State of GeorgiaDepartment of Community

HealthState Health Benefit Plan

Benefits Administration TrainingA.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 V3 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 V3 will interface with the payroll location

4. Demographic/Employment Record: The V3 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 V3 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 V3. 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 pre-certification process.

8. Interface: The interaction of two computer systems. The V3 will interface with the payroll location, but the payroll system may interface with other systems in the employers’ HR offices.

Glossary Items9. 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 V3 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 V3 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 V3 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 V3 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 V3 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 V3 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 V3 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 V3 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 V3 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 V3 Health Plan Administration

System is scheduled for implementation in ____.

7. All employees, whether benefits eligible or not, are required to have a V3 HPAS __________ record.

8. Events that allow for coverage changes outside open enrollment periods are called __________ events.

Discussion Items 6. The V3 Health Plan Administration

System is scheduled for implementation in 2007.

7. All employees, whether benefits eligible or not, will be required to have a V3 HPAS employment record.

8. Events that allow for coverage changes outside open enrollment periods are called qualifying events.

FEATURESOF THE V3 HPAS

Features of the V3 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 V3 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 Items9. The V3 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 Items9. The V3 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 Items11.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 Items11.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 Items13.Once the V3 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 Items13.Once the V3 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 Items15.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 Items15.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

• Seasonal Employees

• Part-time Employees

• Short-term Employees

• Temporary Employees

• Emergency Employees

Discussion Items17.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 Items17.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 Items19.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 state-sponsored or state-related retirement system.

Discussion Items19.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 state-sponsored or state-related retirement system.

Discussion Item21.Employees not eligible to participate in

the Georgia State Health Benefit Plan include _______ employees, _________ employees, _________ employees, __________ employees, _________ employees, and _________ employees.

Discussion Item21.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 Items24.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 Items24.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 Item26.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 Item26.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 Item27.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 Item27.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 V3• 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 Items28.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 Items28.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 Items31.The employer is responsible for ensuring

that the ___________ and __________ records have been established in the V3 HPAS.

32.Due to time constraints programmed into the V3 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 Items31.The employer is responsible for ensuring

that the demographic and employment records have been established in the V3 HPAS.

32.Due to time constraints programmed into the V3 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 Item35.After the Open Enrollment Period ends,

the SHBP only allows changes when there is a __________ event.

Discussion Item35.After the Open Enrollment Period ends,

the SHBP only allows changes when there is a qualifying event.

Discussion Items36._________ 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 Items36.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 V3 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, mail, 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 V3 HPAS.

42._______ ________________________ will have access to a Web site where they can enter the required information about a new employee in the V3 HPAS.

Discussion Items

41.All employees should be setup in the V3 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 V3 HPAS.

Discussion Items43.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 V3 HPAS with demographic and employment records, employees will be able to logon initially using their ______ ________ Number, ____ name, and date of _____.

Discussion Items43.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 V3 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 V3 HPAS creates a more _________ environment and relies on ____________ documents instead of forms.

49.Employees should be directed to the V3 HPAS Website to perform necessary demographic _______ or _______.

Discussion Items

48.The implementation of the V3 HPAS creates a more paperless environment and relies on verification documents instead of forms.

49.Employees should be directed to the V3 HPAS Website to perform necessary demographic changes or updates.

Discussion Items50.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 Items50.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-U020 and Procedure 60-U200 are no longer ______, nor will be ________ by the SHBP after the implementation of the V3 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-U020 and Procedure 60-U200 are no longer needed, nor will be accepted by the SHBP after the implementation of the V3 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