Employer Resource Guide

Transcription

Employer Resource Guide
(ACA)
Welcome to Dean Health Plan
At Dean Health Plan it is our mission to improve our members’ health and create peace of mind with
insurance products and health programs that feature our caring partners throughout the Dean network. We
will promote the right care, at the right place, at the right time and with the right person.
The customer is every employee’s number-one priority. Our relationships with agents, employers, members,
providers and even our fellow employees is the foundation of our success. We promise to continually strive
to earn your trust with this simple promise: we will guide you down a smooth and simple path to the service
you need and the care our members deserve.
This guide has been designed to assist you in understanding our administrative procedures. We have
attempted to cover the majority of questions you may have regarding the enrollment of newly eligible
employees and their dependents, changes in coverage and handling the monthly billing, along with your
annual renewal process. We know that you will likely have additional questions—please contact us anytime.
Important Contact Information
Dean Health Plan Office:
Phone: (608) 836-1400 Toll Free: (800) 356-7344
Fax: (608) 827-4152
deancare.com
If your employees have
questions about benefits,
coverage, prior authorization,
claims and providers please
contact the Customer Care
Center.
Toll Free: (800) 279-1301
TTY: 711
Fax: (608) 827-4212
deancare.com/contact-us
Street Address:
1277 Deming Way, Madison, WI 53717
Mailing Address:
P.O. Box 56099, Madison, WI 53705
For group premium invoice or
enrollment & eligibility
questions please contact the
Enrollment & Billing
department.
Toll Free: (800) 649-0258
Fax: (608) 252-0873
E-mail: [email protected]
For questions about the group
renewal or contract please
contact your Account
Manager, Associate Account
Manager or the Sales &
Retention department.
Phone: (608) 836-1400
Fax: (608) 252-0834
For Medicare eligibility, premiums and coordination of benefits questions please contact the Medicare
Coordination of Benefits Analyst, Victoria Labovsky, at (608) 827-4189.
Please mail premium payments to:
Employer Premium Payment Address: Dean Health Plan, PO Box 673111, Chicago, IL 60695-3111
Social Security Administration
Phone: (800) 772-1213 ssa.gov
Medicare Coordination of Benefits Center
Phone: (800) 999-1118
Medicare
Phone: (800) 633-4227 medicare.gov
Wisconsin Office of the Commissioner of Insurance
(800) 236-8517 oci.wi.gov
U.S. Department of Labor
Phone: (202) 219-8776 dol.gov
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Table of Contents for ACA plans
Welcome to Dean Health Plan
Important Contact Information
1
1
Table of Contents for ACA plans
2
Employee Enrollment
4
Eligibility
4
Plan Type Eligibility
5
Dependent Eligibility
5
Eligibility File
6
Enrolling
6
Special Enrollment/Coverage Changes
7
Qualifying Events/Special Enrollments
7
Qualifying Event Guidelines, Effective Dates and Form(s) Needed
8
Annual Enrollment
10
Employee Status Changes
11
Termination of Employee Coverage
13
Termination(s) of Coverage
13
Dependent Terminations
13
COBRA/State Continuation
14
COBRA (Groups with 20 or More Employees)
14
State Continuation (Groups with 19 or Fewer Employees)
14
Employer Knowledge
14
Group Continuation Chart
15
COBRA Offering Guidelines (For Companies with 20 or More Employees)
16
Frequently Asked Questions
18
Online Tools and Member Materials
20
Health Care Reform & Compliance
20
Plan Administration Resources
20
DeanConnect
20
Website for Your Employees: deancare.com
21
Monthly Group Billing
22
Premium Invoice
22
Payment of your Premium Invoice
22
Determining an Employee’s Rate
22
Discrepancy Reports
23
Medicare
Enrollment
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24
2
Employer Group Size
25
Center for Medicare and Medicaid (CMS) Medicare Secondary Payer
25
Medicare Questionnaire
25
Primary Payment Notice or PPN
26
Medicare Demand Letters (Requests for a Refund)
26
Eligibility Summary Charts
28
Medicare Contact Information
29
Retirees
30
Retiree Segment Requirements and Set Up
30
Enrolling in a Retiree Segment
31
Group Renewal and Contract
32
Renewal
32
Changing Contract Provisions
33
Changes in Ownership or Business Structure
33
Summary of Benefits and Coverage (SBC)
34
Group Master Policy (GMP)
35
Claims
35
Coordination of Benefits (COB)
35
Subrogation
36
Explanation of Benefits (EOB)
37
Grievance and Appeals
38
Samples, Reports and Forms
39
Due to constant updates and changes in Health Care Reform, visit deancare.com/reform for the most
current information.
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Employee Enrollment
For the most up-to-date information about Health Care Reform, please see deancare.com/reform.
Eligibility
An eligible employee is one who:
•
Appears on your payroll records;
•
Is actively at work performing his/her duties on the date his/her coverage is to become effective;
•
Works at least the minimum number of hours per week required under the Employer Group Master
Policy; and
•
Has completed any waiting period required before coverage is effective.
Eligible employees also include commissioned salespeople for whom the policyholder or designated
employer is paying Worker’s Compensation, premiums, unemployment taxes and social security. An eligible
employee does not include an employee who accepts a severance package in conjunction with the
termination of his or her employment and who no longer meets the definition of an eligible employee as
described above.
The 1995 Wisconsin Act 289 defines an eligible employee as one who normally works 30 hours per week on a
permanent basis. W2 does not permit an employer to require an employee to work more than 30 hours per
week to be eligible for group health insurance coverage.
A non-eligible Employee is one who is:
•
Temporary
•
Substitute
•
Contracted
•
Limited term employee (LTE)
Please refer to your Group Master Policy for the eligibility statement for your group. (For more information
about the Group Master Policy see the Group Renewal and Contract section of this guide.)
Newly hired, eligible employees and their dependents will be eligible for coverage after serving the
probationary period established by your group. The probationary period is noted in your Group Master Policy
contract. To make a change to the probationary period, you must notify your Account Manager in writing
prior to the date of the change. Please be aware that the probationary period cannot extend beyond 90
days.
Please note that coverage for the eligible employee and any qualified dependents may not become effective
if the eligible employee is not actively at work on the effective date. Please refer to the Member Certificate
for further details.
Employees and their dependents who initially waived coverage may be eligible for benefits at a later time
due to a qualified status change or event. Please refer to Special Enrollments and Coverage Changes for
more information.
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Plan Type Eligibility
If your group offers PPO and/or POS segments, the following employees are eligible to enroll in those
segments:
•
All benefit-eligible employees may enroll in the HMO or POS segment if they either live or work in
our service area* or
•
Employees who reside outside the state of Wisconsin or outside of the Dean Health Plan service
area may enroll in the PPO segment. Members may be eligible for the PPO product based on their
resident zip code. See the eligible zip codes on the back of the PPO map.
*The Dean Health Plan service area includes the following counties: Adams, Columbia, Crawford, Dane,
Dodge, Fond du Lac, Grant, Green, Green Lake, Iowa, Jefferson, Juneau, Lafayette, Marquette, Richland, Rock,
Sauk, Vernon, Walworth and Waukesha.
See the most recent Service Area Map.
Dependent Eligibility
An eligible dependent is defined as the subscriber’s:
•
Legally married spouse, domestic partner*, biological child, adopted child, child placed for
adoption and/or stepchild to the end of the month the dependent turns age 26.
*Not all group plans cover Domestic Partners. Please see your Group Master Policy.
•
Dependent who is under the age of 26 who is called to active duty. He or she can be reinstated
to the parent’s plan upon return from active duty.
•
Dependent who is age 26 or older who was called to active duty prior to reaching age 27. He or
she can be reinstated to the parents’ plan if he or she was a full-time student before military
service and re-enrolls as a full-time student after military service.
•
Biological child of an unmarried dependent child until the dependent child (who is also covered
as a dependent) is 18 years of age. Coverage for the child of the dependent will be terminated
on the dependent’s 18th birthday.
If the subscriber’s dependent is disabled, coverage may be available beyond age 26. To qualify as disabled, a
subscriber’s dependent must be approved by the Underwriting Department. Please see your Member
Certificate for definition of disabled dependent.
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Eligibility File
If you employ 51 or more employees, or you use a Third Party Administrator (TPA) for benefits enrollment,
you may consider sending us a HIPAA-compliant Electronic Enrollment Transaction (834) in lieu of Employee
Application for Group Coverage Forms.
Getting Started
If your group is interested in sending an 834 Enrollment Transaction, please contact your Account Manager to
get started, or read more about HIPAA transactions on our website.
Enrolling
Enrollment Methods
For an employee electing coverage, he or she must complete an Employee Application for Group Coverage
Form. You can enroll new hires through our online portal DeanConnect. To learn more about DeanConnect
please see the Online Tools and Member Materials Section.
Please note: Notify your Account Manager if DeanConnect access should be removed upon staff changes
and/or if new staff needs to be given access.
Timely Enrollment
The form(s) must be signed by the employee and received by us no later than 31 days from the eligible
employee’s effective date of coverage. If an application is not received within 31 days from the effective date
they will be considered a late enrollee, if late enrollees are allowed by the group. For small employers (less
than 51 employees) this means the employee’s effective date will be 90 days following the date Dean
receives the application. Large employers should review their Group Master Policy for Late Enrollment
provisions.
Example (small employer): If an employee is hired on January 4 and the group’s probationary period is the
first of the month following 30 days from date of hire, then the effective date of coverage would be March 1
and the application would be due to us by March 31. If an application is received after March 31, the
employee would then be effective 90 days following receipt of the application.
Avoiding Enrollment Delays
Be sure to complete the section at the top of the application labeled “For Employer Use Only” and review
each application to make sure your employee completed all of the information before sending it to us. Please
pay special attention to the following areas:
•
Date of hire
•
Social Security number(s) - for each person applying for coverage
•
Date(s) of birth – for each person applying for coverage
•
Primary care provider(s) election for each person applying for coverage. This is not required for Point
of Service/PPO plans
•
Address
•
Signature and date
•
Group number
•
Employee Plan Selection
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•
Reason for application
•
Gender
Please note that if an application is not signed or dated, or if any of the above information is missing we will
request a completed application from the employer. This may delay the application unnecessarily; please pay
close attention to this section before sending us the application.
Waiver of Coverage
If an employee chooses not to take coverage when it becomes available to them, employers should have the
employee complete the Waiver of Coverage Form and maintain that form in their files.
A sample is included in the Samples, Reports and Forms section.
Government Mandate to Collect Social Security Numbers
Social security numbers are now required in accordance with Section 111 of the Medicare, Medicaid and
SCHIP Extension Act of 2007. Provisions for this are found under 42 U.S.C. 1395y(b)(7). We may contact you
or the member/dependent directly to request the Social Security Number.
If the number is not provided, we may delay or deny payment of medical claims for that specific member.
Social security numbers will only be used to report or to establish Medicare eligibility.
ID Cards
If the application is not missing any information, the employee is enrolled within five business days and an
identification card is mailed to the employee’s home address seven to 10 business days from receipt of the
application. If the application is missing information needed to enroll the member, the enrollment will be
delayed until this information is obtained. All missing information required to enroll the member must be
received within 31 days of the initial application. Temporary ID cards may be printed from DeanConnect, but
not until the enrollment is complete.
The “employee copy” or yellow copy of the Group Application From may be used as a temporary ID card until
he or she receives an ID card. If you print the form online, a photocopy of the form can also be used as a
temporary ID card. The provider should make a copy of the form if they send the original to Dean Health
Plan. If the provider used DeanConnect, they should keep the original. The provider can also call our
Customer Care Center to verify the coverage date of the employee/dependent. If services are needed prior to
receiving an ID card please have the member contact our Customer Care Center for assistance.
Please note: ID card samples are included in the Samples, Reports and Forms section.
Special Enrollment/Coverage Changes
For the most up-to-date information about Health Care Reform, please see deancare.com/reform.
Qualifying Events/Special Enrollments
A special enrollment or qualifying event is an event that allows an eligible employee who satisfied the group’s
probationary period to enroll in the plan after having initially waived the coverage. It may also allow an
employee to add a spouse/dependent(s) to the plan. Qualifying events are sometimes referred to as life
events or family status changes.
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Enrolling with a Qualifying Event/Special Enrollment
Please refer to the qualifying event chart on the following pages to determine the type of event, when the
coverage becomes effective and what documentation is needed to enroll.
An employee must qualify as an eligible employee under the group Member Certificate to be eligible for a
special enrollment.
Except for certain exceptions discussed in the table below, the forms must be received by Dean Health Plan
within 31 days of the event; otherwise, the employee/dependent(s) will be considered a late enrollee.
Applications must be submitted after the qualifying event has taken place (example: marriage on May 12th –
application to add new spouse should be submitted after May 12th but within 31 days of May 12th.
Mid-year changes between dual option plans are not allowed. Dual option enrollment changes are only
allowed upon your anniversary. Mid-year changes between carriers are not allowed. Dual choice enrollment
changes are only allowed upon your anniversary.
Special enrollments do not apply to retiree segments (unless specifically noted in your Retiree Addendum).
Special enrollments do not apply to other non-working segments.
Qualifying Event Guidelines, Effective Dates and Form(s) Needed
Qualifying Event
Loss of other
coverage
Voluntary or
involuntary
Marriage
Birth
Guidelines
Applications must be received within 31
days of other coverage termination. This
does not include other coverage sponsored
by your group.
Employee, spouse and newly acquired
dependents may apply or Employee may
add spouse and newly acquired
dependents. Must receive application after
the marriage date but within 31 days of
marriage.
Employee, spouse, qualified dependent and
newborn may apply, or Employee may add
spouse and/or newborn.
Other dependents added at this time may
be considered late enrollees.
Effective Date
Date following other
coverage
termination
Form(s) Needed
Employee
Application for Group
Coverage
Qualifying Event
Questionnaire or
Certificate of
Creditable Coverage
from prior carrier
Date of Marriage
Employee
Coverage
Date of birth of
newborn child
Employee
Coverage
Application to add a newborn should be
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Qualifying Event
Guidelines
received within 60 days of the birth.
Effective Date
Form(s) Needed
Applications received from day 61 to 1 year
will be billed premiums back to the
newborn’s date of birth and interest may
be applied.
Application to add other dependents must
be received within 31 days of the birth.
Relocation
to US
(Spouse or
dependents of
insured
employee)
Spouse/dependent(s) may join the group
plan.
Application must be received within 31
days of transfer.
Date of arrival in the
USA
Employee, spouse and new dependent may
apply, or employee may add spouse
and/or new dependent.
Adoption
Application to add adopted child must be
received within 60 days of
adoption/placement.
Date of order for
legal adoption or
placement
Application to add other dependents must
be received within 31 days of
adoption/placement.
Legal
Ward
Employee may add legal ward. Employee
needs to be covered under the plan at the
time the legal ward is declared in order to
enroll the appointed ward.
Application must be received within 31
days from date of legal ward declaration.
Military
Leave
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If a person is absent from a job less than 31
days, they must report to the employer by
no later than the beginning of the first full
regularly scheduled work period on the first
full calendar day following the completion
of the active service.
Date of legal
custody or
placement of legal
ward
Eligibility will assign
effective dates
based on the dates
requested by the
group for those
employees from
military leave. If a
Employee
Coverage
Questionnaire &
copies of visas are
required
Employee
Coverage
Copy of court order
placing child for
adoption
Employee
Coverage
Copy of court order
placing child with
employee or spouse.
Verification of
residence and
percentage of
support
provided
Employee
Coverage
9
Qualifying Event
Guidelines
If the active service lasted more than 31
days, but less than 181 days, the person
must report to the employer no later than
14 days after the completion of the active
service.
If active service lasted for more than 181
days, but less than 5 years, the person must
report to the employer no later than 90
days after the completion of the active
service.
Employment
Transfer
into
Service Area
Applications must be received within 31
days of other coverage termination.
This does not include other coverage
sponsored by your group.
Effective Date
group indicates an
effective date equal
to the date an
Employee returned
from the military,
Dean Health Plan
will honor that date.
Form(s) Needed
If a group applies a
probationary period
for a returning
employee, Dean
Health Plan will
honor that request
as well.
Date following other
coverage
termination
Employee
Coverage
Qualifying Event
Questionnaire
Certificate of
Creditable Coverage
from prior carrier
The following types of health plans are considered creditable coverage:
•
Group or Individual health insurance coverage
•
Medicare or Medicaid
•
Health Insurance Risk Sharing Plan (HIRSP)
•
Federal Employees Health Benefits Plan
•
Public Health Plan (i.e. BadgerCare Plus)
•
Medicaid Care Program of the Indian Health Service or Tribal Organization
•
Military sponsored health care or Peace Corps plan
•
Short term medical policy
Please note: National Health Care of a foreign country (e.g. Canadian Health Care) and supplemental plans
are not considered creditable coverage.
Annual Enrollment
For groups offering more than one health insurance carrier:
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Dual Choice – for groups with more than 51 employees
It is your responsibility to ensure Dean Health Plan has all health plan carriers offered on file. This is done by
completing and returning the Group Information Form that is included in your annual enrollment materials.
See the Group Information Form (large group) in the Samples, Reports and Forms section.
Dual choice enrollment period is when an employee, already insured under another plan offered by your
group, can change to Dean Health Plan at the group’s anniversary date. We automatically allow a dual choice
period each year for all employers with two or more health insurance carriers.
During the dual choice enrollment period, employees and their currently-insured dependents can enroll in
other plans offered by Dean Health Plan.
The employer may determine the length of the dual choice enrollment period; however, the effective date of
coverage will always be the group’s anniversary date. Applications must be received by us within 31 days of
the anniversary date.
Example: If your anniversary date is January 1, your enrollment period can be held in November or December.
Thus, any employee changing plans would be effective with Dean Health Plan coverage as of January 1 and
the application would have to be received by Dean Health Plan no later than January 31. Midyear changes
between plans are not allowed.
Open Enrollment – for groups with more than 51 employees
We define an “open enrollment” period as a one-time opportunity each year at renewal for all eligible
employees or dependents to join the group’s health insurance plans, regardless of whether the employee or
dependents are currently insured under another health insurance plan.
Employee Status Changes
Part-time to Full-time or Temporary to Permanent Employment
An employee who changes from part-time to full-time employment on a permanent basis or from temporary
to permanent employment will be eligible for coverage after serving the probationary period as a permanent
employee listed on the Group Master Policy. The probationary period is established based on the full-time,
permanent employment date. We may require additional documentation to support this change.
Please note: The 1995 Wisconsin Act 289 does not allow an employer to require an employee to work more
than 30 hours per week to be eligible for group health insurance coverage.
Lay-off/Disability
If an employee is not active at work and/or not meeting the eligibility guideline (30 hours per week in most
cases), our standard policy is the employee should be terminated from active coverage immediately and
offered COBRA/Continuation.
If your group has a special policy for these situations whereby employees are not terminated from active
coverage immediately or you are offering a severance agreement that includes extended health insurance
benefits, you must contact your Account Manager to determine if the policy is acceptable to us.
Example: Laid-off employees receive an additional month of coverage from the date of lay off before being
terminated and offered COBRA/Continuation. If the request is approved, the special provision is effective the
first of the month following approval.
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Rehired previously-terminated employees
If an employee’s coverage was terminated because of termination of employment, temporary lay-off, leave
of absence or temporary reduction of hours and the employee is rehired as an eligible employee, the
employee and previously covered dependents are eligible for coverage upon completion of the probationary
period established by the group and listed on the Group Master Policy.
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Termination of Employee Coverage
Termination(s) of Coverage
You may terminate an employee/dependent’s coverage by doing any one of the following:
•
Terminating them on DeanConnect.
•
Mail, fax, or email a memo to the Enrollment and Billing Department with the employee’s name,
member number, date and reason of termination. Please see contact information on page 1.
•
If you receive a monthly invoice, make a note on the Employee/Dependent Terminations Section of
your group’s monthly premium billing invoice and mail, fax or email the page to the Enrollment and
Billing Department with the employee’s name, member number, date and reason of termination.
•
Have the employee complete an Employee Application for Group Coverage Form and send it to our
Enrollment and Billing Department.
Please note that omitting a member from an application or simply not paying for the member will not
terminate the member’s coverage. A termination request must be received in one of the formats listed
above.
We will refund or adjust premiums for retroactive terminations for up to three months. The month the
request for the retroactive termination is received is counted as one month.
Dependent Terminations
Divorce
The employee is responsible for notifying you of the divorce and the date of divorce. The divorced spouse
and dependents cannot be removed from the policy until the judgment of divorce is final. For example: the
individual cannot be removed because a divorce is pending or a Certificate of Readiness has been issued. The
termination date will follow the employer’s termination provision.
In most cases, you will need to offer COBRA/State Continuation coverage to the divorced spouse (and
dependents if applicable). Please refer to your COBRA/Continuation guidelines or consult your attorney if you
have questions.
Death
If an employee/spouse/dependent dies, his or her coverage will end on the date of death. In the case of an
employee’s death, the surviving spouse/dependents coverage will continue through the end of the month in
which the employee died. Again, COBRA/State Continuation coverage must be offered to the
spouse/dependents.
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COBRA/State Continuation
COBRA (Groups with 20 or More Employees)
COBRA stands for Consolidated Omnibus Budget Reconciliation, which is a federal law enacted in 1985. This
law requires most insured and self-insured group health plans to provide continuation of coverage to
employees, spouses and dependents who lose coverage under the plan for certain reasons.
State Continuation (Groups with 19 or Fewer Employees)
State Continuation (Wis. Stat. § 632.897) is the Wisconsin legislation similar to the federal COBRA. All
employers and insurers within the state of Wisconsin must comply with State Continuation, regardless of size
(except for self-insured plans). Since both laws apply for many employers, the employer must comply with
the law that is most beneficial for the employee. Therefore, it is important for employers to be familiar with
both COBRA and State Continuation requirements.
Hereafter, COBRA and State Continuation may be referred to as “group continuation,” which means either
COBRA and/or State Continuation depending on which law will apply.
Employer Knowledge
As the employer, you are responsible to:
•
Provide written notification to your employees and their dependents of their rights to group
continuation coverage; and
•
Know which events qualify the employee/dependents for continuation.
As the employer, you must:
•
Terminate the employee from your active group coverage segment;
•
Obtain written documentation for the election of continuation from the eligible
employee/dependent(s) for their continuation coverage;
•
Enroll the terminated employee into the COBRA segment of your group coverage; and
•
Know the guidelines for terminating participants for non-payment.
Those who elect COBRA coverage are responsible for sending you the monthly premium payments; in turn,
you will make payment to us.
COBRA/State Continuation is an employer-administrated benefit. We have provided this information for
reference purposes only. You should consult with your attorney or COBRA administrator (if applicable)
regarding specific situations or concerns regarding the administration of group continuation. For more
detailed information regarding the laws, you may also contact the following:
To find out more about COBRA, contact:
(202) 219-8776
dol.gov
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To find out more about State Continuation contact:
State of WI Office of the Commissioner of Insurance
(608) 266-3585 or (800) 236-8517
oci.wi.gov
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Group Continuation Chart
Applicability
COBRA
State Continuation
This law applies to employer insurance policies
purchased for insured or self-insured group
plans, for companies with 20 or more
employees.
This law regulates group health insurance
policies purchased for all insured group
plans, regardless of size, that operate in
the state of Wisconsin.
The former spouse of a covered employee
upon divorce or annulment.
Persons
Eligible to
Elect
Continuation
Any qualified beneficiary who on the day
before the qualifying event is covered under
the group plan and who would lose coverage
under the group plan as a result of the
qualifying event.
The spouse or dependent of the covered
employee upon employee’s death.
The covered employee and any
dependents upon termination of
employment unless discharged for
misconduct.
Note: The employee or spouse/dependent
must have been insured continuously for at
least three months prior to the event.
The employer must provide written notice to
each covered employee and his/her spouse of
the continuation rights as provided by COBRA
upon initial enrollment.
Notification
Upon the occurrence of a qualifying event, the
employer must notify the Plan Administrator
within 30 days.
Once notified, the Plan Administrator has 14
days to notify qualified beneficiaries of their
COBRA election rights.
The employer must provide notice within
five days after the employer receives
notification to terminate coverage.
The qualified beneficiary has 60 days from the
date of the Plan Administrator’s notice to elect
COBRA coverage.
Scope
of
Election
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A qualified beneficiary has the option to
continue coverage under the group plan.
At the time coverage would otherwise
terminate, a beneficiary has the option to
select continuation coverage under a group
policy.
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COBRA
State Continuation
The 18 month period applies to an employee
and dependents if the employee and
dependents lose coverage due to employee
termination/employee loss of eligibility.
The maximum length of the group
continuation coverage is 18 months for the
employee and dependents.
The 36 month period applies when a second
qualifying event occurs entitling the
dependents/spouse to an 18 month extension.
The 18 month period can be extended to 29
months if the employee/dependent is disabled.
Election
Period
Allowable
Premium
Amounts
Payment
of
Premium
The qualified beneficiary has 60 days from the
date of the Plan Administrator’s notice to elect
COBRA coverage.
The election period commences on the
date the insured receives notification from
the employer and ends 30 days after.
The premium for any period of continuation
coverage may not exceed the group rate in
effect (including the employer’s contribution)
for a covered employee.
The premium for any period of
continuation coverage may not exceed the
group rate in effect (including the
employer’s contribution) for a covered
employee.
Coverage under the group plan continues
uninterrupted if an appropriate election is
made and the premium is tendered within 45
days of the election.
A grace period of 30 days applies to all
subsequent premium payments.
Continuation coverage will continue
uninterrupted if an appropriate election is
made and the premium is received within
30 days after receipt of notification from
employer.
COBRA Offering Guidelines (For Companies with 20 or More Employees)
Qualifying Events
Reduction in Work Hours
Applies to all covered employees going from full-time to part-time
Strike
Non-FMLA Medical Leave
Military Leave
Termination ( Voluntary or Involuntary)
Applies to all covered members
Layoff
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Duration of Coverage
18 Months
18 Months
16
Qualifying Events
Duration of Coverage
Excludes termination for gross misconduct
Employer Files Chapter 11 Bankruptcy
Applies to retirees and their covered dependents only
Divorce
Spouse and any dependent children losing coverage are eligible
Employee becomes Medicare eligible
Spouse and any dependent children are eligible
Death of Subscriber
Applies to all surviving dependents
Dependent losing coverage because of reaching maximum age under
the plan
Applies to dependent children and grandchildren who have reached
the maximum age under the plan
36 Months
36 Months
36 Months
36 Months
36 Months
If your employee or a dependent is determined by the Social Security Administration (SSA) to have been
disabled at any time during the first 60 days of COBRA coverage, the employee must notify you (the plan
administer) within 60 days of SSA’s determination. If the employee or a dependent chooses to extend COBRA
coverage, it must be elected before the end of the 18 month period by giving written notice (of election to
extend COBRA coverage). All members can receive up to an additional 11 months of COBRA coverage, for a
total maximum of 29 months.
An individual may elect COBRA regardless of whether he or she is covered by another group health plan or is
entitled to Medicare. COBRA must be offered and cannot be discontinued due to having other coverage or
Medicare if the individual was enrolled in other coverage or Medicare before electing COBRA. If the
individual enrolls in other coverage or Medicare after electing COBRA, COBRA can be discontinued in that
situation.
Medicare will always be primary for an individual on COBRA because he or she is no longer actively at work,
and Dean Health Plan will be the secondary payer of claims. This means that a Medicare carve-out (reduced)
rate will be charged rather than the full active employee rate. If you know the individual has Medicare at the
time of enrollment in COBRA coverage, please make sure that his or her Medicare numbers are submitted to
us so claims are paid properly and premium is charged accordingly.
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Frequently Asked Questions
Upon annual open enrollment, should COBRA participants be given the opportunity to change
plans or add dependents?
Yes. COBRA participants must be allowed the same rights as active employees during annual open
enrollment. This includes, but is not limited to, changing between health plans offered at that time or adding
dependents. You must notify them of their options at annual open enrollment, similar to what you do for
your active employees.
What happens if a COBRA participant is on the HMO plan and subsequently moves out of the
service area?
If you offer both an HMO plan and a Point of Service (or freedom of choice) plan to your active employees
(either through Dean Health Plan or another carrier), you are required to offer the COBRA participant the
opportunity to change over to the freedom of choice plan at the time they move out of the service area. If
you do not offer any options other than an HMO plan, the COBRA participant will have the option of
purchasing any Individual market policy offered in the participant’s new location, either through the Health
Insurance Marketplace or by purchasing one directly from an area insurer. Please have the participant call
our Customer Care Center directly for more information.
If a person becomes eligible for COBRA due to a reduction of hours (for more than 18 months)
and then is subsequently terminated or leaves employment, do you have to offer an additional 18
months of COBRA?
No. The second qualifying event must be a “36 month event” such as death of covered employee, divorce
from covered employee, etc., in order for the time to be extended to 36 months. Two “18 month events” do
not add up to a 36 month event, so the maximum time allowed would be 18 months.
Does each family member have his/her own election rights under COBRA?
Yes. Furthermore, a former employee cannot decline COBRA for other qualified beneficiaries (i.e. family
members). Because of this rule, a very cautious approach to offering COBRA would be to send out two
COBRA election notices: one addressed to the employee and family and one addressed to the spouse and
family.
How is the disability extension of COBRA handled (meaning the additional 11 months beyond the
18 months)?
In order to qualify for the disability extension, the individual must have been disabled during the first 60 days
of COBRA coverage and have been determined by the Social Security to be disabled under its definition.
Written notice from the Social Security Administration confirming the disabled determination must be
provided to Dean Health Plan within 60 days of the date of the determination, in order for the extension to
be considered. The extension includes all members covered prior to the extension, including spouse and
dependents.
Is someone eligible for COBRA if they are already eligible for Medicare or another group health
plan at the time of their COBRA enrollment?
Yes. An individual may elect COBRA regardless of whether he or she is covered by another group health plan
or is entitled to Medicare. COBRA must be offered and cannot be discontinued because of other coverage or
Medicare if the individual was enrolled in the other coverage or Medicare before electing COBRA. If the
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18
individual enrolls in another plan or Medicare after electing COBRA, COBRA can be discontinued in that
situation.
If the individual has Medicare and COBRA coverage, which is the primary coverage?
Medicare will always be primary for an individual on COBRA because he or she is no longer actively at work,
and Dean Health Plan will be the secondary payer of claims. This means that a Medicare carve-out (reduced)
rate will be charged rather than the full active employee rate. If you know the individual has Medicare at the
time of enrollment on COBRA, please make sure that his or her Medicare numbers are submitted to us so
claims are paid properly and premium is charged accordingly.
If the group terminates its group coverage are the employees eligible for COBRA coverage?
COBRA/Continuation is not available to employees if the employer terminates its group coverage. However,
the employees may call the Customer Care Center at (800) 279-1301 to get information about the Individual
policies that Dean Health Plan offers.
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Online Tools and Member Materials
Dean Health Plan has developed an
employer section of our website
(deancare.com/employers) dedicated to our
employer groups. All the information you
need to administer your plan and answer
employee questions is organized in one
convenient location.
Health Care Reform & Compliance
Keeping up with all the state and federal
changes in health care and how they affect
your business and your employees can be a
full-time job. We have a team of professionals
charged with monitoring the new laws and sharing the impact on your business. These updates can be found
at deancare.com/reform.
Plan Administration Resources
This section of the website will connect you to all the resources you will need to manage your plan.
•
There is a welcome video on the main page with valuable contact information and a brief
introduction to the new website.
•
Below the video are quick links to:
o
Forms/Policies/Manuals
o
Supply Request Form
o
Link to Group Certificate Review
o
FAQs
o
Fraud Awareness
o
DeanConnect Training Videos
•
There is an interactive Employer Resource Guide. We have pulled out the sections of the Guide you
access the most to make it easier for you.
•
“Communication Kits” to help you share valuable information about coverage benefits such as Dean
on Call, MyChart, Living Healthy and more.
DeanConnect
DeanConnect is Dean Health Plan’s web portal that opens a world of online conveniences to you. Go to
deancare.com/employers and click on the DeanConnect button from the Helpful Links panel. Some of the
most used features of DeanConnect are:
•
Enroll new employees
•
Add or delete an employee’s dependents
•
Terminate existing members as you experience employee turnover
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20
•
Print temporary ID cards and order new ID cards
DeanConnect transactions are processed the next business day if submitted before 3:00 p.m. You will be able
to follow up on them two days later in DeanConnect, saving you and your employees’ valuable time. To begin
using DeanConnect, contact your Account Manager and request access to DeanConnect . You will need to
provide the name and email address of each of the employees you wish to have access.
A user ID and password will be created and emailed to each person. Be sure to notify Dean Health Plan
when you have staff changes so we may disable access to DeanConnect if a person’s role changes and they
should no longer have access.
There are also helpful DeanConnect tutorial videos available to walk you through using the portal.
Website for Your Employees: deancare.com
Just as deancare.com/employers is dedicated to you as a group administrator, deancare.com is dedicated to
our members and Dean Clinic patients. We invite you and your employees to explore the website and all the
information available to you.
Some of the most utilized areas on the website are:
•
New to Dean (deancare.com/newmember): Whether your employees are new Dean Health Plan
members, Dean Clinic patients or both, we have created a page dedicated to walking them through
the system to help ensure they are getting the most out of their coverage.
•
Find a Doctor (deancare.com/find-a-doc): A quick and easy way to find a provider by last name,
clinic location, specialty type and more.
•
Find a Location (deancare.com/locations): Use the interactive map on this page to find a PCP
location, urgent care facility, hospital and specialty clinic by city. Not finding what you’re looking for?
To the right of the map is a convenient search form where your employees can click on the type of
location they are looking for and the zip code or city they want to find it in.
•
Member Center (deancare.com/members): Everything your employees need to manage their
coverage and benefits in one place.
o
o
o
o
o
•
Member and pharmacy forms
Wellness programs
Member benefit and coverage information
DeanConnect for members (deancare.com/member-benefits)
Drug formulary and pharmacy programs
Classes (deancare.com/classes): A list of classes and webinars offered by Dean.
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21
Monthly Group Billing
Premium Invoice
Invoices for premiums are mailed around the 10th of the month and premium payment is due on the due
date indicated on the premium bill or other premium-related notice. That payment applies to the month’s
premium.
Example: January’s premium invoice would be mailed out on December 10 and is due on January 1, per the
invoice notice, and applies to premium to January.
Updates
In order for changes to be processed and reflected on the next premium invoice, they must be received no
later than the first of the month prior to the premium invoice mailing date.
Example: To have updates included in the April premium invoice, changes would need to be received by
March 1st to be processed in time to be reflected on the April bill, which is mailed March 10 and due on
April 1.
Grace Period
You have a grace period of 31 days from the due date of the bill to make the premium payment. Your group
coverage will remain in effect during the grace period. You will receive a late payment notice from us, this is a
standard notice mailed when a premium payment is not made. The premium payment must be received by
the end of the grace period or cancellation will occur.
To keep your invoice as current as possible, please notify us of enrollment changes as timely as possible.
Please make additions or changes on DeanConnect or fax your requests directly to Enrollment and Billing at
fax number (608) 252-0873 or send them by secure email to [email protected].
Invoice Adjustments
You should always pay your premium as billed. Any membership adjustments submitted will be reconciled on
your next month’s premium invoice.
Payment of your Premium Invoice
We offer you two options when paying your premium invoice.
1. Payment by check upon receipt of your premium invoice, which includes a reply envelope.
2. Automatic Withdrawal (ACH) from your group’s bank account. A sample of the ACH Form is included
in the Sample Forms & Reports section of this guide. Please contact the Enrollment and Billing
Department for additional information and a copy of the ACH form.
Determining an Employee’s Rate
If your group’s rate is based on your employee’s age, please refer to the rate table received with your most
current renewal or contact your Account Manager to determine the monthly premium rate for newly eligible
employee. Rate changes may occur when an employee’s enrollment status changes or upon your renewal.
When you call your Account Manager, you will need to have the following information ready.
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22
•
Employee’s date of birth
•
Coverage Type (Single, Family, Employee & Spouse, Employee and Child(ren)
If your group’s rate is based on enrollment coverage type (i.e. single/family) please refer to the rates
provided to you for the current benefit period with your most current renewal. Your Account Manager will be
able to assist with any questions regarding rates.
Mid-month Adjustments
If your group has an “End of Day” termination rule, coverage for an employee may end in the middle of a
month. If the effective date or termination date is during the middle of the month, we will bill premiums as
follows:
• If the effective date is between the 1st and the 15th of the month, you will be billed for that month’s
premium. For a termination, you will not be billed for that month’s premium.
•
If the effective date is between the 16th and the end of the month, you will not be billed for that
month’s premium. (This is because we do not prorate for a half month.) For a termination, you will
be billed for that month’s entire premium.
Discrepancy Reports
Each monthly invoice will reflect the current month’s billing activity and any balance brought forward. The
invoice will not list details on any outstanding balances. Any changes, such as a new or terminated subscriber
will appear on the invoice IF they completed the enrollment process during the month. If you have an
overpayment or credit on your account or have an outstanding balance due that we are unable to reconcile
you will receive a Discrepancy Report following monthly payment reconciliation by the Enrollment and Billing
Department. We will continue to keep you informed of the status of any outstanding balances or
discrepancies.
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Medicare
The information below is meant to advise you on issues surrounding Medicare coverage and concerns only
the coordination of benefits for Medicare Part A and Medicare Part B.
General Information
Subscribers and/or dependents can become eligible for Medicare for various reasons. The most common are:
•
Age
•
Disability
•
End Stage Renal Disease (ESRD)
It is your and/or your employee’s responsibility to advise us of any eligibility and/or enrollment in Medicare
Part A or Part B, regardless of the reason for that enrollment. Failure to do so may cause delays or incorrect
processing of claims.
Enrollment
Enrollment in a Dean Health Plan group policy is based on an employee’s current employment status at the
time he or she qualifies to enroll (Actively at Work, Retired, COBRA or Severance).
The Social Security Administration (SSA) and Dean Health Plan follow the same guidelines to determine
employees’ Medicare eligibility. Use the attached charts which contain a Medicare summary to help you to
identify when employees are “working” and “not working” to determine if enrollment in Part B is advisable to
reduce the employee’s out-of-pocket expenses. The only exception to this rule is if the employee is covered
under Medicare’s ESRD program.
We cannot force any subscriber/dependent to enroll in any part of Medicare. However, per your Member
Certificate, we will pay as if the employee was enrolled, which means the person will incur out-of-pocket
expenses for amounts that Medicare would likely have paid.
If a subscriber is getting ready to enroll in any non-actively-working segment, such as Retiree, COBRA,
Continuation, Long Term Disability (LTD), Severance or other “non-working” status while covered by the
employer’s plan, remind the employee to review his or her responsibility to enroll in Medicare, if eligible.
Employees may check on their Medicare eligibility by contacting the local SSA office or by calling our
Medicare Coordination of Benefits (COB) Analyst for assistance. The contact numbers are in the Medicare
section of this document.
If the employee contacts the SSA office, he or she should be prepared to give as much detail as possible
concerning his or her planned retirement or termination from work. This may include the employer size, his
or her work status and the work status of his or her spouse. Any paperwork the employer can furnish
indicating the member’s retirement/termination may prevent delayed or denied medical claims.
Regardless of circumstances, it is ultimately your and/or the affected employee’s responsibility to ensure we
are made aware of Medicare eligibility and enrollment, for any reason.
If you or your employee is unsure when Medicare enrollment is advisable to avoid out-of-pocket expenses,
please call the Medicare COB Analyst at the number indicated at the end of this section.
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Employer Group Size
Group size is determined by the number of employees on the payroll records for the prior IRS calendar year
as indicated in the Medicare Secondary Payer Manual. Dean Health Plan will be the primary payer only when
required by federal regulations.
The chart included in this section displays the criteria that SSA uses when determining beneficiary eligibility
and whether Dean Health Plan will be the primary payer before Medicare. It is very important for
coordination purposes that you report accurate employee numbers to us on the Group Information Form
sent each year with your renewal, or the Employer Application for Group Coverage Form when initially
enrolling with us.
Medicare Secondary Payer Manual, Chapter 2 indicates:
•
•
10.3 - The 20-or-More Employees Requirement: This rule applies if an Employer has 20 or more
fulltime and/or part-time employees for each working day in each of 20 or more calendar weeks in
the current or preceding year.
30.2 - The 100-or-More Employees Requirement: This rule applies to employers that employed 100
or more full-time and/or part-time employees on 50 percent or more of its business days during the
previous calendar year.
Medicare is secondary for all employees enrolled in a multi-employer plan, such as a union plan which covers
employees of some small employers as well as employees of at least one employer that meets the 100-ormore employee requirement, including those that work for small employers. There is an exception to the
working aged provision, as it does not apply to the payment order determination if the employee is enrolled
in Medicare due to a disability. An employer will be considered to employ 100 or more employees on a
particular day if the employer has at least 100 full-time or part-time employees on his/her employment rolls
on that day, regardless of the number of employees who work or who are expected to report for work on
that day.
Center for Medicare and Medicaid (CMS) Medicare Secondary Payer
Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007 established mandatory reporting
requirements for group health plans. All group health plans, including Dean Health Plan, are required to
comply.
Each December, a form (attached in the Samples, Forms & Reports section) will be sent to you requesting
information about your group size for the current year. We must report this information to CMS so it is
essential that the form is completed accurately and promptly returned to us. It is your responsibility to notify
us immediately if your group size changes from fewer than 20 to 20 or more employees for 20 weeks or more
(the weeks do not have to be consecutive).
Each May (which is 20 weeks into the year) a reminder notice is sent to Groups that reported fewer than 20
employees in the previous year, to help groups remember to report a change to 20 or more employees. The
reminder notice must be returned if the Group has increased the number of employees to 20 or more for 20
or more weeks (the weeks do not have to be consecutive) since January 1 of the current year.
Medicare Questionnaire
Each month, we send a Medicare Questionnaire to employees who are about to reach the age of 65. This is
sent to members approximately 60 days prior to the member’s birth date.
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25
Each letter is specific as to the subscriber’s current work status and is personally addressed to that individual.
If no response is received within 30 days, a second request is sent. If no response is received from the second
request, we will complete a review using the Medicare Data Match through the Centers for Medicare and
Medicaid Services (CMS). We will update its system based on the information obtained through CMS. In cases
where information is not provided by the subscriber, member or employer, the information from Medicare
will take priority. By State law, if we have on record that you employ 19 or fewer individuals you will also
receive a copy of this questionnaire. We appreciate your assistance in timely return of this information.
Primary Payment Notice or PPN
Prior to a Medicare Demand Letter (below) the Coordination of Benefits & Recovery Center (CRC) will send a
Primary Payment Notice (PPN) to both the impacted employer and the insurer/TPA (Third Party Payer). The
PPN is a notice to the employer to advise them that the Centers for Medicare & Medicaid Services (CMS) has
identified instances where Medicare may have mistakenly made a primary payment when other primary
insurance exists. Enclosed with this notice is a PPN worksheet that lists Medicare beneficiaries and
corresponding coverage dates. The notice requests the employer to review the worksheet, make corrections
and additions as necessary, and mail or fax the completed worksheet to the CRC.
Medicare Demand Letters (Requests for a Refund)
These requests are sent to the last Employer known to Medicare. These requests are sent as a result of a
possible debt that may be owed to Medicare because it may have mistakenly paid primary for medical claims
we should have paid. These requests are extremely time sensitive and require immediate action by the
employer. If the response to these requests is not received by Medicare within 60 days from the date of the
initial request, interest is added and is accrued monthly. Medicare does not make allowances for Postal
Service delays.
If you receive a Medicare demand letter and the individual concerned was insured with us, please contact the
Dean Health Plan Medicare COB Analyst to ensure Dean Health Plan has received a copy. Dean Health Plan
will review all claims sent to us, make payments as necessary and ensure the employer receives a copy of the
final disposition of that request.
After Medicare completes its review, it will respond with a letter indicating no further payment is required
and the “case is closed,” or it will request additional information or payment.
If the employee is insured by Dean Health Plan, it is your responsibility to ensure that we are advised of all
such letters. If you have any questions about these requests, please call our Medicare COB Analyst.
Failure to comply with the federal laws concerning these refund requests can make the Employer Group
responsible for the amount due (Medicare Secondary Payer Manual, Chapter 7). In addition, if there is any
delay determined as “inappropriate” by Dean Health Plan, the Employer Group may be liable for any
interest accrued from that delay.
Failure to Notify Dean Health Plan of Medicare Eligibility Resulting in Claim Reversals and
Premium Changes
If the employee/dependent fails to inform you or us that they are eligible for Medicare, the situation will be
reviewed and action may be taken. We have the legal right to recover funds paid incorrectly when
information of this type is discovered.
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•
The specific employee will be notified by letter of this change to the primary payer of the medical
claims and given the reasons and dates in question.
•
The employee/dependent will also be referred to the nearest SSA office to consult about possible
options available.
Medicare premiums will only apply if Medicare is the primary payer regardless if the member is
enrolled in Medicare Part B.
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Eligibility Summary Charts
Medicare Eligibility Summary for an Employee who is:
CURRENTLY WORKING
NUMBER OF
EMPLOYEES
2-19
2-19 & Medicare
Disabled
20-99
20-99 &
Medicare
Disabled
100+
ENROLLMENT IN MEDICARE A & B
To ensure employee has the least outof-pocket amounts, strongly
recommended for
employee/dependents
recommended for
employee/dependents
Not mandatory, may defer for
employee/dependents
recommended for
employee/dependents
Not mandatory, may defer for
employee/dependents regardless of
age or Medicare disability
PRIMARY
PAYER
SECONDARY
PAYER
RATING
STRUCTURE
Medicare
Dean Health
Plan
Medicare Rate
Medicare
Dean Health
Plan
Medicare Rate
Dean
Health Plan
Medicare
Full
Medicare
Dean Health
Plan
Medicare Rate
Dean
Health Plan
Medicare
Full
Medicare Eligibility Summary for an Employee who is:
NOT CURRENTLY WORKING
NUMBER OF
EMPLOYEES
2-19
2-19 & Medicare
Disabled
20-99
20-99 &
Medicare
Disabled
100+
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ENROLLMENT IN MEDICARE
A&B
To ensure employee has the lowest
out-of-pocket amounts, strongly
recommended for
employee/dependents
recommended for
employee/dependents
recommended for
employee/dependents
recommended for
employee/dependents
PRIMARY
CARRIER
SECONDARY
CARRIER
RATING
STRUCTURE
Medicare
Dean Health
Plan
Medicare Rate
Medicare
Dean Health
Plan
Medicare Rate
Medicare
Dean Health
Plan
Medicare
Dean Health
Plan
Medicare Rate
Medicare
Dean Health
Medicare Rate
Medicare Rate
28
NUMBER OF
EMPLOYEES
ENROLLMENT IN MEDICARE
A&B
recommended for
employee/dependents regardless of
age or Medicare disability.
PRIMARY
CARRIER
SECONDARY
CARRIER
Plan
RATING
STRUCTURE
Coverage for individuals with End-Stage Renal Disease (ESRD) does not vary with employer group size or
active work status of the individual or spouse. The employee should contact the SSA for more information.
These guidelines do not reflect all the possible criteria affecting the primary payer determination. For further
details, please contact the Social Security Administration.
Medicare Contact Information
Medicare COB Analyst
Victoria Labovsky
Phone: (608) 827-4189
Social Security Administration (SSA)
Phone: (800) 772-1213
Website: ssa.gov
Medicare
Phone: (800) 633-4227
Website: medicare.gov
Medicare Coordination of Benefits Center
Phone: (800) 999-1118
Phone: (202) 219-8776
Website: dol.gov
State of Wisconsin Office of the Commissioner of Insurance
Phone: (608) 266-3585
Toll Free: (800) 236-8517
Website: oci.wi.gov
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Retirees
If the group does not offer retiree coverage, retiring employees may be offered COBRA/State Continuation.
Please refer to the COBRA/State Continuation section for additional information.
Please note: An employee is eligible for COBRA /State Continuation if he or she is Medicare-eligible. A second
option is enrolling the employee in a group retiree segment through Dean Health Plan, provided one has
been previously approved for your group.
Retiree Segment Requirements and Set Up
The company’s retiree policy must address and meet the following guidelines:
•
You have a formal, written policy outlining retiree benefits offered.
Example: Insured employees who have at least 25 years of service and who are age 55 are eligible for
retiree benefits. The definition must apply for all eligible insured employees within our service area.
•
The definition must state how long a retiree can remain covered under the retiree segment. This is
usually limited to age 65 or eligibility for Medicare.
•
The eligibility requirement should contain clarification on coverage for spouses/dependents.
Example: The spouse and dependents can remain covered under the retiree segment as long as they
were insured prior to the employee’s retirement.
•
In addition, your policy should also clarify what happens to coverage of the spouse/dependents
should the retiree pass away.
•
If you offer health plans from other carriers, they must agree to allow the retiree coverage. If the
other carriers do not agree to offer the retiree coverage or cancel the retiree coverage at a later
date, you must notify us.
•
Your premium contribution to the retiree’s coverage must be at least 25 percent of the single
premium across all tiers and must be the same for all insured. This may be achieved through pension
benefits or accrued sick and vacation time the company allows to be used for health insurance
premium payments.
•
The options for coverage changes at annual enrollment time must be noted.
Example: Can the retirees switch between health plans at annual enrollment or are they required to
remain on the plan chosen at retirement indefinitely?
•
Medicare – If we approve a policy that covers retirees who are Medicare-eligible, such retirees are
required to enroll in both Medicare Parts A and B. We will pay secondary to Medicare whether or not
the retiree elects Parts A and B.
•
Special Enrollments – If a retiree acquires a new dependent as a result of marriage, birth, adoption or
placement for adoption, the retiree may be able to enroll himself or his qualified dependents in the
plan provided that we receive an application for enrollment within 31 days after the date of the
event. If the retiree waives Dean Health Plan retiree or dependent coverage when initially eligible for
coverage under the retiree plan, one subsequent enrollment into the retiree plan will be allowed,
but only if other group coverage (excluding dual choice coverage) is involuntarily lost and we receive
an application for enrollment within 31 days following the date coverage was lost.
•
Standard Retiree Participation Levels and Ongoing Monitoring – Maximum retiree participation
levels have been established to control the amount of risk presented by retiree policies. For groups
with two to 25 total employees, the standard maximum participation level for retirees may not
exceed 10 percent of the total group enrollment with us. For groups with 26 or more employees the
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standard maximum participation level for Dean Health Plan retirees may not exceed 25 percent of
the total group enrollment with us.
Please note: A group may elect to freeze retiree enrollment at any time to prevent retiree participation from
growing further. In any case, rates would be adjusted to appropriately reflect the risk presented by the retiree
population if it exceeds 10 percent and retirees may be rated separately if appropriate based on the below
guidelines.
Contact your Account Manager for information on how to set up a retiree segment.
Enrolling in a Retiree Segment
An Employee Application for Group Coverage Form must be completed by the employee upon retirement.
•
The employee will check “transfer to retiree segment” under “Reasons for Application” and should
indicate effective date of change.
•
The employee should also note in Section D of the application if he or she has enrolled in Medicare.
•
Because Medicare is the primary payer for members on the retiree segment, all retirees and
dependents who qualify for Medicare are strongly advised to enroll in both Part A & B because we
will pay claims as if they are enrolled.
•
The Employee Application for Group Coverage Form should be received by Dean Health Plan within
31 days of the retirement date. Retirees will be noted on the billing statement under a separate
group number (similar to COBRA enrollees).
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Group Renewal and Contract
Renewal
Large Group Renewals (50 + employees)
You will receive renewal materials 60 days prior to your renewal date. The following documents will be
included:
•
Cover Letter – providing the date we need to receive plan changes
•
Explanation of Renewal
•
Rate Table for the Renewal Plan
•
Rate Sheet – Complete and return
This form provides your new rates for the renewal plan and may contain some alternate plan
options. You will need to complete the acceptance information, which includes indicating the plan
you wish to renew with and your contact information. To ensure your premium billing and Summary
of Benefits and Coverage distribution are correct, be sure to return the Rate Sheet by the date
indicated in the cover letter.
•
Benefit Summaries for all plans quoted
•
Benefit Changes (if applicable)
o Community-Wide Benefit Changes
o Legislative mandates
•
Group Information Form – Complete and return
Please return this form with your Rate Sheet. It will be used to determine:
o Medicare eligibility and requirements
o COBRA participation and contribution strategies
o Other Carriers offered
•
Plan Brochure(s)
Samples can be found in the Samples, Reports & Forms Section.
Your Account Manager can help if you need to make any changes to your contract or plan at renewal time. If
you elect to change your benefit plan design, all plan changes need to be requested and approved prior to
your renewal/anniversary date. Benefit upgrades are subject to review and approval.
Please Note: If the Rate Sheet is not returned by the date indicated, we will renew your group with the current
or closest available ACA-compliant plan. Failing to return the Rate Sheet will not result in the termination of
your group policy. Group terminations require written notification to your account manager.
Small Group Renewals (2-49 employees)
You will receive renewal materials 60 days prior to your renewal date. The following documents will be
included:
•
Cover Letter – providing the date we need to receive plan changes
•
Rate Sheet – Complete and return
This form provides your new rates for the current or closest available ACA-compliant plan and may
contain some alternate plan options. You will need to complete the acceptance information, which
includes indicating the plan you wish to renew with and your contact information. To ensure your
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premium billing and Summary of Benefits and Coverage distribution are correct, be sure to return
the Rate Sheet by the date indicated in the cover letter.
•
Rate Table
•
Benefit Changes (if applicable)
o Community-Wide Benefit Changes
o Legislative mandates
•
Group Information Form – Complete and return
Please return this form with your Rate Sheet. It will be used to determine:
o Medicare eligibility and requirements
o COBRA participation and contribution strategies
•
Plan Brochure(s)
Samples can be found in the Samples, Reports & Forms Section.
Your Account Manager can help if you need to make any changes to your contract or plan at renewal time. If
you elect to change your benefit plan design, all plan changes need to be requested and approved prior to
your renewal/anniversary date. Benefit upgrades are subject to review and approval.
Please Note: If the Rate Sheet is not returned by the date indicated, we will renew your group with the current
or closest available ACA-compliant plan. Failing to return the Rate Sheet will not result in the termination of
your group policy. Group terminations require written notification to your account manager.
Changing Contract Provisions
If you need to change any of your contract provisions, please contact your Account Manager. Any changes
that are approved will be effective on the first of the month following the date we receive the request. All
requests are subject to Dean Health Plan approval, such as:
•
New hire probationary period
•
Return from lay-off
•
Employee termination
•
Rehire provision
Changes in Ownership or Business Structure
If your group has any changes in ownership or changes in your business structure (e.g. mergers or
acquisitions) please notify your Account Manager immediately. Certain changes may require additional forms
to be completed for our records.
It is your responsibility to notify us within ten days of a change in legal status, expansion of business,
dissolution of business, merger, buyout or any other significant business operational change. In addition, you
must notify us at least 90 days in advance of any additional employee segments being added. The addition of
segments is subject to our approval.
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Summary of Benefits and Coverage (SBC)
Important Information about the Summary of Benefits and Coverage Document for Group
Members
The ACA requires that health insurance providers and employers begin providing the SBC document to
potential and current health plan members beginning September 23, 2012.
The final regulations require that the SBC be provided in several instances:
Upon application: If written application materials are distributed for enrollment, the SBC must be provided
as part of those materials. Written application materials include any forms or requests for information in
paper form, website or email that must be completed for enrollment. If written or electronic application
materials for enrollment are not distributed, the SBC must be provided no later than the first date on which
the participant is eligible to enroll in coverage.
By first day of coverage (if there are any changes): If there is a change to the SBC provided upon application
and before the first day of coverage, the plan or issuer must update and provide a current SBC no later than
the first day of coverage.
Special enrollees: The SBC must be provided to special enrollees no later than 90 days from the date of
enrollment.
Open Enrollment: If participants are required to actively elect to maintain coverage or change coverage
options during an open enrollment period, the SBC must be provided at the same time open enrollment
materials are distributed.
Upon renewal: If there is no requirement to renew, and no opportunity to change coverage options, renewal
is considered to be automatic and the SBC must be provided no later than 30 days prior to the first day of the
new plan or policy year. Dean Health Plan will mail SBCs to all members 30 days prior to their renewal date.
Upon request: The SBC must be provided upon request as soon as practicable but in no event later than
seven business days following receipt of the request.
Mid‐contract plan change: The SBC must be provided to the participant 60 days prior to the effective date of
the plan change. All mid‐contract plan change requests must be received by Dean Health Plan at least 75 days
prior to the new effective date.
SBCs for all group plans are available at: https://app.deancare.com/sbc/EmployerGroup.aspx. Below is a
screenshot of the webpage where you can find and print your group’s SBC(s).
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Group Master Policy (GMP)
The Group Master Policy (GMP) is the legal contract between your group and Dean Health Plan. The GMP,
along with the Group Member Certificate, the SBC, the Employer Application for Group Coverage Form, the
Employee Applications, and any applicable riders, amendments and/or addendums, constitutes the entire
policy between Dean Health Plan and Employer Group.
The first section of the GMP contains a Signature Page that should be signed and returned after a new or
revised GMP is sent to you. The Overview of Coverage Conditions section contains provisions specific to your
group. This is followed by the General Provisions that apply to all groups.
Claims
Coordination of Benefits (COB)
If an employee or dependent has Dean Health Plan insurance and is also covered by another health plan, we
will coordinate benefits. In this case, there will always be a primary payer and a secondary payer. A more
detailed description of the COB process is provided in the Member Certificate.
Primary Payer and Secondary Payer?
•
Birthday Rule - When each parent has family health insurance coverage, each has primary coverage
for themselves and secondary coverage for their spouse under their respective plans. The parent
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whose birth date occurs earliest in the calendar year provides primary coverage for their dependent
children. The other parent’s coverage would be secondary.
•
Divorce situations - The birthday rule usually applies unless a court order specifies otherwise. We
require a copy of the court order indicating who is to provide coverage for dependent children in
divorce, custody and paternity determination cases.
When Medicare is involved, we may be primary based on the employee’s work status (example: working
or not working). Please refer to the Medicare section for additional information.
Submitting a Claim for COB
Claims must be sent to the primary plan first even if the employee believes the primary plan will not pay the
claim. After the primary plan processes the claim, the Explanation of Benefits (EOB) will be mailed to the
member and will indicate how the claim was processed. The EOB must accompany the original claim and be
sent to the secondary payer for processing. In most cases, COB provisions are designed so that the total
benefits available from two or more health plans reimburse up to 100 percent of medical expenses, if
possible. If you have any questions about which coverage is primary, please call our Customer Care Center at
(800) 271-1301.
Please note: In most cases the provider of services will submit the claims to both the primary and secondary
health insurance companies on your employee’s behalf.
Subrogation
Employees should notify us through our Customer Care Center immediately when they file any claim related
to an illness or injury caused by a third party or for which a third party is liable. This includes, but is not
limited to, claims for auto accident coverage, worker’s compensation, injury benefits and any disability
benefit act or other employee benefit act.
In all cases except worker’s compensation, we will process the related illness or injury claims according to
covered benefits and then pursue the responsible party for a recovery of benefits paid. For worker’s
compensation cases, we will only consider payment of work-related illness or injury claims according to
covered benefits when the worker’s compensation carrier has denied medical benefits. A copy of the
worker’s compensation carrier’s denial must be submitted along with notification of whether or not the
member is appealing the denial.
Please note that an employee/dependent whose claims have been flagged as a possible subrogation issue
will be mailed an Injury Report Form asking for more information regarding the incident (see the sample in
the Samples, Forms and Reports section). The employee/ dependents must complete the questionnaire
within ten days of receipt or the claims related to the injury will be denied. To complete the form the
member has the following options:
•
Call the Customer Care Center at (800) 279-1301
•
Call the Subrogation Department at (608) 827-4136 or (608) 827-4127
•
Complete the form online for worker’s compensation issues or at deancare.com/injuryquestionnaire
for subrogation issues
•
Fax the form to the Subrogation Department at (608) 827-4098
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Your employees have the right to appeal a decision by filing a formal internal grievance. After the internal
grievance process is complete, your employee may also have the right to request an independent external
review. If the matter is urgent in nature, your employee may be entitled to an expedited independent
external review.
Explanation of Benefits (EOB)
Any time a claim is processed that results in member responsibility for the service, an EOB is generated and
mailed to the member. At the same time an Explanation of Payment (EOP) is mailed to the provider of
services. (EOBs are not generated if the only member responsibility is an office copay.)
The definitions below will assist you in reading an EOB and understanding any amount(s) that are the
member’s responsibility:
Contract Period
Your benefits are determined based upon your policy’s contract period. Please refer to your Member
Certificate for specific information.
Service Date
The date the service was provided.
Claim Number
The internal number used by Dean Health Plan to identify your claim.
Amount Allowed
The amount Dean Health Plan accepts as the maximum allowable fee to be paid to a provider as defined in
your Member Certificate. The difference between a provider’s charge and the amount allowed may be the
member’s responsibility.
Deductible
The amount that you must pay each calendar year before Dean Health Plan will pay for covered services as
specified in your Schedule of Benefits. The amount or percentage that is your responsibility each time
covered services are provided, subject to the maximums specified in your Schedule of Benefits. Depending on
your plan, the required deductible obligation may be listed for an individual, for the entire family, or broken
out into separate medical and pharmacy deductible limits depending on your plan.
Patient Responsibility
The cumulative amount of the following: Amount not covered, Copayment/Co-insurance, Deductible and the
difference in a provider’s charge and amount allowed amount (on certain policies, please see your Schedule
of Benefits about maximum allowable fee). Member responsibility limits are capped at the maximum out-ofpocket expense as indicated on your Schedule of Benefits. Once this limit is reached, your employee is not
responsible for any additional out-of-pocket costs until the following contract period.
Adverse Benefit Determinations
In the event of an adverse benefit determination as defined by the US Department of Labor, the reverse side
of the EOB contains appeal rights available to your employee.
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Grievance & Appeals Process
If you have questions about benefit determinations for requested services or claims payment, please
call our Customer Care Center at (608) 828-1301 or (800) 279-1301. If you have a concern, we encourage you
to call us first because most problems can be resolved informally.
You are entitled to an internal review of an adverse benefit determination. An adverse benefit
determination is when a plan: denies, reduces, or terminates a benefit; fails to pay for a benefit; or rescinds
coverage. A request for internal review must be made in writing by you or your authorized representative.
The request can be mailed to Dean Health Plan at the address listed below. Within 5 business days of
receiving your grievance, we will send you a confirmation letter. The letter will notify you of the date and
time of the next scheduled Grievance Committee meeting, which will be at least 7 calendar days after the
date on the letter and less than 30 calendar days after we receive your grievance. You have the right to
attend that meeting in person or by phone. If you wish to attend, you must call to schedule a time. You also
have the right to submit information about your grievance and be assisted or represented by a person of
your choosing. We will provide the following information automatically so that you will have time to respond
prior to our grievance determination: 1) any new or additional evidence considered, relied upon, or
generated by us in the course of the grievance process, or 2) any new or additional rationale on which the
determination will be based. If you wish to receive a free copy of any other documents relevant to the
outcome of your grievance, send a written request to the address listed below. Your grievance will be
resolved within 30 days calendar days of receipt.
If your grievance involves urgent care, your grievance will be expedited and resolved within 72 hours
of receipt. Your grievance will automatically be expedited if: your grievance is related to an admission or
continued stay in a facility, your physician or the Dean Health Plan Medical Director determines the standard
review timeframe could endanger your health or subject you to severe pain, or your physician states your
claim involves urgent care. You or your authorized representative may also make an oral or written request
for an expedited internal review. In this same manner, a request may also be made to have an independent
external review (IER) conducted in the same expedited timeframe as your internal review.
You may be entitled to an IER if your adverse benefit determination was based on the policy
requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness of
care, or the classification of services as experimental or investigational. A policy rescission is also eligible for
IER. You must exhaust our internal review process before requesting an external review unless: 1) we fail to
comply with internal claims and appeals requirements, 2) you request an expedited external review when
you request an expedited internal review, or 3) we grant your request to bypass our internal review process.
To request an IER, you or your authorized representative must mail your written request to the
address listed below so that we receive it within four months of the date your internal review was decided.
When we receive your request, a URAC-accredited independent review organization (IRO) will be assigned to
your case through an unbiased, random selection process. You have the right to submit additional
information to the IRO, the IRO will explain how. The IRO will send written notice of its decision to you and
Dean Health Plan within 45 calendar days of receiving your review request. Neither you nor Dean Health Plan
can appeal an IRO decision, unless other remedies are available under State or Federal law.
Dean Health Plan, Attention: Grievance & Appeals Department, PO Box 56099, Madison WI 53705
You may also file a complaint with the Wisconsin Office of the Commissioner of Insurance (OCI) at
(800) 236-8517 or [email protected], and the Employee Benefits Security Administration (EBSA)
at (866) 444-3272. If your group plan is covered by the Employee Retirement Income Security Program
(ERISA), you may also be entitled to sue in federal district court.
For more information about grievance and appeal procedures, you may refer to your Member
Certificate/Handbook, call our Customer Care Center at (608) 828-1301 or (800) 279-1301, visit
deancare.com or speak with your plan administrator.
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Samples, Reports and Forms
A. Employee Application for Group Coverage
Used for adding a new employee, electing Continuation or COBRA coverage for an employee who is
leaving, updating employee information and adding or deleting dependents.
B. ID Cards
Examples of the ID cards for HMO, POS and PPO plans. ID cards are mailed to the subscriber’s home in
seven to 10 days from date requested.
How to Read Your Member ID Card
C. Monthly Group Invoice Sample
Premium billing is sent around the 10th of the month, and the premium is due by the due date indicated
on the premium invoice or other premium-related notice. The last page of the invoice can be used to
delete employees from coverage.
Please email to [email protected] or fax to (608) 836-9620.
D. Automatic Bank Withdrawal Form (ACH Form)
Allows groups to set up automatic withdrawal from a bank account to pay the group’s insurance
premium each month.
E. Medicare Questionnaire
Sent each month directly to members who will reach age 65 within 60 days. Verifies employment status
and assists in determining the need to enroll in Medicare part A and/or Medicare part B and indicates
who the primary payer is for claims.
F. Large Group Renewal Materials
a. Rate Sheet: Sent approximately 60 days prior to your renewal date as part of your renewal
packet. Provides rates for renewal plan and rates for alternate plan options when available.
The form must be completed and returned to us. See the due date on the renewal cover
letter if you are making a plan change. If the Rate Sheet is not returned we will renew your
group on the renew-as-is plan for the next year.
b. Group Information Form: Sent as part of your renewal packet. Used to obtain Medicare
eligibility requirements and COBRA participation and contribution strategies, which are
based on group size. This form must be completed and returned to us with the Rate Sheet
prior to renewal date.
G. Small Group Renewal Materials
a. Rate Sheet: Sent approximately 60 days prior to your renewal date as part of your renewal
packet. Provides rates for renewal plan and rates for alternate plan options when available.
The form must be completed and returned to us. See the due date on the renewal cover
letter if you are making a plan change. If the Rate Sheet is not returned we will renew your
group on the renew-as-is plan for the next year.
b. Group Information Form: Sent as part of your renewal packet. Used to obtain Medicare
eligibility requirements and COBRA participation and contribution strategies, which are
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based on group size. This form must be completed and returned to us with the Rate Sheet
prior to renewal date.
H. Explanation of Benefits (EOB)
Any time a claim is processed that results in member responsibility other than a copay, an EOB is
generated and mailed to the subscriber indicating we processed a claim and there is member
responsibility for which the provider of services will be billing you.
EOB Example
I.
Qualifying Event Questionnaire
Upon receipt of an enrollment for a special event, the Enrollment Department will send this
questionnaire to the member to gather additional information. The enrollment will be pended until that
additional information is received.
J.
CMS Medicare Secondary Payer Requirements
In December of each year you will receive a letter from Dean Health Plan requesting information in
regard to your total number of employees. It is essential that you complete the form and return it to us
promptly. All group health plans must comply with this requirement.
K. Injury Report Form
If the submitted claims contain codes that are common to injuries that may have third party liability, an
Injury Report Form will be mailed to the member. Claims will not be paid until the member responds to
the Injury Report Form.
L.
Waiver of Coverage Form
If an employee chooses not to take coverage when it becomes available to them, employers should have
the employee complete the Waiver of Coverage Form and maintain that form in their files.
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Employer Resource Guide

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