CHOICES | Archive

To search the archive by keyword, use the Find feature in your browser. For example, in Internet Explorer, use CTRL+F and enter keyword ‘dental’ to find references to dental coverage.


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?

I just hired a new employee who has not had health insurance for the last six months. What does she need to know about her coverage?

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.

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?

Claims

My son is attending a university in another state and may need to have medical services. Can he receive our benefits out-of-state?

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?

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?

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?

Service

When our practice hires a new employee, I sometimes get confused about the probationary period that applies and when benefits are effective. Can you explain the different probationary periods and effective dates of coverage?

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?


When pondering probationary periods for new hires, it’s important to remember that practices are given four probationary period options at their initial enrollment in the NCMS Plan.

The four options are as follows:
• 0 True: Coverage is effective on date of hire.
• 30 Days: Coverage is effective on the next first of the month following 30 days of employment.
• 60 Days: Coverage is effective on the next first of the month following 60 days of employment.
• 90 True: Coverage is effective on date following 90 days of employment.

Return to Top


Certainly! The NCMS Plan provides members and their dependents with access to health benefits anywhere in the world. Specifically, dependents attending a university in another state and needing to be seen by a physician can simply call the physician-access line at 1-800-810-BLUE to find a participating doctor in their area. When they arrive at the office or facility, they just present their NCMS Plan identification card to receive in-network benefits. In the event of an emergency, they should go to the nearest hospital. There should not be any claim forms to be completed, nor any charges to pay up front for medical services – other than for plan-specific expenses such as copayments, deductible and coinsurance.

Return to Top


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.

Return to Top


Actually, it does not. The NCMS Plan’s Metlife dental contract year is 8/1 to 7/31 for all practices regardless of the 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 every August 1st.

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 on each August 1st.

Return to Top


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.

Return to Top


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.

Return to Top


Most importantly, since it’s been six months since the employee had health coverage – she needs to be aware that she will be subject to a waiting period for pre-existing conditions. For the purposes of health coverage, HIPAA regulations define pre-existing conditions as those conditions for which medical advice or treatment was received or recommended within the six-month period immediately preceding the effective date of the participant’s coverage. As an example, the employee may have had arthritis for many years before she came to your practice. If she did not have medical advice, diagnosis, care, or treatment recommended or received in the 6 months before she enrolled in the NCMS Plan, then the prior condition cannot be subject to a pre-existing condition exclusion. If she did receive medical advice, diagnosis, care, or treatment within the past 6 months, then the NCMS Plan imposes a pre-existing condition exclusion for that condition (arthritis). In addition, HIPAA prohibits plans from applying a pre-existing condition exclusion to pregnancy, genetic information, and certain children.

If the employee had any prior coverage, also known as “creditable” coverage with no lapse of longer than 63 days, then the waiting period for pre-existing conditions could be reduced or eliminated.

HIPAA requires that group health plans reduce any waiting period for pre-existing conditions by the length of any prior creditable coverage. Creditable coverage includes prior coverage under either group or individual insurance. Prior coverage is considered creditable only if there is no lapse in coverage of longer than 63 days. Probationary periods do not count toward any lapse so this time is included as “prior coverage” to reduce a waiting period for pre-existing conditions. So, if your new employee was covered for at least 12 months under another group or non-group health plan within 63 days of the date her new coverage starts, the waiting period for pre-existing conditions does not apply. If she was covered less than 12 months without a break in coverage of more than 63 days, her waiting period for pre-existing conditions will be reduced by whatever length of time was spent with the prior coverage.

Remember, a pre-existing condition exclusion relates only to benefits for your employee’s (and your employee’s family’s) pre-existing conditions. If the employee enrolls, they will receive coverage for the plan’s other benefits during that time.

Return to Top


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.

Return to Top


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?

Return to Top


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.

Return to Top


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.

Return to Top


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.

Return to Top


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/.

Return to Top


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.

Please remember that MDs and non-MDs can have different probationary periods if you choose.

Return to Top


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.

Return to Top


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.

Return to Top