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NATIVE AMERICAN SCHOOLS HEALTH & WELFARE TRUST SELF FUNDING OVERVIEW ELIGIBILITY ENROLLMENT EFFECTIVE DATE TERMINIATION BILLING ADJUSTMENTS APPROVED.

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Presentation on theme: "NATIVE AMERICAN SCHOOLS HEALTH & WELFARE TRUST SELF FUNDING OVERVIEW ELIGIBILITY ENROLLMENT EFFECTIVE DATE TERMINIATION BILLING ADJUSTMENTS APPROVED."— Presentation transcript:

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2 NATIVE AMERICAN SCHOOLS HEALTH & WELFARE TRUST

3 SELF FUNDING OVERVIEW ELIGIBILITY ENROLLMENT EFFECTIVE DATE TERMINIATION BILLING ADJUSTMENTS APPROVED LEAVE

4 How does Self-Funding Work? Contributions Administration Claims Employer’s General Assets Employee Benefit Plan Fixed Costs Actual Claims

5 Claims Flow Employee Doctor Visit Payment Claim Your Contributions Your Contributions

6 Native American Schools Health Plan© EFFECTIVE JULY 1, 2011 Maximum Benefit While Covered By this Plan $1,000,000 Unlimited Maximum Benefit Per Benefit Year$1,000,000 /\ Summit

7 Stop Loss Specific Deductible Specific Deductible

8 /\ Summit Eligibility Criteria - Employee Generally employees must work 20 hours or more per workweek. Understand that this does not apply to summer or scheduled breaks during school.

9 /\ Summit Eligibility Criteria – Dependent Spouse 1.Legal Spouse (State Law) 2.Common Law Spouse provided it meets legal requirements of Navajo Nation.

10 /\ Summit Eligibility Criteria – Dependent Child 1.Employee’s child to age 26: a.Natural child, b.Step child, c.Legally adopted child, d.Foster Child, e. Guardian: a)Not Power of Attorney b)Legal guardianship through courts -Emancipation at age 18 -To age 26, court document must decree 2Qualified Medical Child Support Order (QMCSO) 3.Disabled child over age 26—must provide proof every 2 years.

11 Eligibility Criteria – Dependent Child PRIOR TO PPACA, PLAN REQUIREMENTS FOR DEPENDENT CHILD a)Lives with the employee b)Unmarried; c)To age 19; d)If Full-time student, then to age 24 NO LONGER IN EFFECT /\ Summit

12 Eligibility Criteria – Dependent Dependent child does NOT include : 1.grandchildren 2.niece or nephew Unless legal guardian

13 /\ Summit Enrollment Timeline Employee— a. New employee: within 31 days b. annual “Open Enrollment” Dependent— a. at the time of employee enrollment, or b. within 31 days of dependent acquisition c. annual “Open Enrollment” APPLIES UNTIL NEXT OPEN ENROLLMENT

14 /\ Summit Open Enrollment –Employee not previously enrolled to enroll for coverage –Dependents not previously enrolled to enroll for coverage –Enrolled dependents to be dropped from coverage –Enrollment elections apply until next open enrollment

15 /\ Summit HIPAA Special Enrollment HIPAA Special Enrollment Period. i. O ther coverage ii. Dependent acquisition iii.Enroll within 31 days of the event iv. CHIPS—60 day enrollment

16 /\ Summit Special Enrollment HIPAA Special Enrollment Period – - Other Coverage i. Termination of the other coverage, including COBRA. ii. Cessation of employer contributions toward the other coverage. iii. Legal separation or divorce. iv. Termination of other employment or reduction in hours. v. Death of the covered person. Enroll within 31 days of the event

17 /\ Summit Special Enrollment HIPAA Special Enrollment Period - Dependent Acquisition i. Marriage ii. Birth of a dependent child. iii. Adoption of a child Enroll within 31 days of the event

18 SPECIAL ENROLLMENT HIPAA Special Enrollment Period CHIP –Termination of Medicaid or CHIP Coverage –Eligibility For Premium Assistance Under Medicaid or CHIP –Enroll within 60 days /\ Summit

19 Enrollment Form to Summit Options: –Fax: – –On-line enrollment: –Snail Mail: P. O. Box 25160, Scottsdale, AZ Retain enrollment form in Personnel file –Compare to next billing ensuring employee is enrolled in the Plan Issue ID card to employee

20 Life Insurance Enrollment Life Insurance Enrollment is done on- line with Lincoln National Summit DOES NOT do Life Insurance enrollments /\ Summit

21 Effective Date of Coverage Employee—1 st of month following date of hire. Dependents, provided enrolled timely: –Date employee coverage is effective –Date dependent is acquired –Date adopted child is “placed for adoption” –Newborn Employee has family coverage = birth Employee has single coverage = birth, provided enrollment form is submitted within 31 days of birth

22 /\ Summit Termination of Coverage Employee: The last day of the month in which the employee CEASES TO MEET THE ELIGIBILITY CRITERIA. Note: this does not necessarily mean the employee terminates EMPLOYMENT.

23 /\ Summit Certified & Contracted Employees: Termination of Coverage  Certified or contracted employee  Signed the contract for next school year  School’s Health Plan provides coverage through the summer months.  The school continues to pay for employee coverage.

24 Termination of Coverage Certified & Contracted Employees /\ Summit  Don’t terminate teachers that are returning next school year!  Keep them on the Health Plan.  Contributions for dependent’s coverage through the summer needs to be addressed through payroll.

25 /\ Summit Termination of Coverage Dependents: - The date an employee’s coverage terminates. - The date the person ceases to meet the eligibility criteria. 1.Spouse: Divorce or legal separation. 2.Child: Reaches the maximum age limit.

26 /\ Summit Termination Notice to Summit Options: –Pull original enrollment form & note bottom with termination information Date of termination Reason for termination (necessary for COBRA) –On-line access: –Notation on corrected census noting termination date

27 /\ Summit Termination Notice to Summit Under Federal law, COBRA: Employer: 30 days to notify Summit –Notify Summit if due to “Gross Misconduct” Summit: 14 days to provide COBRA election Failure to provide timely notice: –could result in litigation and/or penalties –potential claims payments

28 /\ Summit BILLING ADJUSTMENTS New Enrollment/Billing If new employee is not on the billing: –Refax enrollment with notation “2 nd submission” –Be aware of the “window” Date of billing census vs. date enrollment sent –Adjust the count on the bill to include employee

29 /\ Summit BILLING ADJUSTMENTS Termination Notice/Billing  Compare the termination notice(s) sent to Summit to next billing  If term’d employee is still on the bill: –Be aware of the “window” –Make the # count adjustment on the bill –Provide documentation to Summit for the adjustment with the check. –Resubmit term notice with “2 nd submission

30 /\ Summit BILLING ADJUSTMENTS Dependent Enrollment Audit  October billing/census will include all dependents covered by the employee  Verify against your records  Coordinate with Summit for corrections

31 /\ Summit Leave of Absence Provisions Conditions that allow continued coverage under the Plan after loss of eligibility: a. Administrative Leave b. Family Medical Leave Act (FMLA) c. Leave of Absence (LOA)

32 /\ Summit Administrative Leave Coverage continued for enrolled employee and enrolled dependents School pays applicable contributions Coverage continues until investigation is closed If administrative action is suspension, coverage for 30 days of suspension.

33 /\ Summit Leave of Absence (FMLA) Employee must have worked for 1,250 hours in the preceding 12 months to be eligible for Leave of Absence under FMLA. Employee must request leave under FMLA.

34 /\ Summit Reason for leave must comply with FMLA criteria. i. “ Serious health condition” ii. For self iii. For immediate family members Leave of Absence (FMLA)

35 /\ Summit  Employee remains covered under the health plan while on FMLA.  Employer pays the employee’s health plan contribution while employee is on FMLA leave. Leave of Absence (FMLA)   Employee is granted leave of absence

36 /\ Summit Leave of Absence (FMLA)   Serious Health Condition = 12 weeks   Military Caregiver Leave = 26 weeks   Qualifying Exigency = 12 work weeks

37 Leave of Absence (FMLA) /\ Summit  Employee returns to work or is terminated from the Plan.  Last day of FMLA is qualifying event for COBRA.

38 /\ Summit Leave of Absence, Regular   When employee does not qualify for FMLA   May be granted or denied LOA   Generally, employee pays the cost of health plan coverage After 90 days of leave, the employee returns to work or is terminated from the Plan.

39 /\ Summit The 90 days coverage under the Plan while on Regular Leave of Absence, applies to the maximum allowable coverage duration under COBRA. Leave of Absence, Regular If an employee is terminated from the Plan, COBRA is offered.

40 /\ Summit Employee was on leave for 90 days (3 months). Employee elects COBRA. Due to termination of employment, COBRA is offered for 18 months. Three months have already been used, leaving 15 months of COBRA continuation of coverage. Leave of Absence, RegularExample

41 /\ Summit Coordinating Paid Time Off with FMLA or Regular Leave Each employer establishes the guidelines. Variables include:  Requirement for employees to use up all available Paid Time Off before going on either FMLA or LOA  Allow an employee to use PTO concurrently with FMLA/LOA

42 Claims Flow Employee Doctor Visit Payment Claim Your Contributions Your Contributions

43 Native American Schools Health Plan© EFFECTIVE JULY 1, 2011 Maximum Benefit While Covered By this Plan $1,000,000 Unlimited Maximum Benefit Per Benefit Year$1,000,000 /\ Summit

44 Stop Loss Specific Deductible Specific Deductible

45 SELF FUNDING OVERVIEW ELIGIBILITY ENROLLMENT EFFECTIVE DATE TERMINIATION BILLING ADJUSTMENTS APPROVED LEAVE


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