The following outlines which employees are eligible to enroll in your group health plan, as well as when they can enroll and make changes. Please read this information carefully and discuss any questions with your sales professional.
Section 125- Permitted Election Changes
Other Changes to a Member/Insured Contract/Policy
Any person who satisfies the membership eligibility requirements is eligible to enroll by submitting a completed enrollment application form to BCNEPA in either a paper or electronic format. BCNEPA may not refuse to enroll eligible employees or their legal dependents on the basis of the health care needs of such individuals, if enrolled during their initial eligibility period or during their annual open enrollment period or at times classified as qualifying events under Section 125 of the IRS Code, even if the group plan is not a qualified plan as defined by Section 125.
Employers that transmit enrollment data electronically to BCNEPA will be responsible for obtaining and maintaining evidence of authorization by the employee of his/her intent to apply for coverage on forms that contain the standard fraud statement and the employee’s consent to release medical information in conjunction with the administration of this policy. The employer will consistently use the electronic enrollment application form. The employee must agree to the terms and conditions of the electronic form. BCNEPA has the right to review and approve the electronic enrollment application form prior to its use.
- The employer must comply with BCNEPA’s Underwriting Requirements.
- The employer agrees to collect payments from members/insureds and to make the required payment to BCNEPA.
- Employers are to utilize the Enrollment Application Change Form or the Self-Service Group Enrollment unless approval is granted by the Enrollment and Billing Supervisor for an employer to utilize an alternate change form.
- A member/insured experiencing a Section 125 election change must make the change effective to his/her contract/policy on the date of the qualifying life event. He/she does not have to wait until open enrollment.
- When a qualifying life event occurs, a Enrollment Application Change Form must be submitted. Coverage will be effective the date of the event if the application is signed by the member/insured within thirty (30) days of the event and received by BCNEPA within sixty (60) days of the event. If the change form is not signed by the member/insured within thirty (30) days or received after sixty (60) days of the life event, the form must be returned to the employer. The member/insured will need to wait until the group’s open enrollment period.
- All changes should be received as follows: prior to the effective date; within sixty (60) days of the life qualifying event; or upon the group’s open enrollment date.
Section 125- Permitted Election Changes
- Open enrollment period – The period of time, immediately prior to the annual renewal date, during which an eligible person of a group may elect to enroll or change their current coverage. Applications for enrollment or changes to current coverage due to open enrollment must be received by BCNEPA prior to the annual renewal effective date. The effective date for open enrollment activity will be equal to the annual renewal effective date. This open enrollment effective date may only be modified if agreed to in advance and in writing by BCNEPA and the employer. Open enrollment activity is irrevocable, unless a qualifying event occurs as defined by Section 125 of the IRS Code, even if your group plan is not a qualified plan as defined by Section 125.
- Entitlement to or loss of eligibility for Medicare or Medicaid: The employee or the employee's dependent becomes entitled to or loses eligibility for Medicare (Part A or Part B) or Medicaid, other than coverage consisting solely of benefits under the program for distribution of pediatric vaccines.
- Special requirements relating to the Family and Medical Leave Act (FMLA): An employee takes leave under FMLA, in which case the employee may revoke an existing election of health plan coverage and make such other election for the remaining portion of the period of coverage as may be provided for under FMLA.
- Significant cost or coverage changes: A cost increase or decrease refers to an increase or decrease in the amount of the elective contributions under the cafeteria plan, whether that increase or decrease results from an action taken by the employee (such as switching between full-time and part-time status) or from an action taken by the employer (such as reducing the amount of employer contributions for a class of employees).
A significant curtailment of coverage consists of an overall reduction in coverage provided under the group plan so as to constitute reduced coverage generally (e.g., a significant increase in the deductible, the copayment, or the out-of-pocket cost sharing limit under a health plan);
The following will be treated as a significant curtailment with a loss of coverage:
- A substantial decrease in the medical care providers available under the option (such as a major hospital ceasing to be a member of a preferred provider network or a substantial decrease in the physicians participating in a preferred provider network or an HMO);
- A reduction in the benefits for a specific type of condition or treatment with respect to which a dependent is currently in a course of treatment; or
- Any other similar fundamental loss of coverage.
- A judgment, decree or order: Resulting from a divorce, legal separation, annulment or change in legal custody (including a qualified medical child support order) that requires health coverage for an employee's dependent child or for a foster child who is a dependent of the employee. The judgment, decree or order is satisfied if it changes the employee's election to provide the required coverage under the employee's plan for the dependent child or permits the employee to make an election change to cancel coverage for the child if the order requires the spouse, former spouse or other individual to provide coverage for the child.
- Changes in status events, which include the following:
- Legal marital status: Change in the employee's legal marital status, including marriage, death of spouse, divorce, legal separation and annulment; non-group conversion coverage will be available to the terminated spouse.
- Number of dependents: Change in the employee's number of dependents, including birth, death, adoption and placement for adoption. If dependent coverage is available under the group policy/plan and an eligible employee who has previously not elected coverage acquires a dependent, we require that the employee must become insured when the eligible dependent becomes insured. Note: A newborn child is automatically covered without fee from his/her date of birth for thirty-one (31) days.
- Employment status: Change in the employment status of the employee or the employee's dependent, including termination or commencement of employment, a strike or lockout, a commencement of or return from an unpaid leave of absence or a change in worksite. This also includes a change in the employee's or the employee's dependent's employment status resulting in the individual becoming or ceasing to be eligible under the group policy/plan.
- Eligible dependent status: Change in the eligibility of a dependent due to reaching a limiting age, change in student status or any similar circumstance. Coverage for students will continue until the student meets the limiting age or until the end of the month in which such child ceases to be a full-time student, marries or becomes employed full-time, whichever occurs first. Eligibility shall be extended to full-time students who remain eligible for coverage as dependent children and who are members of the Pennsylvania National Guard or any reserved component of the armed forces of the United States and called or ordered to active duty or to active State duty, other than active duty for training, for a period of thirty (30) or more consecutive days. The extension shall be for a period equal to the duration of the eligible member’s/insured’s service or active duty or active state duty, or until the eligible member/insured is no longer a full-time student provided, the eligible member/insured submits to BCNEPA forms approved by the Department of Military and Veterans Affairs: notifying BCNEPA that the eligible member/insured has been placed on active duty; notifying BCNEPA that the eligible member/insured is no longer on active duty; or showing that the eligible member/insured has re-enrolled as a full-time student for the first term or semester starting sixty (60) or more days after the member’s/insured’s release from active duty.
Overage disabled dependents may be eligible to be covered on the member/insured’s agreement. Approval must be obtained from the BCNEPA Medical Director upon receipt of the change form.
- Residence: Change in the place of residence of the employee or the employee's dependent provided that the change in place of residence affects the eligibility for the employee or the employee's dependent's coverage under the group policy/plan.
- Addition or improvement of a benefits package option. If a plan adds a new benefit package option or other coverage option, or if coverage under an existing benefit package option or other coverage option is significantly improved during a period of coverage, employees may revoke their election under the cafeteria plan (whether or not they have previously made an election under the cafeteria plan or have previously elected the benefits package option) and instead make an election on a prospective basis for coverage under the new or improved benefit package option.
- Change in coverage under another employer plan. An employee may make a prospective election change that is on account of and corresponds with a change made under another employer plan (including a plan of the policy holder or of another employer) if:
- The other cafeteria plan or qualified benefits plan permits participants to make an election change that would be permitted under the applicable provisions of Section 125; or
- The cafeteria plan permits participants to make an election for a period of coverage that is different from the period of coverage under the other cafeteria plan or qualified benefits plan.
- Loss of coverage under other group health coverage. An employee may make an election on a prospective basis to add coverage under the group policy/plan for the employee or employee's dependent if such employee or dependent loses coverage under any group health coverage sponsored by a governmental or educational institution, including a:
- State's children's health insurance program under Title XXI of the Social Security Act;
- Medical care program of an Indian Tribal government, the Indian Health Service, or a tribal organization;
- A state health benefits risk pool; or
- A foreign government group health plan.
Consistency Rule: In all cases, any election change as a result of any change in status must be on account of and correspond with a change in status that affects eligibility for coverage under BCNEPA. For example, if the change in status is the employee's divorce, annulment or legal separation from a spouse, the death of a spouse or dependent child, or a dependent ceasing to satisfy the eligibility requirements for coverage, an employee's election to cancel health coverage will apply only to the spouse involved in the divorce, annulment or legal separation, the deceased spouse or dependent child, or the dependent that ceased to satisfy the eligibility requirements.
Other Changes to a Member/Insured Contract/Policy
All requests must be signed by the member/insured within thirty (30) days of the event and received by BCNEPA within sixty (60) days of the event. If the change form is not signed by the member/insured within thirty (30) days or received after sixty (60) days of the life event, the form must be returned to the employer. The member/insured will need to wait until the group’s open enrollment period. A late addition will not be processed until the group’s open enrollment. It is the responsibility of the employer to resubmit the form during the group’s open enrollment period.
- Death: The termination of the member/insured or dependent will occur the day after the date of death. For retroactive requests, refunds are limited to sixty (60) days of premium providing benefit eligibility has not been enforced. Refund requests beyond sixty (60) days, must be submitted in writing and approved by the Membership Review Committee. Non-group conversion coverage will be offered to the terminated spouse.
- Dual Coverage: The cancellation for a member/insured or dependent due to the member/insured or dependent’s termination of coverage will daily pro-rate. The daily pro-ration will be applied in conjunction with the date of the event. For retroactive requests, refunds are limited to sixty (60) days of premium, providing benefit eligibility has not been enforced. Refund requests beyond sixty (60) days, must be submitted in writing and approved by the Membership Review Committee. Non-group conversion coverage will be offered to the terminated spouse.
- Deleting a Dependent: A dependent can be deleted throughout the year. A member/insured does not have to wait for open enrollment or a life event. The request must be received prior to, but not more then sixty (60) days of the date requested. If the change is received after the date requested, you need to verify if benefits have been enforced. If benefits have been enforced, the change will be processed the day after utilization has stopped. If benefits were not enforced, proceed using the date of request. For retroactive requests, refunds are limited to sixty (60) days of premium, providing benefit eligibility has not been enforced. Refund requests beyond sixty (60) days must be submitted in writing and approved by the Membership Review Committee. Non-group conversion coverage will be offered to the terminated spouse.
- A member/insured who is eligible for Medicare or turns age 65 has different options of coverage dependent upon the size of the group. The information contained in 1A and 1B list the member’s/insured’s options:
- For an employer with over 20 employees for 20 or more calendar weeks in the previous calendar year (TEFRA A) - In the event that a member/insured is Medicare eligible or becomes eligible for Medicare, if the member/insured is a full time employee, he/she may remain as a member/insured of the active group or select to leave the group and enroll in the non-group coverage. If the member/insured selects non-group in this situation, they must sign a Medicare waiver form. If the member/insured is retired, the member/insured must transfer to either their company’s retiree group (if available), or a Medigap non-group product. Coverage changes may not be retroactive beyond the Medicare Timely Claim Filing date as determined by the Federal Government.
- For an employer with less than 20 employees for 20 or more calendar weeks in the previous calendar year (TEFRA B) - In the event that a member/insured is Medicare eligible or becomes eligible for Medicare, if the member/insured is a full time employee, he/she must be removed from the active group. The member/insured will have the option of enrolling in a group Medigap (if available) or he/she may enroll in the non-group coverage. If the member/insured is retired, the member/insured must transfer a Medigap non-group product. Coverage changes may not be retroactive beyond the Medicare Timely Claim Filing date as determined by the Federal Government.
- ESRD - Medicare is secondary to group health plans (GHPs) for individuals entitled to Medicare based on ESRD for a coordination period of 30 months regardless of the employee and employer status. The provisions for ESRD are applied without regard to the number of individuals employed and the employer coverage does not have to be based on current employment only. Medicare is secondary to GHP coverage from COBRA or a retirement plan. Medicare is secondary during the coordination period, even if the employer policy or plan contains a provision stating that its benefits are secondary to Medicare.
- Applies to BlueCare HMO and BlueCare HMO Plus only. The following applies for changes to Primary Care Physician.
- Unless a specific effective date is requested, primary office changes will be effective the date of receipt.
- Any retroactive adjustments will not be more than six (6) capitation cycles from the date received by BCNEPA.
- Any retroactive adjustments over six (6) months must be approved by the Provider Reimbursement Department.
Common Law Marriages require a notarized certificate to add a spouse to the contract/policy. The marriage must have occurred prior to January 1, 2005 for the Common-Law spouse to be added to the contract/policy. The request to add the spouse will be effective upon the group’s open enrollment.
With the passage of legislation in the fall of 2004, Common-Law Marriages which have been entered into on or after January 1, 2005 will no longer be considered a valid legal entity within the Commonwealth of Pennsylvania.
However, the legislation provided that Common-Law marriages entered into prior to January 1, 2005 may be considered valid from a legal perspective if there is evidence that the parties entered into the relationship or contract/policy prior to January 1, 2005.
In order to be recognized, the member must submit a notarized Common-Law Marriage Affidavit form along with an Enrollment Application/Change Form requesting to add the Common-Law spouse to the contract/policy. The member must be able to supply two forms as evidence or proof of the common law union and its existence prior to 1/1/05. Proof of Common Law Marriage documentation includes, but is not limited to, real estate records, bank statements, utility invoices and titles to personal property.
Current Billing Period: This period is defined as effective the first of the following month if received by the Enrollment/Billing Team on or before the 9th day of the month (standard bill generation date is the 12th day of the month). For example, work received on or before December 9th will be effective January 1st. Work received after December 9th will be effective February 1st.
Dependent: To be eligible to enroll as a dependent, a person must be: a) the spouse of the member/insured; or b) the member/insured’s or member/insured’s spouse’s unmarried child(ren) including: newborn children, step-children, children legally placed for adoption, legally adopted children, handicapped individuals and children covered under guardianship. BCNEPA may require legal written documentation to verify the relationship between a dependent and member/insured.
Eligibility shall continue past the limiting age for unmarried children who are incapable of self sustaining employment due to mental retardation, physical handicap, mental illness or developmental disability if such disability commenced while the child was a validly enrolled dependent on the parent’s policy and has been certified as disabled by BCNEPA.
Employee: An individual, who performs services in the regular course of the business of the policy holder, is considered full time, works a minimum of thirty (30) hours per week, receives wages or salary in accordance with the Pennsylvania minimum wage laws and is reported on federal and/or state payroll tax. The term employee of a church or convention or association of churches will include a duly ordained, commissioned, or licensed minister of a church in the exercise of his or her ministry regardless of the source of his or her compensation. The term employee also includes persons eligible to enroll in a bona-fide Taft-Hartley Health and Welfare Plan.
Full Time Student: An individual who is either a high school student or enrolled in a recognized college or university carrying a minimum of twelve (12) undergraduate credits or nine (9) graduate credits per semester, or enrolled in a trade or secondary school. The term "full-time" does not include those students attending night school or summer school only, or those attending school on a part-time basis.
Group: A collection of employees who qualify as insured persons under this contract/policy, who are enrolled by BCNEPA and whose premiums are remitted to BCNEPA by the policy holder. A group cannot be formed for the express purpose of purchasing insurance.
Domestic partner(s): An individual who is a member of a domestic partnership consisting of 2 partners each of whom: (i) is at least 18 years of age or older; (ii) resides with the other partner and intends to continue to reside with the other partner for an indefinite period of time; (iii) is not related to the other partner by adoption or blood; (iv) is not married to anybody else; (v) is the sole domestic partner of the other partner, with whom he/she has a close committed and personal relationship, and has been a member of this domestic partnership for the last 6 months; (vi) agrees to be jointly responsible for the basic living expenses and welfare of the other partner; and (vii) is able to demonstrate financial interdependence by submission of proof of 3 or more of the following documents:
- A joint mortgage or lease
- A designation of one of the partners as beneficiary in the other partner’s will
- A durable property and health care powers of attorney
- A joint title to an automobile, or joint bank account or credit account
- Such other proof as is sufficient to establish economic interdependency under the circumstances of the particular case
TEFRA: The Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 was designed to make Medicare the secondary payer for certain employees and dependents. Under the TEFRA law and subsequent legislation, the group health plan is the primary payer and Medicare is the secondary payer of claims for working-aged employees and certain dependents in employer groups with 20 or more full-time and/or part-time employees.
OBRA: Omnibus Reconciliation Act (OBRA) establishes Medicare as secondary payer for persons covered through a Group of 100 or more employees who are enrolled in Medicare due to disability. This means that BCNEPA is primary and the member/insured carries the same coverage as the rest of the group. OBRA excludes those on Medicare disability by reason of End-Stage Renal Disease. If a member/insured wants Medicare to be primary, he/she must transfer out of the group to our non-group product.