30 Section B Virginia Point-of-Service Product(s) OFF-SHOP BlueChoice Plus HSA/HRA $1500 BlueChoice Plus $2000 BlueChoice Plus HSA/HRA $2000 BlueChoice Plus HSA/HRA $3500 Yes or No – The VA POS Group Contract Application covers the Traditional/Preferred Dental and BlueVision Plus if sold VA/GRPAPP/HCR (1/14) (POS) HealthyBlue Plus HealthyBlue Plus HRA/HRA BlueChoice Advantage BlueChoice Advantage HSA/HRA HealthyBlue Advantage HealthyBlue Advantage HSA/HRA 62 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > DC and VA Group Contract Application Matrices (continued) ACA Virginia OFF-SHOP Products Effective 1/1/2014 Note: No Retiree Coverage is available under ACA Medical Product(s) SOLD SOLD With or Without Traditional/Preferred Dental/BlueVision Plus Required Group Applications Employer Sponsored/ Voluntary Section C Virginia CareFirst BluePreferred Product(s) OFF-SHOP BluePreferred PPO BluePerfered PPO HSA/HRA HealthyBlue PPO HealthyBlue PPO HSA/HRA Yes or No – VA PPO Group Contract Application covers the Traditional/Preferred Dental and BlueVision Plus if sold VA/GRPAPP/HCR (1/14) (PPO) Point-of-Enrollment Group Contract Application (POE) Note: Any time you are selling multiple ACA medical products together from Sections A, B and C, with or without Traditional/Preferred Dental and/or BlueVision Plus, you can use one of the following POE Applications for all products sold. This is the ONLY application that you will need to complete. You will also use the POE Application when you are adding Traditional/Preferred Dental and/or BlueVision Plus to any Section A Product or combination of Section A Medical Products. Point-of-Enrollment (POE) – VA Section D VA/GRPAPP/HCR (1/14) (POE) Freestanding Traditional/Preferred Dental, Blue Dental Traditional/Preferred, and/or BlueVision Plus Only use when there is no medical plan with CareFirst. Group Contract Application For Freestanding Dental and Freestanding Vision Products – VA 63 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL VA/GRPAPP/HCR (1/14) (D-V Only) CONTENTS > > Highlights of Small Group Legislation— DC, VA, Federal District of Columbia DC Health Insurance Portability and Accountability statute (DC Official Code, §313303.01 et seq.) Specifically apply to small employer groups. ■■ Any portion of the premiums or benefits is paid by or on behalf of the employer ■■ The eligible employee or dependent is reimbursed, whether through wage adjustments or otherwise, by or on behalf of the employer, for any portion of the premium; or ■■ The health benefit plan is treated by the employer or any of the covered individuals as part of a plan or program for the purpose of Section 106, 125, or SearchTerm5162 of the United States Internal Revenue. Jury and Marriage Amendment Act of 2009 Effective July 7, 2009, the District of Columbia began recognizing marriages legally entered into in another jurisdiction between two persons of the same sex. The bill notes that: ■■ Insurance products that cover the spouse of a primary insurance policyholder or group policyholder shall cover the same-sex spouse of the insured; provided the marriage was performed in a jurisdiction where marriage between two persons of the same sex is legal. ■■ For marriages that were performed on or prior to July 7, 2009, the effective date of the legislation is the date of a “qualifying event” for determining benefits. ■■ For marriages performed after July 7, 2009, the date of the “qualifying event” for determining benefits will be the date on which the legal marriage took place. CareFirst will extend the “qualifying event” enrollment period for same-sex spouses so notification of the benefit can be provided to groups. Members will have 30 days to enroll same-sex spouses from the date the contract amendment is received by the group. 64 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL Domestic Partnership Judicial Determination of Parentage Amendment Act of 2009 Effective July 18, 2009, the District of Columbia will recognize as domestic partnerships, those relationships other than marriages, which are recognized in other jurisdictions as having all the rights and duties of marriage, regardless of the description of the relationship. These include civil unions and domestic partnerships. The D.C. Department of Insurance, Securities and Banking issued guidance for health insurers that states: ■■ Insurance products that cover the domestic partner of a primary insurance policyholder or employee of a group policyholder shall cover the same-sex domestic partner of the insured for those relationships recognized as domestic partnerships in other jurisdictions. ■■ For same-sex couples who entered into a domestic partnership in another jurisdiction on or before July 18, 2009, the “qualifying event” date for determination of benefits will be July 18, 2009. ■■ For same-sex couples who entered into a domestic partnership in another jurisdiction after July 18, 2009, the “qualifying event” date for determination of benefits will be the date in which the two persons entered into a recognized domestic partnership in another jurisdiction. CareFirst will extend the “qualifying event” enrollment period for same-sex domestic partners so notification of the benefit can be provided to groups. Members will have 30 days to enroll. Insurance Coverage for Emergency Department HIV Testing Amendment Act of 2008 Effective March 21, 2009, health benefit plans are required to reimburse the cost of a voluntary HIV screening test performed on its insured while the insured is receiving emergency medical services, other than HIV screening, at a hospital emergency department. This is regardless of whether or not the HIV screening test is necessary for the CONTENTS > > Highlights of Small Group Legislation—DC, Va, Federal (continued) treatment of the medical emergency which caused the insured to seek emergency services. The mandated benefits shall: ■■ Include at least one HIV screening test annually, if performed in connection with an unrelated emergency department visit. ■■ Reimburse the costs of administering the test, all laboratory expenses to analyze the test, the cost of communicating to the patient the results of the test, and any applicable follow-up instructions for obtaining health care and support services. ■■ Not be subject to any annual or coinsurance deductible or any co-payment other than the copayment that the insured would have to pay for the applicable hospital emergency department visit. Enhanced BlueVision Plus Products in DC and VA (Effective 6/1/12) CareFirst is now offering new voluntary and employersponsored BlueVision Plus vision plans in DC and Virginia. The vision plans mirror our existing BlueVision Plus group plans in Maryland. Voluntary benefits can offer added financial security to employees with no direct costs incurred by employers. There is no participation requirement for voluntary vision. Employees gain access to enhanced coverage that otherwise might not be available to them. Removal of Prior Authorization for Inpatient Maternity Admissions in VA, DC and MD (Effective 12/1/12) Most small-mid risk contracts require an inpatient authorization for maternity admissions with a length of stay longer than 48 hours (normal delivery) or 96 hours (caesarean delivery). Analysis shows claims initially denied for lack of authorization are overturned on appeal more than 99% of the time. When the cost of the appeal, medical review and adjustment as well as the impact to the member are considered, CareFirst has determined authorization should no longer be required for an inpatient maternity admission, regardless of the length of stay. New Pharmacy Benefit Manager (PBM) (Effective 1/1/14) CareFirst selected CVS CareMark* as the company’s new PBM. Members will receive new ID cards. Transitions of care will be made and member communications will be coordinated. Virginia Virginia Prosthetic Parity Act The Virginia Prosthetic Parity Act requires health insurers to offer coverage for prosthetic devices (i.e., arm, leg, foot or any portion of an arm, hand, leg or foot), including the repair, fitting, replacement and components to those mentioned devices. This mandate is effective on January 1, 2010 and impacts Virginia risk business only. VA HB1075 (Effective 7/1/1998) Virginia law requires every Health Maintenance Organization (HMO) when offering a health plan to a group contract holder to provide or include a “point-of-service” (POS) benefit as an additional benefit for the enrollee, at the enrollee’s option, individually to accept or reject. In connection with its group enrollment form, HMOs must make available to the prospective group contract holder and to all prospective enrollees, in advance of the initial enrollment and each re-enrollment, a notice, approved by the Commissioner, which completely and accurately explains to the group contract holder and prospective enrollee the point-of-service benefit and permits each enrollee to make his or her election. Virginia approved point of service offerings include CareFirst BlueChoice Opt-Out Open Access, BlueChoice Advantage and BluePreferred. CareFirst BlueChoice Opt-Out Plus Open Access does not meet the requirements of VA HB1075. (38.23407.12, 38.2-4319). Each enrollee completes an enrollment form and a Point-of-Service Selection form. The enrollee individually accepts or rejects the POS options on the POS form. * C VS Caremark is an independent company that provides pharmacy benefit management services. 65 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Highlights of Small Group Legislation—DC, Va, Federal (continued) Direct Reimbursement for Ambulance Providers (Effective April 2012) VA Code 38.2-3407.9 states that if a policy provides coverage for ambulance services sand the ambulance service provider presents an Assignment of Benefits (AOB), the Insurer must pay the ambulance provider directly. This legislation applies to Virginia Risk Groups and Consumer Direct members residing in Virginia only, in addition to any ambulance provider. Enhanced BlueVision Plus Products in DC and VA (Effective 6/1/12) CareFirst is now offering new voluntary and employersponsored BlueVision Plus vision plans in DC and Virginia. The vision plans mirror our existing BlueVision Plus group plans in Maryland. Voluntary benefits can offer added financial security to employees with no direct costs incurred by employers. There is no participation requirement for voluntary vision. Employees gain access to enhanced coverage that otherwise might not be available to them. be required for an inpatient maternity admission, regardless of the length of stay. Revision to the Virginia Insurance Continuing Education (CE) Program Requirements (Effective 1/1/13) The Virginia General Assembly amended Article 7 of Chapter 18, Tittle 38.2 of the Code of VA to streamline the CE process for insurance agents subject to VA Insurance CE requirements. These amendments included the elimination of the provision that required agents whose licenses had been terminated for failure to comply with CE requirements to wait 90 days before reapplying for a license. Secondly, all resident insurance agents subject to VA Insurance CE are required to complete 3 CE hours of insurance ethics in lieu of the previously required 2 hours of insurance laws and regulations. These 3 credit hours of insurance ethics may include insurance law and regulations applicable in VA. VA HB1273 Parity of Coverage for Oral Chemotherapy Medications (Effective 7/1/12) New Pharmacy Benefit Manager (PBM) (Effective 1/1/14) Requires individual and group health plans to provide coverage for prescribed, orally administered anticancer medication on parity with coverage provided for intravenously administered or injected cancer medications. CareFirst has implemented the mandate for all fully insured groups headquartered in Virginia. Members in these groups, regardless of where they reside, have a $0 copay for specific oral chemotherapy drugs when dispensed at a pharmacy. CareFirst selected CVS CareMark as the company’s new PBM. Members will receive new ID cards. Transitions of care will be made and member communications will be coordinated. Removal of Prior Authorization for Inpatient Maternity Admissions in VA, DC and MD (Effective 12/1/12) Most small-mid risk contracts require an inpatient authorization for maternity admissions with a length of stay longer than 48 hours (normal delivery) or 96 hours (caesarean delivery). Analysis shows claims initially denied for lack of authorization are overturned on appeal more than 99% of the time. When the cost of the appeal, medical review and adjustment as well as the impact to the member are considered, CareFirst has determined authorization should no longer 66 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Highlights of Small Group Legislation—DC, Va, Federal (continued) Federal Notice of Intent to Grandfather a Plan The Patient Protection and Affordable Care Act (PPACA), also known as the federal health reform law, was enacted on March 23, 2010. This law established new benefits that increase the coverage under many health plans. This law also created the option for groups to elect “grandfathered status” for their qualified health plan, and be exempted from some provisions under the law. To be eligible for grandfathered status, a plan must: ■■ Have been in effect on or before March 23, 2010, with at least one enrollee ■■ Have maintained continuous enrollment since then ■■ Not have undergone any changes that would disqualify the plan, including increasing copays, deductibles and employee contributions beyond certain limits ■■ Provide certain disclosures to plan participants as required by federal law The decision and the responsibility for maintaining the status of a plan belongs to the group, not to CareFirst BlueCross BlueShield (CareFirst). Groups that wish to maintain the grandfathered status of a plan will have to maintain additional documents for inspection by members, and by state and federal officials. If a group intends to continue Grandfather status a notice of intent needs to be submitted annually. Federal Mental Health Parity Federal Mental Health Parity states that there must be parity between medical benefits and mental health benefits which are offered to the member. The bill does not require group health plans to offer mental health or substance abuse disorder benefits. Rather, it establishes parity requirements between medical/ surgical benefits and mental health or substance abuse disorder benefits for group health plans that provide mental health or substance abuse disorder benefits. Federal Mental Health Parity applies to: ■■ 51+ fully insured accounts in MD, DC, VA ■■ MD Parity groups ■■ Small groups in DC and VA with 51+ employees (not enrollees or eligibles) ■■ Self-insured accounts with standard benefits Medical Loss Ratio Under the Patient Protection and Affordable Care Act (PPACA), beginning in 2011, health insurers must spend a minimum percentage of the premiums they collect on health care services and quality improvement activities for their members. This percentage is called the Medical Loss Ratio (MLR). In addition, insurers must publically report this information each year. The same calculation developed for Federal Mental Health Parity will be used for MLR. This calculation is referred to as the Federal Employer size and must be updated annually. Federal Employer Size = Number of Full Time Employees + Part Time employee hours worked Total annual hours for the employer (52 weeks X 40 hours = 2, 080) 67 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS > > Highlights of Small Group Legislation—DC, Va, Federal (continued) Request for Group Size Data: Full-Time Equivalent (FTE) Calculation (Effective September 2013) Based on recently published regulations from both federal and state agencies, pursuant to the Affordable Care Act, CareFirst BlueCross BlueShield and CareFirst BlueChoice Inc. (collectively, CareFirst) must use a new method to categorize groups as either a small or large employer. To do this, we are asking groups to calculate the average number of employees—part-time, seasonal and full-time—using a Full-Time Equivalent (FTE) calculation that classifies an employee working a 30-hour work-week (120-hour work-month) as full-time. By having this information n on file, we will help ensure that groups receive the appropriate plans and correlating rates at renewal. Additionally, it’s important that groups are categorized correctly for purposes of Medical Loss Ratio calculation and potential l future refunds. The collection and reporting of FTE data by CareFirst is required under federal mandate and is used to determine the average number of all employees (not just the number of covered lives) who worked for a company in the calendar year prior to their renewal. Employers with more than 50 full-time employees on a temporary or seasonal basis will not qualify as a large employer, unless the number of full-time employees exceeded 50 for more than 120 days. CareFirst BlueCross BlueShield is the business name of Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association. ® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc. CST2308 Broker Manual_DCVA (4/14) 68 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL CONTENTS >
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