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What are “qualifying events”?
An employee has two opportunities to enroll in the health plan:
- within 31 days of the date of hire
- at open enrollment, to be effective the beginning of the following calendar year.
Outside of those opportunities, one of the following “qualifying events” must occur if employees wish to add, change, or drop health coverage:
- the birth or adoption of a child by the employee
- the marriage or divorce of the employee
- the death of the employee’s spouse or dependent
- beginning or ending employment for an employee’s spouse
- becoming ineligible for benefits because of a reduction in hours
- a significant change in a spouse’s health coverage through his or her employer.
If one of the above events occurs, you may make a change to your health coverage as long as
- you do so within 31 days of the qualifying event and
- you provide proof of the qualifying event.
Recently the law was changed to include as a qualifying event eligibility for a premium assistance subsidy under Medicaid or the Children’s Health Insurance Program, provided the plan administrator is notified within 60 days of eligibility. That is, someone who declined coverage at hire may enroll upon eligibility under Medicaid or CHIP for premium assistance. You must enroll within 60 days. These are requirements of the Internal Revenue Service, the U.S. Department of Labor, and health plan rules.
I notice some pharmacies like Wal-Mart and Kroger offer some drugs for only a few dollars. Would it be less expensive to fill my prescription there?
It might be. It depends on the medication. Both Wal-Mart and Kroger, and maybe others, offer some common drugs at a greatly reduced price. In some cases you might be able to get a 90-day prescription there for much less than your co-pay through mail order. It’s worth doing some comparison shopping next time you have a maintenance medication to fill or refill.
If I leave employment with the diocese, can I convert my life insurance into an individual policy?
Yes. There are two situations where this may occur: at termination of employment or upon becoming disabled. (1) Within 31 days of your date of termination (or if you lose eligibility due to reduced hours), you can apply for an individual policy in an amount equal to or less than $30,000. (2) If you become disabled, your life insurance coverage may be continued for a specific time and your premium waived, if you qualify. Please refer to your summary plan description for more detailed information.
If I become ill while outside the United States, is my health coverage still effective?
If you need medical treatment while traveling, you will have to arrange to pay the charges yourself in some manner. However, when you return to the U.S., submit the paperwork you have to United Healthcare. To file a claim for medical care outside the United States, click here for an international claim form. In addition, our life insurance carrier, UnumProvident, offers emergency travel assistance (though not payment for care) that would be helpful in the event of illness overseas.
My spouse is self-employed and is covered as my dependent under the diocesan health plan. If he has a work-related accident or injury, will it be covered?
No. Tennessee requires employers to carry workers compensation insurance. The diocesan health plan summary plan description includes an exclusion for a work-related injury or illness.
My spouse is covered by Medicare and by our health plan. Does it matter which plan pays first?
Yes, it does. Medicare is an insurance program for those over age 65 (with some others eligible based on individual situation). If an individual is Medicare eligible but enrolled in a group health plan (GHP) as well, the law stipulates that the GHP must be the primary payor, with Medicare the secondary payor.
Sometimes medical providers automatically bill Medicare first, so it is important the individual point out to the provider’s billing office that the GHP (currently United Healthcare for the Diocese of Knoxville) is primary. Please examine your explanation of benefits forms when you receive them to ensure your provider billed correctly. If Medicare pays first in error, the diocesan health plan can be liable for all claims paid in error. This liability could be in the thousands of dollars.
Periodically you may wish to review your Medicare and GHP coverage to see if you have the most economical combination for your (or your dependent’s) needs.
I have family coverage. When our child is born, will he or she be covered automatically?
The birth of a baby is considered a qualifying event (see further explanation of qualifying events below). When United Healthcare begins receiving claims for the new baby, it adds the child to plan for 31 days. At the expiration of 31 days, if the diocesan plan administrator doesn’t add the new baby to the plan, the baby is no longer covered. To prevent automatic expiration of coverage, complete an enrollment form within 31 days of the baby’s birth and submit it and your proof of qualifying event to your bookkeeper or business manager. If more than 31 days elapses, you will have to wait for open enrollment. Further, a change in the Medicare Secondary Payer law requires that you report your baby’s Social Security number to the health plan or face civil penalties up to $1,000 per day. Do not, however, wait until you have a Social Security number to complete an enrollment form or the 31-day limit for enrollment may expire while waiting for a Social Security card.
What is a “certificate of creditable coverage”? Why do I need one?
Sometimes called a “HIPAA certificate,” a certificate of creditable coverage is issued by United Healthcare when an employee or dependent terminates from the health plan. This certificate provides the name of the terminated individual, social security number and beginning and ending dates of coverage. It proves prior coverage to your next insurer and may be necessary in the event of a pre-existing condition limitation in the next plan. This is an important document. Be sure to put it someplace you can readily locate it.
My doctor, who is a preferred provider, referred me to another doctor for treatment. Will the second doctor’s charges be treated as “in network”?
Not necessarily. From a cost standpoint, it is best when the second doctor is part of our network. Networks have contracts with individual doctors regarding usual, customary, and reasonable charges, when the doctor may expect payment, etc. If the second doctor is not a network provider, she or he is not bound to accept an agreed-upon fee, to file your claim for you, etc. Although under certain circumstances the claim may be paid at the preferred benefit (that is, at 90 percent instead of 70 percent), you may remain liable for any portion not covered by insurance.
Must I obtain pre-certification for outpatient surgery?
Why do I have to provide my children’s Social Security Numbers to United Healthcare?
Beginning January 2010, federal law requires all covered participants in a health plan to have his or her Social Security number on file with the plan. This is a change to the Medicare Secondary Payer statute and applies to everyone, even those under age 65 (including newborns). Failure to supply this information will result in civil penalties of up to $1,000 per day, according to the law. The diocese’s health plan requires new plan beneficiaries to be enrolled within 31 days of their date of eligibility (date of birth in the case of a newborn). The assignment of a new Social Security number may take longer than 30 days. Thus, it is critical that employees report the assigned Social Security number to the Benefits Office as soon as it is received in order to avoid the costly penalty.