Employers

Group Administrator's Manual

Group Coverage Guidelines

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Enrolling New Employees

All permanent, full-time employees (minimum of 30 hours per week and 48 weeks per year) are eligible for group coverage. Please ask new employees to complete and sign an application. All full-time employees should either enroll or waive coverage, if they are eligible for coverage.

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Applications for Non-BluesEnroll Groups

Applications for insurance coverage should be completed and emailed or faxed to Arkansas Blue Cross no more than 60 days prior to the effective date of coverage. Please remember that applications that require completion (employers with 2-50 lives and late enrollees for all other groups) will be returned if the application is received more than 60 days prior to the effective date of coverage. Since these groups require medical underwriting, the medical questionnaire on the application must be completed within 60 days of the effective date (regardless of the date of hire or length of the waiting period) unless the group has a 90-day probationary period as to when they can submit applications as to the date of hire.

Applications may be submitted less than 60 days before the effective date of coverage, but must be received no later than 30 days after the employee's eligible effective date of coverage.

If applications are returned for additional information, the completed application must be received by Arkansas Blue Cross in order to be medically underwritten with timely, accurate medical information listed on the application. (This includes no more than 30 days beyond the employee's eligible effective date of coverage for a timely enrollee or no more than 60 days beyond the signature date for a late enrollee.)

Applications can be sent three ways:

  1. Emailed — quoteHIPAA@arkbluecross.com
  2. Faxed — 501-378-2926
  3. Mailed — Arkansas Blue Cross and Blue Shield
    P. O. Box 2181
    Little Rock, AR 72203-2181
    Attn: Mandated Group/HIPAA Compliance Unit

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Applications for BluesEnroll Groups

Online enrollment for insurance coverage should be completed and transmitted to Arkansas Blue Cross no more than 60 days prior to the employee's effective date of coverage.

Applications may be submitted less than 60 days before the effective date of coverage but must be received no later than 30 days after the end of the waiting period.

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Coverage Effective Dates

New Employees

A new employee will be eligible for coverage following the new employee waiting period, provided the application is received in a timely manner. A timely application is one that is received during the eligibility period or within 30 days following the end of the waiting period.

Existing Employees

An existing employee must submit an application with the medical questionnaire completed for him or her and any dependents if the employee wishes to become insured or add dependents after eligibility. Employees can apply for coverage or change to family coverage at any time. In some instances, employees will be asked to complete the medical questionnaire on the application to allow our underwriters to assess additional or unusual risk in providing coverage, which will cause an adjustment in the group's premium. In addition, the employee or dependent may be subject to an 18-month pre-existing condition exclusion period.

NOTE: BluesEnroll — Employees may not apply for coverage or change to family coverage except during a special enrollment period or open enrollment period.

Dental Policies

Dental policies are not subject to medical underwriting and do not have pre-existing condition exclusion periods; therefore, there is no late enrollment in dental groups. Enrollment occurs at initial eligibility or as the result of a qualifying event. (Applications must be received by Arkansas Blue Cross before the last day of open enrollment to be given the month of the anniversary as the effective date.)

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Identification Cards

ID cards are sent directly to you, the group administrator, by Arkansas Blue Cross for distribution to appropriate employee(s). Please encourage your employees to keep their ID cards with them at all times.

Coverage Effective Date Guidelines

Member Qualifying Event Effective Date Remarks
Spouse Marriage First of month after date of marriage Application must be submitted within 30 days of marriage
Spouse Loss of other coverage First of month after loss of coverage Application must be submitted within 30 days of loss of coverage
Natural child of employee Loss of other coverage First of month after loss of coverage Application must be submitted within 30 days of loss of coverage
Newborn child Birth of child Date of birth Enrolled within 90 days of date of birth
Adopted child – newborn Petition for adoption Date of birth Enrolled within 60 days of date of birth
Adopted child – not a newborn Petition for adoption Date placed for adoption or date of petition for adoption filed Enrolled within 60 days of placement or filing of petition for adoption
Court ordered coverage for child Court order First of month after application received Custodial parent or child support agency can submit copy of court order
Grandchild/other Court appointed guardianship or legal custody First of the month after receipt of application (date of birth if newborn) Enrolled within 30 days of qualifying event (90 days for newborn); proof of custody or guardianship required
Stepchild Loss of other coverage, marriage (addition or family members) First of the month after receipt or date spouse eligible Enrolled within 30 days of qualifying event
Current member – mentally or physically incapacitated dependent Dependent reaches age 26 or dependent maximum age per group contract First of the month after dependent reaches age 26 (or maximum dependent age) To prevent any break in coverage, should be enrolled as incapacitated dependent within 30 days (proof of incapacity of dependent form in Forms section)
New member – mentally or physically incapacitated dependent Dependent over age 19 and was covered on previous group health plan Date member is effective for new group Proof of incapacity before age 19 and creditable coverage since age 19 must accompany Application
Reinstatement military personnel Return from active military duty Date returned to work Application must be submitted within 90 days of returning to work

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Pre-existing Condition Limitations

Application of Pre-existing Condition Exclusion Period

NOTE: BluesEnroll groups do not have late enrollees.

This 12- or 18-month period is referred to as the "look forward period." If the employee submits an application for coverage during the waiting period, the 12-month look forward period starts on the first day of the waiting period. If the employee did not apply within the waiting period, the look forward period starts on the covered person's effective date.

This exclusion is not applicable to:

  • Pregnancy

  • A newborn child who is covered under this group insurance contract or other creditable coverage within 90 days of the date of birth and continues to be covered without a 63-consecutive day break in coverage.

  • An adopted child who is covered under this group insurance contract or other creditable coverage within 60 (within 60 days of the date of adoption of the date the child is placed for adoption is more lenient than federal guidelines) days of the date of adoption or the date the child is placed for adoption and continues to be covered without a 63-consecutive day break in coverage.

  • Individuals up to age 19.

Periods of creditable coverage will reduce the pre-existing condition exclusion period. Please refer to the Schedule of Benefits for more information.

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Changes in Coverage

Increase or Decrease in Group Benefits

If you would like to increase or decrease your group's benefits, please contact your group marketing representative before your group's anniversary date. In order to serve your needs, changes need to coincide with your anniversary date.

Loss of Concurrent Coverage

Plans and insurers must allow employees and/or dependents that are eligible for — but not enrolled in — the group health plan, to enroll in the plan when individuals are losing other coverage (including COBRA) and all the following conditions exist:

  • The individual was covered under another group health plan or other health insurance when the employer's plan was first offered.

  • The coverage was either COBRA coverage that was exhausted or other group health coverage canceled due to loss of eligibility or due to cancellation of the employer contributions toward coverage.

  • The employee requests enrollment within 30 days of the end of the other health coverage.

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New Enrollments or Changes Due to Special Events

Change Due to Marriage

If one of your employees marries, an application must be received within 30 days of the date of marriage to be considered a timely addition. The new spouse will be added to the group policy effective at the beginning of the policy month following the date of marriage. A timely addition is subject to a 12-month pre-existing condition exclusion period that may be offset by prior creditable coverage.

If the application is not received within 30 days of the date of marriage, the spouse will be added on the next available effective date after the completed application is received. The spouse will be considered a late enrollee and an18-month pre-existing condition exclusion will apply. A certificate of marriage will be required in all instances (including a difference in last names to verify dependent status).

For BluesEnroll — If the application is not received within 30 days of the date of marriage, the new spouse will be considered a late enrollee. The new spouse will have to wait until a special enrollment period or the next open enrollment period to apply for coverage. The spouse added late is subject to a 12-month pre-existing condition exclusion period that may be offset by prior creditable coverage. Please obtain a certificate of marriage and make it available to upon request.

For BluesEnroll Small Group — If the application is not received within 30 days of the date of marriage, the new spouse will have to wait until a special enrollment period or the next open enrollment period to apply for coverage. If the spouse is added at open enrollment, the spouse is subject to a 12-month pre-existing condition exclusion period that may be offset by creditable coverage.

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Change Due to Newborn

In order for coverage to begin on the date of the newborn child's date of birth, the member must enroll the child within 90 days of the date of birth. The timely addition of a newborn is not subject to a pre-existing condition exclusion period.

If an employee does not enroll the newborn child within 90 days of the date of birth, the child will be considered a late enrollee. If the employee does not enroll the newborn child within 90 days of the date of birth, the child will be added on the next effective date after the completed application is received.

The employee will be asked to complete the health questions on the application/change form with respect to the child. Coverage effective date will be the premium due date after approval.

Parental proof (birth certificate listing the policyholder’s name as father or mother, court order for child support or paternity test results) will be required when the policyholder is unmarried and/or the child’s last name differs from that of the employee. Parental proof may be required at any time.

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Change Due to Adoption

In the case of an adopted child, an employee will be required to enroll the newly adopted child within 60 days of the date of adoption or the date the child is placed for adoption for the child to be considered a timely addition. The timely addition of an adopted child is not subject to a pre-existing condition exclusion period.

If an employee does not enroll the newly adopted child within 60 days of the event, the adopted child will be considered a late enrollee and the child will be added on the next available effective date after Arkansas Blue Cross has received the court documents.

The employee will be asked to complete the medical questionnaire on the application. Adoption papers are required in all instances.

The coverage shall be canceled upon the dismissal, denial, abandonment or withdrawal of the adoption, whichever occurs first.

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Change From Family to Individual Coverage

If one of your employees would like to change from family coverage to individual coverage, please mail a signed application/change form to Arkansas Blue Cross. The dropped dependent(s) will be assigned the next available effective date following the date of receiving the application.

The group administrator's signature will be required on all change forms. This will ensure his or her awareness of changes in family status that may affect COBRA or cafeteria plan requirements.

A change from individual to "other" (employee/spouse, employee/child or family) will require an application be completed to add the dependent.

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For BluesEnroll (Including Small Group)

If one of your employees would like to change from family coverage to individual coverage, he or she may only do so during a special enrollment period or an open enrollment period. The change will be effective on the premium due date following the date of receipt in the home office. A change from individual to "other" (employee/spouse, employee/child or family) will require an online application be completed to add the dependent during a special enrollment period in limited instances or during the open enrollment period.

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Change Due to Divorce

In the event of divorce, a change form must be completed to remove the former spouse. A divorced spouse is no longer eligible and must be removed by the end of the month of the date of divorce. The cancellation of spousal coverage requires the group administrator’s signature and date. If the former spouse has children, and the employee is not the parent and is not the legal guardian, it is important to note that the stepchild(ren) will no longer be covered on the policy.

IMPORTANT: Please refer to the COBRA Section for more information.

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Dependent Coverage

A dependent is covered under the family coverage from birth to the end of the billing period in which the child reaches the dependent maximum age of the policy, unless other provisions in the group policy have been agreed to in writing. Note that a dependent child that reaches the limiting age is eligible for COBRA continuation. It is the employee's responsibility to make sure that his or her dependents are covered. Dependent age coverage is listed on the Schedule of Benefits.

A dependent is defined as the employee's natural child, a stepchild or a legally adopted child. Employees who have been awarded permanent custody of a child must furnish a copy of the court order stating they are the custodial parent. Temporary custody of a child is not considered a basis for coverage.

Incapacitated Dependents

Continuation of insurance for a handicapped dependent child:

  • If a dependent is not capable of self-sustaining employment due to mental retardation or physical handicap, his insurance shall not end when the child reaches the limiting age for dependency. The insurance will continue as long as the child remains handicapped, unless coverage ends as described in the Termination of Dependent Insurance provision. The employee must give Arkansas Blue Cross proof that the child is (1) incapable of self-sustaining employment and (2) chiefly dependent on the employee for support and maintenance.

  • The employee must give Arkansas Blue Cross written proof after the child reaches the limiting age for dependency and at any time after as Arkansas Blue Cross may require. Arkansas Blue Cross shall not require proof more than once per year after the two (2) year period following the date the child reaches the limiting age for dependency.

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Special Circumstances Regarding Coverage

Military Service

If an employee is called to active duty in the armed services of the United States of America, the employee's (and any covered dependents) coverage may be continued on COBRA for a period of 18 months or under the Uniformed Services Employment and Reemployment Rights Act (USERRA). A former employee returning from active military service may enroll in the Plan within 90 days of his or her return to employment, provided the employer continues to sponsor the Plan and payment of premium is made in a timely manner. The company may require a copy of the returning member’s orders ending active duty or other proof of the active duty or end date.

Over Age 65

A full-time (works 30 hours or more per week) employee who reaches age 65 has the choice of either continuing Arkansas Blue Cross group coverage or becoming a Medi-Pak member. If an employee chooses Medi-Pak, he or she will be billed at his or her home address.

If one of your employees would like to become a Medi-Pak member, please delete the employee from your group billing and submit a Medi-Pak application within 30 days of the last billing. If there is no lapse in coverage, the employee can transfer to Medi-Pak. If the employee chooses to continue Arkansas Blue Cross group coverage, no action is necessary.

An employee turning 65 years of age also may take advantage of Medicare coverage. As the group administrator, please note which health plan pays first for those with Medicare. If you would like a copy of Medicare Secondary Payer: Information for Employers, or would like to receive an updated copy every year, please write to the address below and ask for the CMS Booklet:

Centers for Medicare/Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244-1850

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Additions to the Group After Initial Enrollment

New Hires

New hires may be added to the group by completing and submitting an application requesting coverage.

NOTE: BluesEnroll groups submit an online application.

New hires in groups with 2-50 employees always must complete the medical section (Section 7) questionnaire on the application. A new hire in groups with 51 or more employees must complete the medical questionnaire only if they are a late enrollee.

NOTE: This does not apply to BluesEnroll groups.

Requesting Exceptions

Requesting a waiver of the eligibility period will not be granted. A group may, however, request their contract be amended to reflect the creation of multiple eligibility periods for future new hires and additions. These eligibility periods must be created for classes of employees only. For instance, sole proprietor, partner or corporate officer would be an identifier for executives. The words "key employee" are not allowed as an identifier.

Omissions and Errors

Arkansas Blue Cross bills every group one time each month. That bill lists each covered employee in the group and an amount due. It is very important that you, as the group administrator, verify that all covered employees are listed on the bill and that any canceled employees are indicated on page 1 of your bill (please refer to Group Billing Procedures for instructions on making adjustments to amount billed). Incorrect removal of an employee may require the submission of payroll records to verify continued employment. We appreciate your help on keeping all records accurate.

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Refund of Premiums

If Arkansas Blue Cross cancels the coverage of an employee and/or dependent, premium payments received on account of the canceled employee and/or dependent applicable to periods after the effective date of cancellation will be refunded to the group within 30 days, and Arkansas Blue Cross will have no further liability under your group policy.

If the group cancels coverage of an employee and/or dependent, you are required to request Arkansas Blue Cross refund premiums paid for such employee and/or dependent's coverage within 60 days from the effective date of cancellation of such coverage in order to receive a refund of premium. If the group does not make a refund request within 60 days of the effective date of cancellation of the employee and/or dependent’s coverage, it will result in the group waiving refund of any premiums paid for such coverage. The cancellation date of coverage for the employee and/or dependent will be the next billing cycle after the receipt of the group change form.

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Retroactive Terminations – PPACA Required Changes Effective Sept. 23, 2010

The Patient Protection and Affordable Care Act (PPACA — through Public Health Service Act section 2712) generally provides that plans and issuers must not rescind coverage unless there is fraud, or an individual makes an intentional misrepresentation of material fact. A rescission is defined in the law as a cancellation or discontinuance of coverage that has a retroactive effect, except to the extent attributable to a failure to pay timely premiums towards coverage. This was effective on Sept. 23, 2010.

This provision limits our ability to make exceptions to retroactively terminate a member’s coverage beyond our normal reconciliation process. Although this was put into the law with the good intention of protecting a member from being terminated if they got sick, it has some unintended consequences that may have a negative impact on the member, the group and the insurance carrier. The most common issue to arise is when a group or member does not term on a timely basis. If the member has paid any part of the premium after the requested termination date, we must extend coverage through the time period the premium covers. In many cases this will cause us to term them prospectively.

Below is some guidance from an FAQ published by the Department of Labor (Oct. 8, 2010):

Is the exception to the statutory ban on rescission limited to fraudulent or intentional misrepresentations about prior medical history? What about retroactive terminations of coverage in the "normal course of business"?

The statutory prohibition related to rescissions is not limited to rescissions based on fraudulent or intentional misrepresentations about prior medical history. An example in the Departments' interim final regulations on rescissions clarifies that some plan errors (such as mistakenly covering a part-time employee and providing coverage upon which the employee relies for some time) may be canceled prospectively once identified but not retroactively rescinded unless there was some fraud or intentional misrepresentation by the employee.

On the other hand, some plans and issuers have commented that some employers' human resource departments may reconcile lists of eligible individuals with their plan or issuer via data feed or billing only once per month. If a plan covers only active employees (subject to the COBRA continuation coverage provisions) and an employee pays no premiums for coverage after termination of employment, the Departments do not consider the retroactive elimination of coverage back to the date of termination of employment, due to delay in administrative record-keeping, to be a rescission.

Similarly, if a plan does not cover ex-spouses (subject to the COBRA continuation coverage provisions) and the plan is not notified of a divorce and the full COBRA premium is not paid by the employee or ex-spouse for coverage, the Departments do not consider a plan's termination of coverage retroactive to the divorce to be a rescission of coverage. (Of course, in such situations COBRA may require coverage to be offered for up to 36 months if the COBRA applicable premium is paid by the qualified beneficiary.)

Our legal department has determined this will not cause us to change our termination policies in the Group Administrator Manuals or Certificates of Coverage. Instead, it is the rules for making exceptions that have changed based on the law.

Therefore, Legal recommends that if we receive a request from an employer to terminate coverage for a covered person within 60 days after the effective date of termination of such coverage, the question that needs to be asked and answered is, "Did this member contribute premium payment after the requested termination date?" If the answer is "no," the response should be we will honor your request. Likewise, if we receive a request beyond 60 days from the effective date of termination and a no answer to the question, we will terminate the employee but not refund premium in accordance with the group contract provision. Article IV, Subsection I.

If we receive a request from an employer to "retro-terminate" coverage for a covered person and the answer to the question, "Did this member contribute premium payment after the requested termination date?" is "yes," you should inform the employer, "Federal health care reform regulations prohibit retro termination under these circumstances unless we have proof that the covered person obtained or kept his coverage due to fraud. We will be happy to terminate the covered person's coverage effective at the end of the period for which he or she paid premium."

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