Insurance II

1. Insurance II Processing tips and open enrollment

2. Eligibility

3. Determining eligibility • New full-time employees (permanent and non-permanent): • Newly hired employee who was determined by employer, as of the date of hire, to be full-time and eligible for benefits. • New variable-hour, part-time or seasonal employees: • Newly hired employee who is not expected to be credited an average of 30 hours per week, as of the date of hire. Employer cannot reasonably determine eligibility for benefits as of the date of hire. • Ongoing employees: • Any employee who has worked with an employer for an entire standard measurement period.

4. New full-time employees • Both permanent and non-permanent. • Are expected to work 30 hours or more per week as of the date of hire. • Enroll within 31 days of date of hire. • No waiting period. • No initial measurement period. • Employees should be offered benefits at the time of hire.

5. New full-time employees • If hired on the first of the month, coverage begins on that day. • If hired on the first working day of the month, but not the first day of the month (Tuesday, September 3, 2019), employee may choose the first of that month or the first of the following month. • If hired on any day other than the first or the first working day of the month, coverage begins the first day of the month after the date of hire.

6. New variable-hour, part-time or seasonal employees • Variable-hour: • Employer does not know if employee will average 30 or more hours per week. • Part-time: • Employer does not expect employee to average 30 hours per week • Seasonal: • Position is customarily less than six months and begins around the same time each year. • Employees must average 30 hours during first 12 months of employment before becoming eligible for insurance coverage. • Refer to the BA Manual Page 35 or http://www.peba.sc.gov/aca.html

7. New variable-hour employees • Initial measurement period: • Begins the first of the month after the date of hire and ends 12 months later. • Measure employee’s hours over the initial measurement period to determine future eligibility for benefits. • Administrative period: • Begins the day after the initial measurement period ends and ends the last day of the same month. • Review the employee’s hours over initial measurement period. If employee averages 30 hours, he is eligible for coverage. Offer benefits to employee effective the first of the following month. • Initial stability period: • Begins the day after the initial administrative period ends and lasts for 12 months. • Period of time employee cannot lose eligibility for benefits regardless of number of hours worked.

8. End of initial stability period • Employee will have been employed for a full standard measurement period. • Review average number of hours worked during previous standard measurement period: • If the employee averaged 30 hours or more, benefits continue for remainder of the plan year. • If the employee averaged less than 30 hours, insurance coverage ends at the end of the initial stability period. Review hours again in October to determine eligibility for next plan year.

9. Ongoing employees • Any employee, including full-time, variable-hour, part-time, and seasonal employees, who has been employed for a full standard measurement period (October 4 - October 3) of the next plan year. • All employees will eventually become ongoing employees.

10. Ongoing employees • Standard measurement period (monitor hours): • October 4 - October 3 of the next plan year. • Period of time to determine eligibility for the upcoming plan year. • Standard administrative period (determine eligibility): • October 4 - December 31. • Period of time to identify and enroll eligible individuals in coverage. • October 4 - October 31: Employers must offer coverage to newly eligible employees. • November 1 - December 31: PEBA uses remainder of the administrative period to process enrollments to ensure employees have access to coverage at the beginning of the standard stability period. • Standard stability period (guaranteed coverage): • January 1 - December 31. • Period of time an eligible employee remains eligible for insurance benefits.

11. Ongoing employees • During the standard measurement period, calculate the average hours of those employed during the full standard measurement period (total hours/52 weeks = average hours). • If employee loses eligibility, employee’s coverage continues until the end of his initial or standard stability period. • If employee is newly eligible, employee may enroll in benefits during the October enrollment period. Benefits will become effective January 1 of the next plan year. • If employee remains eligible, no action is required. Employee can make changes to coverage for the next plan year.

12. Enrollment Online (EBS/MyBenefits) vs. paper Notice of Election (NOE)

13. Online advantages • EBS/MyBenefitsprovides a direct link with PEBA databases. • Built in edits for coverage limits, options, required fields: • Helps prevent rejections. • Save time and resources: • Expedited processing and no postage costs (nothing to mail, won’t get lost in mail, misfiled, legible, less chance of errors). • Greater accuracy and employee engagement.

14. EBS enrollment

15. MyBenefits new hire

16. MyBenefits enrollment

17. MyBenefits enrollment • Subscriber will receive email from noreply@peba.sc.govwith link to make elections and upload required documentation. • Enrollment transaction will appear on your EBS Approval tab for employer approval and documentation upload. • Link can be resent from your EBS console. • Subscriber will receive reminder emails with this message: • If you do not complete your enrollment by the deadline, you will default to refused all coverage. This means you will not be able to enroll in insurance benefits until the next open enrollment period or until a special eligibility situation occurs.

18. MyBenefits enrollment

19. Electronic file upload

20. Electronic file template

24. Successful upload

25. Using a paper NOE

26. New hires, changes, open enrollment • For new hires and members making changes including during open enrollment: • Verify coverage and any changes. Do this before the subscriber makes doctors’ appointments or fills prescriptions. • Obtain card, review MyBenefitsor contact vendor.

27. EBS/NOEs tips • Use any time an employee begins an insurance-eligible position. • Complete the form even if the employee refuses coverage. • These forms also assist in all special eligibility situations. • Use the most current forms. • Do not highlight, use * or underline information on documentation. • Ensure forms are complete and include all required documentation. • Incomplete forms and missing or illegible documentation will result in rejections. • Coverage becomes active after the completion of the transaction. • Requires that subscriber sign within the allowed time.

28. Request for reviews and the appeals process When to send one, what to send, and the appeals process

29. Requests for review • Submitted by subscriber request or due to clerical error/delay: • Explain situation and any contributing factors that caused the delay or error. • Include NOE or other form with the requested change. • Include all necessary paperwork and documentation: • Dependent documentation. • Loss/gain of coverage letters. • Maximum one year retroactive: • Premiums for retroactive coverage will apply. • Indicate if subscriber has been paying premiums and/or if he is aware retroactive premiums will be due.

30. Requests for review – eligibility appeals • If request is denied: • Only subscriber may appeal. • Request must be made within 90 days of denial (instructions and address included on form). • Appeals are legal process and take time to complete. • If appeal is denied: • Subscriber may seek judicial review by filing a case with the Administrative Law Court within 30 days.

31. Termination reasons • Not eligible (T5): • Member not in a stability period or has left employment. He is eligible for COBRA. Conversion packet from life insurance. • Reduction in hours or unpaid leave (TH): • Member in a stability period but had reduction in hours and voluntarily dropped insurance. Member not eligible for COBRA. • Service retirement (T7): • Member retiring due to years of service. Continuation packet from life insurance. • Disability retirement (T2): • Social Security Administration approved member for disability.

32. Retirement and insurance

33. Eligibility for retirement, retiree insurance • Eligibility for retirement is not the same as eligibility for retiree insurance. • Rules for retiree insurance are complicated: • Unique eligibility rules for employees hired into an insurance-eligible position on or after May 2, 2008; • Partial employer premium funding in some cases; and • Different rules for optional employers. • Retiree insurance flyers are available for members and for employers. 

34. Retiree insurance eligibility • Only PEBA can determine eligibility for retiree insurance. • Employees should contact PEBA prior to leaving employment. • General eligibility guidelines found in Retiree group insurance chapter of Insurance Benefits Guide.

35. Retiree Insurance Eligibility Determination RIED project

37. Determination in EES

38. Member Access

39. Member Access

40. Determination letters • Examples: • In response to your request for verification of your eligibility for retiree insurance coverage, PEBA has reviewed your employment and service history. PEBA determined you will be eligible to enroll in retiree insurance coverage at the funded rate on [date]. You will pay the retiree portion of the premium only. • In response to your request for verification of your eligibility for retiree insurance coverage, PEBA has reviewed your employment and service history. PEBA determined you will be eligible to enroll in retiree insurance coverage at the non-funded rate on [date] until [date], after which you will pay the partially-funded rate. • In response to your request for verification of your eligibility for retiree insurance coverage, PEBA reviewed your employment and service history and determined that you do not meet the requirements to enroll in the retiree group insurance program because your last five years of insurance-eligible employment were not served in a full-time position with an employer participating in the State Health Plan.

41. Pre-determination letters

42. Return-to-work retirees

43. Requirements for return-to-work retirees • Return-to-work retirees hired into insurance-eligible positions must enroll in active coverage. • Non-Medicare part-time teachers exempt. • Return-to-work retirees currently enrolled in retiree insurance coverage should be transferred to active coverage. • Transfer counts as a new hire event, allowing retiree to make changes. • On NOE include RTW Retiree to Active coverage. • Change is effective the first of the month after the signature date.

44. Requirements for return-to-work retirees • Return-to-work retirees are eligible for Supplemental Long Term Disability, Optional Life¹ and MoneyPlus. • After leaving covered employment, retirees can re-enroll in retiree insurance coverage within 31 days of termination. • Employees who have retired and returned to work are not earning additional service credit for eligibility for retiree insurance or retiree insurance funding. 1Only if retiree ends continued coverage.

45. Optional Life coverage forreturn-to-work retirees • May enroll in active Optional Life coverage. • If return-to-work retiree continued policy at retirement: • Can keep continued policy and pay premiums directly to MetLife; or • Can drop continued policy and enroll in active Optional Life coverage. • If return-to-work retiree converted policy at retirement, he can keep it and enroll in active Optional Life coverage.

46. Open enrollment for 2020 plan year

47. Supplemental long term disability (SLTD) salary updates • September 15, 2019: • EBS opens for updating SLTD salary information. • October 31, 2019: • Deadline to update SLTD salary information. • PEBA will not accept updates past the deadline. • SLTD tutorial video available on PEBA’s website: www.peba.sc.gov/itrainingresources.html.

48. Open enrollment options • Health: • Change from one health plan to another: • Standard Plan; • Savings Plan; or • TRICARE Supplement Plan. • Enroll yourself or any eligible dependents in health coverage. • Drop health coverage for yourself or any dependents. • Dental: • Change from one dental plan to another: • Dental Plus; or • Basic Dental. • Enroll yourself or any eligible dependents in dental coverage. • Drop dental coverage for yourself or any dependents.

49. Open enrollment options • Vision: • Enroll in or drop State Vision Plan coverage for yourself and/or your eligible dependents. • Life insurance: • Optional Life: • Add, drop or decrease coverage. • Add or increase only with medical evidence. • Short form Statement of Health. • Dependent Life-Spouse: • Decrease or drop coverage. • Add or increase only with medical evidence. • Dependent Life-Child: • Add or drop coverage.¹ 1Dependent Life-Child coverage can be added anytime.

50. Open enrollment options • MoneyPlus: • Enroll in or refuse the Pretax Group Insurance Premium feature. • Enroll or re-enroll in Medical Spending Account and Dependent Care Spending Account. • Enroll in Health Savings Account and Limited-use Medical Spending Account if in Savings Plan. • New $500 carryover provision for 2020. • Applies to Medical Spending Account and Limited-use Medical Spending Account only.