CHOICES | Archive

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Benefits

Some of my practice’s employees have never had health insurance before and have recently become eligible for benefits. How can I best explain the difference between the deductible and coinsurance?

We have a temporary employee who has been working with our practice for a long time and will soon be hired full-time. We have a 90-day probationary period, but since she has already worked at least this long as a temp, can we start her benefits right away or would she still have to satisfy the 90-day probationary period?

Our practice has a physician that is eligible for Medicare. Can she enroll on Medicare and not be covered by the NCMS Plan? I am under the impression that all of our practice’s physicians must be covered by the NCMS Plan so the practice can be eligible for the benefits.

We have an employee that would like to enroll in NCMS Plan medical coverage. When are they eligible to enroll? Can it be at any time they choose?

We recently switched our Health Savings Account (HSA) administrator from BenefitWallet (BW) to HealthEquity (HEQ). I’m confused about what will happen to the money in my employees’ and physicians’ BW HSAs when their HEQ HSAs are opened. Can you tell me how this will work?

Under the Affordable Care Act (ACA), I read that employers are required to report the cost of employer-sponsored coverage on employee W-2 forms beginning with the 2012 tax year. Does this apply to my practice?

Billing and Enrollment

We recently enrolled as a new practice with the NCMS Plan and want to be certain that future employee enrollments and changes are processed quickly and accurately. What is the best way to send you our NCMS Plan health insurance enrollment and change information?

We recently terminated an employee from our practice. Once we submit the termination notification, will the NCMS Plan’s administrator, BCBSNC, send out a notice to the employee letting them know of the termination of their NCMS Plan health insurance and the dates they had coverage with the NCMS Plan?

I received my billing statement and just noticed that we are still being billed for an employee that left several months ago and needs to be terminated. What should I do?

One of our employees recently added a live-in partner to their health benefits. Why did the employee have to complete an Affidavit of Domestic Partnership and submit with their enrollment form when enrolling their domestic partner?

Claims

We have a physician who is traveling out of the country on vacation. Will she and her family have coverage with their NCMS Plan benefits?

One of my employees recently received an Explanation of Benefits (EOB) for medical services and their claim was denied. The employee believes this was an error. How can they appeal this decision?

I recently had an employee tell me that their screening three-dimensional (3D) mammogram was not covered. Aren’t all screening mammograms covered as a preventive service at 100%? What am I missing?

Continuation

We have an employee that has been with our practice for many years who will be retiring soon but won’t be eligible for Medicare for several years. She would like to maintain coverage but COBRA will not extend coverage for this employee beyond 18 months. What options does she have until she is eligible for Medicare?

We are a newly formed practice with 17 employees now covered by the NCMS Plan. We have an individual who recently separated from employment and has indicated that they want COBRA. We are not certain of our responsibility and do not know how to proceed. Can you help?

Our practice offers a high deductible health plan (HDHP) and I have a question about the deductible. One of our employees with family coverage recently got divorced and the spouse has elected COBRA. They met their family deductible prior to the divorce. How is the deductible handled in this situation?

We have an employee leaving our practice, do we offer them COBRA and how does that process work?

Dental

Our practice has an NCMS Plan dental product underwritten by Metlife. I have an employee who asked me if the contract year for her dental benefits matches the calendar year or not. Basically, she wants to know if the contract year maximum starts over and if the deductible resets on January 1st. Does it?

Does the NCMS Plan offer group dental benefits?

We have group dental insurance with MetLife through the NCMS Plan. We hired a new employee February 2, 2014, who is subject to our 90-day probationary period. This employee signed and submitted a dental enrollment on May 8, 2014, and was informed by MetLife that they are considered a “late entrant” subject to coverage waiting periods. Why is this employee considered a “late entrant”?

Service

Our practice currently has a 90 day probationary period for employees and we would like to change it to 60 days. How do we go about changing it?

An employee recently gave birth to her first child. How much time after the date of birth does she have to add the child to her health insurance?

We recently hired a new employee and downloaded an enrollment form from BCBSNC to enroll her. After we submitted the form, it was returned to us for being the incorrect form for NCMS Plan enrollment. We were then sent an NCMS Plan enrollment form which we completed and the enrollment processed sucessfully. Since it appears that we are covered by BCBSNC, why are we required to use an NCMS Plan enrollment form rather than one from BCBSNC, what is the difference?

Our NCMS Plan health plan renews in August and two of our employees are considering enrolling on their spouse’s employer’s group health plan. We have six eligible employees total and currently all six are enrolled. Will their change jeopardize our ability to continue to participate in the NCMS Plan?

Our practice has an employee that is not working full-time hours but would like to have the health benefits. We know that only “full-time” employees are eligible for the coverage but what defines a full-time employee and how can we get this employee covered?

Our group health renewal was April 1, 2013. We sent our renewal information back to you on March 29th. When I contacted Member Services on April 1st to verify coverage, I was told our practice had not been renewed yet. What can I do to ensure our renewal is processed so our health insurance will show active on the effective date?

Whenever our practice has an employee with an address change or an employee who adds a new child to insurance, I send you paper applications. Is there an online option for me to process these transactions myself and have access to employee benefit information?

I know it’s March 1, 2015, but we have an employee that left employment with our practice in October, 2014 and we forgot to submit the termination notice. Can you terminate their health insurance back to October 31, 2014?

I have an employee who left employment and their benefits have been
terminated. They are asking me for a Certificate of Creditable Coverage to prove loss of coverage.
Is there a way I can request this for them or should I refer them to the NCMS Plan’s administrator,
BCBSNC?

Our practice not only participates in the NCMS Plan medical program, but also is enrolled in the NCMS Plan group dental program underwritten by MetLife. My question is this, we recently submitted a NCMS Plan medical enrollment form for a new employee. She has been enrolled under the medical benefits but is still not shown enrolled with the NCMS Plan/MetLife dental. What am I missing?


Your practice can change the probationary period at the first of the month going forward. To make this change we need a letter on your practice’s letterhead informing us of this change. This change will be for all employees that are hired on or after the effective date of the change, again, the first of the following month. For example, if your change was effective October 1st, any employees hired on or after October 1 would be subject to the 60 day probationary period with their insurance becoming effective on the 1st of month following 60 days. For an employee hired on September 1st, they would still be subject to a 90 day probationary period.

The NCMS Plan offers four probationary periods.

0 True: No probationary period, employees are eligible for insurance on their date of hire.

30 Days: Employees are eligible for insurance the 1st of the month after 30 days are completed (e.g. an employee hired on October 1st would be eligible for insurance on November 1st. Their 30 days would be completed on October 30th but insurance would take effect November 1st)

60 Days: Employees are eligible for insurance the 1st of the month after 60 days are completed (e.g. an employee hired on October 1st would be eligible for insurance on December 1st. Their 60 days would be completed on November 29th but insurance would take effect December 1st)

90 True: Employees are eligible for insurance after completing a 90 day probationary period (e.g. an employee hired on October 1st would be eligible for insurance on December 30th. Their 90 days would be completed on December 29th and their insurance would take effect on the 91st day)

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Yes, the NCMS Plan does provide coverage out of state and out of country as well. When traveling out of state you should carry your current member ID card. You can access a National doctor and hospital finder at BCBS.com, use the BCBS Global Core app or call Blue Card Access 1.800.810.BLUE (2583). After you receive care, you should not have to complete any claim forms or pay up front for medical expenses except for out-of-pocket expenses like copayments, deductibles, and coinsurance, and you will receive an Explanation of Benefits (EOB) from BCBS.

If you are traveling outside of the US, you should still carry your current member ID card. Before you travel, contact BCBS for coverage information, as coverage outside of the United States may be different. If you require medical assistance, call the Service Center for BCBS Global Core, 1.800.810.BLUE (2583). You can call 24 hours a day, 7 days a week. More information can be found by visiting www.bcbsglobalcore.com.

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The deductible is the amount of allowable charges for covered services that must be paid by the employee before the NCMS Plan will assume any liability for the cost of any covered services. For example, the PPO 1500-80 plan has an individual in-network deductible of $1,500, so the employee would pay $1,500 for in-patient and out-patient services before the NCMS Plan would pay any portion of the remaining allowable charges.

Coinsurance is simply a type of “cost-sharing” that comes into play after the deductible has been met. Once the deductible is met, the employee pays a percentage of the cost of covered medical services as an out-of-pocket payment to the provider. Using the previous example, the PPO 1500-80 plan would have the NCMS Plan pay 80% of the cost and the employees pay the remaining 20% up to a given out-of-pocket maximum.

All NCMS Plan health products have an out-of-pocket maximum which upon being met, increases the plan benefits (the NCMS Plan’s payment) to 100% (excluding copayments).

All NCMS Plan health products also have some deductible amount that must be met within a given benefit period. It’s important to remember that the deductible does not include copayments, coinsurance, charges beyond the allowed amount, or amounts for non-covered services.

One last note, PPO and HDHP/HRA family deductibles work differently. PPO deductibles are individual; if one or more dependents are covered, each covered person has an individual deductible and a maximum combined family deductible (the individual deductible x 3). HDHP/HRA family deductibles are aggregate. The employee (or individual) deductible applies if employee selects “employee only” coverage; otherwise, the family deductible applies. All covered family members contribute to the same family deductible. Once the family deductible is reached, it is met for all covered family members.

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Actually, it does not. The NCMS Plan’s Metlife dental contract year varies depending on your practice’s original group effective date. Of the four NCMS Plan dental products, it appears that your group has selected Plan D since it is the only option with a deductible. The initial dollar amount you must incur before Metlife will assume liability for any remaining costs due to dental claims is $50 per covered individual. The deductible is waived for preventive services. This deductible has a per individual family limit of $150 meaning that only three people in a given family must meet the deductible. The contract year maximum under Plan D is $1,500. Both the deductible and the contract year maximum reset at your practice’s benefit period effective date.

For comparison, the other NCMS Plan dental products, Plans A through C, each have no deductible but do have different contract year maximums. Plan A has a contract year maximum of $1,000, Plan B’s contract year maximum is $1,250, and Plan C has a contract year maximum of $1,500. Again – all NCMS Plan dental products will reset any deductible and contract year maximums at your practice’s benefit period effective date.

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On a typical day at the NCMS Plan, we receive a substantial volume of health insurance enrollment and administrative documentation. The NCMS Plan Employee Enrollment Application and Change Form is used for indicating any enrollment information subsequent to your practice’s initial enrollment. This form is available at http://www.ncmsplan.com/forms/. Remembering to include some key items on the form will make any enrollment or change process quickly and smoothly. Always write your six-digit group number in the upper right hand corner of the application in the shaded area entitled “Completed by Group Administrator Only”. In this same area, also complete the Effective Date of the enrollment or change being made.

If making a change, Section A. has the most common change options with a box that can be checked. Just select the change you need processed. Completing Section B. will ensure your employees are enrolled on the right plan and type of coverage. Section C. has the indispensible employee birthdate, hire date, name & address as well as a field for employer name. Applicants should indicate any dependents to be covered in Section D. Complete Sections E. & F. to show any prior coverage or coordination of benefits with another carrier.

In Section G., an employee can name a beneficiary for the NCMS Plan life coverage (if offered) and, finally, have the employee sign the form for validation.

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Congratulations to your employee on her first child! The employee now has the option of adding her newborn as a dependent under her policy – but must do so within 30 days of the birthdate to be considered “timely” and for the coverage to be effective from date of birth.

Other timely enrollees are those that apply for coverage and/or add dependents within a 30-day period following these qualifying events:
• Employee or their dependents become eligible for coverage
• Employee gets married
• Employee gains a dependent through adoption or foster care placement
• Employee or dependent loses coverage under another health plan
Since the NCMS Plan does not process enrollments or changes retroactively beyond 30 days, it’s always best to submit any transactions concerning dependent coverage within that “timely” 30-day timeframe.

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The NCMS Plan has made a special eligibility class available for physician and non-physician retirees to keep their group health coverage until they are eligible for Medicare. A practice has the option of offering this retiree coverage or not.

The criteria for eligibility differs for physicians (MD’s) and non-physicians (all other staff) but hinges on the practice’s continued participation in the NCMS Plan and the individual not becoming eligible for another group’s health plan.

Physicians can elect the retiree coverage at any age and at any time as long as they were a member of the NCMS Plan immediately prior to retirement, maintain membership in the NC Medical Society after retirement and do not become eligible for any other subsequent group health plan.

Retired non-physician employees must meet the following criteria: the employee must be at least age 55, be employed by the participating employer for at least 10 years, and be a member of the NCMS Plan immediately prior to retirement. If these criteria are met, the employee is eligible for continued until Medicare eligibility.

Retiree benefit elections for eligible physicians and non-physicians should be submitted to the NCMS Plan on group letterhead indicating member information and date of retirement. You will receive written confirmation of receipt and the member will continue to appear on your group billing statement.

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First, let me apologize for the inconvenience, but I hope this answer will clarify things for you. The NCMS Plan is an employee benefit plan separate and distinct from BCBSNC. The NCMS Plan has contracted with BCBSNC to provide it with certain administrative services, such as billing, claims processing, and provider networks. But your contractual relationship is with the NCMS Plan, not with BCBSNC.

Because the NCMS Plan offers a number of benefit plans, eligibility classes, and other features that are unique to it and not offered by BCBSNC, it is important that you use NCMS Plan forms to ensure timely enrollment.
10. Question: George, our NCMS Plan health plan renews in August and two of our employees are considering enrolling on their spouse’s employer’s group health plan. We have six eligible employees total and currently all six are enrolled. Will their change jeopardize our ability to continue to participate in the NCMS Plan?

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The NCMS Plan’s requirement is that at least 75% of eligible employees be enrolled. In the count of eligible employees in your group there can be employees that are “eligible waivers” and therefore do not count against your practice for the participation calculation. The Plan considers an eligible waiver as being an eligible employee who elects coverage under a spouse’s group health plan or an eligible employee who is covered by a government-sponsored health plan such as Tricare or Medicare.

Based on the information you have presented regarding the two employees electing their spouse’s group coverage, they are eligible waivers and your group remains compliant with NCMS eligibility.

To further illustrate:

You have 6 eligible employees. Subtract the 2 employees with eligible waivers (i.e. other group health coverage) and you are left with 4 employees, all of which are enrolled in the NCMS Plan. This is 100% participation.

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You may be surprised to know that the NCMS Plan gives participating practices a choice of how they define a full-time employee. A full-time employee is eligible for benefits if they are regularly scheduled to work at least twenty-four (24) or thirty (30) hours per week depending on your practice’s preference. If a practice chooses the 24 hour definition, then any employee, physician or non-physician, must be offered coverage if they meet that criteria.

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Yes. The NCMS Plan does indeed offer group dental benefits, underwritten by MetLife, to participating practices. As with our health program, practices benefit from the size of the NCMS Plan with both competitive pricing and product design options.

Practices can choose from four different products, three of which can be offered with or without child orthodontia benefits. Employees can seek treatment from any dentist. However, employees will save money by choosing a dentist from MetLife’s Preferred Dental Program network.

Practices can select one product or offer a dual option to employees. If offering a dual option, one product offered must be Plan A.

New groups can have a dental benefit period that matches their health benefit period. For example, if your health benefits renew January 1, we can set up a dental benefit period that begins January 1 and runs to December 31. Practices do not have to be enrolled in the NCMS Plan health program to enroll in the NCMS Plan dental program.

To enroll, practices must have a minimum of 75% of eligible employees electing the coverage and the practice must contribute 25% of the employee only premium. You can vist our website www.ncmsplan.com for a plan summary and enrollment information.

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When you submit the notification of termination, BCBSNC will automatically issue a HIPAA Certificate of Prior Creditable Coverage (HIPAA Certificate) to subscribers once their health coverage officially ends.

HIPAA Certificates will provide the documentation requested by successive insurance carriers for the individual reducing or eliminating any waiting periods for coverage of pre-existing conditions.

Although there are circumstances where benefits will terminate for a member or dependent on the true day of the event that eligibility ended such as death or divorce – in the case of an employee termination, benefits for the former employee will end on the last day of the month in which the employee is terminated.

If anyone does not receive their certificate, they can request one directly from BCBSNC Customer Service by calling 877-275-9787 or online through Member Services at http://www.bcbsnc.com/members/ncms/.

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The long-term temporary employee will still need to complete a 90-day probationary period as a new full-time employee. This is because part-time and temporary employment status does not satisfy the NCMS Plan eligibility requirement. A probationary period for new full-time hirees begins on the first day of full-time employment with benefits effective when the probationary period ends.

When completing the enrollment form, your applicant will need to enter their full-time date of hire in the field requesting “Date of Full-Time Employment” right below the field for “Date of Birth”. The probationary period will be applied based on the hire date entered.

Should you find that a 90-day probationary period no longer suits the needs of your practice, you can change your probationary period by submitting a letter on your practice letterhead indicating your change. Changes to probationary periods, however, are not retroactive and would be effective for hire dates on or after the date the letter is received.

Available NCMS Plan probationary period options are as follows:

Zero days: Eligibility on date of full-time employment.
30 days: Eligibility on the next first of the month following 30 days of employment.
60 days: Eligibility on the next first of the month following 60 days of employment.
90 days: Eligibility on the 91st day of full-time employment.

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Though the NCMS Plan welcomes all eligible physicians, Medicare eligible physicians can choose to enroll on Medicare and drop NCMS Plan coverage. Since the North Carolina Medical Society sponsors the NCMS Plan, all physicians in a given group must be active NCMS members for the practice as a whole to be eligible for the Plan, but all physicians are not required to be covered by the benefits. Meanwhile, the physicians and practice staff that do want the coverage are eligibile to enroll. Or, stated another way – physicians who have other group coverage through their spouse or are covered by Medicare, can be covered under that plan and do not have to coordinate coverage with the NCMS Plan. The eligibility of the entire practice for the NCMS Plan is unaffected.

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The NCMS Plan is administered by BCBSNC. This administration includes claims adjudication and management of the appeals process. When an employee disagrees with the way a claim has been processed, their first step is to call BCBSNC Member Services, 1-877-248-3334. A BCBSNC representative can review the claim with them, explain the EOB, and discuss the specific reasons for the denial.

If the employee is not satisfied with the explanation and continues to believe the claim was processed in error, there is an appeals procedure (including a First & Second Level Appeal) for resolution by a BCBSNC review panel. A First Level appeal can be initiated via phone with BCBS Member Services at the number referenced above, or by mail at BCBSNC Customer Service P.O. Box 2291 Durham, NC 27702. The first level appeal must be submitted within 180 days of claim denial. Requests for review should always include your name & id number, the name of the patient, the nature of the appeal and any information or clinical data that may be helpful for the review. BCBSNC’s Member Services website provides more information about the appeals process and a Member Appeal Form.

If the employee is dissatisfied with the outcome of the First Level Appeal, they have the right to initiate a Second Level Appeal. The appeal data will again be reviewed and findings mailed to the employee. Employees can appeal to the North Carolina Department of Insurance if the First and Second Level Appeals do not result in the outcome they believe is correct. Instruction for NC DOI appeals are included in Benefit Booklets available on BCBSNC’s Member Services website.

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In order to enroll in NCMS Plan medical coverage the employee must:

1. Meet the full-time employee eligibility defined by your practice, either 24 or 30 hours per week, and

2. complete the applicable probationary period selected by your practice.

If employees wish to enroll outside of their initial eligibility period or your practice’s annual medical open enrollment period they must have a qualifying event. Below are some examples of qualifying events:

•Getting Married
•Obtaining a dependent through birth, court order, adoption, placement in anticipation of adoption or foster care placement of an eligible child
•The employee or their dependents lose coverage under another health plan

If one of these qualifying events is met, then the employee and/or dependents can be added within 30 days of the qualifying event.

NCMS Plan dental coverage (underwritten by MetLife) works differently than NCMS Plan medical coverage. If an eligible employee does not enroll in NCMS Plan dental coverage when first eligible following their probationary period, they will be considered a late entrant subject to a benefit waiting period if they enroll later without a qualifying event. There is no annual open enrollment for NCMS Plan dental coverage.

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You may recall in the last issue of CHOICES (Sept ’14) we described the change in HSA administrators and how it will impact practices over the next few months. Your practice has the option of remaining with BW or working with HEQ going forward. However, the HSA balances that exist in BW HSAs will not transfer automatically over to the new HEQ HSAs. Each accountholder must act independently if they choose to transfer their balance. They may also choose to do nothing and spend down their BW balance while also depositing money into their new HEQ HSA. There is no rule that prevents an accountholder from having more than one active HSA as long as combined contributions into either or both accounts do not exceed IRS limits.

When a new HEQ HSA is opened, employees receive a welcome kit that includes an HEQ debit card. Employees should not destroy their BW debit cards until after the BW account is closed or funds have been depleted or transferred. The BW debit card will still work and allow access to HSA funds in that account.

A member can transfer or rollover their HSA balance. For transfers, BW will process a member’s request as a Trustee-to-Trustee transfer and send a check for them directly to HEQ. BW does charge a $25 check issuance fee for this service. The funds should be received and available within 3-6 weeks. No tax form will be issued by either party since the transaction is simply a balance transfer.

For rollovers, accountholders can only request one rollover every 12 months. A 1099-SA tax form will be issued by BW to report the distribution and a 5498-SA tax form will be issued by HEQ to report the rollover.

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You can send an NCMS Plan enrollment/change form, but the NCMS Plan has a 30-day retroactive change limit. If for example, the employee’s termination occurred in October 2012, but you did not submit the termination or notice they remained on your bill until February 2013, we can only retroactively terminate the employee back to January 31, 2013.

To avoid another instance where several months premium is remitted for a separated employee in error, practices should audit their monthly billing statements to provide a measure of internal control. This will ensure that former employees do not continue to appear on the bill for months after they separated from employment. Additionally, always remember to promptly notify us of employee terminations.

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While subscribers can add a domestic partner, the NCMS Plan requires validation that the relationship status of the subscriber and domestic partner is, in fact, as presented. An affidavit serves this purpose. The Affidavit of Domestic Partnership is simply a statement of fact reflecting evidence that both parties are responsible for each other’s welfare and is signed by both the subscriber and the domestic partner.

The domestic partner’s children may also be covered under the NCMS Plan as long as the children meet the Plan’s definition of an eligible dependent.

A domestic partner may qualify as a “tax dependent” per the IRS provided certain qualifying conditions are met. If the domestic partner qualifies as a tax dependent per the IRS regulations, the employee will not pay any additional tax to cover the dependent. On the other hand, if the domestic partner does not qualify as a tax dependent the added value of providing them coverage is taxable to the employee.

There are tax consequences to the employee if the domestic partner’s eligible dependent children are enrolled. The employee is taxed on the amount (the added value) that provides coverage for the domestic partner’s dependent children.

The IRS rules for determining whether a domestic partner or dependent children qualify as tax dependents are complicated. Employees should consult with their tax advisor to determine if the dependent(s) qualify as a tax dependent.

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It depends on the size of your practice. Yes, a requirement of the ACA is that employers are required to start reporting the cost of their employer-sponsored health coverage on the W-2’s issued to employees for 2012. However, the requirement only applies to employers filing 250 or more W-2 forms for the preceding calendar year. Employers filing less than 250 W-2 forms are exempt and the reporting of the cost is optional at this time.

Additional information about the W-2 reporting requirement and a helpful guide can be found at GrantThornton.com

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The NCMS Plan sets a deadline for renewal submissions approximately three weeks prior to the coverage effective date. This deadline is important because it provides sufficient time to process all renewals. If renewals are submitted by that deadline, members will be active on the first day of the new benefit period.

Renewals that are submitted after that deadline, and especially those submitted the week prior to the coverage effective date, are less likely to be processed in time for coverage to be active on the first day of the new benefit period. Renewal processing can take 5-7 business days to complete and for member ID cards to be issued. Renewals will be processed in the order that they are received. Submitting your renewal as early as possible will allow sufficient time to complete processing and have ID cards received by your employees by the renewal date.

Even if your renewal is submitted after the deadline and your group is not active on the first day of the new benefit period, members will still have coverage and any claims initially denied, will be adjudicated per benefits retroactively to the beginning of the benefit period.

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You indicate that you have 17 employees enrolled in NCMS Plan coverage, however, you may have more employees on your payroll. That is an important point and will ultimately determine whether your practice is subject to the federal COBRA program or state continuation.

Practices with 20 or more employees on more than 50 percent of its typical business days in the previous calendar year are subject to COBRA. Both full and part-time employees are counted to determine whether a plan is subject to COBRA. Each part-time employee counts as a fraction of an employee, with the fraction equal to the number of hours that the part-time employee worked divided by the hours an employee must work to be considered full time.

If in fact, based on the above description, your practice is not subject to COBRA, then your practice would be subject to the regulations governing NC State Continuation. Both COBRA and NC State Continuation provide continuation of group health coverage that otherwise would be terminated. Ultimately, it is up to the practice to determine which applies.

Once your determination has been made, the NCMS Plan can assist you appropriately. Either with COBRA and administration of continuants at no charge to your practice through Ceridian, or provide you with information from the NC Department of Insurance regarding NC State Continuation as well as an election form that you can relay to those in your group that are separating from employment

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The HDHP family deductible is an aggregate of amounts contributed by all covered persons. In this situation, where the divorced spouse elects COBRA, the spouse becomes enrolled separately under their own identification number. Any deductible amount accumulated specifically by that spouse is credited to them under their new identification number. The total amount credited to the family aggregate deductible remains with the employee and the spouse on COBRA (now shown as “employee only”) must meet whatever outstanding balance remains of their individual deductible.

Ultimately, at your group renewal, the deductible accumulation for both would be reset and both the employee and the spouse on COBRA would have a new benefit period deductible to meet.

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Depending on your practice size you would offer the employee State Continuation (under 20 employees) or COBRA (20 or more employees). Both full-time and part-time employees are counted. State Continuation and COBRA have a timeline and actions required that will first terminate the employee and then reenroll them as a continuant if elected.

If your practice is subject to COBRA, when you terminate an employee from NCMS Plan coverage you should also notify your COBRA administrator. Many NCMS Plan practices use Flores & Associates as their COBRA administrator…a free service with your NCMS Plan coverage. For this example, we will assume your practice uses Flores. When Flores receives the qualifying event notification, they will notify the former employee of their eligibility for COBRA and provide instruction for electing continuation. The former employee has 60 days from notification to decide if they would like to continue coverage. If they elect COBRA you will receive a report from Flores indicating they have enrolled. At this point you would send this report and an Enrollment/Change Application to the NCMS Plan informing them this member is now on COBRA. This is communicated to BCBSNC. The member pays Flores directly each month and in turn you will receive a check from Flores for the member’s premiums. You will continue to receive reports from Flores on a weekly basis. If you are notified by Flores that your continuant has terminated their COBRA coverage, send this notification and a change form to terminate their COBRA coverage with the NCMS Plan, otherwise the continuant will remain on your plan and bill.

If your practice has less than 20 employees, the process is similar to above. State Continuation differs from COBRA in that the former employee must have been covered by your health plan for three consecutive months prior to losing eligibility (typically by termination). Terminate the employee’s coverage as you normally would, but your practice extends the offer of State Continuation to them. Although not required, you may give oral or written notification of the employee’s eligibility for State Continuation. If the employee wants to elect coverage they notify your practice, complete an Enrollment/Change Application and provide premium payment. In this scenario, the employee would send the group a check each month for the full premium that the group is charged each month by BCBSNC. To terminate an employee’s continuation you could simply let us know by sending a change form and we can forward to BCBSNC

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Yes, there is indeed an online option for you, it’s called eBenefitsNow. This is an excellent online resource that can really serve all of your health insurance enrollment needs. With eBenefitsNow, you can access, enroll & make changes to your employee benefit information from the office – or even your home 24/7. If this sounds like it will meet the needs of your practice, you can start the implementation process at your convenience.

To start implementation of eBenefitsNow, go to www.eBenefitsNow.com/ServiceAgreement.html and enter access code: NC675899.

You will be directed to complete their online service agreement. Once you complete this agreement, a representative from BenefitFocus will contact you to get your practice setup and to train you on how to use the system. You may also be pleased to know that there is no cost for your group to use eBenefitsNow.

For more information about eBenefitsNow including a training video library, go to http://start.benefitfocus.com/start/ebenefitsnow/.

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We can process termination for this employee, however, at this point, processing of this termination will be effective back only to January 31, 2015. NCMS Plan practices are subject to a 30-day retroactivity limit. This limitation applies to all benefit transactions, including enrollments and terminations.

To avoid situations where the 30-day retroactivity limit would generate an effective date other than what was wanted or expected, practices should submit employee enrollments, changes, or terminations as soon as possible. Practices should also review each monthly billing statement so that any potential discrepancy can be uncovered and rectified quickly and without issue.

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We can process termination for this employee, however, at this point, processing of this termination will be effective back only to January 31, 2015. NCMS Plan practices are subject to a 30-day retroactivity limit. This limitation applies to all benefit transactions, including enrollments and terminations.

To avoid situations where the 30-day retroactivity limit would generate an effective date other than what was wanted or expected, practices should submit employee enrollments, changes, or terminations as soon as possible. Practices should also review each monthly billing statement so that any potential discrepancy can be uncovered and rectified quickly and without issue.

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We appreciate your participation in the NCMS Plan for both group medical and dental coverage, and always want groups to experience a benefit integration that is as seamless as possible. However, MetLife is separate from BCBSNC (our medical plan administrator) and each requires a separate enrollment form. Please visit us at www.ncmsplan.com to access forms and other information regarding the benefits. Here is the link specifically for the Metlife dental enrollment form.

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MetLife requires that all new hires either accept or decline the dental benefits within 31 days of their hire date, regardless of the date they may be actually eligible. In this circumstance, your employee would need to have submitted the signed enrollment by March 5, 2014 to be considered a timely enrollee not subject to a late entrant penalty.

If you have questions about MetLife enrollment or eligibility, MetLife Employer Service can be reached at (800) 488-8757.

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Only conventional two-dimensional (2D) mammography is covered as a preventive mammogram service paid at 100%. 3D mammography, also known as Digital Breast Tomosynthesis, is considered an investigational procedure under BCBSNC’s current medical policy. The NCMS Plan, which defers medical policy determinations to our plan administrator BCBSNC, does not provide coverage for Digital Breast Tomosynthesis or any investigational service or procedure. A machine equipped with breast Tomosynthesis can perform 2D digital mammography, 3D digital mammography, or a combination of both.

BCBSNC medical policies are reviewed regularly and if policy changes are issued, the NCMS Plan will follow.
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The deductible is the amount of allowable charges for covered services that must be paid by the employee before the NCMS Plan will assume any liability for the cost of any covered services. For example, the PPO 1500-80 plan has an individual in-network deductible of $1,500, so the employee would pay $1,500 for in-patient and out-patient services before the NCMS Plan would pay any portion of the remaining allowable charges.

Coinsurance is simply a type of “cost-sharing” that comes into play after the deductible has been met. Once the deductible is met, the employee pays a percentage of the cost of covered medical services as an out-of-pocket payment to the provider. Using the previous example, the PPO 1500-80 plan would have the NCMS Plan pay 80% of the cost and the employees pay the remaining 20% up to a given out-of-pocket maximum.

All NCMS Plan health products have an out-of-pocket maximum which upon being met, increases the plan benefits (the NCMS Plan’s payment) to 100% (excluding copayments).

All NCMS Plan health products also have some deductible amount that must be met within a given benefit period. It’s important to remember that the deductible does not include copayments, coinsurance, charges beyond the allowed amount, or amounts for non-covered services.

One last note, PPO and HDHP/HRA family deductibles work differently. PPO deductibles are individual; if one or more dependents are covered, each covered person has an individual deductible and a maximum combined family deductible (the individual deductible x 3). HDHP/HRA family deductibles are aggregate. The employee (or individual) deductible applies if employee selects “employee only” coverage; otherwise, the family deductible applies. All covered family members contribute to the same family deductible. Once the family deductible is reached, it is met for all covered family members.

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Actually, it does not. The NCMS Plan’s Metlife dental contract year varies depending on your practice’s original group effective date. Of the four NCMS Plan dental products, it appears that your group has selected Plan D since it is the only option with a deductible. The initial dollar amount you must incur before Metlife will assume liability for any remaining costs due to dental claims is $50 per covered individual. The deductible is waived for preventive services. This deductible has a per individual family limit of $150 meaning that only three people in a given family must meet the deductible. The contract year maximum under Plan D is $1,500. Both the deductible and the contract year maximum reset at your practice’s benefit period effective date.

For comparison, the other NCMS Plan dental products, Plans A through C, each have no deductible but do have different contract year maximums. Plan A has a contract year maximum of $1,000, Plan B’s contract year maximum is $1,250, and Plan C has a contract year maximum of $1,500. Again – all NCMS Plan dental products will reset any deductible and contract year maximums at your practice’s benefit period effective date.

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On a typical day at the NCMS Plan, we receive a substantial volume of health insurance enrollment and administrative documentation. The NCMS Plan Employee Enrollment Application and Change Form is used for indicating any enrollment information subsequent to your practice’s initial enrollment. This form is available at http://www.ncmsplan.com/forms/. Remembering to include some key items on the form will make any enrollment or change process quickly and smoothly. Always write your six-digit group number in the upper right hand corner of the application in the shaded area entitled “Completed by Group Administrator Only”. In this same area, also complete the Effective Date of the enrollment or change being made.

If making a change, Section A. has the most common change options with a box that can be checked. Just select the change you need processed. Completing Section B. will ensure your employees are enrolled on the right plan and type of coverage. Section C. has the indispensible employee birthdate, hire date, name & address as well as a field for employer name. Applicants should indicate any dependents to be covered in Section D. Complete Sections E. & F. to show any prior coverage or coordination of benefits with another carrier.

In Section G., an employee can name a beneficiary for the NCMS Plan life coverage (if offered) and, finally, have the employee sign the form for validation.

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Congratulations to your employee on her first child! The employee now has the option of adding her newborn as a dependent under her policy – but must do so within 30 days of the birthdate to be considered “timely” and for the coverage to be effective from date of birth.

Other timely enrollees are those that apply for coverage and/or add dependents within a 30-day period following these qualifying events:
• Employee or their dependents become eligible for coverage
• Employee gets married
• Employee gains a dependent through adoption or foster care placement
• Employee or dependent loses coverage under another health plan
Since the NCMS Plan does not process enrollments or changes retroactively beyond 30 days, it’s always best to submit any transactions concerning dependent coverage within that “timely” 30-day timeframe.

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The NCMS Plan has made a special eligibility class available for physician and non-physician retirees to keep their group health coverage until they are eligible for Medicare. A practice has the option of offering this retiree coverage or not.

The criteria for eligibility differs for physicians (MD’s) and non-physicians (all other staff) but hinges on the practice’s continued participation in the NCMS Plan and the individual not becoming eligible for another group’s health plan.

Physicians can elect the retiree coverage at any age and at any time as long as they were a member of the NCMS Plan immediately prior to retirement, maintain membership in the NC Medical Society after retirement and do not become eligible for any other subsequent group health plan.

Retired non-physician employees must meet the following criteria: the employee must be at least age 55, be employed by the participating employer for at least 10 years, and be a member of the NCMS Plan immediately prior to retirement. If these criteria are met, the employee is eligible for continued until Medicare eligibility.

Retiree benefit elections for eligible physicians and non-physicians should be submitted to the NCMS Plan on group letterhead indicating member information and date of retirement. You will receive written confirmation of receipt and the member will continue to appear on your group billing statement.

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First, let me apologize for the inconvenience, but I hope this answer will clarify things for you. The NCMS Plan is an employee benefit plan separate and distinct from BCBSNC. The NCMS Plan has contracted with BCBSNC to provide it with certain administrative services, such as billing, claims processing, and provider networks. But your contractual relationship is with the NCMS Plan, not with BCBSNC.

Because the NCMS Plan offers a number of benefit plans, eligibility classes, and other features that are unique to it and not offered by BCBSNC, it is important that you use NCMS Plan forms to ensure timely enrollment.
10. Question: George, our NCMS Plan health plan renews in August and two of our employees are considering enrolling on their spouse’s employer’s group health plan. We have six eligible employees total and currently all six are enrolled. Will their change jeopardize our ability to continue to participate in the NCMS Plan?

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The NCMS Plan’s requirement is that at least 75% of eligible employees be enrolled. In the count of eligible employees in your group there can be employees that are “eligible waivers” and therefore do not count against your practice for the participation calculation. The Plan considers an eligible waiver as being an eligible employee who elects coverage under a spouse’s group health plan or an eligible employee who is covered by a government-sponsored health plan such as Tricare or Medicare.

Based on the information you have presented regarding the two employees electing their spouse’s group coverage, they are eligible waivers and your group remains compliant with NCMS eligibility.

To further illustrate:

You have 6 eligible employees. Subtract the 2 employees with eligible waivers (i.e. other group health coverage) and you are left with 4 employees, all of which are enrolled in the NCMS Plan. This is 100% participation.

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You may be surprised to know that the NCMS Plan gives participating practices a choice of how they define a full-time employee. A full-time employee is eligible for benefits if they are regularly scheduled to work at least twenty-four (24) or thirty (30) hours per week depending on your practice’s preference. If a practice chooses the 24 hour definition, then any employee, physician or non-physician, must be offered coverage if they meet that criteria.

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Yes. The NCMS Plan does indeed offer group dental benefits, underwritten by MetLife, to participating practices. As with our health program, practices benefit from the size of the NCMS Plan with both competitive pricing and product design options.

Practices can choose from four different products, three of which can be offered with or without child orthodontia benefits. Employees can seek treatment from any dentist. However, employees will save money by choosing a dentist from MetLife’s Preferred Dental Program network.

Practices can select one product or offer a dual option to employees. If offering a dual option, one product offered must be Plan A.

New groups can have a dental benefit period that matches their health benefit period. For example, if your health benefits renew January 1, we can set up a dental benefit period that begins January 1 and runs to December 31. Practices do not have to be enrolled in the NCMS Plan health program to enroll in the NCMS Plan dental program.

To enroll, practices must have a minimum of 75% of eligible employees electing the coverage and the practice must contribute 25% of the employee only premium. You can vist our website www.ncmsplan.com for a plan summary and enrollment information.

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When you submit the notification of termination, BCBSNC will automatically issue a HIPAA Certificate of Prior Creditable Coverage (HIPAA Certificate) to subscribers once their health coverage officially ends.

HIPAA Certificates will provide the documentation requested by successive insurance carriers for the individual reducing or eliminating any waiting periods for coverage of pre-existing conditions.

Although there are circumstances where benefits will terminate for a member or dependent on the true day of the event that eligibility ended such as death or divorce – in the case of an employee termination, benefits for the former employee will end on the last day of the month in which the employee is terminated.

If anyone does not receive their certificate, they can request one directly from BCBSNC Customer Service by calling 877-275-9787 or online through Member Services at http://www.bcbsnc.com/members/ncms/.

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The long-term temporary employee will still need to complete a 90-day probationary period as a new full-time employee. This is because part-time and temporary employment status does not satisfy the NCMS Plan eligibility requirement. A probationary period for new full-time hirees begins on the first day of full-time employment with benefits effective when the probationary period ends.

When completing the enrollment form, your applicant will need to enter their full-time date of hire in the field requesting “Date of Full-Time Employment” right below the field for “Date of Birth”. The probationary period will be applied based on the hire date entered.

Should you find that a 90-day probationary period no longer suits the needs of your practice, you can change your probationary period by submitting a letter on your practice letterhead indicating your change. Changes to probationary periods, however, are not retroactive and would be effective for hire dates on or after the date the letter is received.

Available NCMS Plan probationary period options are as follows:

Zero days: Eligibility on date of full-time employment.
30 days: Eligibility on the next first of the month following 30 days of employment.
60 days: Eligibility on the next first of the month following 60 days of employment.
90 days: Eligibility on the 91st day of full-time employment.

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Though the NCMS Plan welcomes all eligible physicians, Medicare eligible physicians can choose to enroll on Medicare and drop NCMS Plan coverage. Since the North Carolina Medical Society sponsors the NCMS Plan, all physicians in a given group must be active NCMS members for the practice as a whole to be eligible for the Plan, but all physicians are not required to be covered by the benefits. Meanwhile, the physicians and practice staff that do want the coverage are eligibile to enroll. Or, stated another way – physicians who have other group coverage through their spouse or are covered by Medicare, can be covered under that plan and do not have to coordinate coverage with the NCMS Plan. The eligibility of the entire practice for the NCMS Plan is unaffected.

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The NCMS Plan is administered by BCBSNC. This administration includes claims adjudication and management of the appeals process. When an employee disagrees with the way a claim has been processed, their first step is to call BCBSNC Member Services, 1-877-248-3334. A BCBSNC representative can review the claim with them, explain the EOB, and discuss the specific reasons for the denial.

If the employee is not satisfied with the explanation and continues to believe the claim was processed in error, there is an appeals procedure (including a First & Second Level Appeal) for resolution by a BCBSNC review panel. A First Level appeal can be initiated via phone with BCBS Member Services at the number referenced above, or by mail at BCBSNC Customer Service P.O. Box 2291 Durham, NC 27702. The first level appeal must be submitted within 180 days of claim denial. Requests for review should always include your name & id number, the name of the patient, the nature of the appeal and any information or clinical data that may be helpful for the review. BCBSNC’s Member Services website provides more information about the appeals process and a Member Appeal Form.

If the employee is dissatisfied with the outcome of the First Level Appeal, they have the right to initiate a Second Level Appeal. The appeal data will again be reviewed and findings mailed to the employee. Employees can appeal to the North Carolina Department of Insurance if the First and Second Level Appeals do not result in the outcome they believe is correct. Instruction for NC DOI appeals are included in Benefit Booklets available on BCBSNC’s Member Services website.

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