Employee: A new full-time, eligible employee may apply for
insurance after they have met their "new hire waiting period". They should
complete the application form and return them to the insurance company 30 days prior to
when the waiting period is completed. If the new employee has had insurance prior to
their employment with you, then they need to include with their application a
"certificate of prior credible coverage" (see below for details). Make
sure the entire form is completed and signed by the employee.
Newborn: All newborn children or adopted children are eligible from their date
of birth or date of placement for adoption. However, a signed change form must be
completed and returned to the insurance company within 30 days of the birth or adoption
placement. If you fail to add the newborn or adoption within the 30 day period then
the child must wait until the group "open enrollment" (anniversary date).
Children from a "live in" companion are NOT eligible (unless they are the
children of the employee). Grand-children are not eligible unless legal custody or
guardianship is given.
Spouse: A newly eligible spouse may be added to the employee's family policy by
completing a "Change/Delete Form" and returning it to the
insurance company within 30 days of the marriage date. "Common Law"
marriage or "Live ins" are NOT eligible. Any pre-existing conditions
would apply unless the new spouse can include a "certificate of prior credible
coverage" with the application forms. A copy of the marriage certificate is
also required. If the new spouse is not added within the 30 day period then they
must wait until the group open enrollment period. The effective date of coverage will be
the 1st or 16th of the following month depending on your contract date.
Certificate of Prior
Credible Coverage: The recent laws passed by Congress now
requires an insurance company or previous employer to provide a "certificate" to
any employee who has terminated off the plan. This certificate shows: the name of
the prior insurance company, the name of the employee and each family dependent who was
covered, the start and end dates that the coverage was in effect. This certificate
must be included with any application to show proof that prior coverage was in effect.
For those who are listed on the certificate, any pre-existing conditions may be
waived. Without the certificate, or if a dependent is not listed on the certificate,
they would have a 12 month pre-existing condition period. Late entrants who apply have an
18 month waiting period. The new employee should contact their previous insurance
company to obtain a copy of this certificate.
Change Forms: This form is
used to make changes on an employee's policy (ie: new address, changing a name, adding or
deleting a dependent child or spouse, changing a primary care provider) Have the
employee complete this form and returnit to Altius within 30 days of the event. If adding
a dependent child or spouse, this must be done within 30 days. If submitted later
than 30 days the dependent must wait until the group open enrollment.
Continuation: COBRA is a federal law
which allows an employee and/or dependents the right to continue their insurance.
There are 5 qualifying events which allows an employee or dependent to continue: 1.
Termination of employment or a reduction in work hours 2. Death of an employee
3. Divorce or legal separation 4. Entitlement of the employee for Medicare 5.
A dependent child ceases to be a dependent child. COBRA applies to all groups
who have 20 or more employees on payroll on an average business day over the past 12
months. The "qualified beneficiary" has 60 days from the date of
termination or date of notification (which ever is later) to make their election.
They then have 45 days to make their first payment. They must have the proper COBRA
forms completed and returned to the employer within their election period. The
employer is allowed to charge them 102% of the premium. 2% for their administration cost.
The employee pays the premium to the employer each month. The employer is not
required to contribute to the premium. Because COBRA is such a complex law, it is
highly recommended that an outside COBRA Specialist be consulted.
State Continuation: This is a state law which is similar to COBRA in
that an employee may continue their insurance upon termination. This is for groups
of 2-20 employees. The employee has 60 days to make their election from the date of
notification and the employer must notifiy the terminated employee within 30 days of
termination of their right to continue. If the employee waits longer than the 60 day
period, then their right to continue is forfeited. The employee must have been
covered under the group plan for at least 6 months prior to the election and can only
extend their coverage for 6 months (vs. 18 or 36 months under COBRA)
An employee may be terminated from the planby drawing a line
through the employee's name on the monthly bill and indicate the date he/she was
terminated. You also need to complete a "Change/Delete Form" and mark the
appropriate boxes. A dependent may be terminated from coverage by completing a
"ChangeDelete Form" and returning it to Altius. In most cases the
employee/dependent has coverage through the end of the month (or billing cycle)
Example: If an employee is terminted from employment on April 20th, their coverage
would continue through the end of April. The insurance company will not retro a
termination more than 60 days ago. (Remember it is important to offer COBRA or
State Continuation to each terminted employee/dependent)
Any full-time employee who works the minimum hours per week
(generally 30 hours) is eligible for insurance. Part time employee's are not
eligible. It is important to have the employee either complete the application forms
or sign a waiver and to do this in a timely manner. The application forms must be
submitted to Altius within 30 days of the completion of their new hire waiting period.
If an employee fails to enroll in a timely manner then they would be a "late
entrant". As such the employee would then wait to enroll during the group open
enrollment period. As a late entrant they would be subject to an 18 month
pre-existing condition waiting period (unless proof of prior coverage is
provided) It is important that each eligible employee complete the application forms
in a timely manner and return them to Altius within 30 days of their completion of the new
hire waiting period.
Event: This provision came as a result of a recent law
passed by Congress known as HIPAA. An employee and/or dependent may apply for
insurance prior to the open enrollment if they have a "life event". A life
event would be: marriage, new baby, loss of coverage (generally by a spouse).
If an employee loses prior insurance coverage then they could apply within 30 days of the
life event. If they wait longer than 30 days, then they must wait until the group
open enrollment. If they include with their application the "certificate of
credible coverage" showing prior coverage for at least 12 months then any
pre-existing conditions would be covered. The effective date of coverage would be the
"date of the life event".
New Hire Waiting Period: Each
employer establishes their own "new hire waiting period". This is the
period of time from when the employee is hired and when he/she can come on the plan.
These periods generally range from 30 days to 180 days. Once the new hire waiting
period is selected, it cannot be changed until the group open enrollment period.
Also, the waiting period applies to all new employees. You cannot discriminate by
allowing one employee to come on the plan earlier than another employee. The only
exception would be if you select different waiting periods for salary vs. hourly
employees. (ie: 30 day wait for salary/ 90 day wait for hourly) This must be
clear on all future applications which waiting period they would have. It is
important to submit the application forms to Altius within 30 days of when the
"new hire waiting period" is completed. If application is received late
then the employee must wait until the group open enrollment period.
Enrollment: Each year on the policy anniversary, most
groups will have an "open enrollment" period. This is when the renewal
rates generally change and any employee who has waived coverage in the past or was late in
applying can reapply. Employee's are guaranteed coverage but there may be a
pre-existing condition period depending on prior coverage or not. Any changes to the
plan or benefits may generally be made at this time.
Non-PPO: PPO (Preferred Provider Organization)
is a list of providers (doctors, hospitals and others) who contract with the insurance
company for lower fees. By using a PPO the employee generally receives better
benefits at lower costs. The provider "writes off" any amounts over the
contracted fee. The employee is not responsible to pay the difference. Also,
all paperwork is handled through the provider and the insurance company. It is
highly recommended to use a PPO provider whenever possible. A NON-PPO are
providers who are not on the panel or "list". With NON-PPO plans you may
receive care from a provider not on the list but your out-of-pocket charges are higher.
You may also be required to submit the bills for reimbursment. Any charges
that exceed the normal contracted fees would also be the responsibility of the employee.
Pre Existing Conditions:
With the recent change in the law, pre-existing
conditions are generally covered. There are some exceptions. If any employee
or dependent did not have prior coverage then they would have to wait the pre-existing
condition time period. Altius has a 12 month period. If an employee is a late
entrant on the group plan then their PEC would be 18 months. It is very
important to include a "certificate of credible coverage" to each employee or
dependent applying for coverage. This "certificate" credits any portion of
the PEC waiting period with the time you have had under the prior coverage.
Coverage: If a new employee chooses to "waive"
coverage, then he/she must wait until the group open enrollment date (anniversary date)
before he/she can apply. The exception to this is if they have a "life
event". If they choose not to be covered when hired, then they should sign a
waiver form showing the insurance was offered to them. Keep this form in their employee