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TABLE OF CONTENTS

METROPLUS HEALTH PLAN 3

SUPPORT 4

PREMIUM PAYMENT 5

BILLING POLICIES 6

UNDERSTANDING YOUR INVOICE 7

OPEN ENROLLMENT PERIOD 8

NEW HIRE ENROLLMENT PROCESS 9

SPECIAL ENROLLMENT PERIODS 10

SMALL GROUP / EMPLOYEE REQUESTED TERMINATION & CANCELLATION RULES 11

TERMINATIONS FOR NON-PAYMENT 12

MBR 20.072v2

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THANK YOU FOR CHOOSING

METROPLUS HEALTH PLAN.

THIS GUIDE

WILL HELP

YOU ADMINISTER

YOUR GROUP’S

EMPLOYEE

BENEFITS.

Please note that covered employees

will receive Member ID Cards and

Welcome Kits prior to their effective

date, or 7-10 business days after our

receipt of initial premium payment.

If you have questions, please call

MetroPlusHealth at 1-855-809-4073

(TTY: 711), Monday-Friday, 8am-8pm

and Saturday, 9am-5pm, or visit our

website at www.metroplus.org.

Thank you again for choosing

MetroPlusHealth for your company,

employees, and / or co-workers.

We look forward to serving you!

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SUPPORT

All employers, employees, and authorized representatives may contact MetroPlusHealth Member Services at (855) 809-4073 to speak with a specialist regarding the following:

• Telephonic enrollment application assistance

• Enrollment questions or concerns

• Payment questions or concerns

When calling the member service center, it is important to listen carefully to the menu prompts to make the appropriate selection. The member service center operating hours are:

• 8am-8pm, Monday – Friday

• 9am-5pm, Saturday

You can also visit our website, www.metroplus.org, for access to Certificates of Coverage

that explain who is covered as well as your benefits and how to access them. We also have

provider directories, formularies (drug lists), and more.

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PREMIUM PAYMENT

New Groups - Initial Binder Payment

New groups are required to submit their first binder payment via

physical check together with employer and employee applications.

Payment Options

• Recurring payments from the employer’s bank, known as ACH (Automated Clearing House), are strongly preferred .

o MetroPlusHealth CANNOT debit the Employer’s account. However, Employers are encouraged to establish recurring payments through their banks (online banking) by setting up “MetroPlus Health Plan, Inc.” as a payee.

o MetroPlusHealth can accept ACH and wire transfer payments: ▪ Bank Name: JPMorgan Chase ▪ Bank Account Number: 001-087932 ▪ Routing Number: 021000021 ▪ Include Business Name, Account number (same as Group ID),

and Invoice Number (if available)

o Employers should be mindful of changing recurring payment amount if they: ▪ Add or terminate an employee (if you add or terminate an employee,

you'll see the premium adjustment on your next month's invoice) ▪ Change bank accounts ▪ Change the payment date ▪ Terminate coverage (you'll need to stop your autopayment or

the funds will continue to be withdrawn from your bank account)

• Check or Money Order:

o Please allow 7-10 days for processing and include payment coupon from invoice

o Include Business Name, Account number (same as Group ID) and invoice number (if available)

o Make payment to “MetroPlus Health Plan, Inc.” Mail to: MetroPlus Health Plan • P.O. Box 28540 • New York, NY 10087-8540

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BILLING POLICIES

You must make your premium payment in full for coverage to become effective by the enrollment deadline and to maintain coverage for your employees.

You are expected to pay your first month’s premium when you complete your application.

MetroPlusHealth will provide payment instructions, including the amount due for the binder

payment. The binder payment is the initial payment when your group first signs up. It binds

your group and MetroPlusHealth in a contract. This initial binder payment starts the coverage.

After your group coverage is effectuated, you will receive a

monthly invoice billing your group’s coverage one month in advance.

The monthly invoice is based on group and member enrollment information available

at the time of billing. If there are enrollment updates made between the time of the

monthly invoice and mid-month, you may receive a mid-month adjusted invoice.

Your invoice will indicate the full premium due and will not provide a breakdown of

the employee and employer contribution level. If needed, the premium amount will

be prorated to the exact date of the qualified event (i.e., daily proration).

The billing cycle occurs after required updates to group and member enrollment records

are made, payments are posted, and non-payment termination processing occurs.

Once the group is enrolled, you must pay your monthly premium on time to

avoid coverage cancellation. If you do not pay the full payment on time, it will

be considered late and your coverage may be terminated.

Payment should be made on or before the invoice due date. MetroPlusHealth

allows at least 2 business days following the invoice due date to pass before

subsequent invoices and final letters are sent.

You will need to pay the current balance on the invoice in full, even if there is an adjustment

that has not yet been reflected on your invoice. This will keep your account in good standing

and prevent an interruption in health coverage. You can make partial payments, but your

payments are late until you pay the entire balance. You must pay your premium in full to keep

your account in good standing. Any needed adjustments will occur in the next billing period.

If your payment is late, you will receive a FINAL LATE NOTICE letter. Additional

outreach from MetroPlusHealth may occur as a courtesy reminder. You will receive

one month of grace when your group’s payment is late. If we do not receive full payment

within that time, your group’s coverage will be terminated for non-payment. If your group’s

coverage is terminated for non-payment, you will receive a FINAL TERMINATION letter.

Invoices, final late notices, and final termination letters can be viewed on the CSI application.

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UNDERSTANDING YOUR INVOICE

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1. Late Notice – If you are currently behind on your payments, your invoice will include a late notice. 2. Company Information – Your company contact person, name, and address. 3. Payment Instructions – Instructions on how to pay this invoice. See “Payment Options” section, above, for more information. 4. Prior Activity – Lists any previous payments or balances you may have. 5. Account Number – Your account number is the same as your Group ID, and should be included on payment by check or money order. 6. Total Amount Column – Itemized list of the charges that you will pay. 7. Payment Coupon – If you are mailing your payment, detach this coupon and include with your check or money order. 8. Due Date – This is the date that payment of this invoice is due. 9. Amount You Pay – This is the total amount that you must pay. 10. Address – This is the address that payment must be mailed to (if you are mailing your payment).

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OPEN ENROLLMENT PERIOD

There are two types of open enrollment scenarios, for new groups and current groups. An eligible business may enroll with MetroPlusHealth as a new group at any time during the calendar year. Once a group effective date is chosen– the first of any month of the calendar year – it becomes the start date for that group’s plan year. For plans who have already enrolled with MetroPlusHealth, there is an annual month-long open enrollment period. It begins 2 months prior to the group’s effective date. For example, if a group’s effective date is April 1st, their open enrollment period will be the month of February. During this period, the employer may make updates to their offering, such as changing the contribution rate, tiers of coverage, or metal levels available to their employees. Employers can also add or remove optional riders during this time. Employers cannot change the coverage tiers they offer mid-year. Currently covered employees can use this open enrollment period to request changes to their coverage based on the available options. For instance, an employee can extend the coverage of their dependent through the age of 29 if the employer makes available Age 29 Rider. Previously non-participating employees may choose to get enrolled at this moment as well. At the start of the new plan year, all covered employees will have the same effective date of coverage as their group.

The chart below shows when the open enrollment period will be, based on your group’s effective date.

Open Enrollment Month Coverage Effective Dates

November January 1

December February 1

January March 1

February April 1

March May 1

April June 1

May July 1

June August 1

July September 1

August October 1

September November 1

October December 1

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NEW HIRE ENROLLMENT PROCESS

New Hires are only eligible to enroll within 30

days of becoming eligible. Coverage begins on

the date determined by the Group’s Probationary

Period and New Hire Effective Date policies1: Probationary Period: 1) None 2) 30 Days 3) 60 Days 4) 90 Days New Hire Effective Date: 1) Date of Hire 2) 1st of the Month Following Date of Hire 3) 1st of the Month Following Probationary Period

See example: Example: Today’s Date = 7/1/17 Hire Date = 3/26/17. Each New Hire Logic below will determine the effective date based on the above dates.

1) Probationary Period = None; New Hire Effective Date = Date of Hire o Effective Date is 3/26/17. o This employee cannot be added as they are outside of the acceptable time frame.

2) Probationary Period = None; New Hire Effective Date = 1st of the Month Following Date of Hire o Effective date is 4/1/16. o This Employee cannot be added as they are outside of the acceptable time frame.

3) Probationary Period = 30 Days; New Hire Effective Date = 1st of the Month Following Probationary Period o Effective date is 5/1/17. o This Employee cannot be added as they are outside of the acceptable time frame.

4) Probationary Period = 60 Days; New Hire Effective Date = 1st of the Month Following Probationary Period o Effective date is 6/1/17. o This Employee can be enrolled because the Effective Date is still within 30 days

of today’s date. The Employee can be added and enrolled up through 7/1/17 for an effective date of 6/1/17.

5) Probationary Period = 90 Days; New Hire Effective Date = Date of Hire o Effective date is 6/23/17. o This Employee can be added and enrolled for an effective date of 6/23/17.

The employee can be added and enrolled up through 7/22/17 for an effective date of 6/23/17

1 See Employer Application Section 4: Eligibility & Enrollment Policies, questions 3 and 4.

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SPECIAL ENROLLMENT PERIODS

Certain qualifying life events will trigger a special enrollment period (SEP) for eligible employees. Members and their dependents who are enrolled in a Qualified Health Plan (QHP) may make certain changes to their enrollment during a qualifying SEP, and eligible employees who are not enrolled in their employer’s SHOP coverage may be able to enroll during a qualifying SEP.

Life Status Change events that may trigger SEPs include:

• Marriage

• Divorce/Legal Separation

• Birth

• Adoption

• Relocation

• American Indian or Alaskan Native

o Can enroll year-round or change plans once per month

• Legal Orders

• Retirement

• Death

• Remove Enrolled Dependent(s)Loss of Medicaid/CHIP Coverage

• Loss of Health Insurance for Qualified Dependent

Upon a qualifying event, an employee can change to any other tier of coverage or plan offered by their employer.

A special enrollment period of 60 days from the date of the event will also be triggered by the loss of CHIP/Medicaid coverage for a qualified dependent - if the employer has offered coverage that would extend to the dependent losing coverage (e.g., individual plus children or individual plus spouse/domestic partner plus children for loss of CHIP; or individual plus spouse/domestic partner or individual plus spouse/domestic partner plus children for loss of Medicaid coverage).

An employee MUST report loss of CHIP/Medicaid within 60 days in order to trigger a special enrollment. Failure to adhere to the time constraints will preclude the employee from opening a special enrollment. For all other triggering events, a special enrollment period of 30 days from the date of the event will be triggered by the event.

• For birth, adoption, death, adding new hire, and certain legal orders, the change in coverage will be effective the date of the triggering event.

• For loss of coverage for an employee (employer roster) or loss of coverage for a qualified dependent, the effective date will be the following day, after the date of occurrence.

An employee MUST report all other triggering events within 30 days. Failure to adhere to the time constraints will preclude the employee from opening a special enrollment.

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SMALL GROUP / EMPLOYEE

REQUESTED TERMINATION

& CANCELLATION RULES

In some situations, coverage can be cancelled or

terminated by the group or by an individual employee.

1. Cancellation – This means that coverage is terminated

going back to the original effective date (retroactive).

a. Cancellation requests must be made by the 10th of the effective contract

month by the Small Group Administrator and/or individual employee.

b. If there are claims during the 10 day-period, the amount paid by

MetroPlusHealth is subject to recoupment from the group

prior to cancellation and premium refund, if any.

c. Employee cancellation requests must be submitted via Employee Enrollment

Application form, signed by employee and Small Group Administrator.

d. Group cancellation requests must be submitted via official

employer email (from the Small Group Administrator)

2. Termination – A termination request can be made for the current month,

or for future months of coverage. Coverage is terminated at the end of the

month that the request is made (proactive).

a. Employee termination requests must be submitted via Employee

Enrollment Application form by the Group Administrator.

b. Small Group termination requests must be submitted via official

employer email (from the Small Group Administrator)

3. Non-renewal – A group can choose to not offer MetroPlusHealth

coverage during Open Enrollment.

a. If a group chooses not to renew their coverage at the end

of their plan year, the group will be terminated in all systems.

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TERMINATIONS FOR NON-PAYMENT

If a group is terminated for non-payment, they may request to be reinstated without a gap in coverage. This can be requested by contacting MetroPlusHealth Member Service, or Sales and Marketing representatives, and paying all back owed premiums, plus an extra premium to cover the next month of premiums (three months' worth of payments in total). Payments for reinstatements must be made at the time of the request through ACH. Reinstatements will only be allowed for up to 15 days from the date on the Final Termination Letter. No enrollment changes will be allowed at this time. After the 15-day window has passed, MetroPlusHealth will only allow groups to re-enroll with a gap in coverage, Groups must submit new group and employee enrollment applications. The group’s plan year will “start over” with a new coverage effective date and all accumulators, such as member deductibles or maximum out of pocket (MOOP), will reset. In addition, the group’s premium rates may increase according to the new effective date and the corresponding quarter rate.

SHOP groups are only allowed one reinstatement or re-enrollment per plan year.