Carrier Administration Guidelines Rev9.9

T: (800) 801-2300

F: (800) 609-0111

www.warnerpacific.com

Warner Pacific Insurance Services

32110 Agoura Road

Westlake Village, CA 91361

CA Insurance License No. 0764260 | CO lnsurance License No. 351162

California Carrier Administration Guidelines

Aetna American General Anthem Blue Cross

Blue Shield of California Delta Dental

Guardian Health Net

Humana Kaiser Permanente

MetLife Premier Access

Principal Sharp Health Plan UnitedHealthcare

VSP


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CaliforniaChoice please see current carrier underwriting guidelines. Information is believed to be current as of the last

date listed below and is subject to change. The accuracy of this information is not guaranteed. It is the employers

responsibility to ensure they are compliant with IRS non-discrimination rules. Last updated on 2/11/15.

Call or visit us today

800•801•2300


CA lnsurance License No. 0764260

TABLE OF CONTENTS

1. EMPLOYER QUESTIONS

Aetna, American General & Anthem | Blue Shield, Delta Dental & Guardian | HealthNet, Humana & Kaiser

MetLife, Premier Access & Principal | Sharp, UHC & VSP

o When will the group administration kit be sent?

o Will the kit be sent to the agent or client?

o If the broker would like a copy of the kit, who do they contact?

o What is included in the administration kit?

o Can a kit be sent to someone else besides the default?

o When should a group expect their first billing statement?

o Who is responsible for sending future enrollment materials?

2. EMPLOYEE QUESTIONS



o When will the member ID card be mailed and are they sent to the group or member?

o Are temporary ID cards available?

o Are personalized ID cards sent and are they paper or plastic?

o If personalized ID cards are sent, do they list each dependent name on them?

o Are separate ID cards generated if enrolled in dental and/or vision along with the same carrier medical plan?

o If yes, do the ID cards list each dependent on them?



o Will each member receive an evidence of coverage book?

o If yes, when are they mailed and will they go to the group or to the member’s home?

3. NEW HIRED EMPLOYEES



o Will new hire ID cards be sent to the group or the member’s home?

o Will new hires receive evidence of coverage books?

o If yes, where will they be mailed?


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4. OPEN ENROLLMENT



o Does the carrier offer a true open enrollment?

o When is the open enrollment period?



o What is allowed at open enrollment?

o What paperwork is required?

o Can someone who initially declined coverage enroll at any other time of the year?

5. DOMESTIC PARTNER



o What verification procedures will you require? Same sex - no age limit or Opposite sex - 62 years and older.

o What verification procedures will you require? Opposite sex – under 62 years of age. o Will the partner be eligible for federal COBRA? Same sex – no age limit or Opposite sex – 62 years and

older. o Will the partner be eligible for Cal COBRA? Same sex – no age limit or Opposite sex – 62 years and older

or Opposite sex and under 62 years of age. o Will the partners be required to be registered domestic partners?

6. DISABLED DEPENDENT CHILD



o Is an over-age disabled dependent eligible to continue coverage through this new insurance carrier if they were covered under their parents’ previous policy?

o Is an over-age disabled dependent eligible to continue coverage through this new insurance carrier if they were not covered under their parents’ previous policy?

o What documentation will be required if the disabled child is eligible to continue coverage?

o How often will the disabled depend child be required to recertify this disability?

o If the answer is no to any of the above questions, would you consider allowing the child to enroll under Cal COBRA / COBRA?


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7. DEDUCTIBLE CREDIT PROCEDURES



o Which documents are acceptable to provide proof of prior deductible met?

o At what point should the documentation be provided for processing?

o Which department should the documentation be directed to?

o By what means will the documentation be accepted?

o Will a member receive any notification that their deductible has been credited?

o Where could someone call to check status on processing?


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Employer Questions

When will the group administration kit be sent?

14-21 days from the effective date, a hard copy administration kit is automatically generated. It is also available through email.

Once the case has been approved, a hard copy administration kit is automatically generated. Clients should receive it within 10-12 business days.

24-48 hours after the group is loaded, a hard copy administration kit is automatically generated.

Will the kit be sent to the agent or client?

It will be sent to the client, unless otherwise specified.


The designated party on the employer application will be sent the kit.

If the broker would like a copy of the kit, who do they contact?

ASG Broker Services (877) 249-2472

Client Services (877) 672-1648, press 4, then press 4, then press 4

Customer Service (800) 627-8797

What is included in the administration kit?

A welcome letter with instructions on how a group administrator can access their administration manual online.

A welcome letter, administration manual, group case summary, premium sheet, instructions and login / password for Online Administration (Virtual Administrator).

Group level: Welcome letter with instructions on how to access the administration manual online, employee notices, master agreement, rate sheets, one EOC of each of the contracts enrolled. Employee level: Welcome letter, ID cards, EOC (one per subscriber per contract enrolled), and employee notices.

Can a kit be sent to someone else besides the default?

Yes, it must be indicated during underwriting.

Yes, the client will need to indicate this at case set up.


When should a group expect their first billing statement?

Within 30 days after the original effective date.

Within 30 days of inception. The first bill will include inception and first month billing.

Bills are generated around the 4th or 5th of each month.

Who is responsible for sending future enrollment materials?

Warner Pacific American General Life Warner Pacific or Anthem Blue Cross


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Employer Questions


Within 31 days after the effective date.

Within 1 week after approval, a welcome email will go out with instructions on how to access this information online.

Once the case has been approved, a hard copy administration kit is automatically generated. Clients will receive it in 10-14 business days.


It will be sent to the client. The client will receive the kit through email.



Producer Services (800) 559-5905

N/A Customer Response Unit (800) 459-9401 [email protected]


A welcome letter, administrative manual, commonly used forms, EOC and the group contract.

Group level: Contract, signature page, HIPAA business associate agreement, notice of privacy practices, EOC, declination form, enrollment form, how to find a dentist, how to print ID cards. Employee level: Personalized ID cards and extra generic ID cards.

A welcome letter, administration manual, plan administration materials, sample forms and instructions for members on how to best utilize their benefits and programs.


Yes, once the group has been approved, you may contact Group Services to request the kit be mailed to a different address. (800)325-5166.

No Yes, the client will need to indicate this at case set up.


Within 30 days after their original effective date.

By the second week of the month following approval.

The billing statement will be available online at GuardianAnytime.com within 2 - 5 business days from approval.


Blue Shield of California upon request.

Allied Administrators Employers and employees can access forms, summary benefit information and certificates of coverage online at GuardianAnytime.com.


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Employer Questions


Medical: Within 7-10 business days after group is loaded in the system. Dental: Within 1 week from approval, a hard copy administration kit is automatically generated.

Humana does not send an administration kit. A welcome letter is mailed out in 5-7 days once ALL documents are received.

Within 30 days after the group is active in the system, a hard copy administration kit is automatically generated.


Medical: The client, unless otherwise specified. Dental: Group

A welcome letter is mailed to the client and broker.

Group


Account Management (800) 447-8812

Small Business Accounts (800)790-4661


Medical: Employer manual, rate tables, and welcome letter. Dental: unknown

A welcome letter acts as Humana’s administration kit. Humana directs their customers and members to humanadental.com. They provide one copy of an EOC.

Administrative handbook and group agreement.


Medical: Yes, it must be indicated during underwriting. Dental: Yes, upon request in writing.

A welcome letter is typically only sent to the customer and the broker.

Yes, upon written request.


Medical/Dental: It varies and is based on when the group is loaded in the system.

Premium statements are generated around the 15th of each month.

It depends on when the group is loaded in the system. Billing statements are mailed around the 15th of each month.


Health Net All materials are located online at humanadental.com.

Kaiser Permanente


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Employer Questions


Within 7-10 days after groups approval.

Within 15-20 days after the effective date.

No hard copy administration kit is generated. Principal will include the Administration Guide as part of the welcome email.


Whichever party is designated on the employer application.

The kit is mailed to both the Client and the Agent/Broker.

Group


Client Broker Services (800) 204-0463

Broker Services (888) 326-3210

<50 lives (800) 843-1371 ext. 57004 >50 lives (800) 843-1371 ext. 78900


Master contract, employee applications, supply request form, and directory.

A welcome letter, contact information, copy of the contract, schedule of benefits, certificate of insurance/evidence of coverage, enrollment forms.

Administrative guide, ERISA information, customer service information, employee applications, waiver forms, COBRA forms, employee change forms, employer change forms, and claim forms.



Yes Yes, it must be indicated during underwriting.


It depends on when the group is loaded in the system.

Within 30 days after the original effective date.

Within 3 weeks after underwriting releases the case.


MetLife Premier Access Warner Pacific


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Employer Questions


2-3 weeks after approval, the group agreement is sent to the client. Included with that agreement are instructions on how to request an administration kit. It is also available through email and the SHP website.

Medical: 10 days after the policy is generated. PPO or Dual Option: Employer receives instructions on how to access the admin kit online. HMO: Administration manual is emailed to the employer. Dental: 30 days after the group is loaded in the system.

Within 24-48 hours from the group being loaded, an administration kit is automatically generated and emailed from VSP to the broker and Warner Pacific Sales Executive.


Agent decision Group Broker and Warner Pacific Sales Executive


Sharp Health Plan assigned Account Service Representative.

Medical: Account Mgmt. (800) 858-9168 option 2 Dental: Account Mgmt. (800) 516-4680

The broker receives the Administration Manual. They may make a copy for themselves.


Administration manual PPO: Contract documents, federal notices, admin manual and marketing materials. HMO: Admin manual, employer contact sheet, employer webinar invite, and marketing materials. Dental: Administration manual, directory, benefit summaries, EE apps.

The approval letter, administration guide, first month invoice and member benefit summaries.


Yes Yes, by written request or phone call.

No


It depends on when the group is loaded in the system.

Medical: It depends on when the case is approved. Dental: Within 1 week after the group is loaded.

Approximately 24-48 hours after loading. The first billing statement is included in their administration kit.


Warner Pacific United HealthCare HealthSmart will send electronic PDF only.


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Employee Questions

When will the member ID card be mailed and are they sent to the group or member?

7-10 days after case approval. They are mailed to the member’s home.

They do not produce ID cards.

Within 24-48 hours after the group is loaded. The cards are mailed to the group.

Are temporary ID cards available?

Yes, the member must register online before they are printable.

N/A No

Are personalized ID cards sent and are they paper or plastic?

Yes, plastic cards are generated.

N/A Yes, 2 plastic cards are generated.

If personalized ID cards are sent, do they list each dependent name on them?

HMO: Each individual receives their own personalized card. All other plans: The subscriber name and all family members will be listed on the subscriber cards.

N/A HMO: Dependents will receive separate ID cards with their name on it if they choose a different IPA/PMG from the subscriber. PPO/EPO/Lumenos: No

Are separate ID cards generated if enrolled in dental and/or vision along with the same carrier medical plan?

The medical ID card will be used for Pediatric Dental, Pediatric Vision and Aetna Dental. The medical ID cards reference the Pediatric Dental but not any additional dental plan they may have purchased. Aetna Vision will have a separate ID card.

N/A Yes, unless the subscriber is on the BeneFits Hospital Preferred plan with the embedded Dental and Vision, then it is one card with the medical.

If yes, do the ID cards list each dependent on them?

Medical, Dental: No Vision: No

N/A No


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Employee Questions


7-10 business days after group approval/installation and they are mailed to the members’ home.

PPO: 2 weeks after approval and mailed to the group. HMO: 2 weeks after approval and are mailed to the members home.

Standard process is to email the group an electronic ID card in a pdf format within 3-7 business days from approval. Members can print their ID cards online at GuardianAnytime.com.


Yes, members must register online then the cards are printable.

Yes, member must register online then the cards are printable.

No


Personalized ID cards are sent. Dependent cards will have the subscribers’ information. If enrollment is employee only, one ID card will be sent. If enrollment is employee plus one or more dependents, two ID cards will be sent.

Yes, paper ID cards are sent. Generic or personalized ID cards (group has choice) are available. The default is generic. Cards are available online at www.GuardianAnytime.com.


HMO: The subscribers’ name and all family members will be on the subscriber cards. All other plans: The subscribers’ information will be on the cards.

Only the subscribers name appears on the ID cards.

HMO: Yes, ID cards will have dependents names listed. PPO: No


Dental receives ID cards, see above. Vision does not provide ID cards. Separate pediatric dental ID cards are sent to enrollees’ homes.

N/A N/A


See above N/A N/A


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Employee Questions


Medical/Dental: Within 7-10 business days from date the group is loaded in the system and is mailed to the members’ home.

Approximately 10 days after coverage is issued and they are mailed to the members’ home.

Within 10 days after enrolled in the system and they are mailed to the members’ home.


Yes, members must register online then the ID cards can be printed.

Yes, the Group Administrator must register the account online then the ID cards can be printed.

Yes, the temporary membership form is available online, no registration is necessary.


Yes, a mixture of paper and plastic cards are generated.

Only members receive ID cards with dependents listed.

Yes, plastic cards are generated.


Both the subscriber and dependents names will appear on the cards.

N/A Yes


Dental: Yes EyeMed Vision: No Separate pediatric dental ID cards are sent to enrollees’ homes.

N/A Yes Medical ID card is used for pediatric dental. Groups purchasing Delta Dental HMO will receive separate ID cards to enrollee’s homes. PPO or FFS plans, no ID cards are issued.


Dental: The subscriber name will be listed and there is a portion that says – Dependent Coverage. This would be followed by “yes” or “no”.

N/A No


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Employee Questions


Within 7-10 days after the group has been approved. DHMO: Members’ home PPO: Group

7-10 days after case approval and they are mailed to the members’ home. If requested, the ID cards can be mailed directly to the group contact.

7-10 days after enrolled in the system and they are mailed to the group. Temporary ID cards are available at www.principal.com


Yes, member can register online to obtain a copy of ID cards. A digital ID card is available through Smartphone and iPad.

Yes, the Group Administrator must register the account online through e-Service before the ID cards are printable.


Yes, paper ID cards are generated.


Yes, 2 plastic ID cards are generated.


Yes Yes, each member will receive their own ID card.

No, the subscriber name is listed with the dependents’ name underneath.


N/A N/A N/A


N/A N/A N/A

http://www.principal.com/


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Employee Questions


2-3 weeks after approval and are mailed to the group.

Medical: 7-10 days after the group is loaded, and they are sent to the member. Dental: 48 hours after the group is loaded, ID cards are sent to the members, unless otherwise specified.

VSP does not use ID cards.


Yes, the Group Administrator and/or member must register online first.

PPO: Yes, the member must register online first. HMO: No

N/A



PPO: Issued 1 card per employee and 1 for enrolled spouse. No ID cards for dependent children. HMO: Issued 1 card per enrolled member.

N/A


Yes PPO: Show the names of all members covered. HMO: Subscribers and dependents each receive separate cards with only their own name.

N/A


Sharp offers a vision rider through VSP and a discount dental program through First Health Dental. The First Health and VSP logo will appear on the medical ID card they elected this rider. Separate ID cards for these benefits are not issued.

Separate dental ID cards are sent to enrollees’ homes. Separate pediatric dental ID cards are sent to enrollees’ homes.

N/A


Members are issued 2 cards. For DHMO if any dependents select a different dental provider, that PCP will be listed on the cards.

N/A


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Employee Questions

Will each member receive an evidence of coverage book? If yes, when are they mailed and will they go to the group or to the member’s home?

By request only. A subscriber will receive a postcard from Aetna, which they must fill out and return if they wish to receive an EOC.

A Certificate of Coverage booklet is emailed and mailed directly to the group. The Group Administrator may then copy or print for each member.

Yes, it is included with the administration kit. Within 24-48 hours after the group is loaded, they are mailed to the group. Each employee will receive their own EOC.

New Hired Employees

Will new hire ID cards be sent to the group or the member’s home?

Members home. Life Insurance does not produce ID cards.

Home, if not designated.

Will new hires receive evidence of coverage books? If yes, where will they be mailed?

By request only. A subscriber will receive a postcard from Aetna, which they must fill out and return if they wish to receive an EOC.

A Certificate of Coverage booklet is emailed and mailed directly to the group. The Group Administrator may then copy or print for each member.

Yes Home, if not designated.

Open Enrollment

Does the carrier offer a true open enrollment?

Medical: Yes Dental: No

No Yes

When is the open enrollment period?

Within the month prior to the groups’ anniversary date.

N/A Within the month prior to the group anniversary date.


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Employee Questions


It is the responsibility of the Employer to distribute EOCs to eligible employees.

One hard copy EOC is generated and mailed to the Group Administrator. The group is then responsible for making copies for each employee as requested. EOCs are mailed 2 weeks after approval are included in the administration kit.

A copy of the certificate of coverage is emailed to the employer for their records. Member access is available online at Guardian Anytime.com.

New Hired Employees


Members home. DPO: members will not receive ID cards unless the member specifically requests one. It would go to the members’ home if requested. DHMO: Members home.

Electronic ID cards are available online at GuardianAnytime.com.


It is the responsibility of the employer to distribute EOCs to eligible employees.

Upon request Group

Yes Certificate of Coverage booklets are available online at GuardianAnytime.com.

Open Enrollment


Medical: Yes Dental: Yes

Yes, provided the member is making payments through payroll deductions using pre-tax dollars.

Yes, if Section 125 is in-force.


Within the month prior to the groups’ anniversary date.

Within the month prior to the groups’ anniversary date

The month prior to the groups’ renewal / anniversary date.


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Employee Questions


A member will receive a letter notifying them that they may access their EOC online after they register. Hard copies are no longer provided. This letter is sent separately from their ID cards.

Each member will receive a hard copy EOC. These are mailed to the members’ home along with their ID cards. EOCs are also available online.

Members need to call Kaiser Permanente Member Services to request an EOC be mailed to them.

New Hired Employees


Members’ home. Members’ home. Members’ home.


A member must register online in order to access their EOC. Hard copies are no longer provided.

Yes, members’ home. The employer is responsible for distributing a new hire enrollment kit which includes the EOC.

Open Enrollment


Medical/Dental: Yes Yes. A load may be associated with the Large Group products (100+). It depends on case size, product offering, & whether it is a voluntary product offering. Small group (2-99) includes the Open Enrollment provision with no load.

Yes


Medical/Dental: During the month prior to the groups’ anniversary date.

31 days before and after the employer groups’ renewal date.

The month before the anniversary date.


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Employee Questions


Yes, within 7-10 business days after the groups’ approval. Employer discretion as to where they are mailed.

If requested, an EOC can be sent to the member. The member can also register on our website to obtain a copy of their EOC.

A group must designate on their employer application if they want a hard copy EOC. EOCs are available online. If they request a hard copy EOC, then after administration is complete a copy would be mailed to the group.

New Hired Employees


Members’ home. Members’ home unless requested to send to the group.

Group


Yes, members’ home. If requested, an EOC can be sent to the member. The member can also register online to obtain a copy of their EOC.

Yes, the group will need to keep a supply on hand to distribute.

Open Enrollment


PPO: All groups of 10 or more eligible lives include annual open enrollment. HMO: Yes, it is built into the plan automatically.

Dental: For an open enrollment, a group must have at least 25 employees enrolled and have a calendar year max of less than $2,000 at the time of their renewal.

Yes


During the month prior to the anniversary date.

During the month prior to the group anniversary date.

During the month prior to the anniversary date.


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Employee Questions


Hard copy EOCs are automatically generated and mailed to each members home.

Medical- PPO: Certificates are available online for either member or Group Administrator to view. HMO: Employer is issued a hard copy EOC with their contract and they are responsible for providing hard copies to employees. Dental: Same time as the ID cards and they go to the members home unless otherwise specified.

There is one EOC provided and that will be sent to the group.

New Hired Employees


Members’ home, unless otherwise specified.

Medical: Members’ home. Dental: Members’ home, unless otherwise specified.

No


Instructions are included in the administration kit on how to download the EOC off the website.

Medical: The employer is responsible for distributing a new hire kit, which includes an EOC, to each employee. Dental: Yes, it will be mailed to the member home unless otherwise specified.

No

Open Enrollment


Yes Medical/Dental: Yes No


Within the month prior to the anniversary date.

Medical/Dental: Within 30 days prior to the groups’ anniversary date.

N/A


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Open Enrollment

What is allowed at open enrollment?

Employees can change plans if the employer offers other plans. Employees or dependents can enroll if they originally declined.

N/A Employees can change plans if the employer offers other plans. Employees or dependents can enroll if they originally declined.

What paperwork is required?

Employee Application. The paperwork may be submitted prior to the anniversary date up through the end of the anniversary month. The effective date will be the anniversary date.

N/A Change of Coverage application / Employee Addition Application. The paperwork may be submitted prior to the anniversary date up through the end of the anniversary month. The effective date will be the anniversary date.

Can someone who initially declined coverage enroll at any other time of the year?

No, only with a non-voluntary qualifying event.

Yes, late entrant penalties will apply.



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Open Enrollment


Employees can change plans if the employer offers other plans. Employees or dependents can enroll if they originally declined.

See footnote (1) at the end of this document.

Employees or dependents can enroll if they originally declined.


Employee Application for those that are enrolling for the first time. Subscriber Change Form for those already enrolled and making renewal changes.

Employee Application is required to add, change or switch an employee and dependent.



Only when enrolling due to a qualifying event.

See footnote (1) at the end of this document.

Yes, late entrant penalties will apply.


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Open Enrollment


Medical: Employees can change plans if the employer offers other plans. Employees or dependents can enroll if they were originally declined. Dental: PPO: Employees and dependents who initially declined coverage can come onto the plan with applicable waiting periods. DHMO: Employees and dependents that initially declined coverage can come onto the plan but with no waiting periods applied.

Enrolling in benefits when previously waiving coverage, Add dependents, Move from one plan to another when the group offers more than one plan.

Eligible employees and dependents who did not elect coverage when eligible may enroll. Employees may change health carriers and or benefits if the employer offers other plans.


Medical/Dental: Employee Application. The paperwork may be submitted prior to the anniversary date up through the end of the anniversary month. The effective date will be the anniversary date.

An enrollment form or change form is required to add or change benefits.

Enrollment Application. The paperwork may be submitted prior to the anniversary date up through the end of the anniversary month. The effective date will be the anniversary date.


Medical/Dental: No, only with a non-voluntary qualifying event.

If the group has an Open Enrollment provision and a late applicant applies for coverage outside of the OE period, the application will not be processed and the member will need to enroll during the next OE period.



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Open Enrollment


Employees can change plans if the employer offers other plans. Employees and dependents can enroll if they originally declined.




Employee Application, Change Form and Reconciliation Worksheet. The paperwork may be submitted prior to the anniversary date up through the end of the anniversary month. The effective date will be the anniversary date.


Employee Application, Change Form and Reconciliation Worksheet. The paperwork must be signed and dated prior to the anniversary date but can be submitted within 30 days after the anniversary month. The effective date will be the anniversary date.


HMO: No, only with a non-voluntary qualifying event. PPO: Yes, with a non-voluntary qualifying event. Employees who do not elect coverage during their 31-day application period may elect coverage later, subject to plan waiting periods.

If the member wants to enroll and doesn’t have a non-voluntary qualifying event, they can enroll but are subject to the following waiting periods: 6 month wait for Basic Services 12 month wait for Major Services 12 month wait for Ortho Services (if applicable)



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Open Enrollment


Any benefit eligible employee and their legal dependents can enroll, even if they previously declined coverage.

Medical: EE/Dep who declined coverage can come onto the plan. EE may change plan if other plans are offered. Dental: EE/Dep who declined coverage can come onto the plan. EE/Dep may disenroll if they originally enrolled and no longer want coverage. Employees may change plan if other plans are offered.

All eligible employees and dependents must enroll at initial enrollment or within 30 days of the qualifying event.



Medical/Dental: Member Enrollment/Change of Status Form. The paperwork may be submitted prior to the anniversary date up through the end of the anniversary month. The effective date will be the anniversary date

Employee Application. The paperwork may be submitted prior to the anniversary date up through the end of the anniversary month. The effective date will be the 1st of the anniversary month if the paperwork is submitted prior to the anniversary month and 1st of the following month for any paperwork received after the 1st of the anniversary month.



Medical/Dental: No, only with a non-voluntary qualifying event.



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Domestic Partners Small and Large Group Small and Large Group Small and Large Group

What verification procedures will you require? Same sex - no age limit or Opposite sex - 62 years and older.

Small group: No documentation required. Large group: If the group elects to extend coverage to both same sex and opposite sex of any age, the group would need to sign a Domestic Partner Agreement, but the member does not need to provide any documentation.

Affidavit of Domestic Partnership.

No documentation required.

What verification procedures will you require? Opposite sex – under 62 years of age.

Small group: No documentation required. Large group: If the group elects to extend coverage to both same sex and opposite sex of any age, the group would need to sign a Domestic Partner Agreement, but the member does not need to provide any documentation.

Affidavit of Domestic Partnership.


Will the partner be eligible for federal COBRA? Same sex – no age limit or Opposite sex – 62 years and older.

Yes No Yes Employer discretion to offer this as an option to the opposite sex, under 62 years of age.

Will the partner be eligible for Cal COBRA? Same sex – no age limit or Opposite sex – 62 years and older or Opposite sex and under 62 years of age.

Yes No Yes

Will the partners be required to be registered domestic partners?

Law states Domestic Partners have to be “registered” with the Secretary of State.

No No


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Domestic Partner Small Group Small and Large Group


SG: No documentation required. No documentation required. No affidavit required for the same or opposite sex domestic partners.


SG: No documentation required. No documentation required. No affidavit required for the same or opposite sex domestic partners.


Yes Yes Yes


Yes Yes Yes


The law states Domestic Partners have to be “registered” with the Secretary of State.

No No


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Domestic Partners Small and Large Group Small and Large Group Small Group


No documentation required. No documentation required. No documents required. Kaiser reserves the right to request proof of eligibility at any time.


No documentation required. No documentation required. No documents required. Kaiser reserves the right to request proof of eligibility at any time.


Yes Yes Kaiser will accommodate an employers’ request to offer Federal COBRA to the domestic partner and his/her dependents if all carriers are offering the same eligibility.


Yes Yes Kaiser will accommodate an employers’ request to offer Cal-COBRA to the domestic partner and his/her dependents if all carriers are offering the same eligibility.


No No No


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Domestic Partners Small and Large Group Small and Large Group


Employer discretion. No documentation required.



Employer discretion. No documentation required.



Yes Yes Yes This is not an option for opposite sex under 62 years of age.


Yes Yes Yes


Employer discretion. The law states Domestic Partners have to be “registered” with the Secretary of State.

No


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Domestic Partners Small and Large Group Small and Large Group Small and Large Group


No documentation required. No documentation required. No documentation required.


Affidavit of Domestic Partnership. No documentation required. No documentation required.


Yes Yes VSP does not determine if the partner is covered for Federal COBRA, but will accept COBRA eligibility for domestic partners


Yes Yes VSP does not determine if the partner is covered for Cal-COBRA, but will accept Cal-COBRA eligibility for domestic partners.


Same sex, no age limits or opposite sex over 62 years of age. State registration form is required when enrolling outside of open enrollment. Opposite sex under 62 years of age. Affidavit of Domestic Partnership required when outside of open enrollment.

Employer discretion. No, VSP has always covered domestic partners without required proof.


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Disabled Dependent Child

Is an over-age disabled dependent eligible to continue coverage through this new insurance carrier if they were covered under their parents’ previous policy?

Yes, pending approval from Patient Management Group Department at Aetna.

Yes, with approval from American General Life Companies.

Yes

Is an over-age disabled dependent eligible to continue coverage through this new insurance carrier if they were not covered under their parents’ previous policy?

No Subject to review by American General Life Companies.

No

What documentation will be required if the disabled child is eligible to continue coverage?

2 forms:

Request for continuation of medical coverage

Attending physician statement

Social security documentation or doctor records.

Proof of prior coverage.

How often will the disabled depend child be required to recertify this disability?

Decided by the patient management group department, usually every 1-2 years.

Usually just once unless the specific disability is not permanent.

Every 2 years.

If the answer is no to any of the above questions, would you consider allowing the child to enroll under Cal COBRA / COBRA?

No No May be reviewed by underwriting to determine if they will allow them to enroll into Cal-COBRA/COBRA.


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Yes, pending approval from Patient Management Group Department at BSC.

Yes Yes, with approval from Guardian Life


No Yes Subject to review by Underwriting. Late entrant penalties may apply.


2 forms:

Request for Continuation of Medical Coverage

Attending Physician Statement

Physician certification that the dependent is disabled.

Date of disability (must be prior to reaching limiting age) and enrollment on prior group for New Business. For inforce plans, adding a new overage disabled dependent, an eligibility form will be required.


Decided by the patient management group department, usually every 1-2 years.

Only at initial enrollment. Periodic proof may be requested, however, after two years, proof will not be requested more than once per year.

IF the answer is no to any of the above questions, would you consider allowing the child to enroll under Cal COBRA / COBRA?

No N/A N/A


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Yes, pending underwriting exception.

Yes Yes, provided the disability occurred prior to reaching the age limit for dependents. Subject to review by a Kaiser physician.


No Yes Yes, provided the disability occurred prior to reaching the age limit for dependents. Subject to review by a Kaiser physician.


HealthNet Disabled Dependent certification form.

None Kaiser disabled dependent form.


Decided by underwriting. If granted permanent certification then only one time required. If granted temporary certification usually every 1-2 years.

N/A Determined by a Kaiser physician.

If the answer is no to any of the above questions, would you consider allowing the child to enroll under Cal COBRA / COBRA?

Yes N/A


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Yes Yes Yes, subject to review by Principal medical underwriters.


Yes No No


No documentation required. An attending physician statement.

Principal’s Application to Continue Handicapped Child Form.


N/A Recertification will be required only if an end date is submitted on the physician’s statement.

Annually


N/A No Subject to review by underwriting.


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Yes Yes, subject to review by a UnitedHealthcare Medical Director. Must provide an Attending Physician Statement with new case submission.

Yes


Yes Yes, subject to review by a UnitedHealthcare Medical Director. Must provide an Attending Physician Statement with new case submission.

Yes


Statement from the Social Security Administration (SSA) indicating that the individual meets the federal definition of disabled. If no information is available from the SSA then documentation from a physician must be provided via medical records and/or statement signed by the physician.

Paperwork from Social Security that deems the dependent disabled.

No documentation is required. Internally Warner Pacific underwriting needs to notify HealthSmart when submitting the case that this dependent is overage and should labeled as relationship type H.


Annually, during January through March.

Determined by a UnitedHealthcare Medical Director.

N/A


N/A Yes, must provide a HIPAA certificate.

N/A


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Deductible Credit Procedures

Which documents are acceptable to provide proof of prior deductible met?

Explanation of Benefits (EOB) from the prior carrier showing deductible met AND Aetna Deductible Credit letter.

N/A Explanation of Benefits (EOB) from the prior carrier showing total deductible met for the year.

At what point should the documentation be provided for processing?

During underwriting or after case approval. Once group is approved each member will receive the Aetna Deductible Credit letter which they need to complete and return.

N/A After case approval.

Which department should the documentation be directed to?

Aetna claims (866) 474-4040 N/A Claims Department Medical fax: (877) 287-1262 Email: [email protected]

By what means will the documentation be accepted?

Fax N/A Mail, fax or email

Will a member receive any notification that their deductible has been credited?

No N/A No

Where could someone call to check status on processing?

Member Services Medical: MC/PPO (888) 802-3862 HMO (888) 702-3862 Dental: (877) 238-6200

N/A Customer Service Medical: (800) 627-8797

mailto:[email protected]



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Explanation of Benefits (EOB) from the prior carrier showing deductible met AND Blue Shield Prior Carrier Accumulation form. If credit is being applied for the family, individual family breakdown must be supplied.

Delta Dental does not give deductible credit.

Explanation of Benefits (EOB) from prior group carrier.


During the Underwriting review process.

N/A With first claim.


UW with submission of group case.

N/A Claims


Fax: (209) 371-5828 or (209) 371-5826 Email: [email protected]

N/A Mail, fax or email


No N/A No


HMO (800) 424-6521 PPO (800) 200-3242

N/A Member Services: Phone number listed on member ID card.



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Explanation of Benefits (EOB) from the prior carrier showing deductible met.

Humana does not give deductible credit.



New business: Preferred during underwriting.

N/A After case approval.


New business: Provide during underwriting. If submitting after case approval and/or new employees or dependents, send to Health Net Account Services by fax at (800) 794-3988.

N/A Claims Department KPIC P.O. box 261155 Plano, TX. 75026


Fax N/A Mail


No N/A No


Dedicated Health Net Account Manager at (800) 547-2967.

N/A Claims (800) 392-8649


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Explanation of Benefits (EOB) from the prior carrier showing deductible met and remaining maximum for dental and orthodontia.


Explanation of Benefits (EOB) from the prior carrier showing deductible met or a report from the previous carrier that identified each insured and the amount of deductible met.


With first claim submitted. During initial enrollment. If providing a report, this should be submitted during underwriting. If providing individual EOBs, they should be submitted with the members first claim


MetLife Claims Department P.O. Box 30930 Laguna Hills, CA 92654

Premier Access Claims Fax: (877) 679-7197

Principal dental claims department attention: Dental claims specialist


Mail for Major services Fax for Basic or Preventive services: (949) 425-4584

Fax, mail or email Mail or email for larger group reports. Mail or fax for individual, smaller reports.


No No No


Member Services (800) 880-1800

Member Services: (888)715-0760

Customer Service (866) 748-6682


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Prior carrier roster VSP does not give deductible credit.


Preferred during underwriting. Any time N/A


Provide during underwriting. If submitting after case approval, submit to Allied National claims department.

Fax: (816) 412-8682

Mail: P.O. Box 419254, Kansas City, MO. 64141-6254

Email: [email protected]

Northern California: [email protected] Southern California: UnitedHealthcare P.O. Box 31355 Salt Lake City, UT. 84130

N/A


Mail, fax or email Northern California: Email Southern California: Mail

N/A


No No N/A


Allied National customer service (800) 825-7531

Customer Service (800) 947-1672 option 1, then option 4

N/A





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1. Delta Dental Open Enrollment Eligibility:

You and your dependents may enroll when first eligible or within 30 days after the date you or your dependents become eligible or during an open enrollment period:

You must agree to make monthly payment through payroll deductions using pre-tax dollars

You may not drop or change coverage other than during an open enrollment period or because of a qualifying status change

If coverage is discontinued, your dependents may not be re-enrolled under this plan except as outlined above or unless your dependent is the subject of a Qualified Medical Child Support Order requiring you to provide your dependent benefits under this plan.

If you choose to enroll your dependents you must enroll all of your eligible dependents. If you do not meet the above criteria below are your eligibility options: Dual Option (HMO/PPO)

Employees can change plans;

Employees who declined (no other coverage) at the time of eligibility can only enroll in DeltaCare USA at the group’s next open enrollment. Those employees must remain enrolled in DeltaCare USA for a year prior to switching plans.

Employees who waived (had other valid coverage) at the time of eligibility may enroll in either plan offered by the ER with proof of non-voluntary loss of coverage.

PPO

Employee/dependents that previously declined coverage when they were originally eligible cannot be enrolled without proof of loss of coverage elsewhere.

DeltaCare

Employee/dependents that terminated during the year and wish to re-enroll may do so but will be required to pay back premiums owed (to a maximum of 12 months).

Documents

Carrier Administration Guidelines Rev9.9