Employer Administration Guide - Resource Brokerage

Employer Administration Guide

for Small Businesses

Welcome to Assurant Health!

Thank you for selecting a small group plan from Time Insurance Company. Assurant Health is the brand name for products underwritten and issued by Time Insurance Company. We provide this Employer Administration Guide so you have a handy reference to important information necessary to effectively administer your plan. We encourage you to review this Guide and use it as a reference for basic plan questions. Information contained in this guide is subject to change without notice. Current business procedures will take precedence over this Guide. You can obtain information specific to your state from our State Variation form. While the Employer Administration Guide will answer most questions, we realize certain situations require personal service. Therefore, we encourage you and your employees to contact our Customer Service Center, and one of our trained service professionals will gladly assist you. Simply call us toll free at 800-743-8463. That number, as well as other addresses, phone and fax numbers you may find helpful are shown at the end of this guide. We look forward to servicing your health care needs and are confident your association with us will be long and rewarding.

Important Note: If there is a conflict between anything contained in this Employer Administration Guide and your contract/certificate or any state and/ or federal law or regulation, the contract/certificate or state and/or federal law or regulation will take precedence.

Table of Contents

Adding Employees/Dependents . . . . . . . . . . . . . . . 2

Eligibility Requirements . . . . . . . . . . . . . . . . . . . . . . . . 2 How to Enroll a New Employee . . . . . . . . . . . . . . . . . . 2 Adding a Spouse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Adding Newborns or Acquired Dependents. . . . . . . . 3 Continuity of Coverage ? Medical. . . . . . . . . . . . . . . . . 4 Creditable Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Late Entrants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Changing an Effective Date . . . . . . . . . . . . . . . . . . . . . . 4 Special Enrollment Period . . . . . . . . . . . . . . . . . . . . . . . 4 Common Reasons for Delays in Issuance . . . . . . . . . . 5

Coverage Changes. . . . . . . . . . . . . . . . . . . . . . . . 5

Medical Plan Changes ? Group Level. . . . . . . . . . . . . . 5 Plan Upgrades . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Short Term Disability ? Group Level . . . . . . . . . . . . . . 6 Dental Plan Changes ? Group Level . . . . . . . . . . . . . . 6 Coverage Changes ? Employee Level . . . . . . . . . . . . . 6

Employee Choice Program. . . . . . . . . . . . . . . . . . 7

Adding the Employee Choice Program to a Group Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Employees Switching between Medical Plans . . . . . . 7

Administrator Changes . . . . . . . . . . . . . . . . . . . . 7

Ownership Changes . . . . . . . . . . . . . . . . . . . . . . 7

Group Address Change . . . . . . . . . . . . . . . . . . . . 7

Termination of Coverage . . . . . . . . . . . . . . . . . . . 8

Notification of Termination. . . . . . . . . . . . . . . . . . . . . . . 8 Specific Coverage Termination. . . . . . . . . . . . . . . . . . . . 8 Lapsed Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Termination of Business. . . . . . . . . . . . . . . . . . . . . . . . . . 9

Continuation of Coverage . . . . . . . . . . . . . . . . . . 9

COBRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 State Continuation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Layoff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Leave of Absence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Military Leave. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Additional Benefit Options . . . . . . . . . . . . . . . . . . . . . 11

Billing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Premium Payments . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Checks Returned Unpaid . . . . . . . . . . . . . . . . . . . . . . . 12 Employee/Dependent Coverage . . . . . . . . . . . . . . . . 12 Adjustments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Premium and Rate Adjustments . . . . . . . . . . . . . . 12

First Year Premium . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Renewal Premium Changes. . . . . . . . . . . . . . . . . . . . . 13 Age Change. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Rating Method. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Medicare Eligibility/TEFRA. . . . . . . . . . . . . . . . . . . . . 13

Health Savings Accounts (HSAs) . . . . . . . . . . . . . . 14

Plan Impacts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 HSAAdministration. . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Health Reimbursement Arrangements (HRAs). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

HRAAdministration . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Claims. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Medical Claims. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Dental Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Drug Card Expenses. . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Disability Claims. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Life Claims. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Appeal Process. . . . . . . . . . . . . . . . . . . . . . . . . . 16

Important Numbers/Addresses . . . . . . . . . . . . . . . 17

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Adding E mploy ees/D ependents

Each eligible/full-time employee needs to complete an Employee Enrollment Form, including all health questions regardless of underwriting status.

If selected as a benefit by the employer, 75% of eligible/full-time employees must carry Life and AD&D. If selected, all eligible/full-time employees must carry Disability coverage.

Eligibility Requirements

Under no circumstances is the effective date of coverage prior to the employee's date of employment.

All add-on employees are subject to the pre-existing condition provision, unless otherwise indicated.

Timely eligible enrollees requesting medical coverage are guaranteed issue where HIPAA regulations require. The first $15,000 of life coverage is guaranteed issue. Any amount above $15,000 is medically underwritten. Disability coverage is also medically underwritten. Parameds may be required on all applicants applying for life amounts greater than $100,000. Completion of the medical questions on the Employee Enrollment Form is required.

Dependents who are currently covered under their parent's policy and become full-time employees of the same business as their parent must follow the guidelines for adding employees. The medical coverage is guaranteed issue and the waiting/ affiliation period is waived. All other lines of coverage are medically underwritten.

Eligible Employees

An eligible employee is any person who performs services on a full-time basis (defined as at least 30 hours per week) and is considered an employee for federal income tax purposes, at any of the employer's business establishments within the United States.

A partner, proprietor or corporate officer of the employer is eligible if he/she performs services for the employer on a full-time basis (defined as at least 30 hours per week), at any of the employer's business establishments within the United States.

The term "Employee" does not include: a) retirees or persons who are not expected to perform any duties, responsibilities or services for the employer; b) "parttime" employees; or c) any "seasonal" or "temporary" employees who work only part of the calendar year on the basis of natural or suitable times or circumstances.

Eligible Dependents

A lawful spouse Unmarried dependent children through age 18 Unmarried dependent children through age 23 if

full-time students (Please review your Certificate of Insurance for dependent eligibility.)

NOTE: We offer coverage that is designed to fit the lifestyle of today's college students. If your employees' dependent children are no longer eligible for coverage under the group plan, our Student Select plan may be the best option. Its $1,000,000 coverage is guaranteed renewable and stays with the student, even if they change schools or leave school.

Contact your agent or use the toll-free number at the end of this guide for more information or to receive an application. (Student Select plans are not guaranteed issue.)

Husband and Wife Employment

On groups of three or more medical certificates, the employer can choose how to cover a husband and wife. A husband and wife can either be covered under one medical certificate or under separate medical certificates. The choice will often depend on tax considerations. If a client is establishing an HSA or HRA, he/she may want to consult with a qualified tax or legal professional regarding plan design.

Regardless of the choice, the husband and wife will maintain separate life and disability coverages.

How to Enroll a New Employee

Eligible full-time employees including the employer/owner need to fully complete, sign and date an Employee Enrollment Form. If the employee had previous health coverage, the prior carrier's effective date, termination date and type of coverage must be provided.

Submit the Employee Enrollment Form to our Underwriting Department 30 days prior to the expiration of your group's waiting/affiliation period (see the Waiting/Affiliation Period Section on page 3) to allow sufficient time for underwriting evaluation and issuance of the certificate.

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If your group has Employee Choice, note on the Employee Enrollment Form the medical plan number (listed on your billing statement) for the plan the employee is being added under.

If the Employee Enrollment Form is submitted more than 30 days after the expiration of the waiting/ affiliation period or lists an effective date later than that for which the employee is eligible, the employee will be considered a Late Entrant and must follow the Late Entrant guidelines on page 4.

Employee Enrollment Forms are valid for 60 days from the date they are signed and dated.

If the employee is approved, you are billed from the effective date of coverage on the next available Billing Notice.

Upon acceptance of the employee by Assurant Health, the new employee's effective date of coverage is the date the group's waiting/ affiliation period expires.

Waiting/Affiliation Period

The group's waiting/affiliation period is stated on the Plan Summary page included in your Administration Kit (30, 60, 90, 120, 150 or 180 days).

All employees must abide by the waiting/ affiliation period chosen. The waiting/affiliation period cannot be waived for any employee.

The waiting/affiliation period may be changed only one time during any 12-month period and applies to all employees on a group level.

The effective date for the waiting/affiliation period change is the first of the month following the date the request is received by Time Insurance Company.

Employees must satisfy the waiting/affiliation period in effect as of their hire date.

Note: Our Short Term Medical coverage is available to fill the temporary gap in coverage during your employees' waiting/ affiliation period and may also be an alternative to COBRA. Contact your agent to determine which is the right coverage for your employees' temporary needs.

Participation and Eligibility Review Process

Participation requirements must be maintained throughout the life of the contract. Renewal questionnaires may be sent or a telephone call may be made to verify participation and eligibility information. Payroll records and/or other documentation may be

requested at any time during the life of the contract. Groups that fail to maintain participation requirements or to supply the requested information to verify participation may be terminated.

Adding a Spouse

A spouse may be added without Evidence of Insurability for Medical and Dental coverage provided written notification is received by us within 31 days of the date of marriage.

The effective date of coverage is the date of marriage.

If notification is not received within 31 days of the date of marriage, the spouse is considered a Late Entrant and must follow the Late Entrant guidelines on page 4.

Adding Newborns or Acquired Dependents

An acquired dependent is a person for whom the certificate holder has assumed a legal obligation for total or partial support of a child in anticipation of the adoption of the child.

Newborns or acquired dependents may be added without Evidence of Insurability for Medical and Dental coverage provided written or verbal notification is received by us within 31* days of the date of birth or the date of legal dependence. We reserve the right to request proof of legal dependence.

The effective date is the child's date of birth or the date of legal dependence.

If notification is not received within 31* days of the date of birth or legal dependence, the child is considered a Late Entrant and must follow the Late Entrant guidelines on page 4.

NOTE: For employer premium payment responsibilities, please see the Billing section on page 12.

*60 days for WI groups

OBRA

The Omnibus Budget Reconciliation Act of 1993 (OBRA93) contains several provisions affecting group health plans (both fully insured and selffunded) which are governed by the Employee Retirement Income Security Act of 1974 (ERISA). This Act is essentially an "employer" law in that it places requirements on employers who maintain group health plans for their employees.

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