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This manual outlines eligibility criteria, enrollment procedures, and policy changes for PEIA health benefits. Learn about COBRA rights, insurer requirements, and managing benefits for dependents.
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PEIA Quarterly Workshop January 2017
Benefit Coordinator Reference Manual • Eligibility • Cobra • Forms • Healthy Tomorrows • Manage My Benefits
Eligibility • Who is eligible? • Spouse , • children under age 26, • stepchildren if still married under age 26, • Disabled children and • children under the age of 18 for whom you are the appointed guardian • Month of the event and the 2 months following to enroll for Health Insurance and Life Insurance. • 60 days from the event to enroll for FBMC.
Existing Policyholders • To make a change to insurance, the policyholder must have a Qualifying event. • To add a dependent, the policyholder must have documentation to prove they are a legal dependent. • The policyholder must also have documentation of the qualifying event.
Divorce Divorce is a different kind of qualifying event. The month the divorce is final, coverage needs to be termed. Coverage termed includes, ex-spouse and stepchildren No exceptions.
Court-Ordered Dependent Children Court-ordered Dependent Children (COD) If a PEIA-insured employee and his or her spouse divorce, and the employee is not the custodial parent for the dependent child(ren), the employee may continue to provide medical benefits for the adopted or biological child(ren) through the PEIA plan. If the non-custodial parent is ordered by the court to provide medical benefits for the child(ren), the custodial parent may submit medical claims for the CODs, and benefits may be paid directly to the custodial parent. Special claim forms are required. The custodial parent will also receive Explanations of Benefits (EOBs) and medical ID cards for the CODs. To initiate this process, the custodial parent must put the request in writing to PEIA
Employee/Spouse Discount Family with Employee Spouse: Two public employees who are married to each other, and who are both eligible for benefits under the PEIA may elect to enroll as follows: 1) Family with Employee Spouse in any plan 2) “Employee Only” and “Employee and Child(ren)” in two different plans(remember they’ll have two deductibles and two out-of-pocket maximums this way) 3) “Employee Only” and “Employee and Child(ren)” in the PPB Plan 4) “Employee Only” and “Employee and Child(ren)” in the same managed care plan. All children must be enrolled under the same policyholder. To qualify for the Family with Employee Spouse premium for health coverage, both employees MUST have basic life insurance. Both employees are eligible to enroll for the basic life policy, as well as for optional and dependent life insurance.
Premium Conversion Plan Policyholders are automatically opted into the Section 125 Plan unless they choose to opt out of the plan. Online that means choosing ‘Yes’ to opting out of the Section 125 Plan. On the paper form it means you must choose ‘No’ to participating in the plan. Benefit Coordinators may view the Section 125 attribute when they log in as a Web Contributions Coordinator and choose Reports from the main tab menu and then Attributes report. The report will export to Excel and can be used to confirm member’s Plan attributes.
Termination • If an active employee terminates employment, he or she must complete a termination form. The termination form MUST be filled out completely and include a current address for the employee and the reason for the termination. • If the employee is not available to sign the termination form, the benefit coordinator can submit the form without the former employee’s signature. On the employee signature line should be written not available for signature. The Benefit Coordinator must sign and date the form and a second employee must sign the form and note their title below the Benefit Coordinator signature line. • As an alternative, a Benefit Coordinator may terminate an employee in the Manage My Benefits system under the Web Contributions portion. Complete directions can be found in the Manage My Benefits section of the Benefit Coordinator Reference Manual.
COBRA All terminated employees or dependents eligible for COBRA will receive a detailed notice of their COBRA rights from HealthSmart. An election to continue coverage under COBRA must be made within 60 days of the end of the group coverage. Managed care participants will be given the same continuation options as those plan members covered by the PEIA PPB Plan. Additionally, if the employee has elected to continue coverage, they will retain the right to change coverage to the PEIA Health Insurance Plan during the annual open enrollment period. In the event the policyholder has a change in status, it is important to advise the terminating employee to complete the COBRA section on the “Change-In-Status Form.” The policyholder must include the address of the dependent if different from the policyholder. If not, the dependent will not receive their enrollment form.
Transfers • A transfer can be initiated by the sending or receiving Benefit Coordinator. • Both must agree on a beginning/ending date • The receiving BC can update the salary index when approving the transfer. • Transfers are not a qualifying event to be able to change policies.
Death of a Policyholder or Dependent In the event of the death of an active or retired policyholder, any eligible dependents who were covered at the time of death are eligible to enroll for health coverage as surviving dependents. To continue health coverage without interruption, surviving dependents must complete the Surviving Dependent enrollment form, which PEIA mails to the surviving dependent upon notification of the death. The form must be completed in the calendar month the death occurs or the two following calendar months.
Surviving Dependents Surviving dependents must enroll in the same plan in which they were covered at the time of the policyholder’s death. During open enrollment, surviving dependents will be mailed the enrollment materials and may select any plan for which they are eligible. Surviving dependents are not eligible for life insurance. Surviving dependents may be eligible to continue certain Mountaineer Flexible Benefits under COBRA. See the Mountaineer Flexible Benefits section of this book for details. Coverage for surviving dependents terminates at the end of the calendar month in which one of the following occurs: • non-payment of premium; • surviving dependent terminates or loses coverage; • child reaches age 26 • surviving spouse remarries; or • disabled dependent no longer meets disability guidelines. If the surviving spouse remarries, he or she is no longer eligible for PEIA coverage. If a divorce occurs after the remarriage, re-enrollment as a surviving dependent is not allowed.
Retirement The retiring employee and all enrolled dependents must re-enroll to continue health benefits into retirement. Non-Medicare retirees must continue coverage in the plan in which they were covered as active employees until the next open enrollment, when they can choose any plan for which they are eligible.
Retirement As a Benefit Coordinator, it is your responsibility to: Provide forms for your retirees or provide them with where they can be found online. You must also fill out the agency portion of the Retirement forms. You must send in a Termination form with the Retirement forms. All forms must be filled out completely.
Forms Forms are being updated. These updated forms are available on our website under Comprehensive Form and Document list. Termination form Health Enrollment Form Basic Life Enrollment Form
Healthy Tomorrows Year ThreePolicyholders must have their blood pressure, blood glucose and cholesterol within an acceptable range or have a physician’s certification that those numbers cannot be met. Forms must be mailed to PEIA. Forms must be received by the end of Open Enrollment in May 2017. .
Healthy Tomorrows Any employee that has PEIA PPB Health insurance prior to Open Enrollment, must send in a completed form or they will have an additional $500 deductible
CCP Program Comprehensive Care Provider Program is program promotes the use of health services to keep the patient well, identify health problems early, maintain control of chronic conditions and to promote efficient utilization of healthcare resources. The CCP provider is responsible for providing preventative services, routine sick care, and coordination of care with specialists when needed. Members who enroll in the CCP program pay reduced or no copayments, deductible or coinsurance for specified services at their CCP provider. Any time a CCP member uses any provider outside the CCP, including another primary care provider, the copayment for the office visit will be $40. Letters will be sent in January regarding a change in the CCP Program. Members that have visited a Comprehensive Care Provider (3) three or more visits will receive a letter that lets them know PEIA is going to move them into the CCP Program. The member will have 30 days to opt out if they have another provider and/or don’t want to participate.
Manage My Benefits View all coverage changes is where you want to check to see if any changes have been made to your employee’s insurance. If you see the grey review box, you need to click it to review the policy changes. If you see NOT FINALIZED, the employee has not completed the change and you can do nothing until they do so.
Manage My Benefits • New auto appeal process • When you go in as a Benefit Coordinator and add a policyholder as a single plan, PEIA will automatically approve the coverage. • This means that PEIA will not be looking over • Basic Life enrollments • Single health enrollments • Optional Life enrollments • Please be sure that you are keying the information correctly. You can upload the form after you have keyed them, but do not send us the forms.
Manage My Benefits From this menu you can choose to upload documentation and forms. It allows you to scan them to your computer and send them to us electronically instead of sending us the forms. It steps you through choosing the policyholder or dependent and what kind of document it is.
New Log-In Procedure Due to a new PEIA policy that BCs/WCC need to update their passwords every 180 days, it is important that you know your security questions and that your email is correct. Please be sure that you have an up to date email listed under the My Account tab in MMB.
Email Audit PEIA has been running a comparison of email addresses for members against a file of who ‘owns’ the email domain. It is important that it is solely your email due to the sensitive nature of the information you receive as a BC.
