Group Administrator Manual How to administer your group’s health coverage

Transcription

Group Administrator Manual
How to administer your group’s health coverage
16430CTEENABS 09/14
Section 1 – Introduction ......................................................................................................................................... 4
Welcome ................................................................................................................................................................................................... 4
Employer responsibilities ............................................................................................................................. ............................................. 4
Section 2 – Important addresses and telephone numbers................................................................................ 6
General correspondence ............................................................................................................................. ............................................. 6
General claims............................................................................................................................ .............................................................. 6
Specialty...................................................................................................................................................................................... ............. 6
Anthem Blue View VisionSM...................................................................................................................................................................... 6
Section 3 – Eligibility ............................................................................................................................................. 8
Eligible employees ............................................................................................................................. ...................................................... 8
Section 4 – Effective dates.................................................................................................................................... 9
Open enrollment ............................................................................................................................. ......................................................... 9
Employee benefit conversion................................................................................................................................................................... 9
Employer group benefit conversions........................................................................................................................................................ 9
New hires ................................................................................................................................................................................................. 9
Newly eligible dependents ..................................................................................................................................................................... 10
Section 5 – Enrollment procedures.................................................................................................................... 11
How to enroll an employee and eligible dependents ............................................................................................................................. 11
Medicare secondary payer (MSP) ......................................................................................................................................................... 11
Enrollment changes ............................................................................................................................. .................................................. 13
Addition or deletion of members ............................................................................................................................................................ 13
Removal of a dependent........................................................................................................................................................................ 16
Changing contact information ................................................................................................................................................................ 17
Correcting dates of birth........................................................................................................................... .............................................. 17
Changing primary care physicians......................................................................................................................................................... 18
Moving out of the service area............................................................................................................................................................... 18
Flexible benefits plans (Section 125 plans) ............................................................................................................................. .............. 18
Special enrollment considerations ......................................................................................................................................................... 18
When to send enrollment forms ............................................................................................................................................................. 19
Open enrollment .................................................................................................................................................................................... 19
Section 6 – Electronic enrollment ...................................................................................................................... 20
Electronic enrollment advantages ......................................................................................................................................................... 20
Electronic enrollment options ................................................................................................................................................................ 20
Online tools and resources for employers ............................................................................................................................. ................ 21
Online tools and resources for members ............................................................................................................................................... 22
2
Section 7 – Coordination of Benefits (COB) ...................................................................................................... 23
Section 8 – Claim filing........................................................................................................................................ 24
Hospital claims....................................................................................................................................................................................... 24
Medical/surgical claims ............................................................................................................................. ............................................. 24
BlueCard®: the out-of-area program ...................................................................................................................................................... 25
BlueCard Worldwide program................................................................................................................................................................ 25
Anthem Dental ............................................................................................................................. .......................................................... 25
Prescription drug claims......................................................................................................................................................................... 26
Home delivery pharmacy prescription.................................................................................................................................................... 26
Section 9 – Billing ................................................................................................................................................ 27
Quick reference guide............................................................................................................................. ............................................... 27
Fully insured groups............................................................................................................................. .................................................. 28
Notification of new employees ............................................................................................................................................................... 28
Waiting period ............................................................................................................................. ........................................................... 28
Effective dates ................................................................................................................................................................................. ...... 29
Notification of left employees ................................................................................................................................................................. 29
Medical Loss Ratio Disclosure............................................................................................................................................................... 31
Common Membership Change messages ............................................................................................................................. ............... 31
Administrative Services Only (ASO) Groups ............................................................................................................................. ............ 32
Section 10 – Accounting and terminations........................................................................................................ 33
Payment............................................................................................................................. .................................................................... 33
Reinstatement........................................................................................................................................................................................ 33
Retroactive coverage changes .............................................................................................................................................................. 34
Employee contract termination .............................................................................................................................................................. 34
Transfer privileges ............................................................................................................................. .................................................... 35
Section 11 – Federal law ..................................................................................................................................... 36
Medicare ................................................................................................................................................................................................ 36
Medicare Secondary Payer (MSP) regulations...................................................................................................................................... 36
Medicare and group coverage: Who is the primary carrier? .................................................................................................................. 37
Dual Medicare eligibility ......................................................................................................................................................................... 38
Family Medical Leave Act (FMLA) ......................................................................................................................................................... 38
Summaries of Benefits and Coverage (SBC) ............................................................................................................................. ........... 39
Health Insurance Portability and Accountability Act of 1996 (HIPAA) ................................................................................................... 39
3
Section 1 – Introduction
Welcome
Thank you for selecting Anthem Blue Cross and Blue Shield! You are important to us, and our number one priority is to
provide you with the prompt, efficient service that you deserve.
To help you manage your group’s benefit program, we’ve developed this benefit administrator manual. The manual includes
summary information on eligibility, enrollment procedures and other important information about your plan. It also gives you
step-by-step instructions on how to enroll employees and fill out the appropriate forms. You’ll find information such as:
Employer responsibilities
As an employer, your responsibilities include:

Giving notice of eligibility to each employee who is or will become eligible for enrollment.

Obtaining and submitting complete enrollment information for eligible employees wishing to enroll.
Note: Incomplete enrollment information will delay enrollment.

Sending Anthem Blue Cross and Blue Shield all applications, notices, or other written information or inquiries
received from eligible employees.

Distributing Anthem Blue Cross and Blue Shield notices to covered employees.

Paying premiums on or before their due dates, even though the group requires a contribution toward the
premium from covered employees.

Maintaining a benefits record file of employee applications for each employee. It should include any changes
of classification, benefit amounts and other relevant details when applicable. We may periodically request
information that would be contained in the benefits record file.

Reporting to Anthem Blue Cross and Blue Shield the following changes and their effective dates:


-
Change in classification
-
Change in earnings (if benefit amounts are affected)
-
Change in dependent status
-
Change of employee name
-
Change of employee address
-
Termination of coverage and the reason
-
Change of employer information
Assisting covered employees in filing claims, if applicable.
Notifying employees of COBRA or continuation coverage eligibility, if applicable.
-



If Anthem Administered COBRA, the employer is responsible for logging in to Benefit Admin
Solutions website, www.benefitadminsolutions.com, and enter the employee entering the Qualifying
Event (QE).
Reporting to Anthem Blue Cross and Blue Shield any of its Qualified Medical Child Support Order (QMCSO)
determinations, and providing Anthem Blue Cross and Blue Shield with copies of such QMCSOs.
Notifying employees of any conversion eligibility upon termination of employment, or when coverage is lost
due to other events as stated in your Certificate, if applicable.
Notifying Anthem Blue Cross and Blue Shield of changes in group size. Note: State and federal legislation will
alter the administration of different aspects of your group health plan depending on the number of employees
in your group. It is important that Anthem Blue Cross and Blue Shield receive notification of changes in
groupsize from 2-19, 20-50 and 51+.

Notifying Anthem Blue Cross and Blue Shield if an employee ceases to meet the eligibility requirements set
forth in the “Eligibility Requirements” section of this manual.

Notifying Anthem Blue Cross and Blue Shield if an employee is not “actively at work” (as defined in the
Certificate) on the date coverage would otherwise be effective.

Tracking who is on COBRA, establishing who is no longer eligible for (has used up their time on) COBRA,
and notifying Anthem Blue Cross and Blue Shield’s Billing Department about the status of these individuals,
if applicable.
Group participation and contribution requirements
To avoid cancellation of your group’s coverage, group participation requirements must be met and consistently maintained.

Small group’s (2-50 eligible employees) minimum participation requires enrollment of at least 75 % of “net
eligible” employees for groups of 10-50 eligible employees. Groups under 10 eligible employees require 100 %
participation (minus spousal waivers). If the small group enrolls at least 50 % of the “total eligible” employees,
then only enrolling employees and enrolling dependents need to fill out the medical portion of the initial
application; for small groups enrolling less than 50 % of the “total eligible” employees, both waiving and
enrolling employees and dependents must fill out the medical portion of the initial application. A minimum of
two must be enrolled in health coverage (including husband and wife-only groups).

For dual choice plans, a large group employer must have a minimum of 10 employees enrolled between the
two plans with at least two covered in the plan with the lowest enrollment, and a small group employer must
have a minimum of 2 employees enrolled with at least 1 employee enrolling in each plan being offered.
Please note: This manual is not a legal policy or contract. It is designed to familiarize you with Anthem Blue Cross and
Blue Shield administrative procedures. While the information in this manual covers topics that affect your group’s benefit
program, the information in this manual is not intended to modify, interpret, replace or govern the terms of the Certificate
of Coverage Group Health Care Benefits Contract (GHCBC).
This manual does not constitute legal advice or counsel. You should always consult your own legal counsel whenever you
have specific legal questions concerning any of the provisions of your group’s benefit program. The procedures followed by
Anthem Blue Cross and Blue Shield and outlined in this manual may be changed without notice.
If you have any questions about your group’s benefit program, please refer to the GHCBC, Certificate of Coverage or
Subscriber Agreement. If you still have questions concerning a specific problem, please contact your sales representative,
account service representative or member services department.
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Section 2 –
Important addresses and telephone numbers
General correspondence
General correspondence:
Commercial Accounts
State of Connecticut
Public Sector Accounts
Anthem Blue Cross and Blue Shield
P.O. Box 1044
North Haven, CT 06473
P.O. Box 554
P.O. Box 1026
General claims
General claims:
General Customer Service: 800-545-0948
Commercial Accounts
State of Connecticut
Public Sector Accounts
P.O. Box 533
P.O. Box 583
P.O. Box 533
Specialty:
Anthem Life and Disability
Customer service number: 800-813-5682
Email: [email protected]
Life claims
Disability claims:
Fax: 877-305-3901
P.O. Box 105448
Atlanta, GA 30348-5448
Fax: 800-850-0017
P.O. Box 105426
Atlanta, GA 30348-5426
Anthem Vision
In-network claims:
Out-of-network claims:
Anthem Vision
P.O. Box 8504
Mason, OH 45050-7111
Anthem Vision
555 Middle Creek Parkway
Colorado Springs, CO 80921
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Anthem Blue View Vision
In-network claims:
Out-of-network claims:
Online services
Blue View Vision Claim
P.O. Box 8504
Mason, OH 45040-7111
Blue View Vision Claim
P.O. Box 8504
Mason, OH 45040-7111
anthem.com (integrated with health
online administration)
Anthem Dental Prime and Complete
Dental claims:
Online services:
P.O. Box 1115
Minneapolis, MN 55440-1115
anthem.com/mydentalvision
Dental claims:
Online services:
Anthem Dental
P.O. Box 659444
San Antonio, TX 78265
anthem.com (integrated with health online administration)
Pharmacy claims
In or out of state:
P.O. Box 66785
St. Louis, MO 63166-6785
7
Section 3 – Eligibility
Eligible employees
To be eligible, an employee must be:

Full-time employee working at least 30 hours per week and paid by W-2.

Full-time working owner or partner.

1099 employee may be eligible if working 30 or more hours per week (unless another hourly requirement has
been mutually agreed upon),and work exclusively for the company with which they are applying, and at least
50 % of the group and at least two covered employees are paid by W-2.
An eligible dependent may be:

The employee’s spouse.

The employee’s or spouse’s child(ren).

The child(ren) for whom the employee or employee’s spouse is the legal guardian. The child(ren) must qualify
as an eligible dependent as defined in your certificate.

For health coverage only, child(ren) who the group has determined are covered under a QMCSO
(Qualified Medical Child Support Order).

Newborns of an enrolled dependent child (third generation). These newborns are covered for the first 61 days
following birth only if and when the certificate holder/subscriber or spouse is appointed legal guardian by the
court, and all other eligibility criteria for a dependent child are met.
Note: Any child(ren) must be within the age limit and criteria defined in the group Certificate and Schedule of Benefits. Appropriate documentation is needed to
confirm legal guardianship.
8
Section 4 – Effective dates
Open enrollment
Coverage for eligible employees and their dependents who select an Anthem Blue Cross and Blue Shield benefit program
during a company’s open enrollment period will begin on the designated effective date following the open enrollment
period. Retroactive effective dates will not be allowed.
Open enrollment periods must be held annually, and are typically no less than 10 working days, and are usually 30 (31)
days, unless otherwise specified, and must be held at the same time for all plans. We require equal access, and we must
be offered as a choice to all eligible employees when open enrollments are required. We also must be offered as a choice
to all new hires upon eligibility.
Some exceptions may include adding new benefits plans or significant changes to employer contribution off anniversary.
An employer may be allowed an election period for currently enrolled members if the employer is introducing or revising
an HRA or HSA product off anniversary, subject to Underwriting approval. Underwriting reserves the right to change rates
that may be needed due to enrollment changes.
Employee benefit conversion
We will allow employees of employer groups with multiple health benefit plans to convert coverage only at the end of the
renewal term, or during the open enrollment period, whichever is applicable. Employees can convert coverage only once
every 12 months.
Employer group benefit conversions
Employer groups will be allowed to convert to upgrade benefits only at the end of the renewal term. Employer groups will
be allowed to convert to downgrade benefits during the term of the group health care benefits contract with our approval.
Anthem Blue Cross and Blue Shield will continue the benefit programs at employer group rates to striking employees,
either through the union strike fund or under the provisions of COBRA, as amended, provided premium payments are paid
to us when due.
The employer group must notify us immediately of the actual or anticipated date of the strike, specific classification
of employees and unions involved, expected duration of the strike and information relative to discontinuance of
premium payments.
New hires
New hires and their dependents will be eligible to enroll following completion of the waiting period, unless another
exception has been mutually agreed upon. The standard waiting period allows new hires to be eligible to enroll for
coverage following 30 days of continuous actively-at-work employment. New hire applications for coverage that are signed
and received more than 31 days (unless 60 days is specified in your plan documents) from the date first eligible will be
considered late entrants.
New hires and their dependents will be effective following the first of the month following 30 days of employment, unless
other guidelines are determined.
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Newly eligible dependents
New spouse
A new spouse is eligible for coverage the first of the month following the date of marriage unless otherwise specified.
The effective date of coverage will not be prior to the date of marriage. A marriage certificate may be required as
proof of eligibility.
Newly adopted children and children legally placed for adoption
Adopted children are eligible for coverage when they are legally placed for adoption. If an Enrollment and Membership
Change Form is not signed and received within 31 days, (unless 60 days is specified in your plan documents)
coverage will be contingent upon approval as a late entrant. Applicable legal placement papers, as well as the
appropriate Anthem Blue Cross and Blue Shield enrollment forms, must accompany the appropriate premiums.
New stepchildren
Coverage will be effective the first of the month following the date of marriage, provided we are notified by the end of the
marriage month and the Enrollment and Membership Change Form and Family Health Statement* have been signed and
received. If these conditions are not met, coverage will be contingent upon approval as a late entrant. Legal proof of the
dependent relationship may be required.
Legal guardianship
Qualified children are eligible for coverage on the date of the guardianship order, provided an Enrollment and Membership
Change Form and Family Health Statement* are signed and received by us within 31 days of the start of the parent/child
relationship. If an Enrollment and Membership Change Form and Family Health Statement are signed and received by us
after 31 days, (unless 60 days is specified in your plan documents) coverage will be contingent upon approval as
a late entrant. Applicable legal placement papers and our required enrollment forms must accompany the
appropriate premiums.
*Applies to Small groups (2-50 eligible employees).
Section 5 – Enrollment procedures
How to enroll an employee and eligible dependents
When an employee and his or her dependents are eligible to apply for membership, they must complete and sign the
Enrollment and Membership Change Form and Family Health Statement, if applicable. They can get the form from you
or obtain one online.
The instructions attached to the Enrollment and Membership Change Form will help employees complete these forms.
After an employee has completed the Enrollment and Membership Change Form and Family Health Statement form,
if applicable, please make sure the forms are accurate and have been signed and dated.
Medicare secondary payer (MSP)
Federal law requires insurers and third-party administrators to gather and report information about Medicare recipients
who have other group coverage.* This helps the Centers for Medicare & Medicaid Services (CMS) and health insurers
coordinate benefit payments so claims can be paid promptly and correctly.
As part of this process, members are asked to provide their Social Security numbers. If any covered members are unable
or unwilling to do so, they must fill out an exception form each year.
If a group member does not either provide a Social Security number or complete the enclosed form annually, both Anthem
Blue Cross and Blue Shield and the group may be penalized.
*Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA), effective Jan. 1, 2009.
11
Enrollment changes
There may be changes in a subscriber’s life that require changes to his or her enrollment. This section explains when
and how the subscriber can change the members on his or her contract, change his or her contact information, or change
a primary care physician.
Addition or deletion of members
Marriage
To add a new spouse (and eligible children, if applicable) to the contract, the subscriber needs to complete a Member
Enrollment/Member Change Form and Family Health Statement, if applicable. A Marriage Certificate is also required
for all Small Groups and some Large Groups. The date of marriage must be noted on the application.
If we receive the Member Enrollment/Member Change Form:

Within 31 days (unless 60 days is specified in your plan documents) from the date of the marriage, coverage
is effective the first of the month following the marriage date, unless otherwise noted in the group contract.

After 31 days (unless 60 days is specified in your plan documents) from the date of the marriage, the
spouse’s application may be submitted during the annual enrollment period or considered a late entrant
subject to penalty depending on type of coverage added.
To end the coverage of a dependent who has married, the subscriber needs to complete a Member Enrollment/Member
Change Form. The married dependent is removed from coverage on the first of the month after the marriage occurs.
Note: A dependent reaching age 26 or divorced spouse is no longer eligible for coverage under the subscriber’s contract and must be removed from coverage. If
your company is required to comply with COBRA, please see Section 10 (Terminations) for information about continuation rights. If your company does not have to
comply with COBRA, the dependent reaching age 26 or divorced spouse may have the option of purchasing individual coverage, subject to the eligibility
requirements of that coverage.
Domestic partner (if domestic partnership benefits are offered)
To add a domestic partner (and eligible children, if applicable) to the contract, the subscriber needs to complete a Member
Enrollment/Member Change Form and the Affidavit of Domestic Partnership as well as a Family Health Statement, if
applicable. The date that the domestic partnership began must be noted on the forms along with a visible notary stamp
or seal.
If we receive the Member Enrollment/Member Change Form

Within 31 days (unless 60 days is specified in your plan documents) from the date of initial eligibility
(12 months from when domestic partnership began, as a general rule), coverage is effective on the first
of the month following the date of initial eligibility.

After 31 days (unless 60 days is specified in your plan documents) from the date of initial eligibility
(12 months from when the domestic partnership began, as a general rule), the forms may be submitted during
the annual enrollment period and coverage will be effective on your annual review date or considered a late
entrant subject to penalty depending upon type of coverage selected.
To end the coverage of a domestic partner, the subscriber needs to complete a Member Enrollment/Member Change Form.
The subscriber is required to submit a Member Enrollment/Member Change Form within 31 days of the termination of the
domestic partnership. Domestic Partners are not eligible for COBRA continuation coverage.
Birth
To add a newborn dependent to the subscriber’s contract, the subscriber needs to complete a Member Enrollment/
Member Change Form.
If we receive the Member Enrollment/Member Change Form within 61 days from the date of birth, coverage is continuous
from the moment of birth, unless otherwise noted in the group contract.
Adoption/placement for adoption
To add a newly adopted dependent or a dependent placed for adoption to the subscriber’s contract, the subscriber
needs to complete a Member Enrollment/Member Change Form.
If we receive the Member Enrollment/Member Change Form and adoption paperwork:


Within 31 days (unless 60 days is specified in your plan documents) from the date of adoption/placement for
adoption with the subscriber and/or spouse, coverage begins on the date of adoption/placement or considered
a late entrant subject to penalty depending upon type of coverage selected.
After 31 days (unless 60 days is specified in your plan documents) from the date of adoption/placement for
adoption with the subscriber and/or spouse, the Member Enrollment/Member Change Form may be
submitted during the annual enrollment period.
Court orders and support orders
To add a dependent child due to a court order or a support order, the subscriber needs to complete a Member Enrollment/
Member Change Form and Family Health Statement, if applicable.

With a support order for a child, the Member Enrollment/Member Change Form may be received any time
following issuance of the support order. Coverage is effective on the first of the month following receipt of the
Member Enrollment/Member Change Form and appropriate support order documents .

With a legal court order changing custody of a dependent child, the Member Enrollment/Member Change
Form must be received within 31 days (unless 60 days is specified in your plan documents) of the date of the
court order changing custody. Appropriate court order documents required. Coverage is effective on the
date of the court order.
To add a spouse due to a court order of coverage for the spouse, the subscriber needs to complete a Member Enrollment/
Member Change Form and Family Health Statement if applicable within 31 days (unless 60 days is specified in your plan
documents) of the date of the court order. Coverage is effective on the first of the month following the date of the
court order.
Health care reform age mandate — Dependent Age Mandate for Connecticut
According to the Dependent to Age 26 federal mandate, eligible dependents are to be covered up to age 26. The
Connecticut State Legislature has changed the age 26 mandate for fully insured groups. Connecticut Public Act 11-58
says that dependent children who turn 26 can stay on their parents’ health plan until the end of the policy year, after the
dependent turns age 26. For ASO groups, a dependent child would be off their parents’ plan on the last day of the month
following the month the dependent child turned 26 unless they have a different arrangement.
14
Divorce and legal separation
A divorced spouse is no longer eligible for coverage under the subscriber’s contract and must be removed. A legally
separated spouse is eligible for coverage under the subscriber’s contract and may remain on the contract until they are
divorced and he or she is no longer a legal spouse. To delete a divorced or legally separated spouse from the subscriber’s
contract, the subscriber needs to complete a Member Enrollment/Member Change Form.
Eligibility for Medicaid or state assistance programs
To delete a spouse, domestic partner or dependent(s) because they have become eligible for Medicaid or other state
assistance, the subscriber needs to complete a Member Enrollment/Member Change Form. The spouse and/or
dependent(s) are removed from the subscriber’s contract for the requested date as long as enrollment forms are received
within 31 days (unless 60 days is specified in your plan documents) .
Death
To delete a deceased subscriber, spouse, dependent or domestic pa rtner, please complete a Member
Enrollment/Member Change form. Coverage will end first of the month following date of death unless the group’s
exception states otherwise.
If the request is received within 31 days of death, no death certificate is required (unless 60 days is specified in your
plan documents). If the date of death is being reported after 31 or 60 days, a copy of the death certificate is required.
Involuntary loss of existing coverage (portability)
Portability is the transfer of membership when previous coverage ends involuntarily. Portability applies for reasons such as:

Termination of employment

Termination (without replacement) of the firm contract or policy

Divorce/legal separation

Termination of domestic partnership

Exhaustion of COBRA benefits

Death
To add a spouse, domestic partner or eligible dependent(s) due to a portability event, the subscriber needs to complete
a Member Enrollment/Member Change Form. We will require proof of the involuntary loss of coverage.
If we receive the Member Enrollment/Member Change Form and Family Health Statement, if applicable:

Within 31 days (unless 60 days is specified in your plan documents) of the loss of firm coverage, coverage
will be effective on the first of the month following the loss of coverage or the first day following loss of
coverage, unless otherwise noted in the group’s contract.

After 31 days (unless 60 days is specified in your plan documents) from the loss of firm coverage, the Member
Enrollment/Member Change Form and Family Health statement if applicable may be submitted during the
annual enrollment period or considered a late entrant and subject to penalty depending upon type of
coverage selected.
The subscriber needs to write the name of the previous insurance carrier, contract number, the date and reason for the loss
of coverage on the Member Enrollment/Member Change Form and/or on a copy of the Certification of Creditable Coverage
form from the previous carrier. We may contact the previous carrier to verify loss of coverage.
Involuntary loss of Medicaid or state assistance programs
To add a spouse, domestic partner or dependent(s) because he or she involuntarily lost Medicaid/MediCare or other
state assistance coverage, the subscriber needs to complete a Member Enrollment/Member Change Form and Family
Health Statement if applicable and include a copy of the letter from Medicaid or the applicable state assistance program
that states the date Medicaid or state assistance program coverage ended, and the reason for the loss.
If we receive the Member Enrollment/Member Change Form and Family Health Statement if applicable to add a spouse
or dependent(s) who involuntarily lost Medicaid or other state assistance coverage:

Within 31 days (unless 60 days is specified in your plan documents) from the loss of assistance, coverage is
effective on the first of the month following the loss of assistance or the first day following loss of coverage,
unless otherwise noted in the group’s contract. A copy of the letter stating that coverage has ended, the
reason coverage ended, and the effective date of the loss must accompany the Member Enrollment/Member
Change Form and Family Health Statement, if applicable.

After 31 days (unless 60 days is specified in your plan documents) from the loss of assistance, the Member
Enrollment/Member Change Form and Family Health Statement, if applicable, may be submitted during the
annual enrollment period or considered a late entrant subject to penalty depending upon type of coverage
selected. A copy of the letter stating that coverage has ended, the reason coverage ended, and the effective
date of the loss must accompany the Member
Enrollment/Member Change Form.
Entrance to or discharge from military service
To add a spouse, domestic partner or dependent because of discharge from the military, the subscriber needs to
complete a Member Enrollment/Member Change Form and Family Health Statement, if applicable.
If we receive the Member Enrollment/Member Change Form and Family Health Statement, if applicable:

Within 31 days (unless 60 days is specified in your plan documents) of the date of discharge, coverage is
effective on the day following the date of discharge.

After 31 days (unless 60 days is specified in your plan documents) from the date of discharge, the Member
Enrollment/Member Change Form and Family Health Statement, if applicable, may be submitted during
the annual enrollment period or considered a late entrant subject to penalty depending upon type of
coverage selected.
To cancel coverage, or to delete a spouse, domestic partner or dependent due to entrance in the military service, the
subscriber needs to complete a Member Enrollment/Member Change Form. The coverage will be canceled as of the
effective date of the military coverage if we are notified within 31 days (unless 60 days is specified in your plan documents) of the
effective date of the military coverage.
Removal of a dependent
To delete a spouse, domestic partner or dependent(s) from coverage, the subscriber needs to complete a Member
Enrollment/ Member Change Form within 31 days of termination date (unless 60 days is specified in your plan documents).
We do not allow retro terminations.
65+ coverage
Three months before a member’s 65th birthday, we send the group a 65+ questionnaire. The group needs to complete and
return this questionnaire to help us determine what benefits we should offer 65-year-old members.
For groups that do not have to comply with TEFRA: Once we have received the completed 65+ Questionnaire,
an eligible employee or eligible employee’s spouse/domestic partner will have the option to:

Remain enrolled in the group’s coverage, with the same coverage as members under age 65. The
employer- sponsored plan is the secondary payer, and Medicare Parts A and B are the primary payers.

Cancel firm coverage and purchase an individual Medicare supplement policy, such as the Companion Plan
(Anthem Blue Cross and Blue Shield’s individual Medigap plan). The individual must be enrolled in both
Medicare Part A and Part B to enroll in the Companion Plan.
For groups that do have to comply with TEFRA: Once we have received the completed 65+ Questionnaire, an
eligible employee or eligible employee’s spouse/domestic partner will have the option to:

Remain enrolled in the group’s coverage, with the same coverage as members under age 65. The
employer- sponsored plan is the primary payer, and Medicare is the secondary payer.

Choose Medicare as primary coverage, cancel the group’s coverage, and purchase an individual Medicare
supplement policy, such as the Companion Plan (Anthem Blue Cross and Blue Shield’s individual Medigap
plan). Also, the individual must be enrolled in both Medicare Part A and Part B to enroll in the
Companion Plan.
Note: You must notify us when an employee who has continued on the firm coverage after age 65 retires or reduces hours below your firm’s minimum. Retirees and
employees who no longer work minimum hours are not eligible to remain on the firm primary coverage. Your company may offer retiree coverage. This information is
in your plan documents.
Retiree benefits
Please refer to your plan documents or contact your account service team for information about benefits available
for retirees.
Changing contact information
A subscriber needs to notify us of the following:

Name changes

Address changes

Telephone number changes (both work and home)
One way to notify us is by submitting a Member Enrollment/Member Change Form. A subscriber can also call customer
service or use the information change form available at anthem.com.
Correcting dates of birth
To correct a member’s date of birth, the subscriber needs to complete a Member Enrollment/Member Change Form.
Subscribers should notify us of birth date corrections as soon as possible to avoid potential problems caused by
inconsistency in membership records. We may require a copy of the birth certificate for verification.
Changing primary care physicians
Members can change primary care physicians at any time. To notify us, members can:

Fill out a Member Enrollment/Member Change Form.

Call our customer service representatives.

Use the information change form available at anthem.com.
The change will be made effective on the first of the month following the date the application is accepted.
Moving out of the service area
If a member of a managed care product (lock-in or choice) moves out of the service area, he or she may transfer to another
type of health plan offered by the group or keep the current coverage.
Flexible benefits plans (Section 125 plans)
The Internal Revenue Code Section 125 allows employers to provide flexible benefits plans to their employees.
The three types of plans are:

Premium-only plans or premium conversion plans: Permits employees to pay the employee contributions to
employer-provided health and welfare benefit plans on a pretax basis.

Flexible spending accounts and flexible reimbursement accounts: Reimburses employees on a tax-free basis
for eligible child care and health care expenses that are not otherwise covered by the employer-sponsored
benefit plan.

Cafeteria plans: Allows employees to choose between certain nontaxable benefits and cash.
Section 125 of the Internal Revenue Code and regulations define situations when an employee can make off-anniversary
changes. Situations when employees can make flexible benefits election changes do not always entitle the subscriber to
make a related change to his or her health coverage. For example, the birth of a child entitles the subscriber to enroll the
child and spouse in the health plan and change the flexible reimbursement account, but not to enroll other dependents in
the health plan or to change their coverage series/benefits. Those changes can only be done at the firm’s renewal time.
A Section 125 plan does not create enrollment opportunities that do not exist without a 125 plan. Work with your Section
125 processor if you have any questions.
Special enrollment considerations
Additional forms are required for:

Dependent child, 26, overage: A Dependent Certification Form

Dependent child, incapacitated, incapable of self-support: A Request for Coverage for a Mentally
or Physically Incapacitated Dependent Child Form

An adopted child: Proof of adoption or placement

Medicare eligible: A copy of the Medicare health insurance card

Adding a child, court order: A copy of the court order

Proof of prior group coverage: A Certificate of Health Plan Coverage from the previous health
insurance carrier, or if a certificate cannot be obtained, other proof of coverage as described by HIPAA.
Anthem Blue Cross and Blue Shield requires a letter from the former carrier stating the loss of
coverage date. Small groups also need to complete the Standardized Health Form (SHF).
18
When to send enrollment forms
The submission deadline depends on the specific enrollment circumstance:
Open enrollment
The Enrollment and Change Form must be received by the last day of the open enrollment month to be
effective on the first day of the anniversary month.
Late enrollees
A late enrollee is an employee who signs an application more than 31 days after the Qualifying Event date (unless 60 days
is specified in your plan documents). The effective date is contingent upon the type of coverage.
Qualifying event special enrollment
For special enrollments, all Enrollment and Change Forms must be received by Anthem Blue Cross and Blue Shield during
the first 31 days of the special enrollment period (unless 60 days is specified in your plan document).
Newly hired employees
Anthem Blue Cross and Blue Shield recommends you submit the Enrollment and Change Form within 31 days of the
qualifying event date or as specified by your contract. The date you submit an Enrollment and Change Form impacts
the effective date for the employee’s medical coverage.
Family status change
The following rules apply to membership enrollments as a result of marriage, birth or adoption.

Marriage: Anthem Blue Cross and Blue Shield recommends that you submit the Enrollment and Change Form
within 31 days of the qualifying event date as specified by your contract. The date you submit an Enrollment
and Change Form impacts the effective date for the spouse’s medical coverage.

Birth: Benefits are provided for the newborn child for up to 61 days following birth. Submit the membership
Enrollment and Change Form within 61 days following the child’s date of birth to ensure uninterrupted
coverage. The date you submit an Enrollment and Change Form impacts the effective date for the child’s
medical coverage. On a family membership: A newborn child is a member from the date of birth. The birth
must be reported to Anthem Blue Cross and Blue Shield within 61 days by submitting an Enrollment and
Change Form for the new dependent to be added to the family records and for claim payments to be
made appropriately.

Adoption: Benefits are provided for an adopted child for up to 31 days following the placement or adoption.
Copies of placement or adoption papers are required, if applicable. Submit the membership Enrollment and
Change Form within 31 days following the child’s date of placement or adoption to ensure uninterrupted
coverage. The date you submit an Enrollment and Change Form impacts the effective date for the child’s
medical coverage. On a family membership: An adopted child is a member from the date of placement.
The placement must be reported to Anthem Blue Cross and Blue Shield within 31 days by submitting an
Enrollment and Change Form for the new dependent to be added to the family records and for claim payments
to be made appropriately.
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19
Section 6 – Electronic Enrollment
Electronic enrollment advantages
Electronic Enrollment is a quicker, easier way to maintain enrollment-related data and manage the enrollment process.

Time saving: Electronic enrollment is a faster, more convenient way to enroll new members and make changes
to existing accounts 24/7. It eliminates paperwork, reduces postage and may require fewer follow-up phone calls.
Best of all, the information is processed on an average of two to four days faster than paper forms.

Safe, secure, accurate: To help protect against unauthorized access to employees’ private information,
Electronic enrollment is enhanced with the latest technical safeguards. In addition, employees receive
a user ID and password that can be personalized during the registration process.
For more information about Electronic enrollment, contact your Anthem Blue Cross and Blue Shield Account Manager.
Electronic enrollment options
With Electronic enrollment, you have two options: file-based transfer and web enrollment. Here are descriptions of both:
Web enrollment
File-based transfer
Description
The same process on paper, but online.
Complete enrollment applications through
online forms.
Ideal for high volumes of enrollment
transactions when a group prefers
to send an enrollment file.
Platform
Web-based, accessed through a browser.
Site-specific, PC-based, Mainframe
Allows enrollment
by Benefit Administrator
Yes
Yes
Allows
enrollment by
employees
Yes
No
Features

New employee enrollment

New employee enrollment

Open enrollment management


Membership maintenance (add,
change, delete, reinstatement,
firm division transfers)
Open enrollment
management

Membership maintenance
(add, change, delete)

Secure

24/7 access

Quicker ID turnaround and
member benefit realization

128-bit encryption for safe,
secure transfer of information

24/7 access

Automated member set up

2 to 4 days faster processing
than paper forms, on average

Quicker ID turnaround and
member benefit realization
Groups should review the file-based
legal agreement to evaluate its
advantages and disadvantages.
20
20
Online tools and resources for employers
With our secure online business tools, it’s easier to administer your benefit package.
Employer Group Inquiry
Through the Employer Group Inquiry (EGI) feature, you can efficiently manage day-to-day benefit administration tasks like:

View contract and coverage information, such as current address, phone number, contract number, plan details
and more.

View benefit details, such as copays and deductibles.

Update primary care physician, if applicable.

Request replacement ID cards.

Request a temporary ID Card

Update member contract information, such as address and phone number changes.

View employee coverage choices from previous years.

Use online group billing:
o
View and pay your premium bills online.
o
View and print detailed premium bills going back 13 months.
o
Pay bills electronically using a checking or savings account.
o
Have the option of eliminating paper bills.
o
Feel confident paying bills in our secure online environment.
Web enrollment
Web enrollment helps reduce excess paperwork, so that you can focus on your core business. This secure,
password-protected application lets you:

Enroll new employees.

Perform enrollment maintenance.

Add or cancel dependents.

Cancel contracts.

Update names and addresses.

Perform self-service tasks for open or new group enrollments.

Reinstate contracts.*

Utilize powerful search functionality.
* Subject to Anthem Blue Cross and Blue Shield’s underwriting guidelines and requires Anthem Blue Cross and Blue Shield’s consent.
File-based transfer
Filed-based transfer is ideal for larger groups. It’s secure and can be used to perform the same eligibility functions as
Web enrollment.
21
21
Online tools and resources for members
Instant access to our online tools makes it easier for employees to perform a variety of self-service functions, so you
can focus on your daily business. The more your employees know about their plan, the better they can use it to their
advantage—without posing time-consuming questions to you or your office staff. Employees have access to programs
and services designed to help them get the most from their benefits.
Anthem.com
The vast amount of health information available at anthem.com gives your employees the tools they need to help them
make health care decisions. Safe and secure, members can log in and:

View benefit details, including copayments and deductibles.

Check claims status.

Choose a new primary care physician, if applicable.

Find a network doctor or hospital.

Request a permanent or temporary member ID card.

Change passwords.

Update an email address.

Sign up for email messages from Anthem Blue Cross and Blue Shield.

Submit benefit questions.
Section 7: Coordination of Benefits (COB)
22
Section 7 – Coordination of Benefits (COB)
Coordination of Benefits (COB) is a procedure to allocate benefits in order to eliminate duplicate payments when two or
more group health plans cover a person. For a description of how COB works, please consult the Coordination of Benefits
section contained in the Certificate of Benefits or the plan benefits description.
23
Section 8 – Claim filing
Please remember that when members incur charges from a nonparticipating provider and are required to submit a claim,
each member needs to submit a separate claim.
Hospital claims
When a member enters a participating hospital as either inpatient or outpatient, the member should present their
Anthem Blue Cross and Blue Shield ID card to the admitting office. The hospital will bill us automatically for services
rendered, less any applicable cost-shares.
If a member receives inpatient services in a nonparticipating hospital, the member should request that the hospital bill us
directly. Otherwise, the member may be required to pay the bill and forward a receipt and itemized copy of the bill to us,
along with a completed claim form.
If a member receives outpatient services at a nonparticipating hospital, the member may be required to pay the bill at that
time. If this is the case, the member should forward a receipt and an itemized copy of the bill to us with a completed claim
form. Members should send this information to:
P.O. Box 533
Members can obtain a claim form at anthem.com or they can call the toll-free member services department phone number
on their Anthem Blue Cross and Blue Shield ID cards.
Medical/surgical claims
Members should present their Anthem Blue Cross and Blue Shield ID card and pay any applicable copays at the time
services are rendered. Participating providers will bill us directly for services and will bill members separately for any
noncovered services.
After we process the claim form, the provider will receive a remittance explanation and payment. As part of the participating
agreement, the provider agrees not to bill the member for any balances beyond our allowed amounts for covered services.
If the services are rendered by nonparticipating providers, the member may be required to submit a claim form. If this is the
case, the member should complete the form and include an itemized bill containing the name and address of the provider,
nature of the condition requiring treatment, date of service, explanation of services rendered and the charge for each
service. The member should also keep a copy for record keeping purposes. The member should send this information to:
P.O. Box 533
Members can obtain a claim form at anthem.com or they can call the toll-free member services department phone number
on their Anthem Blue Cross and Blue Shield ID cards.
Members will receive an Explanation of Benefits (EOB) only when there is a patient balance for the claim (other than
a copay). Members may be charged amounts beyond what we allow for nonparticipating providers.
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BlueCard®: the out-of-area program
To locate participating out-of-area providers, members can call the BlueCard ® PPO Access Line at 800-810-BLUE (2583).
When members visit health care providers (institutional or professional) located outside of Connecticut, Maine or
New Hampshire, they should present their Anthem Blue Cross and Blue Shield ID card when services are rendered.
The three-letter prefix on the ID card identifies Anthem Blue Cross and Blue Shield as the home plan — the destination
of all provider claims. Providers must include this prefix on the claim form to expedite claims processing.
In the event of urgent care needs, a member can seek the services of an out-of-area provider who will submit the claim
on behalf of the member to the local Blue Cross and Blue Shield plan for processing, as long as the provider is participating
with the Blue Cross and Blue Shield plan in that state. The member is responsible at the time of service for any applicable
copay, coinsurance or deductible. Participating out-of-area providers may not balance bill members.
BlueCard Worldwide program
When members receive services from a BlueCard Worldwide participating provider for inpatient services rendered
out of country, the provider should submit the claim on the member’s behalf.
For services rendered out of country for outpatient and professional medical care by a nonparticipating BlueCard
Worldwide hospital or when inpatient care was not arranged through the BlueCard Worldwide Service Center, the member
will need to pay any charges up front and submit an International Claim Form for reimbursement.
The Blue Card Worldwide international claim form can be found at BC BS. com. In the Search window, enter the words
“claim form,” then select “International Claim Form (English letter paper size).” This form, along with any itemized bills,
should be sent to the following address for processing. Itemized bills do not have to be translated into English or dollars.
BlueCard Worldwide Service Center
P.O. Box 72017
Richmond, VA 23255-2017
Please make a copy of the claim and related information (such as a breakdown of charges and receipts) before submission.
Anthem Dental
When a member receives dental care from a participating dentist, he or she should present the member ID card at the time
services are rendered. The dentist will bill us for services. Payment for covered services, as provided in the policy,
will be made directly to the dentist.
When a member receives dental care from a nonparticipating dentist, a dental claim form or an American Dental
Association (ADA) claim form must be completed. Members should send completed dental claim forms signed by the
dentist to the claims address on the back of their member ID card
If claim forms are not available at the dentist’s office, members can obtain them at anthem.com or they can contact the
member services department at the toll-free phone number on the back of their member ID cards. In Connecticut, payment
for covered services will be made directly to the dentist. If a member is submitting a claim for services with a
nonparticipating dentist, the members can choose to have the payment sent directly to them.
25
Prescription drug claims
Members purchasing prescription drugs from a participating pharmacy should present their member ID card and pay any
applicable copay at the time the prescription is filled. The pharmacy will bill us. Payment for covered services, as provided
in the policy, will be made directly to the pharmacy.
When prescriptions are purchased at a nonparticipating pharmacy, the member must submit the claim to us. Members
should use a prescription drug claim envelope and enclose the original itemized prescription receipts containing:

Patient’s name and member identification number

Pharmacy name

Prescription number

Date of purchase

Name and quantity of the drug

Amount paid
Payment for covered services, as provided in the policy, will be made directly to the member.
Note: Photocopies of prescription drug receipts will not be accepted for processing.
Home delivery pharmacy prescription
To start receiving prescriptions through the mail, members placing an order for a maintenance drug prescription should:
1.
2.
Contact the Home Delivery Pharmacy, managed by Express Scripts, Inc. at: 866 -281-2966

800-221-6915, 800-871-7138 (Hearing impaired)

866-924-8534 (Physician phone number), 800-600-8105 (Physician fax)
Have their prescription information, doctor’s name and phone number, and credit card (VISA, MasterCard,
American Express, Discover Card or bank issued debit card).
Home Delivery Pharmacy Customer Service representatives are available 24/7
Members placing an order for a new prescription should:
1.
2.
3.
Contact their physician for a new prescription.
Complete an order form.
Send the original prescription, the completed form and appropriate copay.
26
Section 9 – Billing
Quick reference guide
Use this checklist to help administer your Anthem plan:
 Pay the invoice as billed
Be sure to detach the bottom portion of the invoice summary and enclose it with your check in the return envelope.
 Submit report of terminations
Please submit the report to Anthem as soon as any terminations occur.
 Submit completed enrollment and membership change forms
Please submit all changes as soon as they occur.
 Check your bill
When you receive your invoice, please verify the following information:

Bill creation date: The date this invoice was prepared for you.

Payment due date: The date your payment is due at Anthem.

Current period: The period covered by the invoice.

Premium amount billed: This month’s premium due for the invoice.

Total amount due for current and prior periods: Total premium due for service.
 Verify Changes

Bill creation date: The date this invoice was prepared for you. If you mailed your changes in after the
invoice was created, you will see them on next month’s invoice, depending on when they were submitted
to Anthem Blue Cross and Blue Shield.

Member detail: Verify names, type of change, product name, class of contract, effective date of change
and amount for all applications submitted.
 Check how much is due

Total amount due for current and prior periods: Total premium due for service.

Amount due for current period: Current period amount due including any retroactive charges.

Total amount due last invoice: Total premium billed for prior invoice.

Net payment activity since last invoice: Premium received since the last invoice.

Balance carried forward: Outstanding premium from the prior invoice.
For assistance
The telephone number appears on the top of the second page of your monthly invoice.
27
Commitment to service
As part of our commitment to improve the service we provide, premium payments will be processed at a separate location
from membership correspondence. To ensure proper processing of monthly premium payments, please mail them in the
return envelope enclosed with your bill.
Membership status changes or correspondence should be faxed or emailed to:
877-651-7946
[email protected]
Reminder
Please remember that all monthly premium payments are due on the first of the month of coverage. Failure to remit your
premium payment in a timely manner will result in cancellation of your account for nonpayment.
Fully insured groups
When you receive your monthly invoice, please remember to:

Pay the invoice as billed. Additions or cancellations will show on following invoices depending on when they
were submitted to Anthem Blue Cross and Blue Shield.

Submit an Enrollment and Membership Change Form for all changes (for example, additions and cancellations)
to your group invoice as they occur.

Notify Anthem Blue Cross and Blue Shield of terminated employees as soon as possible to avoid paying
unnecessary premiums for these individuals.
Note: COBRA-eligible employees who elect to continue coverage within the indicated timeframe will be reinstated.
Notification of new employees
Applications for new employees should not be sent with your payment. Please fax applications to Anthem Blue Cross
and Blue Shield at the membership address in the “Commitment to service” section.
Waiting period
New hires and their dependents will be eligible following completion of the waiting period. The standard waiting period allows new
hires to be eligible to enroll for coverage following 30 days of continuous actively -at-work employment. Please see your group’s
specific contract with Anthem Blue Cross and Blue Shield for details. Rehire policy states that if a rehire occurs in less than
thirteen (13) consecutive weeks (or 91 calendar days) after a break in employment, the Orientation Period and/or Waiting period
will be waived. If a rehire occurs in greater than thirteen (13) consecutive weeks (or 91 calendar days) after a break in
employment, the employer’s Orientation Period and/or Waiting period may apply .
Examples:
Date of Release
Date of Rehire
Orientation + Waiting Period
Benefit Effective Date
January 10, 2014
February 15, 2014
N/A
February 15, 2014
January 10, 2014
April 14, 2014
120 days
August 12, 2014
Effective dates
New hires and their dependents will be eligible following completion of the waiting period. The standard waiting period allows
new hires to be eligible to enroll for coverage following 30 days of continuous actively-at-work employment. Please see your
group’s specific contract with Anthem Blue Cross and Blue Shield for details.
Notification of left employees
Groups are required to send Anthem timely notification of members who are no longer legitimately entitled to receive
benefits under the health plan. “Left-employ” terminations will not be retroactive. It is important that you report left-employ
notifications in advance of the cancellation effective date. If you do not comply with this policy, the effective date of the
termination will be changed to the first of the current month of the date received. This will extend your claim liability period.
Cancellations will be reflected on your next scheduled invoice, and the amount due will be adjusted based on the
effective date. Please remember this is dependent upon the date they were submitted to Anthem Blue Cross
and Blue Shield.
(Public Act No. 09-126) provides small employers an election to terminate an employee’s coverage under a group health
insurance policy, on termination of employment, under certain conditions. These conditions are:

Employee voluntarily terminates, or

Employer terminates an employee for reasons other than layoff
If the employer elects to request a refund/credit of the employee’s pre-paid premium, the attached request form must be
fully completed and faxed to Anthem within 72 hours of the employee’s termination date. If this form is received after the
72-hour period, the refund/credit request will not be honored.
29
Medical Loss Ratio Disclosure
Public Act 09-46 – Disclosure of Medical Loss Ratio in Consumer Report Card, Insurance
Applications and Plan Descriptions
Public Act 09-46 amends laws related to health insurers reporting of medical loss ratios for all fully insured groups. The bill
adopts a uniform definition of the term and adds a new disclosure requirement of the medical loss ratio within the
insurance application for insurance applicants.
Please share the most current MLR information on the anthem.com website with all new applicants. For insurance entities,
the term “medical loss ratio” refers to the ratio of incurred claims to earned premium for a prior calendar year. The MLR is
calculated for managed care (HMO) and PPO/Indemnity plans, one for state law purposes and the other as determined
under federal law.
The Certificate of Coverage will be updated with the most current Medical Loss Ratio.
Common Membership Change messages
Message
Explanation
Addition
Employee (member) has been added.
Employee (spouse) has been changed to a Medicare Supplemental Part A or B.
Employee (member) has been added to a COBRA eligibility extension firm division.
Add Dependent
Employee (member) has added dependent(s).
Cancel
Employee (member) has been canceled.
Cancel Dependent
Employee (member) has been canceled as a result of reaching the maximum age allowed
for dependent coverage.
Employee (member) has canceled dependent(s)
Name Change
A change in name has been processed for an employee (member).
Transfer In
Employee (member) has been transferred into a health plan at your request.
Transfer Out
Employee (member) has been transferred out of a health plan at your request.
Product Conversion Add
Employee (member) has been added to a health plan due to a product conversion.
Product Conversion Cancel
Employee (member) has been canceled from a health plan due to a product conversion.
Reinstatement
Employee (member) has been re-added with no break in coverage.
Reattach
Reattach employee (member) with a break in coverage.
31
Administrative Services Only (ASO) Groups
ASO groups receive a monthly member detail report for membership audit purposes.
Questions?
Please call 877-898-0654 if you have any questions about your billing invoice.
32
Section 10 – Accounting and terminations
This section explains your invoice, payment requirements, how to adjust your bill, how to terminate employee/subscriber
health care coverage and the conversion privileges available to terminated employees.
Payment
Premium payments are due by the date shown on your firm invoice. Make your firm’s check payable to Anthem Blue Cross
and Blue Shield, write your billing account number on the check and send it with the bottom section of the bill to:
For large group
P.O. Box 1168
Newark, NJ 07101-1168
For large group (overnight mail):
TransCentra
Wellpoint ACES 4168
365 West Passaic Street, 5th floor, STE 530
Rochelle Park, NJ 07662
Our invoices are normally mailed between the 9th and 23rd day of the month prior to the due date, unless another date
is specifically requested by the group upon initial setup. Premium payments are due on the first of each month.
If payment is not received by the due date, the firm is considered delinquent. We will send a letter informing the firm that
payment is past due and that firm coverage may be canceled if we do not receive full payment by the date specified in the
letter. (If we are responsible for the delay in sending the bills, the firm will not receive a delinquency notice.)
If we do not receive payment by the date specified in the letter, coverage will end 31 days after the premium or fee due
date. A cancellation notice is mailed to the firm and its members, as required by state law.
Note: If your firm has an alternative financial arrangement, different policies may apply. Contact your account service team for information.
Reinstatement
A firm may request reinstatement following cancellation of firm coverage according to the process listed below:

Contact our Credit & Collections area at 888-894-8053.

All past due premiums or fees and any current premiums and a reinstatement fee must be paid in full.

We will review the firm’s financial status, including reviewing the firm’s payment history or any other information,
and may request a Dunn and Bradstreet report, credit references or a bank letter.

The firm’s participation level must be at least 75 % of all eligible employees who do not have coverage
elsewhere and who are not within the waiting period, and member eligibility must be confirmed by furnishing a
copy of quarterly 941 and/or payroll records.

A reinstatement fee of $150 must be included with the reinstatement request and is nonrefundable.
The request for reinstatement must be made within 30 days of cancellation. After 30 days, a firm must contact their
agent/producer or sales account executive to request enrollment as a new firm.
33
Retroactive coverage changes
Anthem Blue Cross and Blue Shield’s standard policy is to allow retroactive additions and cancellations of no more
than 31 days regardless of claims activity. Anthem Blue Cross and Blue Shield reserves the right to recover any
claim dollars incurred in the 31-day retro term period.
We require that firms notify us promptly if a member becomes ineligible for coverage. If a firm provides a cancellation
request to us within 31 calendar days of the date that coverage should have ended, we will process the request and
allow the cancellation to become effective as of the date that coverage should have ended.
Requests for retroactive additions to subscriber and dependent coverage beyond 31 days will be processed as late entrants
and will follow the late entrant enrollment policy.
On a case-by-case basis, special consideration will be given to requests for retroactive coverage changes under
the following limited circumstances:
Retroactive terminations:

Death: Terminations as a result of death will be allowed up to one year upon receipt of a copy of the
death certificate.

Retirement over 65: Terminations allowed for a period of up to six months back to the effective date of Medicare
A&B upon receipt of a copy of the Medicare card.
Retroactive Additions:

Newborns: Additions allowed up to 6 months.

COBRA: Additions allowed for 105 days.
Groups who use a Third-Party Administrator (TPA) will fall under the same guidelines listed above including COBRA.
It is important to note that where Anthem Blue Cross and Blue Shield is responsible for a documented membership
processing error, and for up to a period of six months following the original request, we will promptly process the change
as originally submitted.
This policy applies to both fully insured and self-insured groups.
Employee contract termination
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that terminated employees receive a
Certification of Creditable Coverage notice within 14 days of the loss of coverage. To ensure compliance with the statute,
we must receive notice of the employee’s termination within five business days. Terminations must be submitted on a
Report of Termination form by fax and/or mail. If you do not notify us of terminations as soon as you know of them, your
firm could be subject to federal monetary penalties for noncompliance with the notification rules. As the benefit
administrator, you should provide the terminated employee with a copy of the Notification of Availability of
Individual Coverage.
34
Transfer privileges
Continuation of coverage rights for firms that do not have to comply with federal COBRA
Members of a small firm not subject to COBRA who are temporarily laid off or who lose employment because of an injury
or disease that the employee claims to be compensable under Workers’ Compensation laws may be eligible to continue
coverage for themselves and their dependents under the firm plan pursuant to Connecticut state law for a period of up
to 18 months at 102 % of premium or fee. Please contact us with questions or to obtain the appropriate application.
Firms that must comply with COBRA
Terminated employees (other than those terminated for gross misconduct) are offered the right to continue firm coverage
at his/her own expense. It is the employer’s responsibility to notify terminated employees (other than those terminated
for gross misconduct) of his or her COBRA rights within 14 days of the qualifying event.
A terminated employee cannot remain on the firm health plan you have for active employees (and retirees, if applicable).
35
Section 11 – Federal law
Federal law may have a direct impact on your firm’s health benefits. Please read the following information carefully.
This is a general guide on these laws, but it is not to be considered legal advice.
Please ask your firm’s legal counsel any questions you have about compliance with these laws. There are substantial
penalties for noncompliance with these federal laws, and these penalties apply to the employer. You are required to
indicate whether or not TEFRA (group size 20-99), OBRA (group size 100 or more) and COBRA (group size over 20)
apply to your group when you apply for coverage. You are also required to promptly notify us in the event that
your status changes.
Medicare
Medicare is a federal health insurance program consisting of three health care program components:

Medicare Part A (hospital benefit) covers usual expenses in hospitals and skilled nursing facilities, and approved
home health care expenses.

Medicare Part B (physician benefit) helps pay for doctor’s services and medical items and services not covered
under the hospital insurance program.

Medicare Part D helps pay for prescription costs.
Medicare Supplement Programs are intended to fill the gaps in benefit coverage not satisfied by Medicare. Medicare
Supplementary coverage for individuals eligible for Medicare will vary depending on the coverage option elected by the
employer. The employer should make available supplementary coverage for individuals who have Medicare as their
primary plan.
Carveout is available for employers who do not offer a Medicare Supplement Program, who have Medicare-eligible
employees actively at work, and who continue to provide group coverage to those employees. Carveout is a process to
coordinate benefits with Medicare in accordance with Federal Medicare Secondary Payer guidelines.
Medicare Secondary Payer (MSP) regulations
The following chart contains general guidelines for determining primary coverage given your group’s size, the active
employees’ or dependents’ status and Medicare qualifying event. To define “active” employment for your group, seek
legal counsel.
If you have a question on determining primary coverage, contact the Centers for Medicare and Medicaid Services (CMS)
at cms .go v.
36
Medicare and group coverage: Who is the primary carrier?
Actively at work:
**Complete a Medicare Supplement Form and return to Anthem Blue Cross and Blue Shield.
(Employee must have both Parts A & B of Medicare to be eligible for the Group Medicomp policy.)
Not actively at work:
For Anthem Blue Cross and Blue Shield groups of 2 or more: Retiree plans may be made available to former employees at
the option of the employer and subject to Anthem Blue Cross and Blue Shield underwriting guidelines.

When Medicare is primary: Medicare is primary for most “not actively at work” employees, such as retirees,
employees covered on an employer’s disability segment for more than six months.
Exception for ESRD: If an employee had Medicare as secondary due to age or disability immediately before he or
she also becomes an ESRD beneficiary, Medicare remains secondary throughout a 30-month coordination period,
even if the employee becomes a “not actively at work” employee covered under retiree or disability. When the
30-month coordination period ends, Medicare becomes primary.

How Medicare works with COBRA: Under federal COBRA law, an employee may continue on COBRA if he or
she also has Medicare, provided that he or she was entitled to Medicare on the day of COBRA election. Medicare
is prime with one exception for ESRD (stated above). If Medicare entitlement occurs after COBRA election,
COBRA coverage may end if the group’s plan documents so designate. (Entitlement to Medicare means that the
member is actually enrolled in Medicare.)
If your employee is on COBRA continuation, Please refer to the COBRA regulations for Medicare Secondary
Payer rules .
The information provided here does not constitute legal advice. Please contact your attorney if you have any questions regarding the application of state and federal laws
to your employee benefit plan.
37
Employer obligations
It is your obligation to ensure that beneficiaries who are covered by the MSP statute are not improperly enrolled in
carveout or Medigap coverage under your plan. If an individual is improperly enrolled in a supplemental or secondary
policy or contract when the individual should be enrolled in a plan that makes the FHP the primary payer, it is Medicare’s
position that Medicare pays secondary and the plan is required to pay primary regardless of contrary language contained
in the plan or contract. Individuals may choose to purchase and pay for Medigap insurance on their own, but neither the
employer nor the FHP may sponsor, contribute to or finance such coverage.
Dual Medicare eligibility
Some people can qualify for Medicare for more than one reason. Special rules apply in this instance. If one of your
employees or his or her dependents qualifies for Medicare for more than one reason, you may contact your account
executive or contact CMS to find out whether your firm health plan or Medicare will be the primary payer.
Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)
Applies to most groups with 20 or more employees
COBRA applies to companies that sponsor a firm health plan and have 20 or more employees on at least 50 % of their
working days during the preceding calendar year. Churches, the federal government and employers that employ fewer than
20 employees are excluded. It is the employer’s responsibility to notify terminated employees (other than those terminated
for gross misconduct) of their COBRA rights within 14 days of the qualifying event.
Family Medical Leave Act (FMLA)
Federal: FMLA of 1993
The federal FMLA applies to firms with 50 or more employees within a 75-mile radius of the workplace in each of 20 or
more weeks in the current or preceding year. The definition of employee includes full- and part-time workers. To be eligible
for leave, the employee must have worked for the firm for at least 12 months before the leave request (the months do not
have to be consecutive) and have worked at least 1,250 hours during that time.
An employee is entitled to a total of 12 work weeks of unpaid leave during any 12-month period. The employer is required
to maintain coverage under any group health plan for the duration of the leave as if the employee were continuously
employed. Coverage is paid for just as it was when the employee was active, but you should consult legal counsel to
determine any reimbursement rights that you may have.
For more information, contact:
U.S. Department of Labor
Pension and Welfare Benefits Administration
Division of Technical Assistance and Inquiries
200 Constitution Ave., NW, Room N-5658
Washington, DC 20210
Or visit: ww w. dol.g ov/ dol/t opic /benefits- le av e/fmla .ht m
38
Summaries of Benefits and Coverage (SBC)
For current group customers that require employees to provide a written application at renewal, the Affordable Care Act
requires that Summaries of Benefits and Coverage (SBCs) be provided to eligible employees with the application materials.
This would occur prior to the groups open enrollment period starting. For current group customers that renew
“automatically” (i.e., no written application from employees is required), SBCs must be provided at least 30 days prior to
the first day of the new plan/policy year.
For groups with custom benefit designs, an Anthem account manager will provide completed SBCs to the group prior
to the group’s open enrollment date or upon request from an employee or broker. For groups with standard benefit
designs, the SBC can be obtained directly by the group or broker at f ind -sbc.com. A new SBC is also required to be
issued to employees when modifications are made to the benefits that change information on the SBC. For material
modifications or off cycle benefit changes, a 60 day advance notification to employees is required. This means the material
modification or benefit change will be made effective the first of the month following the 60 day advance notification.
Questions on SBCs should be directed to your Account Manager.
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
HIPAA is legislation enacted by the federal government to streamline the health care industry and provide additional
rights and protections to participants in health plans.
Remember, under HIPAA, there are two employer components — the group health plan and the plan sponsor.
HIPAA regulations may vary for your company depending on which component wishes to receive PHI, and how much
information each component needs.
39
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc., an independent licensee of the Blue Cross Blue Shield Association.
ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks
of the Blue Cross and Blue Shield Association. Additional information about Anthem Blue Cross and Blue Shield in Connecticut is available at anthem.com.

Group Administrator Manual How to administer your group’s health coverage

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