State of Georgia Department of Community Health State

State of Georgia Department of Community Health State Health Benefit Plan Benefits Administration Training A. L. Burruss Institute of Public Service Kennesaw State University

Introductions Presenter Introduction SHBP Representative

Purpose of Meeting To bring you up to date on changes in the administration of the Georgia State Health Benefit Plan

Before We Begin… Glossary items….

Glossary Items 1. Employer: The department or agency for which the employee works. You are the legal representative of the employer to the employee as he/she learns of health care plan options. 2. Payroll locations: The physical location of the payroll office. The V 3 will interface with the payroll location

Glossary Items 3. Qualifying Event: Event will allow for changes in health care plans outside open enrollment Payroll locations: The physical location of the payroll office. The V 3 will interface with the payroll location 4. Demographic/Employment Record: The V 3 will require that all employees have demographic and employment records to enroll in health care plans. The demographic record is a subset of the employment record.

Glossary Items 5. Paperless system: The V 3 will create a paperless system in which computer screens will replace forms and documents will be scanned and images not documents retained by the system. 6. LWOP: Leave without pay rules will change under the V 3. These changes will empower the employing

Glossary Items 7. Pre-certification; A determination of eligibility for benefit coverage. This is the responsibility of the employee. Employers will not be involved in the precertification process. 8. Interface: The interaction of two computer systems. The V 3 will interface with the payroll location, but the payroll system may interface with other systems in the employers’ HR offices.

Glossary Items 9. Enrolled v Covered: Employees can be enrolled in a health care plan, but not covered. For example employees hired early in one month may have to wait 6 -7 weeks to be covered even though they have enrolled. Coverage may also be suspended due to nonpayment of premiums. 10. Eligible v Enrolled: Employees may be enrolled, but not yet met their eligibility date. This could be especially true during the first few weeks of employment.

Glossary Item 11. Termination: End of work relationship with an employer. If an employee is terminated, he/she is no longer eligible for health care.

Today’s Agenda • • Overview Introduce and discuss V 3 HPAS Discuss eligibility to participate in SHBP Discuss division of responsibilities Review internal processes Review processing of new employees Review processing miscellaneous data updates

Today’s Agenda (Cont’d) • Discuss the elimination of forms • Discuss coverage changes outside open enrollment periods and leave without pay • Discuss issues to review and remember • Determine the next steps • Provide contact information • Collect evaluations

Overview • Review the business rules • Check ourselves before we wreck ourselves • Clean-ups in progress

Discussion Item 1. Under the V 3 system, what if new employees forget to enroll in the benefit program within 31 days of their hire/eligibility date? The employees must wait until the next ___________.

Discussion Item 1. Under the new V 3 system, what if new employees forget to enroll in the benefit program within 31 days of their hire/eligibility dates? The employees must wait until the next open enrollment period.

Discussion Item 2. Under the new V 3 system, what if a benefits administrator/coordinator forgets to create an employment record for an employee within the first 31 days after hire or eligibility date? The employee must wait until the next __________.

Discussion Item 2. Under the new V 3 system, what if a benefits administrator/coordinator forgets to create an employment record for an employee within the first 31 days after hire or eligibility date? The employee must wait until the next open enrollment period.

Discussion Item 3. Under the new V 3 system, what if an administrator/coordinator accepts a paper form from an employee concerning the employee’s enrollment in the State Health Benefit Plan? It becomes the administrator’s ______________ to enroll the employee in the plan.

Discussion Item 3. Under the new V 3 system, what if an administrator/coordinator accepts a paper form from an employee concerning the employee’s enrollment in the State Health Benefit Plan? It becomes the administrator’s personal responsibility to enroll the employee in the plan.

Discussion Item 4. Under the new V 3 system, what if the administrator forgets to create an employment record? The employee ___ __ coverage and _____ any coverage until the next open enrollment period.

Discussion Item 4. Under the new V 3 system, what if the administrator forgets to create an employment record? The employee has no coverage and can’t get any coverage until the next open enrollment period.

Discussion Item 5. What if employees, or members of their families, become ill or have accidents during the time that they thought they had coverage? They have __ coverage. Who is going to pay their medical bills?

Discussion Item 5. What if employees, or members of their families, become ill or have accidents during the time that they thought they had coverage? They have no coverage. Who is going to pay their medical bills?

Discussion Items 6. The V 3 Health Plan Administration System is scheduled for implementation in ____. 7. All employees, whether benefits eligible or not, are required to have a V 3 HPAS _____ record. 8. Events that allow for coverage changes outside open enrollment periods are called _____ events.

Discussion Items 6. The V 3 Health Plan Administration System is scheduled for implementation in 2007. 7. All employees, whether benefits eligible or not, will be required to have a V 3 HPAS employment record. 8. Events that allow for coverage changes outside open enrollment periods are called qualifying events.

FEATURES OF THE V 3 HPAS

Features of the V 3 HPAS • Provides 24/7 web-based access; Nothing to download; Accessible anywhere; No cost to users • Has ability to allow employees to make selections and changes via the web

Features (continued) • Paperless system • Creates greater empowerment of employers and employees • Creates tiers which are driven by the number and type of dependents a member selects for coverage

Business Rules of SHBP After V 3 HPAS Implementation An administrative error letter to the state cannot get additional time, get an employee enrolled in the plan, or make any changes to the plan.

Discussion Items 9. The V 3 health plan administration system will have web-based access and will be available __ hours per day and _ days per week. 10. Members will have the ability to ______ for coverage, _______ addresses, and make changes based on _____ events.

Discussion Items 9. The V 3 health plan administration system will have web-based access and will be available 24 hours per day and 7 days per week. 10. Members will have the ability to enroll for coverage, update addresses, and make changes based on qualifying events.

Discussion Items 11. If members fail to document a _____, there will be an adjustment of their coverage and there may be an adjustment of their ____ and _______. 12. The new system provides for greater _____ of employers and employees, but the tradeoff is that both must provide _______ information in a ______ manner.

Discussion Items 11. If members fail to document a qualifying event, there will be an adjustment of their coverage and there may be an adjustment of their tier and premium. 12. The new system provides for greater empowerment of employers and employees, but the tradeoff is that both must provide accurate information in a timely manner.

Discussion Items 13. Once the V 3 Health Plan Administration System is implemented, the _______ of the State Health Benefit Plan are programmed into the system. 14. Once a hire date is entered as part of the employee’s record, which it will need to be for the employee to get paid, the ability to make changes or enroll in the plan will terminate in a maximum of __ days.

Discussion Items 13. Once the V 3 Health Plan Administration System is implemented, the business rules of the State Health Benefit Plan are programmed into the system. 14. Once a hire date is entered as part of the employee’s record, which it will need to be for the employee to get paid, the ability to make changes or enroll in the plan will terminate in a maximum of 31 days.

Discussion Items 15. An administrative error letter to the state _____ get additional time, get an employee _______ in the plan, or make any ______ to the plan. 16. The data in the system will remain as is until either a _____ event occurs, or an _________ period begins.

Discussion Items 15. An administrative error letter to the state cannot get additional time, get an employee enrolled in the plan, or make any changes to the plan. 16. The data in the system will remain as is until either a qualifying event occurs, or an open enrollment period begins.

ELIGIBILITY FOR THE SHBP

Employees Eligible to Participate in the Georgia SHBP A full-time employee of: • The State of Georgia • The Georgia General Assembly • An agency, board, commission, department, county administration, or contracting employer eligible by law to participate

Employees Eligible to Participate in the Georgia SHBP (Cont’d) • Certified public school teachers or library employees • Non-certified service employees of a local school system • Employees eligible to participate in public school employees’ retirement system • Retired employees of one of these listed groups • Employees in other groups as defined by law

Employees Not Eligible to Participate in the Georgia SHBP • Student Employees • Short-term Employees • Seasonal Employees • Temporary Employees • Part-time Employees • Emergency Employees

Discussion Items 17. Full-time state employees must work at least __ hours a week consistently and the employment must be expected to last at least _ months to participate in the SHBP. 18. Certified public school teachers or library employees who work half-time must work at least ___ hours per week to participate in the SHBP.

Discussion Items 17. Full-time state employees must work at least 30 hours a week consistently and the employment must be expected to last at least 9 months to participate in the SHBP. 18. Certified public school teachers or library employees who work half-time must work at least 17. 5 hours per week to participate in the SHBP.

Discussion Items 19. Non-certified service employees of a local school system eligible to participate in the Teacher’s Retirement System must work at least __ percent of a standard schedule, but not less than __ hours a week to participate in the SHBP. 20. Retired employees are eligible to participate if they were ____ in the plan at _____ and are eligible to receive an annuity from a statesponsored or state-related retirement system.

Discussion Items 19. Non-certified service employees of a local school system eligible to participate in the Teacher’s Retirement System must work at least 60 percent of a standard schedule, but not less than 20 hours a week to participate in the SHBP. 20. Retired employees are eligible to participate if they were enrolled in the plan at retirement and are eligible to receive an annuity from a statesponsored or state-related retirement system.

Discussion Item 21. Employees not eligible to participate in the Georgia State Health Benefit Plan include _______ employees, _________ employees, and _____ employees.

Discussion Item 21. Employees not eligible to participate in the Georgia State Health Benefit Plan include student employees, seasonal employees, part-time employees, short-term employees, temporary employees, and emergency employees.

Employee Dependents Eligible to Participate in SHBP • The employee’s legally married spouse • Natural or legally adopted children of the employee under age 19 • Stepchildren under age 19 that live with the employee • Other children of employee under age 19 • Continued eligibility of children age 19 or older

Not Eligible for Dependent Coverage • A former spouse (ex-spouse) of the employee • A married child or formerly married child • A child in military service • A child age 19 or older who does not qualify as a fulltime student or is not disabled • A child age 26 or older who is not already covered as a disabled dependent • A parent or grandparent of the employee

Not Eligible for Dependent Coverage (Cont’d) • A fiancé of the employee • A grandchild who cannot be considered an eligible dependent (unless the employee is the legal guardian of his/her grandchild) • A stepchild who does not live in the employee’s home at least 180 days per year • A person living in the home of the employee that is not related by marriage or birth, unless otherwise noted

Discussion Items 22. An employee’s _______ (under Georgia law) spouse is eligible to participate as a dependent in the Georgia State Health Benefit Plan. 23. A natural or legally adopted child over age 19 would not be eligible to participate in SHBP as a dependent if he/she were also eligible for coverage as an ____.

Discussion Items 22. An employee’s legally married (under Georgia law) spouse is eligible to participate as a dependent in the Georgia State Health Benefit Plan. 23. A natural or legally adopted child OVER age 18 would not be eligible to participate in the SHBP as a dependent if he/she were also eligible for coverage as an employee.

Discussion Items 24. Children who are legally adopted through the judicial courts become eligible as a dependent in the SHBP only after they are placed in the employee’s ______. 25. To be eligible for the SHBP, stepchildren under age 19 must ____ with the employee at least ___ days per year and the employee must provide satisfactory _______ they are dependents.

Discussion Items 24. Children who are legally adopted through the judicial courts become eligible as a dependent in the SHBP only after they are placed in the employee’s physical custody. 25. To be eligible for the SHBP, stepchildren under age 19 must live with the employee at least 180 days per year and the employee must provide satisfactory documentation they are dependents.

Discussion Item 26. To be eligible for the SHBP, other children under the age of 19 must live with the employee _____ and depend on the employee for ____ support. The employee must also have a court order, judgment, or other satisfactory proof from a court of competent jurisdiction.

Discussion Item 26. To be eligible for the SHBP, other children under the age of 19 must live with the employee permanently and depend on the employee for financial support. The employee must also have a court order, judgment, or other satisfactory proof from a court of competent jurisdiction.

Discussion Item 27. For continued coverage in the SHBP, all children between the ages of 19 and 26, except disabled children, must be _______ students at accredited institutions and, if employed, are not ____ for a medical benefit plan from their employer.

Discussion Item 27. For continued coverage in the SHBP, all children between the ages of 19 and 26, except disabled children, must be fulltime students at accredited institutions and, if employed, are not eligible for a medical benefit plan from their employer.

RESPONSIBILITIES FOR ADMINISTRATION OF THE SHBP

Responsibilities for Administering the SHBP • Responsibilities of Employers • Responsibilities of Benefits Administrators • Responsibilities of Employees

Current Responsibilities of Employers • Submit membership information • Withhold and submit proper monthly premiums • Enroll all eligible employees in the SHBP, unless employees decline coverage • Provide enrollment information to SHBP administrators • Distribute SHBP materials and hold group meetings at the administrator’s request

Current Responsibilities of Employers (Continued) • Administer the Family and Medical Leave Act (FMLA) and Leave Without Pay • Provide information about continued coverage under FMLA • Provide termination of coverage information • Notify employees of plan amendments

Responsibilities of the Employers’ Benefits Administrators/ Coordinators Under the V 3 • Ensure all of the responsibilities of the employer are fulfilled • Ensure that a demographic record has been established for each employee • Ensure that an employment record has been established for each employee • Ensure the distribution of plan materials • Provide assistance to employees as needed

Discussion Items 28. The employer is the _____, ______, or other ______ for whom the employee works. You are the legal representative of the employer to the employee. 29. If the employer does not send premiums and documentation in a timely manner, the SHBP may suspend _______.

Discussion Items 28. The employer is the department, agency, or other entity for whom the employee works. You are the legal representative of the employer to the employee. 29. If the employer does not send premiums and documentation in a timely manner, the SHBP may suspend coverage.

Discussion Item 30. The employer, via the administrator, has the responsibility to provide all employees with the ______ they need to participate in the SHBP.

Discussion Item 30. The employer, via the administrator, has the responsibility to provide all employees with the information they need to participate in the SHBP.

Discussion Items 31. The employer is responsible for ensuring that the ______ and _____ records have been established in the V 3 HPAS. 32. Due to time constraints programmed into the V 3 HPAS, _______ should remind employees, especially new employees, to make and enter their choice of coverage in a timely fashion. This issue cannot be stressed enough.

Discussion Items 31. The employer is responsible for ensuring that the demographic and employment records have been established in the V 3 HPAS. 32. Due to time constraints programmed into the V 3 HPAS, administrators should remind employees, especially new employees, to make and enter their choice of coverage in a timely fashion. This issue cannot be stressed enough.

Responsibilities of Employees • Make proper and timely premium payments • Make appropriate enrollment choices • Take the time to understand how the SHBP options work. • Know when and how participation can end • Contact the medical certification program (MCP) before undergoing specific treatments or services • Follow prior approval procedures

Responsibilities of Employees (Continued) • Notify the SHBP of an address change • Notify the SHBP if a change in status can affect coverage, or eligibility for coverage, for the employee or a covered dependent • Furnish the SHBP with information required to implement SHBP provisions • Update the SHBP on the status of eligible dependents • Notify the SHBP of Medicare enrollment

Discussion Items 33. Premium payments are usually made through _______ deductions. 34. It’s the _____ responsibility to make sure that the employer is deducting the right amount from their paychecks for their option and coverage plan.

Discussion Items 33. Premium payments are usually made through payroll deductions. 34. It’s the employees’ responsibility to make sure that the employer is deducting the right amount from their paychecks for their option and coverage plan.

Discussion Item 35. After the Open Enrollment Period ends, the SHBP only allows changes when there is a _____ event.

Discussion Item 35. After the Open Enrollment Period ends, the SHBP only allows changes when there is a qualifying event.

Discussion Items 36. _____ are the managers of their health care needs and, therefore, they must take the time to _____ the SHBP choices to make the best decisions. 37. Generally, coverage ends when the employee no longer meets the job _______ or _______-_____ requirements for eligibility. If an employee is terminated, he/she is no longer eligible.

Discussion Items 36. Employees are the managers of their health care needs and, therefore, they must take the time to understand the SHBP choices to make the best decisions. 37. Generally, coverage ends when the employee no longer meets the job classification or working-hours requirements for eligibility. If an employee is terminated, he/she is no longer eligible.

Discussion Items 38. Employees may have to pay penalties, or their claims may be denied if they do not follow ________ rules. 39. An employee should notify the SHBP if a change in status can affect ____, or ______ for coverage, for the employee or a covered _____.

Discussion Items 38. Employees may have to pay penalties, or their claims may be denied if they do not follow precertification rules. 39. An employee should notify the SHBP if a change in status can affect coverage, or eligibility for coverage, for the employee or a covered dependent.

Discussion Item 40. Coverage won’t continue automatically after an eligible dependent turns 19 – the employee must _______ it.

Discussion Item 40. Coverage won’t continue automatically after an eligible dependent turns 19 – the employee must request it.

PROCESS CHANGES

Review Current Processes • Evaluate current process flow • Analyze timeliness issues • Take immediate action – Clean ups • Obtain acceptance – Model positive attitude • Identify system issues

Processing a New Employee Under the V 3 System • Establish demographic record • Establish employment record • Notify employee of their ability to access system and enroll in coverage • Remind employee of 31 -day window • Verify demographic data • Enroll in coverage

Demographic Data Needed for Enrolling New Employees • • • Name of employee Social Security Number Date of hire Date of birth Gender Benefits eligibility status

A Few Suggestions From Previous Sessions • Computers in the reception area • Disclaimers on any forms that you wish to keep • Pre-addressed envelopes for employees to mail in documents • Instruction sheets for employees on how to access their information • Email, posters • Things to remind employees about: retirement annuity v lump sum, full-time student paperwork, maternity leave update, getting information to SHBP…. .

Discussion Items 41. ___ employees should be setup in the V 3 HPAS. 42. ________________ will have access to a Web site where they can enter the required information about a new employee in the V 3 HPAS.

Discussion Items 41. All employees should be setup in the V 3 HPAS. 42. Benefits Administrators/ Coordinators will have access to a Web site where they can enter the required information about a new employee in the V 3 HPAS.

Discussion Items 43. The new _____ record is established by identifying a specific member as employed and benefits eligible or ineligible for a given payroll location. 44. After new employees are setup in the V 3 HPAS with demographic and employment records, employees will be able to logon initially using their ________ Number, ____ name, and date of _____.

Discussion Items 43. The new employment record is established by identifying a specific member as employed and benefits eligible or ineligible for a given payroll location. 44. After new employees are setup in the V 3 HPAS with demographic and employment records, employees will be able to logon initially using their Social Security Number, last name, and date of birth.

Discussion Items 45. New employees have __ days from hire/eligibility date to enroll in coverage or decline coverage in the SHBP. 46. Employees can make changes to their choice of coverage in the SHBP as many times as they wish inside the 31 -day window. The ____ change made will be recognized as the election at the end of the 31 days.

Discussion Items 45. New employees have 31 days from hire/eligibility date to enroll in coverage or decline coverage in the SHBP. 46. Employees can make changes to their choice of coverage in the SHBP as many times as they wish inside the 31 -day window. The last change made will be recognized as the election at the end of the 31 days.

Discussion Item 47. How are employment records established? _______________

Discussion Item 47. How are employment records established? Manual entry Payroll interface

Processing Miscellaneous Data Updates • Recognize the paperless environment • Employees go online to request a qualifying event change in their coverage • Employees go online to prevent dependent coverage expiration – Highlight age 19

Elimination of Forms • Utilize verification documents only • Allow forms within payroll locations • Reflect process changes

Discussion Items 48. The implementation of the V 3 HPAS creates a more _____ environment and relies on ______ documents instead of forms. 49. Employees should be directed to the V 3 HPAS Website to perform necessary demographic _______ or _______.

Discussion Items 48. The implementation of the V 3 HPAS creates a more paperless environment and relies on verification documents instead of forms. 49. Employees should be directed to the V 3 HPAS Website to perform necessary demographic changes or updates.

Discussion Items 50. Letters are mailed to members with a dependent whose coverage is about to expire. Letters are generated __ days prior to coverage expiration and again at __ days prior to expiration. 51. Appropriate _______ for dependents receiving coverage past age 19 must be provided prior to coverage expiration for coverage in the SHBP to ____.

Discussion Items 50. Letters are mailed to members with a dependent whose coverage is about to expire. Letters are generated 90 days prior to coverage expiration and again at 45 days prior to expiration. 51. Appropriate documentation for dependents receiving coverage past age 19 must be provided prior to coverage expiration for coverage in the SHBP to continue.

Discussion Items 52. The forms specified in Procedure 60 U 020 and Procedure 60 -U 200 are no longer ______, nor will be ____ by the SHBP after the implementation of the V 3 HPAS, only ______ documents. 53. Forms used ______ payroll locations for documenting employee responsibilities, insurance acknowledgement, etc. , may continue to be utilized.

Discussion Items 52. The forms specified in Procedure 60 U 020 and Procedure 60 -U 200 are no longer needed, nor will be accepted by the SHBP after the implementation of the V 3 HPAS, only verification documents. 53. Forms used within payroll locations for documenting employee responsibilities, insurance acknowledgement, etc. , may continue to be utilized.

QUALIFYING EVENTS

Qualifying Events That Allow Coverage Changes Outside Open Enrollment Periods • The employee gets married • The employee gains dependents by birth, adoption, or legal guardianship • The employee gets divorced • The employee or dependent loses other coverage • The employee acquires new coverage under a spouse’s employer’s plan

Qualifying Events That Allow Coverage Changes Outside Open Enrollment Periods (Cont’d) • The employee, spouse, or enrolled dependent loses or discontinues coverage from other employment, Medicaid, or Medicare • The spouse or only enrolled dependent’s employment status changes, resulting in a gain of coverage under a qualified plan • A former spouse loses coverage, resulting in loss of the employee’s dependent’s coverage

Qualifying Events That Allow Coverage Changes Outside Open Enrollment Periods (Cont’d) • A spouse makes an open enrollment change under their employer’s plan, creating an overlap or break in coverage because the spouse’s coverage has a different plan year • The employee, spouse, or enrolled dependent moves out of the employee’s HMO option’s approval service area • The employee’s HMO goes out of operation

Qualifying Events That Allow Coverage Changes Outside Open Enrollment Periods (Cont’d) • The employee or spouse is activated/ deactivated into military/reservist service • The employee retires and immediately qualifies for a retirement annuity • The employee, spouse, or all enrolled dependents become eligible for Medicare or Medicaid

Other Events That Impact Coverage • • • Qualified medical child support orders Unpaid leaves of absence Approved disability leave Family and medical leave act (FMLA) Continuing coverage during military leave Dependent coverage at active employee’s death • COBRA continuation coverage

Steps to Contine Coverage During Approved Leave of Absence Without Pay (LWOP) • Determination of employee’s eligibility for LWOP is responsibility of employing entity • SHBP will audit the determination of the employing entity • Employing entity responsible for updating the employee’s employment record • Report status of employee to SHBP within ten (10) working days of last payroll deduction—Employee will be billed by SHBP.

Conditions and Requirements for Continuation of Health Benefits During LWOP • Disability leave • Reduced working hours due to partial disability • Educational leave • Military leave • Suspension or other leave of absence • Employer’s convenience leave • Family medical leave

Discussion Items 54. Qualifying events require the ____ to submit ______ documents directly to the SHPB. Benefits administrators will not be involved in this process. 55. Verification documents cannot be _____, or _____to the SHPB.

Discussion Items 54. Qualifying events require the employee to submit verification documents directly to the SHPB. Benefits administrators will not be involved in this process. 55. Verification documents cannot be faxed, emailed, or phoned in to the SHPB.

Discussion Items 56. LWOP qualifying conditions have ___ changed. Administration of the LWOP has shifted authority to grant LWOP to the _______. 57. Employees on LWOP will be ______ by the SHBP for their premiums.

Discussion Items 56. LWOP qualifying conditions have not changed. Administration of the LWOP has shifted authority to grant LWOP to the employing entity. 57. Employees on LWOP will be billed by the SHBP for their premiums.

IN CONCLUSION….

Issues to Review and Remember • Create employee’s demographic and employment record ASAP • Employees are much more responsible for their choices in a timely and appropriate manner • State will not accept paper enrollment forms!

• • Next Steps Update your process now Clean up errors in balances Create positive change environment Attend technical training sessions Read “Partners” newsletter Avoid personal liability Keep an open mind Promote a positive attitude

Contact Information for the Georgia Department of Community Health State Health Benefits Plan • 404 -656 -6322 • 800 -610 -1863 • www. dch. georgia. gov/shbp

The answers to all of the discussion items are in sequential order located in the back of this book.

Thank You! • Please turn in the evaluations before you leave • Your time and attention is appreciated • I applaud your participation