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DC / VIRGINIA GROUP ELIGIBILTY
A Small Employer Group
Eligibility tool for CareFirst
products sold in the District
of Columbia and Virginia
Broker Manual
>
Welcome
This manual was last revised on April 1, 2014.
To: CareFirst Distributors
This Small Employer Group Eligibility Manual was developed to educate and assist you in selling all
CareFirst products sold in the State of Virginia and the District of Columbia.
Many of you who have participated in previous training sessions may be familiar with this document; for
some of you, this may be your first exposure to CareFirst’s Small Group Eligibility Manual. Regardless of
which category you fall into, this reference manual should be utilized by you on an ongoing basis to assist
you in both new business and renewal sales; grandfathered and ACA compliant products. Additionally,
changes and additions have been shaded to assist you.
This manual was originally released in September 1997 and has now been revised to include many new
sections and to incorporate the guidelines associated with selling all of our small group products in Virginia
and the District of Columbia. We hope that the additional information will be of value to you and will help
facilitate more efficient writing of both new business and renewal sales.
With the 2014 implementation of the Affordable Care Act, additional State and Federal legislation has been
implemented that has modified the original document. CareFirst has also implemented internal changes
regarding our small group business policies. Lastly, some of our groups elected to remain “grandfathered,”
in their pre ACA benefits and rating structure; therefore, you will see sections of the manual identified
as such to assist you as you address your clients’ questions. Note that all new groups may not be sold
“grandfathered” products and must adhere to the ACA rules and rating methodology.
Every effort has been made to ensure that the information is complete and accurate. The information
provided in this manual is based on the CareFirst interpretation of State and Federal legislation in addition
to CareFirst Sales and Underwriting policies and guidelines. Further detail on any section of the Manual can
be found in the Sales Flash communications that we have relied on for many years or from your assigned
CareFirst Broker Sales Representative. Because so much information is being released based on the
implementation for ACA, policy may change during the year; when this occurs we will make every effort to
keep this document current.
We believe that the information here will provide you with the basics to successfully prospect and sell any
small group account in Virginia and the District of Columbia and to then retain and renew that business.
Please review all sections carefully, as our guidelines will vary at times, based on the product sold.
As our appointed and contracted Distributors, your continued support and adherence to our policies and
guidelines is appreciated. Any questions regarding the information contained within this manual should be
directed to your assigned General/Full Service Producer or your CareFirst Broker Representative.
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Table of Contents
If you are viewing this file online (PDF format), BOOKMARKS have been added
which link to the page being referenced.
■■ Click on the BOOKMARKS tab in the left-hand navigator pane to view.
■■ Click the plus sign (+) to expand sub-categories.
■■ Click the topic to be linked to the page referenced.
CareFirst Product Offerings................................... 1
Continuation of Coverage.................................... 32
Defined Geographic Regions................................. 3
COBRA (Consolidated Omnibus Budget
Reconciliation Act of 1986)................................. 33
DC Market Rules.................................................... 4
Doing Business with CareFirst.............................. 5
Keeping You Informed........................................... 7
Connecting with CareFirst..................................... 8
Contacts................................................................ 9
Calendar Year vs.
Contract Year Benefit Periods............................. 11
Enrolling Eligible Dependents............................. 34
Multiple Option Offerings................................... 37
Movement Between Products............................. 38
Consumer Driven Health Products (CDH)............ 39
Small Group Rating............................................. 40
New Business...................................................... 42
Deductible Credit................................................. 12
Requesting a Quote............................................. 43
Deductible Carryover........................................... 13
New Group Paperwork........................................ 44
Determination of Group Size ACA-Compliant...... 14
Renewal Business............................................... 45
Determination of Group Size Grandfathered....... 15
Existing Groups that Move Their Headquarters
Outside of MD, DC, N. VA.................................... 47
Group Eligibility for ACA-Compliant Small Group
Benefits............................................................... 16
Group Eligibility For Grandfathered Small Group
Benefits............................................................... 17
Retirees, Part-time Employees and Full-time
Employees with Other Coverage: Grandfathered
Products Only...................................................... 19
Request for Anniversary Date Change................ 48
Contract Issuance................................................ 49
Matrix: Eligibility, Rating & Participation........... 50
Medicare Eligibility, Rating And Participation for
“Grandfathered” Products Only.......................... 52
Medicare Retirees and Eligibles: ACA-Compliant
Products.............................................................. 20
Dental Benefits.................................................... 55
Segment Eligibility Effective 1/1/14................... 21
DC/VA Product Portfolio...................................... 59
Affiliated Companies........................................... 22
DC and VA Group Contract
Application Matrices........................................... 60
Account Eligibility Verification............................ 25
Tax Documentation.............................................. 26
Husband/Wife Businesses.................................. 28
Enrolling Eligible Employees............................... 29
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Vision Benefits.................................................... 58
Highlights of Small Group Legislation—
DC, VA, Federal.................................................... 64
District of Columbia......................................... 64
Virginia............................................................ 65
Federal............................................................. 67
CONTENTS
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CareFirst Product Offerings
CareFirst, Inc. is made-up of several subsidiaries
that are licensed separately and as such are
viewed as separate carriers by the Insurance
Divisions. However, for new sales bonus and
Broker of Record transfer requirement purposes,
any business in these subsidiaries is considered
“existing CareFirst business.” Various products are
offered through each CareFirst carrier as shown in
the chart below:
Medical/Dental/Vision Products Effective 1/1/14
Group Hospitalization and Medical
Services, Inc. (GHMSI)
CareFirst BlueChoice, Inc.
BluePreferred PPO
BlueChoice HMO Referral
BluePreferred PPO HSA/HRA
BlueChoice HMO
Select Preferred Provider Plan (SPPP)*
BlueChoice HMO Opt-Out Open Access*
BlueChoice Opt-Out Plus Open Access*
BlueChoice HMO HSA/HRA
BlueChoice Plus
BlueChoice Plus
BlueChoice Plus HSA/HRA
BlueChoice Plus HSA/HRA
BlueChoice Advantage
BlueChoice Advantage
BlueChoice Advantage HSA/HRA
BlueChoice Advantage HSA/HRA
HealthyBlue HMO
HealthyBlue HMO HSA/HRA
HealthyBlue PPO
HealthyBlue PPO HSA/HRA
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CareFirst Product Offerings (continued)
Group Hospitalization and Medical
Services, Inc. (GHMSI)
CareFirst BlueChoice, Inc.
HealthyBlue Plus
HealthyBlue Plus
HealthyBlue Plus HSA/HRA
HealthyBlue Plus HSA/HRA
HealthyBlue Advantage
HealthyBlue Advantage
HealthyBlue Advantage HSA/HRA
HealthyBlue Advantage HSA/HRA
DHMO Ridered Parallel Dental*
Traditional Ridered Parallel Dental*
Preferred Ridered Parallel Dental*
BlueVision Plus Ridered Parallel Vision
*Available to “grandfathered” groups only.
Note that:
HealthyBlue Advantage CDH cannot be offered with BlueChoice Plus, Blue Choice Plus CDH
HealthyBlue Advantage non-CDH cannot be offered with BlueChoice Plus, BlueChoice Plus CDH
BlueChoice Advantage CDH cannot be offered with BlueChoice Plus, BlueChoice Plus CDH
BlueChoice Advantage non-CDH cannot be offered with BlueChoice Plus, BlueChoice Plus CDH
A broker can determine in which Legal Entity a prospect/group is being quoted by the Plan Code noted on the
proposal (listed under the product name)
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■■
B in the 5th position = GHMSI C in the 5th position = BlueChoice
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Defined Geographic Regions
CareFirst Marketing Sales Area
District of Columbia, Maryland and the
Commonwealth of Virginia, the cities of Alexandria
and Falls Church, the counties of Arlington and the
portion of Fairfax east of Route 123 including the
incorporated limits of Fairfax City and the town
of Vienna in their entirety. (Helpful hint: use the
BCBS website (www.bcbs.com) to determine the
appropriate BlueCross BlueShield plan.)
The zip codes that are split by Route 123 are (refer
to map):
■■ Fairfax County: 22030, 22039, 22079, 22101,
22102, 22124, 22180, 22181, 22182, 22191,
22192
■■ Prince William County: 22125, 22191, 22192
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DC Market Rules
Beginning January 1, 2014 any District of Columbia
small employer group not currently offering group
health benefits that then elects to offer group
health benefits must purchase those benefits
through the DC Health Link (SHOP).
Beginning January 1, 2015 any small employer
group offering group health benefits must
purchase or renew on the DC Health Link (SHOP).
Any new small group sale or small group renewal
effective 1/1/15 must go through the DCHL.
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Doing Business with CareFirst
CareFirst products are sold through brokers who
are contracted with us directly and/or through a
General Producer (GP)/Full-Service Producer (FSP).
It is important for all distributors selling CareFirst
products to understand their role in the sales
process in order to efficiently service our members.
Please use the following details as a guideline for
selling CareFirst products:
The role of the CareFirst Broker Sales
Representative is to educate the General Producer
(GP) and their staff on CareFirst products and
procedures.
The role of the Full-Service Producer (FSP):
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The role of the General Producer (GP):
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Establish and maintain compliance with all
regulatory requirements
Assist with contracting and appointment of
brokers
Provide brokers with rate quotes for new groups
and alternative options for existing groups
Gather, review, and submit all paperwork
required for new group enrollment, off-cycle
benefit changes and renewals
Provide brokers with marketing/sales materials
and literature
Distribute renewals to brokers and groups
Submit/upload complete and accurate
paperwork to CareFirst via Broker Express
by the deadlines established in the Account
Installation (AI) Calendar (Broker/Agent
Administrative Manual)
Assist brokers with benefits and eligibility
questions
Assist with the Quote to Bill Process: customer
service, CareFirst Connect, enrollment and
billing issues
Distribute CareFirst Broker Sales Flashes to
their brokers
The General Producer (GP) is also responsible
for educating brokers and their staff on the
requirements for new group and benefit change
submissions. In addition, the General Producer
(GP) is expected to hold broker training sessions
on CareFirst products, enrollment eligibility
requirements and other important topics. CareFirst
Representatives also attend these sessions to
assist and answer questions.
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Establish and maintain compliance with all
regulatory requirements
Assist with contracting and appointment of
brokers
Provide brokers with rate quotes for new groups
and alternative options for existing groups
Gather, review, and submit all paperwork
required for new group enrollment, off-cycle
benefit changes and renewals
Provide brokers with marketing/sales materials
and literature
Distribute renewals to brokers and groups
Submit complete and accurate paperwork to
CareFirst via Broker Express by the deadlines
established in the Account Installation Calendar
(Broker/Agent Administrative Manual)
Assist brokers with benefits and eligibility
questions
Distribute CareFirst Broker Sales Flashes to
their brokers
Bill and collect premiums for groups
Send termination notices to groups and brokers
Update and maintain enrollment records,
service accounts and members regarding billing,
enrollment and customer service issues
The CareFirst Broker Sales Representative is
responsible for assisting the Full-Service Producer
with broker training sessions. In addition, they
are responsible for training and educating the
Full-Service Producer on all changes and updates
related to doing business with CareFirst.
CONTENTS
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Doing Business with CareFirst (continued)
The role of the CareFirst Representative for
the Direct Broker is:
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Establish and maintain compliance with all
regulatory requirements
Provide training on CareFirst Products and policies
Provide training on the CareFirst Quote to Bill
process
Assist in new sales and renewals
Assist with enrollment meetings (groups with 25 or
more enrollees)
Provide materials necessary to sell and renew
CareFirst products
Maintain a positive relationship with all brokers
Assist with benefit and eligibility questions
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Keeping You Informed
CareFirst BlueCross BlueShield strives to keep our
broker community informed. Timely updates result
in better service to our accounts and members.
Information and product updates are available as
described below.
Broker Sales Flash
The CareFirst Sales Flash covers a variety of
sales-related topics including product updates,
administrative matters, application and form
changes, among many other subjects. The Sales
Flash is market-specific and is distributed on a
weekly basis via email. In addition, Sales Flashes
are available on www.carefirst.com via the Broker
& Agents portal. General/Full Service Producers
are responsible for providing brokers with Sales
Flash information. Direct Brokers can contact their
Broker Sales Representative to be added to the
distribution list to receive the Sales Flash directly
from CareFirst.
Broker Forums
Broker forums are held to keep brokers informed
of CareFirst product initiatives and enhancements,
pricing updates and other sales related
information. These forums are generally held on an
annual basis and brokers are notified in advance
by invitation.
Broker Council
The CareFirst Broker Council is comprised
of approximately twenty experienced health
insurance brokers representing Maryland, DC and
Northern Virginia. New members are appointed to
the Council each year. The Council meets quarterly
and provides the opportunity for members of
the Council to discuss issues and concerns in the
broker community. The Broker Council represents
CareFirst’s entire distributor networks. We strongly
encourage brokers to contact any member of the
Broker Council with any questions, comments or
concerns. To request a copy of the list of Council
members, please contact your Broker Sales
Representative.
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Connecting with CareFirst
General Producer(s) (GP), Full-Service Producer(s)
(FSP) or Direct Brokers doing business with our
DC location, may contact our Sales Associates at
202-479-8595 or toll-free at 877-315-2254.
The Broker Sales email address is:
brokersales4@CareFirst.com and the DC fax
number is 301-470-8049.
Brokers working with a General/Full-Service
Producer should not use this email address or
RightFax number; instead, they should contact
their General/Full-Service Producer directly.
Direct Brokers only:
As part of the workflow process, all paperwork
should be submitted via Broker Express for new
and renewing business. Please send the following
requests to the above-stated email address or the
DC fax number:
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■■
Signed renewals
Benefit booklet & group contract requests for
existing groups (please allow 6–8 weeks
for shipment)
Group updates (i.e. address change, group
administrator, enrollment eligibility)
Group cancellation letters
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Contacts
Broker Customer Service
Brokercustomerservice@carefirst.com
1-888-4CF-BRKRS (423-2757)
Consumer Driven Health (CDH):
CDH.Service@carefirst.com 1-888-755-2656
Billing Enrollment and ID Card Inquiries
Group Enrollment:
Group Enrollment Fax (including subsidy paperwork):
Billing & Collections (Invoices)
Group Conversion 202-479-2730
301-470-7604
1-888-232-2335
1-888-567-9155
BluePreferred Member Services
Monday-Friday 7:00am – 7:00pm
Pre-Authorization
Toll Free (800) 321-3497
TTY 202-479-3546
1-866-773-2884
Bluechoice Member Services
Monday-Friday 7:00am – 7:00pm Pre-Authorization
Toll Free (866) 520-6099
TTY 1-800-828-3196
1-866-773-2884
HealthyBlue Member Services
Monday-Friday 7:00am – 7:00pm
1-866-452-2217
When writing to CareFirst BlueCross BlueShield, always include the Member Identification Number and
group number. Please address your correspondence to:
CareFirst BlueCross BlueShield
P.O. Box 14114
Lexington, KY 40512-4114
HealthFitness
Monday-Friday 8:00am – 8:00pm
1-866-454-5375
Additional Contacts
CareFirst Connect Command Center
carefirstconnect@benefitfocus.com
1-888-323-4595
CareFirst Connect Retroactive Enrollment Requests
cfconnect@carefirst.com
BlueVision (Davis Vision)
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1-800-783-5602
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Contacts (continued)
FirstHelp (24 hour Emergency Assistance)
1-800-535-9700
CVS CareMark (Rx Services)
1-800-241-3371
Dental Benefits
1-866-891-2802
The Dental Network 410-847-9060 / 1-888-833-8464
CareFirst Switchboard (DC location)
202-479-8000
Individual Sales
410-356-8000 / 1-800-544-8703
Commission Information / Broker Accounting
Group
Individual
410-998-6718
410-998-7187
Broker Contracting and Compliance
BCC@carefirst.com
410-998-6919
Contract and Evidence of Coverage Booklets requests
Contract.Booklets@CareFirst.com
BlueCard® Provider Information
1-800-810-BLUE (2583)
Magellan Mental Health Services
1-800-245-7013
PayFlex
301-530-9400 / 1-866-208-8587
HFS Benefits
www.hfsbenefits.com
410-771-1331 / 1-888-460-8005
Broker Portal and Broker Express Help Desk Broker.support@carefirst.com
877-526-8390
My Account
Members have the capability to check the status of their medical claims history, covered members, eligibility,
benefits and e-mail questions to customer service through “My Account” located in the Members & Visitors
section of www.carefirst.com.
Members will need their ID number or SSN to register for “My Account.” Due to changes in state and federal
privacy rules, adult dependents will only have access to claims information about themselves.
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Calendar Year vs.
Contract Year Benefit Periods
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■■
■■
BluePreferred/BlueChoice sold for first of the
month effective dates normally have contract
year benefit periods with deductible/maximum
beginning/renewing on the effective date.
Groups may request a calendar year benefit
period. Under a calendar year benefit period,
the deductible and maximums reset each year
on January 1.
BluePreferred/BlueChoice groups sold on a
15th of the month effective date have calendar
year benefit periods. Under the calendar year
benefit period, the deductible and maximums
reset each year on January 1 even if the group
changes its benefits upon renewal during the
year.
Groups have the option to change benefit
periods at their renewal or in conjunction with
an approved off-cycle benefit change.
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Deductible Credit
For ACA compliant products, deductible credit is
only available for those products where language
has been filed and approved to allow the benefit.
CareFirst BlueCross BlueShield has implemented
the following changes to the business rules around
deductible credit.
■■
■■
The following is currently in effect for groups
in the 1-200 market for CDH products and Blue
Selections that include a CDH product:
■■
■■
Deductible Credit For New Business
●● For 15th of the month—no deductible credit
and remains calendar year
●● Contract year—no deductible credit
●● Calendar year—(except for 15th of the month
effective dates) provide deductible credit as
long as they are currently in a calendar year
plan with a competitor. This ensures that we
are not extending their deductible period
longer than 12 months, thus making the plan
out of compliance with the IRS.
Deductible Credit for Renewals
●● Off-cycle renewals—no deductible credit
for contract year; deductible credit DOES
apply for calendar year. For ACA-compliant
products, deductible credit is only available
for those products where language has been
filed and approved to allow the benefit.
●● Moving from calendar year to contract year
or vice versa—no deductible credit.
●● Remaining on calendar year but changing
benefits on renewal—deductible credit
applies.
The following business rules have been in effect
for non-CDH products sold as standalone or not
offered with CDH as part of Blue Selections:
■■
products where language has been filed and
approved to allow the benefit.
●● For new business—manual process
●● For existing business—manual process when
a group changes benefits
Deductible credit is not permitted when a group
changes benefit effective periods
Rx deductible credit is not a CareFirst business
or industry practice
Please refer to the following charts that outline
the business rules for both new and renewing
business.
Deductible Credit Business Rules—
New Groups
Calendar
Yes*
Contract
No
15th of Month (Calendar)+
No
Deductible Credit Business Rules—
Renewing Groups
Off Cycle Change
Calendar—Yes
Contract—No
Moving Calendar to
Contract (vice versa)
No
Remaining Calendar Year—
changing benefits
Yes
* Must currently be calendar year plan with competitor -- ensures we
are not extending their deductible period longer than 12 months, thus
making the plan out of compliance with the IRS.
+ 15th of the Month Contract Year Not Available.
Non-CDH products sold stand alone or not offered with CDH as part of
Blue Selections: Existing Deductible Credit Rules Apply.
When a CDH product is offered standalone or
as part of Blue Selections, deductible credit is
ONLY ALLOWED on calendar year new or renewing
business.
Medical deductible and out-of-pocket credit
is available. For ACA-compliant products,
deductible credit is only available for those
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Deductible Carryover
For ACA-compliant products, deductible carryover
is only available for those products where
language has been filed and approved to allow the
benefit.
Deductible carryover is available as a benefit
enhancement to all medical options as well as all
RX options that have an in-network deductible and
a calendar year benefit period.
■■
Not available with any HSA or HRA BlueFund or
Compatible options
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Determination of Group Size
ACA-Compliant
ACA Compliant Small Group: Effective 1/1/14,
product eligibility and group size will be
determined based on the Full Time Equivalent
(FTE) calculation that uses a 30-hour work week
and 120-hour work month.
This calculation not only includes full-time
employees working 30 or more hours per week,
but also includes seasonal and aggregates the part
time employees.
If an employer was not in existence throughout
the preceding calendar year, the determination of
whether the employer is a small employer shall be
based on the average number of employees that
the employer is reasonably expected to employ on
business days in the current calendar year.
Employers are encouraged to use Federal guidance
in conjunction with accountants and/or legal
counsel when determining their group size.
Please access our “Full-Time Equivalent
Calculation” form on the Broker Portal. This
calculation is used to determine the average
number of all employees, not just the number of
covered lives, who worked for your company in the
calendar year prior to your new sale or renewal
effective date.
Included in FTE Calculation
for Group Size
Not Included in FTE Calculation
for Group Size
All F/T employees (including those in
probationary period). However, employee must
complete their contractual probationary period
prior to enrolling in the plan even if the Open
Enrollment occurs during the probationary
period.
F/T independent contractor—1099 employees
Seasonal employee
COBRA ex-employee or dependent
Part-time employee (less than 30 hrs)
Retiree or dependent
F/T owners
Board Members
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Determination of Group Size
Grandfathered
Grandfathered Small Group: Existing small
group accounts which were enrolled under the
pre ACA guidelines (either prior calendar year or
prior quarter) are able to remain in their current
grandfathered product. However, if they choose
to make a benefit change, they must move to an
ACA-compliant plan and they must meet the group
eligibility requirements under ACA.
to actually be moved from one TEFRA/Non-TEFRA
designation to another. Centers for Medicare and
Medicaid Services (CMS) has put this in place
to avoid groups moving between designations
repeatedly. Groups are responsible for determining
their designation and should enlist assistance from
their accountant if there is confusion.
Employee Eligibility Requirements
Board members of accounts are not considered
eligible for coverage under an employer group plan
because they are not employees.
The following employees (and their dependents)
are eligible for coverage, as long as they meet
the additional eligibility requirements set forth in
the Certificate of Coverage or Group Enrollment
Agreement, and any attachments thereto.
All employees (including owners and partners) who
are regularly employed on a full-time basis working
at least 30 hours a week. (Seasonal employees,
subcontractors, consultants or other persons
issued 1099’s by the Group are not eligible.)
All former employees and their dependents whose
eligibility for group coverage has been extended
due to COBRA requirements.
Note: No individual is eligible under your Group
coverage both as a Subscriber and as a Dependent.
If your Group employs both a husband and wife
(or Domestic Partner, if applicable), they may not
both have Individual + Adult Coverage or Family
Coverage.
TEFRA vs. Non-TEFRA
TEFRA only applies to a group health plan
sponsored by or contributed to by an employer that
has 20 or more employees for each working day in
each of 20 or more calendar weeks in the current
or preceding calendar year. Segments of employees
(i.e.: union members) not eligible for plan benefits
are not included in the calculation to determine
TEFRA/Non-TEFRA designation. Groups should also
note that there is a period of time that a group
must maintain the required number of employees
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Board Members
Terminated Employees in COBRA Election
Period
If an employee is within their 60 day COBRA
election period, they should not be included
in the group census. If the employee then
elects coverage, they will be provided coverage
retroactive to their termination date and the group
will be re-rated.
Retirees, Part-time Employees and Fulltime Employees with Other Coverage
The group can elect to provide coverage for the
following:
■■ Part-time employees working at least 17.5 hours
a week for more than six months each year.
(Those working less than these required time
periods are not eligible.)
■■ Retirees who have retired prior to the effective
date of this coverage. (Available only if covered
under the Group’s prior health coverage.) Proof
will be required which may include a copy of
prior carrier’s contract and most recent billing
statement.
■■ Retirees who retire on or after the effective
date of this coverage. (Available only if covered
under the Group’s prior health coverage.)
■■ All employees who terminated employment
due to disability prior to the effective date of
this coverage for a period of not more than two
years. If for a shorter period of time, please
indicate . (Available only if covered under
the Group’s prior health coverage.)
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Group Eligibility for ACA-Compliant Small
Group Benefits
“Small Employer” means an employer
headquartered in VA or DC that, during the
preceding calendar year, employed an average of
not more than fifty employees during the preceding
calendar year. The group must be defined as
a single and employer under IRS code 414(b),
(c), (m), or (o). At least one full time currently
employed Eligible Employee must be enrolled
under the Group’s coverage or have a valid waiver
at all times who is not the owner or the owner’s
spouse.
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Group Eligibility For Grandfathered Small
Group Benefits
There must be at least one contract in the service
area and the group must be headquartered and
physically located (a P.O. Box is not sufficient) in
DC, MD or Northern Virginia East of Route 123
including the city of Fairfax and town of Vienna to
be covered under a small group product.
Enrolled groups that drop to less than two full-time
employees should contact their Broker, General
Producer (GP), Full-Service Producer (FSP) or Sales
Representative to obtain information.
Minimum Participation Requirements: ACA
Compliant Products:
The group must enroll and maintain enrollment of
at least 75% of all eligible employees for medical
coverage and for each ancillary product purchased,
if offered (or 100% if the employer pays the
entire Individual coverage premium). The ancillary
products are dental and vision benefits. If at any
time there are less than 75% enrolled in any of the
medical or ancillary products, CareFirst reserves
the right to rescind the proposal, revise the rates,
or terminate the product that does not meet the
75% requirement.
The Group cannot enroll in their HMO programs
(other than CareFirst BlueChoice) more than 25%
of the total number of employees enrolled in all
health programs offered through the Group. The
Group cannot continue to enroll new employees in
their staff model HMO.
For participation purposes, all eligible employees
are included in the participation calculation except
for:
■■ Those with spousal coverage under a public
or private plan of health insurance or another
employer’s health benefit arrangement,
including Medicare, Medicaid, and CHAMPUS,
that provides benefits similar to or exceeding
the benefits provided under the Group Contract.
■■ Those who are under the age of 26 years who
are covered under their parent’s health benefit
plan.
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■■
■■
Those who neither live nor work in the CareFirst
BlueChoice service area when that is the only
CareFirst affiliate being offered by the Group.
Those who are able to obtain a federal subsidy
through enrollment on the public Exchange.
These requirements are waived for a small
employer enrolling between November 15 and
December 15 of any calendar year with an effective
date of January 1.
Minimum Participation Requirements:
“Grandfathered” Products:
The requirements in this section do not apply to
Virginia small groups electing coverage under
Virginia Essential or Standard Health Benefit Plans.
The Group must enroll and maintain enrollment
(unless otherwise approved by CareFirst/CareFirst
BlueCross BlueShield) as stated below:
If Point of Enrollment or BlueChoice Opt-Out Plus
Open Access is selected, this must be the sole
health plan offered by the Group to its employees.
Groups must enroll and maintain enrollment of
75% of all employees eligible for medical coverage
and for each ancillary product purchased, if
offered (or 100% if the employer pays the entire
Individual Coverage premium). The ancillary
products are dental and vision benefits. If at
any time there are less than 75% enrolled in any
of the medical or ancillary products, CareFirst
reserves the right to rescind the proposal, revise
the rates, terminate the product that does not
meet the 75% requirement, or refuse to renew the
product that does not meet the 75% requirement.
Voluntary Dental requires 35% participation or 10
enrolled whichever is less. Voluntary Vision has no
participation requirement.
The Group cannot enroll in their HMO programs
(other than CareFirst BlueChoice) more than 25%
of the total number of employees enrolled in all
health programs offered through the Group. The
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Group Eligibility For Grandfathered Small Group Benefits (continued)
Group cannot continue to enroll new employees in
their staff model HMO.
The following employees should be excluded from the
above counts:
1. Those employees who have coverage under their
spouse’s or parent’s group coverage, CHAMPUS,
Medicare as primary under TEFRA, or their prior
employer’s plan under COBRA.
2. Those employees enrolled in other Company
coverage or covered under any Company affiliate.
At least two employees must be employed fulltime and enrolled under the Group’s coverage at all
times. (Note: Those employees with complementary
to Medicare coverage do not count toward the two
employee minimum enrollment requirement.) Enrolled
Groups that drop to less than two full-time employees
should contact their Sales Representative to arrange
for individual direct pay coverage.
a valid waiver, not an owner or their spouse. Any
existing groups of this nature will be migrated to an
ACA compliant product and may not make a benefit
change.
For “grandfathered” business: will be renewed with
no benefit change.
A company insured with CareFirst must be an active
entity with a Federal Tax I.D., engaged in a trade or
business, consisting of at least 2 eligible employees.
Employer Contribution:
To be eligible for Group coverage, the employer
must contribute an amount equal to at least 50%
of the cost of the Individual Coverage for enrolled
employees.
If at any time total enrollment increases or decreases
by 10% or more, the Company reserves the right to
rescind the proposal, revise the rates, terminate this
contract, or refuse to renew this contract.
The basis for determining whether an enrollment
increase or decrease has occurred will be the total
enrollment:
1. On the effective date or contract renewal date
versus the total enrollment proposed at the time
the rates were developed; and
2. On the first day of any month during the contract
period versus the total enrollment proposed at the
time the rates were developed.
The Company may change the applicable premium
rates at any time by giving no less than thirty (30)
days prior written notice to the Group. If, however, the
proposed premium rate increase exceeds thirty-five
percent (35%) of the annual premium charged, the
Company will give the Group prior written notice of no
less than sixty (60) days.
Sole Proprietorships, Partnerships or
Corporations:
Under ACA requirements, there must be at least one
full time “common law” employee enrolled or with
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Retirees, Part-time Employees and Fulltime Employees with Other Coverage:
Grandfathered Products Only
Note that the Group Contract Application allows
groups the option only to cover part-time
employees effective 1/1/14.
The group can elect to provide coverage for the
following:
■■ Part-time employees working at least 17.5 hours
a week for more than six months each year.
(Those working less than these required time
periods are not eligible.)
■■ Retirees who have retired prior to the effective
date of this coverage. (Available only if covered
under the Group’s prior health coverage.) Proof
will be required which may include a copy of
prior carrier’s contract and most recent billing
statement.
■■ Retirees who retire on or after the effective
date of this coverage. (Available only if covered
under the Group’s prior health coverage.)
■■ All employees who terminated employment
due to disability prior to the effective date of
this coverage for a period of not more than two
years. If for a shorter period of time, please
indicate . (Available only if covered under
the Group’s prior health coverage.)
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Medicare Retirees and Eligibles:
ACA-Compliant Products
For ACA-compliant products, any active employee
with Medicare must enroll as an active employee
under the member level rating methodology.
Under ACA-compliant products, retirees currently
enrolled may remain enrolled on the group plan as
long as the group does not make a benefit change
that requires a new Group Contract Application.
Coverage will not be extended to retirees not
currently enrolled and seeking group benefits.
TEFRA vs. Non-TEFRA: TEFRA only applies to a
group health plan sponsored by or contributed to
by an employer that has 20 or more employees for
each working day in each of 20 or more calendar
weeks in the current or preceding calendar year. All
active members are included in the calculation to
determine TEFRA/Non-TEFRA designation. Groups
should also note that there is a period of time that
a group must maintain the required number of
employees to actually be moved from one TEFRA/
Non-TEFRA designation to another. CMS has put
this in place to avoid groups moving between
designations repeatedly. Groups are responsible
for determining their designation and should
enlist assistance from their accountant if there is
confusion.
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Segment Eligibility Effective 1/1/14
Existing groups that have chosen to designate
product(s) as “grandfathered” may renew in the
current product and segment. However, if a benefit
change is made, the ability to “grandfather” ends.
Then based on their Full-Time Equivalent
calculation, they must move into an ACA-compliant
product if their FTE is 50 or less, or to a product
offered in the 51–199 market if the FTE calculation
is over 50.
21 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
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Affiliated Companies
Under ACA regulations, certain affiliated
employers with common ownership or who
are part of a controlled group must aggregate
their employees for determining group size and
specifically for the Full-Time Equivalency (FTE)
calculation. CareFirst looks to the employer and
their counsel for this certification.
In determining the number of eligible employees,
companies which are affiliated companies or which
are eligible to file a consolidated federal income
tax return shall be considered one employer. The
key phrase here is “eligible to file;” the type of
affiliation between the parent company and the
others will determine whether or not they are
eligible to file a consolidated tax return or separate
returns.
22 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
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Affiliated Companies (continued)
“Parent
Company”
Tax Filing
Method
Corporations
If corporation has
80% Ownership or
more in the other
businesses, they
have a choice of
filing separate
returns OR a
consolidated tax
return.
If corporation has
less than 80%
ownership in the
other businesses,
they must file
separate tax
returns.
Sole
Proprietors
Must file separate
tax returns
Legislative Interpretation
Either way they choose, they are eligible to file consolidated
returns. Therefore, they are considered one employer.
Since they are not eligible to file consolidated tax returns, then
under there must be sufficient proof that they are affiliated
companies under common ownership and common control in order
to be written as one group.
“Common ownership” is shown by one person or entity having more
than 50% ownership in both companies. When there is proof that
one entity owns another in excess of 50% but less than 80%, thus
establishing ownership, CareFirst may request that the company
provide additional information including a certification in order to
determine whether or not the owner exerts control over the owned
entity or entities. Corporations, LLC’s, Partnerships, and Sole
Proprietorships are all subject to this rule.
Since they are not eligible to file consolidated tax returns, there must
be sufficient proof that they are affiliated companies under common
ownership and common control in order to be written as one group.
“Common ownership” is shown by one person or entity having more
than 50% ownership in both companies. When there is proof that
one entity owns another in excess of 50% but less than 80%, thus
establishing ownership, CareFirst may request that the company
provide additional information including a certification in order to
determine whether or not the owner exerts control over the owned
entity or entities. Corporations, LLC’s, Partnerships, and Sole
Proprietorships are all subject to this rule.
Partnerships
Must file separate
tax returns
Since they are not eligible to file consolidated tax returns, there
must be sufficient proof that they are affiliated companies under
common ownership and common control in order to be written as
one group.
“Common ownership” is shown by one person or entity having more
than 50% ownership in both companies. When there is proof that
one entity owns another in excess of 50% but less than 80%, thus
establishing ownership, CareFirst may request that the company
provide additional information including a certification in order to
determine whether or not the owner exerts control over the owned
entity or entities. Corporations, LLC’s, Partnerships, and Sole
Proprietorships are all subject to this rule.
23 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
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Affiliated Companies (continued)
■■
■■
■■
Just because two companies have different names
and different employer tax ID numbers does
not necessarily mean that they are Small Group
eligible as two separate employers!
YOU NEED TO CHECK ON THE AMOUNT OF
OWNERSHIP BETWEEN THE COMPANIES AND HOW
THE COMPANIES INTERACT WITH EACH OTHER!
The “Affiliated Companies/Common Ownership
Certification” form should be completed by any
group that is applying for coverage that has
Affiliated Companies, Subsidiaries, or enough
Common Ownership to apply for coverage under
one entity. The form can be obtained from the
Broker Sales Representative.
24 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
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Account Eligibility Verification
As a requirement for all new business and upon
request at renewal, an account must provide a
copy of their most recent quarterly Wage and Tax
Statement. This quarterly document, filed with
the State of Maryland, Virginia and the District
of Columbia lists all compensated employees
for unemployment tax purposes. It is via this
document that CareFirst will be able to determine
the total number of eligible employees. When the
Wage and Tax is submitted, the account should
note eligibility status next to each employee. For
example:
Mary Peters
no insurance
John Smith
group spousal waiver
Steve Meyers part-time
Susan Jones
probationary/waiting period
whether the employer is a small employer shall be
based on the average number of employees that
the employer is reasonably expected to employ on
business days in the current calendar year. Group
must have at least one common law employee who
is not the owner or spouse in order to be a viable
small group.
Note that the most current Wage and Tax statement
filed with the State of Maryland, Virginia or the
District of Columbia is required on all new accounts
including those transferring from one company
within CareFirst to another (GHMSI, BlueChoice).
CareFirst requires a duplicate copy of the Wage and
Tax sent to the state or District. W-4’s are required
for those employees not appearing on the Wage and
Tax, unless they are an owner. The owner’s name
and social security number should be written on the
bottom of the Wage and Tax and identified as such
with the number of hours worked per week and
eligibility status.
Segment Migrations between small group
and 50+:
Payroll Registers in Lieu of a Wage and
Tax:
Payroll registers will be accepted in lieu of the
Maryland Wage and Tax when the payroll register
is filed as an amendment. This option should
only be exercised on an exception basis when the
Wage & Tax Statement is not available. If a payroll
register is provided, it must be generated by a
payroll service (EasyPay, ADP, etc.) and must not
be generated by software via desktop computers.
Newly Formed Companies:
If an employer was not in existence throughout
the preceding calendar year, the determination of
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If the newly formed company does not have a
Wage and Tax, they should submit a notarized
letter on company letterhead listing their
employees, the number of hours per week and
their eligibility status. W-4’s must be submitted for
each employee as well as the business formation
documents. The application for the Wage and Tax
should be submitted as well, if available.
Renewals will be released 60–120 days in
advance of the effective date using the group’s
FTE calculation based on the prior calendar year.
Groups are required to keep this number current
with CareFirst so that we can accurately apply
rating calculations required for the number of FullTime Equivalents in the group.
Groups with New Federal Tax ID Numbers:
A new Fed tax ID number is generally consistent
with a change of entity for the group (i.e.: sole
proprietorship shifting to a partnership or new
ownership) and requires that the original group
be termed and the new entity written as a new
group. This may be of concern for existing groups
currently offering a high deductible plan.
Annual Enrollment Certification:
CareFirst and/or CareFirst BlueChoice, Inc. reserve
the right to inspect the records of the Group after
sixty (60) days from the effective date of the
Group coverage in order to verify the eligibility of
employees and their dependents. In addition, the
Group may be required to complete and return to
CareFirst and/or CareFirst BlueChoice an eligibility
audit and/or census report annually.
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Tax Documentation
The following information was either provided
by State legislation (as in the case of a selfemployed individual), or by the Maryland Office of
Type Of Business
Wage and Tax
Required If
Employees Are
Unemployment Insurance to determine which tax
documents are available to verify eligibility of an
employer group and its employees:
Wage and Tax
Not Required
If Employees
Are
If No Wage and Tax
Required, Submit Instead
Self-Employed
Individuals
Signed Form 1040 or 1040EZ
and any one of the following:
Schedule C, C-EZ, F, SE, Form
1120, 1120-S or Form 1065
with K-1, Form 7004, and
Form 4868.
Self-Employed “Licensed
Professionals”
such as attorneys,
physicians (LLP “Limited
Liability Partnership”
excluded)
Articles of (Professional)
Incorporation and “Letter
of Good Standing” from
licensing group
Non-Profit Organization
IRS Form 501(c)(3) a.k.a.
“Letter of Determination” w/
notarized letter on company
letter-head, listing employees,
hours per week/eligibility
status*
(1 sole eligible employee
working 20 hrs/wk)
NOTE THAT THE ABOVE TYPES ARE NO LONGER ELIGIBLE FOR COVERAGE UNDER ACA REGULATIONS;
IF THEY HAVE “GRANDFATHERED” AND CONTINUE TO MEET THE “GRANDFATHERING” REQUIREMENTS
THEY MAY RENEW WITH NO BENEFIT CHANGE.
26 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
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Tax Documentation (continued)
Type Of Business
Wage and Tax
Required If
Employees Are
Wage and Tax
Not Required
If Employees
Are
Corporation
If No Wage and Tax
Required, Submit Instead
Form 1120, Form 1120-S or
Articles of Incorporation
showing owners of business
Must have at least 1 FT
common law employee,
not the owner or spouse
Note: In most cases, corporations will have a formal Wage & Tax**
Non-Profit Organization
IRS Form 501(c)(3) a.k.a.
“Letter of Determination”
w/ notarized letter on
company letter-head, listing
employees, hours per week/
eligibility status; in lieu of
501(c), Charter Document w/
notarized letter
1 FT common law
employee, not the owner
or spouse
Sole Proprietorship
Must have at least 1 FT
common law Employee,
not the owner or spouse
Partnership
Must have at least 1 FT
common law employee,
not the owner or spouse
Signed Schedule C/F
showing at least Husband and
wife as Owners**
Owner’s children
(over age 21)
working full time
Other employees
working full or
part time
Spouse, owner’s
children, other
employees
Partners
Form 1065 and signed K-1
forms for each Partner
Note that for Corporations, Sole Proprietorships, and Partnerships, there must be 1 full time common law employee who is not the owner/spouse.
Note that a current Wage and Tax Statement is required on all accounts including those migrating between CareFirst companies. Stock certificates are not
accepted as proof of ownership.
27 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
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Husband/Wife Businesses
Under ACA regulations, groups of only a husband
and a wife are not eligible for coverage. There
must be one common law employee other than the
owner and their spouse.
Husband/Wife groups currently enrolled can
remain on group benefits as long as they do not
make a benefit change.
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Enrolling Eligible Employees
Eligible Employees in ACA-Compliant
Groups:
■■
■■
■■
■■
■■
■■
■■
A full-time employee (including owners and
partners) who works, on average, at least 30
hours per week.
Seasonal employees and independent
contractors, such as subcontractors, who receive
a 1099 are not eligible employees. The IRS has
issued guidance on when individuals are to be
treated as either an employee or independent
contractor and the group should consult with
their tax advisor if they have questions relative
to offering coverage to this classification.
Former employees and their dependents that
fall under COBRA or Continuation provisions are
eligible for coverage.
Groups may also choose to offer benefits to
part time employees as long as the part time
employee has a normal workweek of at least
17.5 hours and are not full time employees. If
the part time employee works less than 17.5
hours in a normal workweek, they are not
eligible for coverage.
Groups may also offer coverage to Domestic
Partners of eligible employees.
Groups must offer benefits to all eligible
employees or to all employees in an additional
designated class (part time, Domestic Partners).
No individual is eligible under the Group’s
coverage both as a Subscriber and as a
Dependent.
For a 1–50 group headquartered in DC/VA or
a 1–50 group headquartered in DC/VA with an
office in another state that is NOT a “separate
purchasing entity” location, all employees should
be underwritten in DC/VA.
For a 1–50 group headquartered Out-of-State can
buy an HMO product only for those employees
working in the CareFirst Service area if the branch
office is not a “separate purchasing entity.”
For a 1–50 group headquartered Out-of-State can
buy an HMO or Indemnity product if the branch
office is a “separate purchasing entity.”
Eligible Employees in “Grandfathered”
products:
A full-time employee of a company who works on
a full-time basis and has a “normal” work week of
30 or more hours, even though the employee may
not be actively at work during the open enrollment.
State law requires that the health benefits be
offered to all employees who work at least 30
hours per week. Groups may not elect to limit their
coverage of employees to only those who work
a greater number of hours than the legislated
30 hours per week (i.e., only offer benefits to
employees working 40 hours per week or more).
An eligible employee must be a person who is
compensated by the company for work/services
performed in accordance with applicable Federal
and State wage and hour laws. This includes those
employees who are not United States citizens but
meet the standard eligibility criteria noted above.
Note: All employees working in excess of 30
hours per week and who otherwise meet the
requirements of “eligible employee”, as well as
their eligible dependents, must be offered all
product options; excluding certain classes of
employees or offering certain products to specific
employees or classes of employees is not allowed.
For a 1–50 group headquartered in DC/VA with an
office in another state that is a “separate purchasing
entity” location, employees working in DC/VA can
be underwritten in DC/VA and employees in the
other State can be underwritten in that State.
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Enrolling Eligible Employees (continued)
For both “grandfathered” and “ACA-compliant”
business, eligible employees may enroll:
■■ As a new hire, after satisfying any employer
waiting period.
■■ During small employer’s annual open enrollment.
■■ Within 31 days of lifestyle change as defined by
the Health Insurance Portability & Accountability
(HIPAA) special enrollment period; this applies to
those who initially declined coverage.
■■ Within 31 days of loss of spouse’s employment
(voluntary or involuntary) that results in loss of
insurance (except gross misconduct).
■■ Within 31 days of significant change in employment
status (i.e. reduction in hours).
■■ Within 31 days of the expiration of COBRA
coverage under another group plan.
■■ If they are full-time employees and are under
the age of 18 as long as they provide proof of
employment and hours worked via a current Wage
and Tax. If a Wage and Tax is not available, a payroll
statement or notarized letter indicating the number
of hours the employee works must be submitted.
Uniformed Services Employment and
Reemployment Rights Act (“USERRA”):
■■
■■
The Uniformed Services Employment and
Reemployment Rights Act (“USERRA”) protects
the job rights of individuals who voluntarily or
involuntarily leave employment positions to
undertake military service or certain types of
service in the Natural Disaster Medical System.
USERRA also prohibits employers, and insurers,
from discriminating against past and present
members of the uniformed services, and applicants
to the uniformed services.
If an eligible employee leaves his or her job to
perform military service, the eligible employee
has the right to elect to continue their group
coverage including any dependents for up to 24
months while in the military. Even if continuation
of coverage was not elected during the eligible
employee’s military service, the eligible employee
has the right to be reinstated in their group
coverage when re-employed, without any waiting
periods or preexisting condition exclusions except
for service connected illnesses or injuries. If an
eligible employee has any questions regarding
USERRA, the eligible employee should contact
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the Plan administrator. The Plan administrator
determines eligible employees and provides that
information to CareFirst.
Enrollment in BlueChoice Products:
All enrolling members must work or reside in the
BlueChoice service area at the time of enrollment in
order to enroll in a BlueChoice product. All members
must choose a primary care provider no matter
what product they are choosing including HMO,
HMO Referral, and HMO Plus. This does not apply to
BlueChoice Advantage or HealthyBlue Advantage.
Part-time Employees:
Part-time employees may not be enrolled on an
employer’s small group policy if they are eligible to be
enrolled as a dependent child on another group policy.
Waiting Period for New Employees:
ACA requires that all groups, including those offering
“grandfathered” products have no more than a
90 day waiting period. For this reason, groups are
contractually offered one of the following waiting
period options:
■■ On the day of employment
■■ On the first day of the month following the date of
employment
■■ First day of the month following 30 days of
employment or eligibility
■■ First day of the month following 60 days of
employment or eligibility
■■ Other specify (note this date
cannot exceed a total of 90 days and must comply
with federal and state law and regulation)
Note that the waiting period options are stated in a
specific number of days rather than months, actual
calendar days must be counted.
■■ Waiting period may not be discriminatory or
involve health related matters.
■■ Once defined in Group Application or Group
Contract, a new Group Application/Contract must
be submitted to change the waiting period.
■■ If the group elects to change their new hire waiting
period current employees who have not completed
their waiting period will be affected as follows:
●● If the new waiting period is longer than the
prior one, the new waiting period is applied to
the employee’s original hire date.
CONTENTS
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Enrolling Eligible Employees (continued)
If the new waiting period is shorter than the
prior one, the employee is effective on the
effective date of the waiting period change.
Day 1 of a waiting period begins the day of hire.
Employees whose employment is terminated for
any reason but are then reinstated must fulfill a
new waiting period and complete a new enrollment
application unless the employer chooses to waive
the waiting period based on the nature of the
reinstatement and applies that decision to all
similar reinstatements.
New employees must fulfill their waiting period
prior to enrolling even if the group’s annual open
enrollment occurs during the waiting period; the
group’s annual open enrollment does not override
the waiting period.
If a group is not offering benefits to P/T employees;
however, a P/T employee moves to F/T status and
is eligible for benefits, the employer can allow the
time worked as a P/T employee to apply to the new
hire waiting period as long as the employer applies
that decision to all similar situations.
●●
■■
■■
■■
■■
Open Enrollment Period:
■■
■■
Subscriber Terminations:
■■
■■
■■
Termination and Rehire:
■■
■■
If an employee is rehired within 30 days of their
termination date, benefits will be reinstated
without a wait period. Benefits will become
effective using the appropriate effective date rule
following the rehire date.
If an employee is rehired more than 30 days after
their termination date, benefits will be reinstated
with a wait period. Benefits will become effective
using the group’s wait period and effective date
rule following the rehire date.
The following provides examples assuming the group
maintains a 30-day wait period:
■■ Termination Date 1/15/14; Rehire date 2/1/14;
Rehire Category Less than 30 days; Benefit Eff.
Date 2/1/14
■■ Termination Date 1/15/14; Rehire date 2/16/14;
Rehire Category Greater than 30 days; Benefit Eff.
Date 4/1/14
31 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
When the Group first offers coverage; there will be
an Open Enrollment Period for Eligible Employees.
During the Open Enrollment Period, the employee
and their dependents may apply for coverage.
The Group will have an annual Open Enrollment
Period that is the 31-day period immediately
preceding the Open Enrollment Effective Date set
forth in the Group Schedule.
■■
■■
Termination occurs on the last day of the month in
which the Subscriber’s employment or eligibility
ends or on the date on which the Subscriber’s
employment or eligibility terminates.
Spouse and dependents may not terminate from
the group coverage during the contact period
unless the Subscriber terminates.
A subscriber may make a mid year reduction or
termination of coverage due to:
●● A reduction or elimination of coverage during
the contract year
●● Spouse’s annual open enrollment
●● Significant increase or decrease in subscriber’s
cost without a less costly and similar alternative
including a change in job classification (FT/PT)
●● Entitlement to Medicare by the subscriber,
spouse or dependent
A subscriber may make a mid-year change to
reduce or terminate coverage of the subscriber or
dependent if one of the following qualifying life
events occur:
●● Legal marital status change
●● Employment status change
●● Dependent status change
●● Residence change for HMO members only
Groups are responsible for disenrolling their
employee under the following conditions:
●● Employee no longer meets the eligibility
requirements for health benefits coverage.
●● Employee is no longer employed by the Group
CONTENTS
> >
Continuation of Coverage
DC
MD
The District of Columbia’s City Council passed an
emergency act, “Continuation of Health Coverage
Act of 2001,” extending health benefits for covered
members of a small employer group with fewer
than 20 employees for a period of three months
beyond termination of coverage. Eligible employees
will have to pay full cost of the policy during the
extension, but the cost may not exceed 102%
of the group rate. Eligible employees must elect
the continuation of coverage benefit and provide
payment to the employer within prescribed time
frames. There are no additional forms to complete.
Maryland Continuation of Coverage enables
members to continue their group’s coverage for
a limited period of time after they cease to be
eligible in the group. There are additional forms to
complete. Events that qualify for continuation of
coverage include:
■■ Involuntary termination
■■ Surviving Spouse
■■ Voluntary termination
■■ Divorce
VA
Virginia continuation of health coverage extends
health benefits for covered members of a small
employer group with fewer than 20 employees
for a period of 12 months beyond termination of
coverage. Eligible employee will have to pay full
cost of the policy during the extension, but the cost
may not exceed 102% of the group rate. Eligible
employees must elect the continuation of coverage
benefit and provide payment to the employer
within prescribed time frames. A Selection Form for
Continuation of Group Coverage is required.
32 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
The above is a general summary in condensed form
of Maryland continuation coverage laws. A person
may be eligible under more than one coverage (i.e.,
continuation or COBRA). If a person is eligible for
more than one continuation coverage, such person
will receive the continuation coverage that is most
favorable at the time of application. A person may
receive only one coverage at a time.
Duration Periods:
DC
VA
MD
3 months
12 months
18 months
CONTENTS
> >
COBRA (Consolidated Omnibus Budget
Reconciliation Act of 1986)
Federal legislation that includes a requirement
for groups with 20 or more employees to offer
extended health insurance coverage at the
member’s expense to members and eligible
dependents who leave the group or otherwise
no longer eligible for the group’s coverage. All
applicants eligible for COBRA should complete an
individual enrollment application and a COBRA
application. The COBRA application should
be completed by the applicant and the group
administrator. These forms are available in the “For
Brokers” section on the CareFirst website.
33 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
CONTENTS
> >
Enrolling Eligible Dependents
Eligible dependents may include a lawful spouse,
a same sex or opposite sex domestic partner,
biological child, stepchild, legal dependent child
of a domestic partner dependent, foster child or
grandchild if legal custody has been appointed to
the subscriber. Eligible dependents may enroll:
■■
■■
■■
■■
■■
■■
Along with newly hired employee.
During small employer’s annual open
enrollment.
Within 31 days of marriage, birth, adoption,
obtaining legal custody or guardianship.
Within 31 days of lifestyle change as
defined by the Health Insurance Portability
& Accountability (HIPAA) special enrollment
period; this applies to those who initially
declined coverage.
Within 31 days of loss of employment (voluntary
or involuntary) that results in loss of insurance
(except gross misconduct).
Within 31 days of the expiration of COBRA
coverage under another Group plan.
Dependent children who meet the definition of a
“dependent child” under the Group Contract will
now be covered to the last day of the month in
which their 26th birthday occurs.
Enrolling a newborn always requires an enrollment
application, even if the subscriber already has
Family coverage.
An elderly parent does not meet the contractual
definition of a dependent; therefore he/she may
NOT be enrolled on the employee’s membership.
Full-Time Students Over the Age of 26:
Grandfathered Products Only
■■
■■
■■
■■
■■
Primary Care Dependent (DC- Based
Groups);
■■
■■
No individual is eligible under the Group’s coverage
both as a Subscriber and as a Dependent.
Full-Time Students:
Beginning with renewals effective 10/1/10, Federal
law allowed for dependent children, whether fulltime student or not, to be covered on the parents’
group policy until the end of the month in which
their 26th birthday occurs.
34 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
Unmarried dependent students may remain
eligible as long as they are enrolled as full-time
students in an accredited institution and have a
student certification form on file with CareFirst.
The student will be covered until the end of the
month of their graduation.
A full-time student is defined as a child who
attends a:
●● public or private high school
●● college or university
●● graduate school
●● trade school
Attendance must meet the requirements of the
institution for full-time status.
If an enrolled, over-age student dis-enrolls from
the subscriber’s coverage for a period of time
and wishes to re-enroll, they may be reinstated
onto the subscriber’s policy, providing they still
meet the eligibility requirements of a full-time
student dependent and are within the age limit.
(A Confirmation of Enrollment Form is required.)
CareFirst requires proof of full-time student
status at the time of enrollment. Forms are
available on www.carefirst.com under the
Broker portal.
■■
The child must be the Subscriber’s grandchild,
niece or nephew.
The child must be under the Subscriber’s
“Primary Care,” (Primary Care means that the
subscriber provides food, clothing and shelter
for the child on a regular and continuous basis
during the time that the District of Columbia
public schools are in regular session); and
If the child’s legal guardian is someone other
than the Subscriber, the child’s legal guardian
may not be covered under an accident or
sickness policy.
CONTENTS
> >
Enrolling Eligible Dependents (continued)
Disabled Dependents:
■■
■■
■■
■■
■■
Eligibility may continue past age 26 for unmarried
dependents who are mentally or physically
incapacitated while covered under the health
benefit plan and became disabled prior to reaching
the limiting age, or the person was covered as a
disabled dependent immediately prior to applying
for coverage.
Certification of eligibility is required through
the submission and acceptance of a Disability
Certification For Overage Dependent form. The
parent must sign the top portion of the form and
the attending physician must complete the bottom
portion of the form. Supporting documentation
from the physician must be attached to the form
when submitted to CareFirst.
Once reviewed and accepted by CareFirst,
the dependent will be coded as a “disabled
dependent” on the subscriber’s policy.
If found ineligible to remain enrolled as a disabled
dependent, the child may select a Consumer Direct
policy.
CareFirst may request proof of mental or physical
incapacity at any time.
Domestic Partner Dependents:
Requirements for Domestic Partner eligibility are
as follows:
■■
■■
■■
■■
■■
■■
Available at the employer’s discretion. Coverage may
also be added off-cycle with no rate or renewal date
impact.
■■
Suggested that the Subscriber consult with a tax
advisor regarding the cost of coverage for a person
who is not a spouse or a child through marriage, as
payments made by the employer may be taxable
income to them.
●● Requirements for eligibility are monitored by
the employer and may be subject to audit by
CareFirst subsequent to the initial enrollment.
■■
■■
35 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
If the couple resides in a jurisdiction that requires
or permits registration with that jurisdiction’s
government as a domestic partnership, the couple
has registered in accordance with the law of that
jurisdiction.
The Subscriber and the Domestic Partner are the
same sex or the opposite sex and both are at least
eighteen years of age and have the legal capacity
to enter into a contract.
The Subscriber and Domestic Partner are not
parties to a legally recognized marriage, either to
each other or to anyone else.
The Subscriber and Domestic Partner share no
blood or familial relationship that would bar
marriage under the laws of the jurisdiction in which
the couple resides, and neither the Subscriber nor
the Domestic Partner are a member of another
Domestic Partnership or substantially similar
relationship within the past 6 months.
The Subscriber and Domestic Partner share
a close, committed and exclusive personal
relationship that is meant to be of lasting duration.
The Subscriber and Domestic Partner have a
shared common legal residence continuously for at
least six months and have submitted documentary
evidence of such cohabitation that is satisfactory
to the Group.
The Subscriber and Domestic Partner are
financially interdependent for at least 6
consecutive months prior to application and submit
documentary evidence of such interdependence
that is satisfactory to the Group; have both signed
the appropriate affidavit, enrollment form, or other
document(s) required by the Group, confirming
their Domestic Partnership and agree to notify the
Group, in writing, within thirty (30) days of the
date of the Domestic Partnership.
Qualifying Life Events allowing the Subscriber
to reduce or terminate coverage: Termination
of a Domestic Partnership or the death of the
Subscriber’s Domestic Partner.
CONTENTS
> >
Enrolling Eligible Dependents (continued)
Michelle’s Law: Continued Coverage for
Dependents on Medical Leave
Michelle’s Law, allows for continued coverage for
dependent children who are certified as dependent
students when they take a medical leave of absence
from a college, university or vocational school
(postsecondary educational institution) due to a
serious illness or injury. Dependent children on a
leave of absence will be covered for one year from the
first day of the leave of absence, or until the date on
which the coverage otherwise would end, whichever
comes first. This law is effective for groups upon their
renewal on and after October 9, 2009 and for new
groups with effective dates on or after October 9,
2009.
Michelle’s Law does not change any benefits.
Dependent children on a leave of absence will
continue to receive all plan benefits. If the plan
changes, dependents will have continued coverage
under the new plan until their coverage ends. This law
applies to all fully insured, self-insured, and direct bill
business; including medical, pharmacy, behavioral
health and, when part of the health plan, dental and
vision coverage.
A dependent is eligible for Michelle’s Law if the
following criteria are met:
■■ The policy is in effect
■■ The plan provides dependent coverage
■■ The serious illness or injury and medically
necessary leave of absence begins during the plan
year
■■ The child was enrolled in the plan, on the basis of
being a student at a postsecondary educational
institution immediately before the first day of the
medically necessary leave of absence
■■ There is written certification from the treating
physician reflecting that the leave of absence is
medically necessary
Subscribers with dependents will be notified of this
change whenever a student certification is requested.
The attached letter will be included with the student
certification form. Additionally, new and renewing
groups with effective dates after October 9, 2009 will
be notified of these changes when they receive their
group contract.
36 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
CONTENTS
> >
Multiple Option Offerings
For both “Grandfathered” and ACA-Compliant
groups, up to 3 medical products can be offered to
a small group.
The following apply to “Grandfathered”
groups:
■■
■■
■■
■■
■■
■■
■■
■■
■■
New/renewal rates are calculated based on
Small Group Rating guidelines.
A 2% discount is provided to groups with a
single option, if dual or triple option is selected
the discount is removed.
Participation requirements will be assessed on
the total enrollment in the account and not on
each option.
Employer may apply up to two new hire
eligibility periods to defined segments of
employees within the same account (i.e.
Managers vs. non-Managers, hourly vs. salary).
All employee segments must be offered all
product options; classing out of employees is
not permitted.
The options offered must be differentiated by
the medical benefits offered, and may not be
limited to an “Open Access” or prescription
drug benefit differentiation.
Dental: If two (2) or three (3) medical plans are
offered, two (2) dental plans may be offered
as long as the offering includes no more than
one (1) option from a product type (Traditional,
Preferred PPO or DHMO).
If one (1) medical option is offered, a Traditional
or Preferred PPO plan may be offered.
Two (2) Rx options can be offered if two (2)
medical options are offered; three (3) RX
options can be offered if there are three (3)
medical options offered.
37 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
The following apply to ACA-Compliant
groups:
■■
■■
■■
■■
■■
■■
■■
New/renewal rates will be calculated based on
the guidelines in the Small Group Rating portion
of this manual.
Participation requirements will be assessed on
the total enrollment in the account and not on
each option.
All employee segments must be offered all
product options; classing out of employees is
not permitted.
The options offered must be differentiated by
the product offered, and may not be limited to a
“referral” differential.
Dental: If two (2) or three (3) options are
offered, two (2) dental plans may be offered
as long as the offering includes no more than
one (1) option from a product type (Traditional,
Preferred PPO or DHMO).
If one (1) option is offered, a Traditional or
Preferred PPO plan may be offered.
“Referral” cannot be used as the only
differentiation between the same option
number under the same product.
CONTENTS
> >
Movement Between Products
CareFirst is made-up of several companies from
which our various products originate. These
include CFMI; GHMSI and BlueChoice. Although
the products offered through these companies are
all offered through CareFirst and are all included
in our Administrative Manual for Broker of Record
transfers and compensation, there are some
legislated requirements that come into play when
moving between our products.
Legislatively, this product movement constitutes
movement between carriers because of the way
CareFirst is structured. These include, look-back
periods for eligibility and paperwork/tax document
requirements which would then apply when
moving between our various companies. Note
that although movement between these products/
companies may require new sales paperwork/
tax documentation, for purposes of broker
compensation, movement between our family
of products is considered migrated (existing)
business and is therefore not applicable under our
new sales bonus. Brokers should also be mindful
of the Account Installation RENEWAL paperwork
submission dates when moving business between
our legal entities.
38 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
CONTENTS
> >
Consumer Driven Health Products (CDH)
In the fall of 2006 CareFirst launched the first
of the line of products categorized as Consumer
Driven Health Products to the MSGR market. The
first were BluePreferred Options that combined
with a Health Savings Account (HSA) fund or with
a Health Reimbursement Account (HRA) fund
administered by our vendor, PayFlex.
These were launched under the banner of
“BlueFund.” At the same time, products were also
made available that employers could offer either
with no fund or through another administrator
referred to as “Compatible.”
Then, in July 2006, HSA products were launched
to the small group market for September 2006
effective dates based off of the BlueChoice Open
Access HMO and the BlueChoice Opt-Out Plus
Open Access products.
In August 2009, BlueChoice HMO HRA products
were introduced for effective dates of September
1, 2009. These included unique employee funding
requirements new to the CareFirst portfolio.
With the advent of the 2014 ACA pricing
methodologies, HRA’s and HSA’s have been priced
under one CDH category and no longer have
variable rating.
Although quite popular and cost competitive,
these products require much understanding of
IRS regulations and CareFirst business rules
on the part of the broker. The CareFirst sales
representative and the General/Full Service
Producers provide ongoing training on these
products and are able to provide additional
training upon request as needed.
39 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
When selling CDH products, please keep the
following in mind:
■■ Additional lead time is required with these
products to ensure that employers and
employees understand how the product works
and to get the most out of the funding, if
applicable.
■■ It is strongly recommended that CDH plans not
be sold exclusively, but instead along with a
second alternative or if “BlueFund” is sold, with
the corresponding “Compatible” plan. By doing
so, those ineligible for funding either as new
hires or during the year will have an alternative
option to accommodate them.
■■ Brokers should use the “accelerated funding”
process for the set-up of BlueFund HSA bank
accounts. The instructions and forms necessary
for completion are available on the Broker
Portal under “Broker Resources.”
■■ A 1st of the month effective date for groups
electing a CDH product is recommended. This
will allow the group to choose a Calendar or
Contract year benefit period. A 15th of the
month effective date automatically defaults to a
Calendar year deductible which can negatively
impact the group.
Please refer to our HSA and HRA Reference Guides
located at www.carefirst.com for basic business
rules for this line of CDH products to be used as a
quick reference to brokers selling these products.
CONTENTS
> >
Small Group Rating
All ACA rating is guarantee issue and medical
underwriting of groups as well as the application
of new group discounts is no longer applicable.
The ACA has required that groups be rated based
on a per member basis; that is, each member will
be rated based on their age. This methodology will
be used for all new group quotes and for any nongrandfathered renewals.
For families, each member will be rated
individually, and these rates will be combined to
form a family premium.
■■ For children under the age of 21, only the rate
for the 3 oldest children will be counted
■■ For dependents age 21–25, the rate for each
dependent will be counted
■■ Rates for ages 0–20 are the same, and the rates
for 21–24 are the same
■■ Rates vary each year beginning at age 25
Rates may only vary by the following factors:
■■ 3:1 for age
■■ 1.5:1 for tobacco use (note that CareFirst has
chosen not to rate for tobacco use in 2014)
■■ Geography
The Rx benefit will now be part of the medical
option chosen and the rate will be combined
with the Medical rate. No longer will the Group
separately choose a medical option and a Rx option.
Metal Level: The ACA has also introduced “metal
levels” to the rating model. The metal levels
represent a range of actuarial values or “AV’s”
that reflect the percentage of expected health care
costs, both medical and Rx, a specific health plan
will cover for the “standard” population.
All non-grandfathered health plans must fall into a
metal level.
■■ Bronze (58%–62%)
■■ Silver (68%–72%)
■■ Gold (78%–82%)
■■ Platinum (88%–92%)
40 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
All standard CareFirst product offerings will have a
.60AV or better.
Dental, vision, and grandfathered products will
continue to use tiered rating.
Medicare rates have been eliminated; subscribers
with both Medicare parts A&B will receive a per
member rate based on their age.
The Retiree Rider has been eliminated for renewal
and sale to non-grandfathered groups and coverage
will not be extended to newly enrolling retirees.
Retirees currently enrolled may remain on the
group plan as long as the group extends coverage
to them.
For “grandfathered” products:
BluePreferred and BlueChoice use average age
rating.
Standard Group Over 65
■■
■■
Accounts that had a non-SEGO Standard Group
over 65 product in place prior to July 1, 1999
with active enrollment will be allowed to
continue to offer that product to their Medicareeligibles and retirees.
If enrollment in this product drops to 0, the
Standard Group Over 65 product will be
terminated and will not be reinstated.
Grandfathered BlueChoice and BluePreferred:
■■
■■
■■
Under the BluePreferred options, and at
the employer’s election, retirees and their
dependents may currently have been offered
health benefits through the Retiree Rider by
opting “yes” to the “retiree” HB8 question on
the rating proposal.
Retirees are not included in the group eligible
count nor counted toward participation.
Retirees (CFMI/GHMSI BluePreferred are
included in the group census; >65 Retirees with
Medicare Parts A & B are capped at age 48; <65
Retirees are rated using their current age.)
CONTENTS
> >
Small Group Rating (continued)
■■
■■
■■
■■
■■
■■
If a group currently offering the Retiree Rider
ceases to exist, there is no COBRA benefit.
Non-TEFRA: Employer can offer coverage to their
active Medicare-eligible employees by opting “yes”
to the “other insurance” HB8 question on the
Group Application.
Non-TEFRA: Active Medicare-eligibles must be
included in the under 65 census along with their
spouses.
TEFRA: Active Medicare eligibles are always
offered benefits and the HB8 election of “yes” to
“other insurance” will not apply to them.
TEFRA: Active Medicare-eligibles are included in
the under 65 census at their actual age and billed
the under 65 rate.
Non-TEFRA: The Medicare-eligible’s age is currently
capped at age 48 and the spouse’s age is currently
capped at 48 if they have Parts A & B, and actual
age if they have Part A only or are not Medicareeligible.
Applicable to all Grandfathered products:
If the active employee is under age 65 and the spouse
is over 65 with Parts A & B of Medicare:
■■ The spouse should not be included in the under 65
census.
■■ The employee should be included in the under 65
census at their actual age.
■■ They should be enrolled as “Husband/Wife” or
“Family,” if appropriate.
Medicare Only Enrollment:
■■
■■
■■
■■
New groups whose enrollment is based solely on
enrollees with Medicare A & B will not be accepted.
Groups with under 65 enrollment of “0” and at
least 1 active Medicare Complementary enrollee
cannot be termed.
Groups should be terminated if the under 65
enrollment drops to “0” and the enrollment in
Medicare Complementary consists only of retirees.
Grandfathered Standard Group Over 65 products
will remain in-force as long as enrollment remains
in the product.
41 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
CONTENTS
> >
New Business
Beginning January 1, 2014 any District of Columbia
employer group not currently offering group health
benefits that then elects to offer group health
benefits must purchase those benefits through the
DC Health Link (SHOP).
Physical Address:
All new accounts must provide their physical
address on the new sales paperwork. The physical
address allows us to verify the account eligibility
and provides us with an address for priority
deliveries including contracts. Likewise, the
physical address of all subscribers is required prior
to enrollment.
County Code:
The address and county code used for rating
purposes must be the headquarters of the group,
not a branch office location. If there is a question,
CareFirst reserves the right to investigate the
actual headquarters of the business through use of
the internet and business listings.
Point of Enrollment—Blue Selections:
The “Referral” feature may not be the only
variation between 2 options of the same plan.
HealthyBlue Advantage CDH cannot be offered with
BlueChoice Plus, BlueChoice Plus CDH
HealthyBlue Advantage non-CDH cannot be offered
with BlueChoice Plus, BlueChoice Plus CDH
BlueChoice Advantage CDH cannot be offered with
BlueChoice Plus, BlueChoice Plus CDH
BlueChoice Advantage non-CDH cannot be offered
with BlueChoice Plus, BlueChoice Plus CDH
Effective Dates for new groups in DC and
VA are available on the1st or 15th of the
month.
Please contact your General/Full-Service Producer,
CareFirst Broker Sales Representative or refer to
the Broker Administrative Manual for deadlines.
15th of Month Effective Dates:
This initial effective date is available under all
medical products. The account will then renew
12 and 1/2 months later. CareFirst strongly
recommends this option not be used; as 15th of
the month effective dates necessitate a calendar
year benefit period.
Initial Premium Requirement:
For all non-FSP business, the first month’s
premium is required in order for the new account
to be processed. For accounts effective on the 15th
of the month, premium will be prorated with the
first 43–47 days required based on the number of
days in the month.
42 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
CONTENTS
> >
Requesting a Quote
Brokers doing business with General or
Full-Service Producer:
When requesting a proposal, please provide
your General/Full-Service Producer with the
following information about the prospective group
regardless of group size.
■■ Name of company
■■ Main location’s physical address and all other
locations
■■ Census information including dates of birth for
employees and covered spouse/dependents
■■ Product information
■■ Number, nature of business and SIC codes of
employees located outside the service area
■■ Federal Employer Size
■■ Full-Time Equivalent (FTE) calculation
CareFirst Direct Brokers:
When requesting a proposal, please provide
your Broker Representative with the following
information about the prospective group
regardless of group size.
■■ Name of company
■■ Main location’s physical address and all other
locations
■■ Census information including dates of birth for
employees and covered spouse/dependents
■■ Product information
■■ Number of employees located outside the
service area
■■ Federal Employer Size
■■ Full-Time Equivalent (FTE) calculation
43 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
CONTENTS
> >
New Group Paperwork
For a checklist of items needed for new and
renewing groups click on the following link:
http://www.carefirst.com/brokers/html/
BrokerChecklist.html
Note: If any item is incomplete or not received by
the cut-off date, the document will be returned,
which may result in the Group changing its
effective date.
44 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
CONTENTS
> >
Renewal Business
All CareFirst renewals are rated based on the
sum of the combined actual enrollment in all the
product(s) offered. New enrollment applications
are required when a change to another product is
made.
Migrating Business:
■■
■■
■■
Business migrating between CFMI/GHMSI
BluePreferred and BlueChoice is considered
“existing” business even though new group
paperwork may be required and as such is not
considered “new” business for purposes of
CareFirst’s new business bonus schedule.
Business migrating between CFMI/GHMSI
BluePreferred and BlueChoice is considered
“existing” business even though new group
paperwork may be required and as such follows
the renewal paperwork deadlines.
Broker of Record Transfer letters are required
when the non-incumbent broker migrates any
CareFirst account from one CareFirst company
to another.
Changing Subscriber to Younger Age:
●● If a husband and wife (working for the
same employer) wish to switch the main
policyholder to the younger of the two,
they may submit an application and alter
the membership during the annual open
enrollment. The renewal is then re-rated
based on this membership change.
Remember, requests for census changes to
renewals must be submitted directly to CareFirst
Small Group Underwriting or through the General/
Full Service Producer and are limited to one
request per group per renewal.
■■
Census change requests are not applicable to ACAcompliant products.
County Code Changes:
■■
Census Change Only “Grandfathered”
Products:
■■
■■
■■
Requests for census changes must be
submitted directly to CareFirst Broker Sales or
through the General/Full Service Producer using
the “Request for Average Age/Average Factor
Adjustment” form. Census change only requests
for these products can be made through the
end of the month prior to renewal.
Note that a group wishing to make a benefit
change to a “grandfathered” product will no
longer be “grandfathered” for that product and
must choose from an ACA compliant option.
Changing from a H/W or Family Contract to 2
Individual Contracts:
●● If a husband and wife (working for the
same employer) wish to change their
membership category from Husband/Wife
to two Individuals, they may submit two
applications and alter their membership
during the annual open enrollment. The
renewal is then re-rated based on this
membership change.
45 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
■■
The address and county code used for rating
purposes must be the headquarters of the
group, not a branch office location. If there
is a question, CareFirst reserves the right to
investigate the actual headquarters of the
business through use of the internet and
business listings.
The address and county code must be updated
in FACETS either through Broker Sales or
through the General/Full Service Producer prior
to a request for a recalculation of rates being
submitted; this may only be done in conjunction
with the group’s renewal, and must be done at
least 3 days in advance of the A/I cut-off so as
to allow time for the renewal rate recalculation
and the approval by the group.
CONTENTS
> >
Renewal Business (continued)
Benefit Changes During Contract Year
(for contract year benefit periods):
Note that a benefit change made to a “grandfathered”
product may eliminate the ability for the group to
remain “grandfathered”. A group is required to
choose an ACA-compliant product if the change
results in one of the following:
1. Elimination of all or substantially all benefits to
diagnose or treat a particular condition.
2. Increase in a percentage cost-sharing requirement
(e.g. raising an individual’s coinsurance
requirement from 20% to 25%).
3. Increase in a deductible or out-of-pocket maximum
by an amount that exceeds medical inflation plus
15 percentage points.
4. Increase in a copayment by an amount that
exceeds medical inflation plus 15 percentage
points (or, if greater, $5 plus medical inflation).
5. Decrease in an employer’s contribution rate
towards the cost of coverage by more than 5
percentage points.
6. Imposition of annual limits on the dollar value of
all benefits below specified amounts.
■■
■■
■■
■■
Mid-contract year benefit changes are defined as
any change initiated by the account to alter the
non-grandfathered product selection and does not
include CareFirst initiated product changes.
Requests for benefit changes to existing products
or movement between products offered by the
same CareFirst entity will not be approved 90 days
prior to the account’s current renewal date.
Accounts wishing to make off-renewal benefit
changes may do so on the first of the month after
their renewal or new sale.
The effective date of the medical benefit change
will become the new renewal date.
46 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
■■
■■
■■
Under a contract year benefit period, Preferred and
Traditional dental products and vision products can
be added to the group mid-contract year without
affecting the medical renewal date.
When adding or changing products during the
contract year, a signed proposal as well as any
contract and supporting documents must be
provided.
Termination of either medical or ancillary, but not
both products must be done as a benefit change
and not a termination to avoid termination of both
products.
Benefit Changes at Renewal:
Note prior section: changes that affect
“grandfathering”
■■ Termination of medical or ancillary, but not both
products must be done as a benefit change and
not a termination to avoid termination of both
products.
Benefit Changes with a Jurisdiction Change
at Renewal:
■■
Benefit Changes must be received prior to deadline
●● If group is located in VA and moves to MD
or DC, the group can keep their current VA
benefits (regardless of medical product). The
group cannot change their benefits unless they
accept MD/DC benefits.
●● If group is located in DC and moves to VA,
within our service area, or MD, the group can
keep their current DC benefits (regardless of
medical product). The group cannot change
their benefits or make enrollment changes
unless they accept VA/MD benefits.
CONTENTS
> >
Existing Groups that Move Their
Headquarters Outside of MD, DC, N. VA
Unless “grandfathered”, these groups will be
termed upon renewal.
47 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
CONTENTS
> >
Request for Anniversary Date Change
Written request (in letter format) must be provided
to Small Group Underwriting for any change of
group anniversary date including the following:
■■ Group name and number
■■ Statement to include: “the group would like to
move to MM/DD/YYY renewal from a MM/DD/
YYYY renewal”
■■ Statement noting that the group understands
that their rates will change effective MM/DD/
YYYY and this may result in an increase in
premium
■■ Letter must be signed by Group Administrator
48 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
CONTENTS
> >
Contract Issuance
Group contracts are issued within 90 days of
receipt of appropriate group contract application.
The process for distributing group contracts has
changed. Effective immediately, you will notice the
following:
■■ A contract will be completed for each group that
renews, even if no changes are made.
■■ Upon renewal, groups will receive one
contract and two benefit booklets for each
product they have. To request additional
paper or electronic copies of the Group
Contract or Member Benefit Booklet, an email
can be sent to our Contracts Department at
Contracts.Booklets@carefirst.com.
■■ A new letter will be included in the package
that’s sent to groups to provide additional
information about this change. For those groups
who choose multiple benefit options, any
outstanding products that are not enclosed may
be shipped separately.
49 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
CONTENTS
> >
Matrix: Eligibility, Rating & Participation
Included in
FTE count for
determination
of group size?
Eligible for
Benefits?
Valid
Waiver?
F/T emp enrolling w/ CareFirst/no other
insurance product
YES
YES
YES
F/T emp w/ no ins coverage, not enrolling
YES
YES
YES
F/T emp w/ other health plan offered by their
employer
YES
YES
NO
P/T emp, not enrolling ( including Independent
Contractor/1099 emp**, ***)
YES
YES
YES
P/T emp (17 1/2 hrs, 4 consec months),
enrolling for coverage* (including Independent
Contractor/1099 emp**, ***)
YES
YES
YES
Seasonal emp
YES
NO
NO
F/T emp w/ other group sponsored coverage not
enrolling
YES
YES
NO
FT emp w/ other group sponsored coverage
enrolling for coverage*
YES
YES
NO
F/T emp w/ CD coverage, not enrolling
YES
YES
YES
F/T emp w/ CD coverage, enrolling for coverage*
YES
YES
YES
F/T new hire in probationary period (not yet
enrolling)
YES
NO
NO
COBRA w/ current grp (no longer emp, enrolling
for coverage) includes divorced dep or qualified
beneficiary
NO
YES
NO
F/T emp. w/COBRA from previous employer
(keeping previous group sponsored coverage,
not enrolling)
YES
YES
NO
Employee Categories
50 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
CONTENTS
> >
Matrix: Eligibility, Rating & Participation (continued)
Included in
FTE count for
determination
of group size?
Eligible for
Benefits?
Valid
Waiver?
F/T Independent Contractor (1099 emp)**, *
(with/without other group sponsored coverage
enrolling)
NO
NO
NO
F/T Independent Contractor (1099 emp)**, *
(with other group sponsored coverage not
enrolling)
NO
NO
NO
F/T Independent Contractor (1099 emp)***
(without other group sponsored coverage not
enrolling)
NO
NO
NO
F/T emp w/MSA enrolling
YES
YES
YES
F/T emp w/Medicare Parts A&B, enrolling for
coverage
YES
YES
YES
F/T emp w/VA coverage, not enrolling
YES
YES
NO
F/T emp w Public Exchange Subsidy, not
enrolling
YES
YES
NO
Employee Categories
*For “grandfathered” products and at the option of the employer, part-time employees meeting the criteria, full-time employees with other group sponsored
coverage and retirees (effective 3/1/11only filed for CFMI/GHMSI BluePreferred may be offered small group coverage. “Group sponsored” coverage includes
Medicare and Medicaid, and all other competitors’ group products.
**Under ACA-compliant groups, part time employees may be offered coverage; independent contractors (1099’s) and retirees may not.
***For “grandfathered” products only and at the option of the employer, full-time independent (1099) contractors may be offered the small group coverage. If
so, all must be offered coverage and will be considered eligible. If enrolling, will be rated and applied towards the 75% participation requirement.
Note: Reference to COBRA above also refers to Continuation
51 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
CONTENTS
> >
Medicare Eligibility, Rating And Participation
for “Grandfathered” Products Only
Medicare Only Enrollment
■■
■■
Groups whose enrollment is based solely on
enrollees with Medicare A & B are not eligible
for group coverage.
Anyone enrolling in any of CareFirst’s Medicare
Secondary products must have parts A & B of
Medicare.
●● Benefits for retirees are only available if
covered under the group’s prior coverage.
●● Non-TEFRA: Employer can offer coverage to
their active Medicare-eligible employees.
●● Non-TEFRA: Active medicare-eligibles must
be included in the census along with their
spouses but not included in the average age.
●● TEFRA: Active Medicare-eligibles are
included in the census at their actual age
and billed the under 65 rate. Only the nonMedicare spouse would be included in the
average age.
●● If the active employee is under age 65 and
the spouse is over 65 with Parts A & B of
Medicare:
›› The spouse should not be included in the
census
›› The employee should be included in the
census at their actual age and enrolled
as “Husband/Wife” or “Family,” if
appropriate
52 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
●●
●●
●●
●●
At the option of the employer, retirees
(available only if covered under their prior
plan) and full-time 65+ employees with
other group-sponsored coverage including
Medicare, may be offered the small group
coverage.
Active employees with Medicare A&B in a
TEFRA group have the group coverage as
primary and are counted towards the eligible
employee and minimum participation counts.
The Medicare rate has only the individual
tier coverage level.
Groups with only Medicare-eligible
employees enrolling will not be accepted.
CONTENTS
> >
Medicare Eligibility, Rating And Participation for “Grandfathered”
Products Only (continued)
GRANDFATHERED Renewal Rating: Medicare Eligibles BlueChoice/BluePreferred
Rate EE (employee)
Rate SP (spouse)
Rate CH (child)
1
EE is Medicare
Rate EE as Medicare if
Non-TEFRA and enroll as
Medicare; If TEFRA, use
EE actual age, and enroll
as Individual.
N/A
N/A
2
EE is Medicare
+ SP
Rate EE as Medicare if
Non-TEFRA and enroll as
Medicare; If TEFRA, use
EE actual age, and enroll
as (Ind/Adult).
Rate spouse as
Individual using their
real age if Non-TEFRA,
and enroll as Individual;
If TEFRA, spouse is not
rated separately.
N/A
3
EE + SP is
Medicare
Rate on Employee ONLY
using their real age as
EE is <65. Must enroll as
(Ind/Adult).
N/A
N/A
4
EE is Medicare +
SP is Medicare
Rate EE as Medicare if
Non-TEFRA and enroll as
Medicare; If TEFRA, use
EE actual age, and enroll
as (Ind/Adult).
Rate spouse as Medicare
if Non-TEFRA, and enroll
as Medicare; If TEFRA,
spouse is not rated
separately.
N/A
5
EE is Medicare
+ CH
Rate EE as Medicare if
Non-TEFRA, and enroll as
Medicare; If TEFRA, use
EE actual age, and enroll
as Individual/Child(ren).
N/A
Rate Child as Individual
if Non-TEFRA, and enroll
as Individual; If Child
is <16, rate at age 16
as this is minimum age
allowed for rating; If
TEFRA, Child is not rated
separately.
6
EE + CH is
Medicare
Rate on Employee ONLY
using their real age as
EE is <65. Must enroll as
Individual/Child(ren).
N/A
N/A
53 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
CONTENTS
> >
Medicare Eligibility, Rating And Participation for “Grandfathered”
Products Only (continued)
Rate EE (employee)
Rate SP (spouse)
Rate CH (child)
7
EE is Medicare +
CH is Medicare
Rate EE as Medicare if
Non-TEFRA, and enroll as
Medicare; If TEFRA, use
EE actual age, and enroll
as Individual/Child(ren).
N/A
Rate Child as Medicare
if Non-TEFRA, and
enroll as Individual; If
TEFRA, Child is not rated
separately.
8
EE is Medicare +
SP + CH
Rate on Employee ONLY
using their real age;
Must enroll as Family.
N/A
N/A
9
EE + SP is
Medicare + CH
Rate on Employee ONLY
using their real age;
Must enroll as Family.
N/A
N/A
10
EE is Medicare +
SP is Medicare
+ CH
Rate on Employee ONLY
using their real age;
Must enroll as Family.
N/A
N/A
11
EE + SP + CH is
Medicare
Rate on Employee ONLY
using their real age;
Must enroll as Family.
N/A
N/A
12
EE is Medicare +
Two or more CH
Rate on Employee ONLY
using their real age;
Must enroll as Family.
N/A
N/A
13
EE is Medicare
+ SP + CH is
Medicare
Rate on Employee ONLY
using their real age;
Must enroll as Family.
N/A
N/A
14
EE + SP is
Medicare + CH is
Medicare
Rate on Employee ONLY
using their real age;
Must enroll as Family.
N/A
N/A
15
EE is Medicare +
SP is Medicare +
CH is Medicare
Rate on Employee ONLY
using their real age;
Must enroll as Family.
N/A
N/A
54 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
CONTENTS
> >
Dental Benefits
CareFirst offers a varied line of dental products
including voluntary and employer sponsored
Traditional, Preferred (PPO) and DHMO. The ridered
products are only available for “grandfathered”
groups. There is also a core Discount Dental fee
schedule for BlueChoice members. Each of these
utilize different networks of providers and all can
be accessed via the CareFirst.com website.
Beginning 1/1/14, we no longer offer parallel
dental benefits to medical unless the medical
product is “grandfathered”.
Dental Overview:
Large provider network across Maryland, D.C.
and Virginia.
■■ Members outside of CareFirst’s service area in
Traditional and Preferred products have access
to a national network of participating dentists.
DentalGRID replaced DNoA for out of area
providers in May 2012.
■■ Unified portfolio of Traditional, Preferred(PPO)
and DHMO dental products.
■■ Ability to sell dental products with medical
coverage, freestanding or as part of a POE/Blue
Selections combination.
■■ Voluntary plans offer lower participation
requirements and no employer contribution.
■■ Consistent underwriting methodology and
business rules:
●● Comprehensive benefits—emphasis on
preventive care
●● No balance billing for members when using
in-network services
●● No claim forms for members to file when
using in-network services
●● Ability to add orthodontics coverage (up to
age 19) to Traditional and Preferred (PPO)
plans. Orthodontia is included in the DHMO
products.
●● Medically necessary orthodontia is included
for members up to age 19 in BlueDental
Preferred and BlueDental Traditional.
■■
55 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
●●
●●
All dental products (Traditional, Preferred,
and DHMO) combine for participation
requirements.
Pediatric dental is an “essential health
benefit” and is included in all ACA medical
plans.
Business Rules:
Employer sponsored: the employer contributes at
least 50% of the cost of Individual coverage
Voluntary: 100% employee paid
■■ Groups offering one medical plan can offer a
DHMO plan combined with either a Traditional
or Preferred plan.
■■ Groups offering two or three medical plans, can
offer up to two dental plans.
●● Note: If group is offering two dental plans,
the two dental offerings must be selected
from different product types.
●● The three product types are:
›› Traditional
›› Preferred (PPO)
›› DHMO (HMO or Opt-out)
◆◆ Example: Group offering two dental
plans could choose one Traditional
plan and one Preferred dental plan.
■■ New and renewing employer sponsored groups
must have 75% of eligible employees enrolling
in the dental plans offered (Traditional,
Preferred, and DHMO).
■■ Groups whose renewal is released with medical
and a dental option, but choose to terminate
the medical must re-write the dental on a
Freestanding basis.
Voluntary (above business rules apply):
■■
■■
New and renewing voluntary Traditional and
Preferred participation requirement: dental
must have the lesser of 10 employees or 35% of
eligibles.
New voluntary Traditional and Preferred dental
group: 12 month benefit waiting period for
classes 3, 4, and 5 will apply if group did not
have 12 months prior dental coverage with
CONTENTS
> >
Dental Benefits (continued)
■■
■■
another dental carrier. “Proof of Prior Group Dental
Coverage for Voluntary Dental” waiver form should
be used to verify prior coverage.
If a group purchases more than 1 voluntary dental
plan, the benefit waiting period must be the same
for both products.
New and renewing voluntary dental can be sold
with either employer sponsored or voluntary vision
and can be sold with a calendar or contract year
benefit period.
Parallel Group Enrollment
“GRANDFATHERED”Medical Only:
■■
■■
■■
■■
For groups that offer both medical and dental
benefits, parallel group enrollment means that all
eligible employees may choose either:
●● Medical & Dental OR
●● No coverage
All employees must enroll in medical and dental
under the same coverage level. (Example: Family
Medical, Family Dental)
Ridered DHMO dental is offered as parallel only.
Voluntary Dental products may not be offered as
parallel.
■■
■■
■■
■■
For groups that offer both medical and dental
benefits, non-parallel group enrollment means that
all eligible employees may choose either:
●● Medical & Dental
●● Medical Only
●● Dental Only: Traditional, Preferred and DHMO
●● No coverage
Employees may enroll differently in medical and
dental. (Example: Family Medical, H/W Dental)
Exception: Even though the employer has selected
non-parallel group enrollment, anytime Ridered
DHMO dental is offered and selected by someone
enrolling in BlueChoice medical, the member
must enroll in Ridered DHMO dental at the same
coverage level that they selected for medical. For
example, if a member chooses BlueChoice family
medical coverage, they must choose family Ridered
DHMO coverage.
Exception: Retirees may not enroll in dental only;
even if the group is set up as non-parallel. Retiree
must be enrolled in BluePreferred or SPPP to enroll
in dental.
56 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
BlueChoice
BluePreferred
DHMO Dental
Traditional Dental
Important Note: BlueChoice members can select
Ridered DHMO or Traditional. If Ridered DHMO is
selected, the member must enroll in the dental at
the same coverage level selected for the medical.
If member elects the Traditional they may enroll
differently in the medical & dental as the employer
has selected Non-Parallel group enrollment.
BluePreferred members can only select Traditional,
but may enroll differently in medical and dental.
Ridered DHMO Enrollment: GRANDFATHERED
PLANS ONLY
■■
Non-Parallel Group Enrollment:
■■
POE Example: POE existing of BlueChoice and
BluePreferred. Group is offering both Traditional
and DHMO dental. Non-Parallel Group Enrollment
selected.
■■
■■
Ridered DHMO enrollment will always be parallel
to the medical enrollment even if the employer
has chosen non-parallel group enrollment (i.e.
BlueChoice family medical / Ridered DHMO family
dental).
In a POE/Blue Selections combination, BlueChoice
members do not have to choose Ridered DHMO
coverage if multiple dental products are offered.
If they do choose Ridered DHMO, they must have
parallel enrollment.
Members enrolling in BluePreferred medical
products cannot enroll in Ridered DHMO dental.
Short Plan Year Dental
■■
■■
■■
Dental products or orthodontia benefits can be
added to existing medical plans for a short plan
year without affecting the medical renewal month.
No changes can be made 90 days prior to the
renewal date. You may not change, remove or add
dental during this timeframe.
A group can replace their current employer
sponsored dental with voluntary dental (or the
reverse) prior to renewal, as long as it is not within
90 days of the renewal date.
CONTENTS
> >
Dental Benefits (continued)
Freestanding DHMO (Provider Choice
$5/$10/$20)
■■
■■
■■
■■
■■
■■
■■
Definition: DHMO underwritten by BlueChoice that
can be offered alongside CareFirst Traditional and
Preferred Dental products and/or medical products
or without other CareFirst medical or dental
products.
Freestanding DHMO may be offered alongside
a Freestanding Traditional or Preferred dental
product.
TDN’s “Provider Choice” products.
Enrollment in these products is combined with
Traditional and Preferred product enrollment to
meet total participation requirement of 75%.
There is no participation requirement for the
Freestanding DHMO if offered with no other
CareFirst dental product.
Available to groups with 2 eligibles; 1 enrolling.
Must be offered non-parallel.
■■
■■
■■
■■
■■
■■
Freestanding Dental Business Rules
■■
■■
■■
■■
■■
■■
■■
■■
■■
Definition: An account with CareFirst dental
coverage and medical coverage with another
carrier.
Employer sponsored or voluntary Traditional
and Preferred products as well as the employer
sponsored Freestanding DHMO products can be
sold as freestanding.
75% participation of eligible employees required
for employer sponsored Traditional and Preferred
products.
No participation requirement on the Freestanding
DHMO products; must have 2 enrolled.
Group must prove medical coverage with another
carrier by submitting current health carrier invoice.
Freestanding dental groups may offer one
Traditional or Preferred Dental plan plus a DHMO
(Preferred Choice) plan.
BlueVision Plus may be added “short plan year” to
an existing Freestanding Dental product.
Freestanding Dental may only be sold with first
of the month effective dates. Freestanding Dental
may not be sold 15th of the month.
New and renewing groups with Freestanding
Traditional and Preferred dental currently receive a
15% rate load.
57 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
■■
There is no rate load on freestanding ACA
compliant BlueDental Preferred and BlueDental
Traditional.
Freestanding Traditional and Preferred dental
groups in DC and VA will be sold under a GHMSI
contract.
Freestanding Dental must be offered non-parallel.
New and renewing voluntary Traditional and
Preferred dental must have the lesser of 10
employees or 35% of eligibles.
New voluntary Traditional and Preferred dental
group: 12 month benefit waiting period for classes
3, 4, and 5 will apply if group did not have 12
months prior dental coverage with another dental
carrier. “Proof of Prior Group Dental Coverage for
Voluntary Dental” waiver form should be used to
verify prior coverage (under “Miscellaneous Forms”
section of Broker website).
If a group purchases more than 1 voluntary dental
plan, the benefit waiting period must be the same
for both products.
New and renewing voluntary dental can be sold
with either employer sponsored or voluntary vision
and can be sold with a calendar or contract year
benefit period.
BlueChoice Discount Dental:
■■
■■
■■
The BlueChoice Discount Dental is core to all
BlueChoice medical products and is not available
to any other CareFirst products.
A fee schedule of discount fees rather than a
percentage of discounts is used.
The Discount Dental fee schedule is an added
feature to the BlueChoice product line and is not a
contractual benefit; nor can it be carved out of the
benefit/rate package.
CONTENTS
> >
Vision Benefits
Overview:
CareFirst offers an array of employer sponsored
as well as voluntary BlueVision Plus options.
BlueVision is not core to ACA-compliant medical
plans.
■■ Vision is being offered by CareFirst BlueCross
BlueShield through Davis Vision.*
■■ BlueVision is included as a core benefit TO
“GRANDFATHERED” GROUPS ONLY EXCEPT in
the following options:
●● BlueChoice HMO Open Access HRA Option 3
CORE
●● BlueChoice HMO Option 6 CORE (but may be
purchased)
●● SPPP Option D CORE (but may be purchased)
■■ BlueVision offers a comprehensive eye exam
for a $10 copay and discounts on eye ware
including lenses, frames and contacts once
per benefit period (12 month period) to
“grandfathered” groups only.
■■ BlueVision Plus offers a comprehensive eye
exam and the opportunity to receive one free
pair of eyeglasses or a supply of contact lenses
each benefit period (12 or 24 month period).
■■ 12/12/12, 24/24/24, or 12/12/24 (exam/lens/
frame) benefit periods are offered based on the
option purchased under BlueVision Plus.
■■ The BlueVision Plus plan is installed on the
same platform as the medical plan for the
Account.
■■ Voluntary plans have no participation
requirements and no employer contribution and
are sold non-parallel only.
■■ Pediatric vision is an “essential health benefit”
and is included in all ACA medical plans.
Business Rules:
Employer sponsored: the employer contributes at
least 50% of the cost of Individual coverage
Voluntary: 100% employee paid
■■ BlueVision (the core product) always has parallel
enrollment to “grandfathered” groups only.
■■ Employer sponsored BlueVision Plus may be
sold non-parallel.
■■
■■
■■
■■
■■
■■
■■
■■
■■
■■
■■
■■
■■
New and renewing employer sponsored
accounts must have 75% of eligible employees
enrolling in the BlueVision Plus plan and
must contribute at least 50% of the individual
premium.
Employer sponsored freestanding vision and
vision offered with dental is available for
accounts with 2 eligible, one enrolled.
Voluntary BlueVision Plus will be sold as nonparallel.
Voluntary freestanding BlueVision Plus and
BlueVision Plus offered with dental has no
participation requirement on the vision.
Voluntary BlueVision Plus has no benefit
waiting period.
Short plan year changes to add BlueVision
Plus or to change from employer sponsored to
voluntary (or the reverse) can be made; except
90 days prior to the Account’s renewal and will
not cause the entire account to be re-rated or
the account to renew as a result.
Groups whose renewal is released with medical
and BlueVision Plus, but choose to terminate
the medical may re-write the vision on a
Freestanding basis.
Groups can change their parallel/non-parallel
enrollment status upon renewal.
●● if the group is changing their medical
benefits; OR
●● if the group is adding Dental or BlueVision
Plus.
BlueVision Plus is not an age-rated product,
therefore, enrollees with vision only will not be
included in the average age.
BlueVision Plus may be offered on a contract or
calendar benefit year period.
For all 1–50 groups (regardless of medical
product), the BlueVision Plus tier rate structure
must be consistent with the medical tier
structure.
Freestanding Vision must be offered non-parallel.
Ridered Vision is only available to
“grandfathered” groups that currently rider
vision. All new business is non-ridered/nonparallel.
* CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. contract with Davis Vision to offer an extensive national network of optometrists,
ophthalmologists and opticians. Davis Vision is an independent company that provides administrative services for vision care to CareFirst
BlueCross BlueShield and CareFirst BlueChoice, Inc. members. Davis Vision is solely responsible for the services it provides.
58 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
CONTENTS
> >
DC/VA Product Portfolio
Brokers have found our Product Portfolio to be a
useful tool in quickly referencing all of the options
offered under CareFirst’s varied product lines with
a high level description of each option. The online
Benefit Summaries available on the Broker website
can then be used to reference detailed benefits for
each option. Please visit CareFirst’s broker portal
under Quick Links for the most recent product
portfolio.
59 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
CONTENTS
> >
DC and VA Group Contract
Application Matrices
ACA District of Columbia OFF-SHOP Products
Effective 1/1/2014
Note: No Retiree Coverage is available under ACA
Medical Product(s) SOLD
SOLD With or Without
Traditional/Preferred
Dental/BlueVision Plus
Required Group
Applications
Employer Sponsored/
Voluntary
Section A
BlueChoice HMO Product(s) OFF-SHOP
BlueChoice HMO Referral
BlueChoice HMO Referral HSA/HRA
BlueChoice HMO
BlueChoice HMO HSA/HRA
HealthyBlue HMO
HealthyBlue HMO HSA/HRA
BlueChoice Plus 100%/80%, $10/$20
NO – DC/CFBC/BCBCOO-OA/GCA/SG
(1/14)
DC/CFBC/BC-BCOO-OA/
GCA/SG (1/14)
YES – Use DC Pointof-Enrollment (POE)
Application listed below
This is the ONLY
application that you will
need to complete
BlueChoice Plus 100%/80%, $20/$30
BlueChoice Plus 100%/60% $20/$30
Section B
District of Columbia Point-of-Service Product(s) OFF-SHOP
BlueChoice Plus HSA/HRA $1500
BlueChoice Plus $2000
BlueChoice Plus HSA/HRA $2000
BlueChoice Plus HSA/HRA $3500
Yes or No – The DC
POS Group Contract
Application covers the
Traditional/Preferred
Dental and BlueVision
Plus if sold
DC/GHMSI/CFBC/POS/GCA/
SG (1/14)
HealthyBlue Plus
HealthyBlue Plus HRA/HRA
BlueChoice Advantage
BlueChoice Advantage HSA/HRA
HealthyBlue Advantage
HealthyBlue Advantage HSA/HRA
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DC and VA Group Contract Application Matrices (continued)
ACA District of Columbia OFF-SHOP Products
Effective 1/1/2014
Note: No Retiree Coverage is available under ACA
Medical Product(s) SOLD
SOLD With or Without
Traditional/Preferred
Dental/BlueVision Plus
Required Group
Applications
Employer Sponsored/
Voluntary
Section C
District of Columbia CareFirst BluePreferred Product(s) OFF-SHOP
BluePreferred PPO
BluePerfered PPO HSA/HRA
HealthyBlue PPO
HealthyBlue PPO HSA/HRA
Yes or No – DC PPO
Group Contract
Application covers the
Traditional/Preferred
Dental and BlueVision
Plus if sold
DC/GHMSI/GCA/SG(1/14)
(PPO)
Point-of-Enrollment Group Contract Application (POE)
Note: Any time you are selling multiple ACA medical products together from Sections A, B and
C, with or without Traditional/Preferred Dental and/or BlueVision Plus, you can use one of the
following POE Applications for all products sold.
This is the ONLY application that you will need to complete. You will also use the POE Application
when you are adding Traditional/Preferred Dental and/or BlueVision Plus to any Section A Product
or combination of Section A Medical Products.
Point-of-Enrollment (POE) – DC
Section D
DC/GHMSI/CFBC/POE/GCA/
SG (1/14)
Freestanding Traditional/Preferred Dental, Blue Dental Traditional/Preferred,
and/or BlueVision Plus
Only use when there is no medical plan with CareFirst.
Group Contract Application For
Freestanding Dental and Freestanding
Vision Products – DC
61 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
DC/GHMSI/GCA/SG (1/14)
(D-V Only)
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DC and VA Group Contract Application Matrices (continued)
ACA Virginia OFF-SHOP Products
Effective 1/1/2014
Note: No Retiree Coverage is available under ACA
Medical Product(s) SOLD
SOLD With or Without
Traditional/Preferred
Dental/BlueVision Plus
Required Group
Applications
Employer Sponsored/
Voluntary
Section A
BlueChoice HMO Product(s) OFF-SHOP
BlueChoice HMO Referral
BlueChoice HMO Referral HSA/HRA
BlueChoice HMO
BlueChoice HMO HSA/HRA
HealthyBlue HMO
HealthyBlue HMO HSA/HRA
NO – VA/GRPAPP/HCR
(1/14) (HMO)
VA/GRPAPP/HCR (1/14)
(HMO)
YES – Use VA Pointof-Enrollment (POE)
Application listed below
This is the ONLY
application that you will
need to complete
BlueChoice Plus 100%/80%, $10/$20
BlueChoice Plus 100%/80%, $20/$30
BlueChoice Plus 100%/60% $20/$30
Section B
Virginia Point-of-Service Product(s) OFF-SHOP
BlueChoice Plus HSA/HRA $1500
BlueChoice Plus $2000
BlueChoice Plus HSA/HRA $2000
BlueChoice Plus HSA/HRA $3500
Yes or No – The VA
POS Group Contract
Application covers the
Traditional/Preferred
Dental and BlueVision
Plus if sold
VA/GRPAPP/HCR (1/14)
(POS)
HealthyBlue Plus
HealthyBlue Plus HRA/HRA
BlueChoice Advantage
BlueChoice Advantage HSA/HRA
HealthyBlue Advantage
HealthyBlue Advantage HSA/HRA
62 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
CONTENTS
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DC and VA Group Contract Application Matrices (continued)
ACA Virginia OFF-SHOP Products
Effective 1/1/2014
Note: No Retiree Coverage is available under ACA
Medical Product(s) SOLD
SOLD With or Without
Traditional/Preferred
Dental/BlueVision Plus
Required Group
Applications
Employer Sponsored/
Voluntary
Section C
Virginia CareFirst BluePreferred Product(s) OFF-SHOP
BluePreferred PPO
BluePerfered PPO HSA/HRA
HealthyBlue PPO
HealthyBlue PPO HSA/HRA
Yes or No – VA PPO
Group Contract
Application covers the
Traditional/Preferred
Dental and BlueVision
Plus if sold
VA/GRPAPP/HCR (1/14)
(PPO)
Point-of-Enrollment Group Contract Application (POE)
Note: Any time you are selling multiple ACA medical products together from Sections A, B and
C, with or without Traditional/Preferred Dental and/or BlueVision Plus, you can use one of the
following POE Applications for all products sold.
This is the ONLY application that you will need to complete. You will also use the POE Application
when you are adding Traditional/Preferred Dental and/or BlueVision Plus to any Section A Product
or combination of Section A Medical Products.
Point-of-Enrollment (POE) – VA
Section D
VA/GRPAPP/HCR (1/14)
(POE)
Freestanding Traditional/Preferred Dental, Blue Dental Traditional/Preferred,
and/or BlueVision Plus
Only use when there is no medical plan with CareFirst.
Group Contract Application For
Freestanding Dental and Freestanding
Vision Products – VA
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VA/GRPAPP/HCR (1/14)
(D-V Only)
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Highlights of Small Group Legislation—
DC, VA, Federal
District of Columbia
DC Health Insurance Portability and
Accountability statute (DC Official Code, §313303.01 et seq.)
Specifically apply to small employer groups.
■■ Any portion of the premiums or benefits is paid
by or on behalf of the employer
■■ The eligible employee or dependent is
reimbursed, whether through wage adjustments
or otherwise, by or on behalf of the employer,
for any portion of the premium; or
■■ The health benefit plan is treated by the
employer or any of the covered individuals as
part of a plan or program for the purpose of
Section 106, 125, or SearchTerm5162 of the
United States Internal Revenue.
Jury and Marriage Amendment Act of 2009
Effective July 7, 2009, the District of Columbia
began recognizing marriages legally entered into
in another jurisdiction between two persons of the
same sex. The bill notes that:
■■ Insurance products that cover the spouse of
a primary insurance policyholder or group
policyholder shall cover the same-sex spouse
of the insured; provided the marriage was
performed in a jurisdiction where marriage
between two persons of the same sex is legal.
■■ For marriages that were performed on or
prior to July 7, 2009, the effective date of the
legislation is the date of a “qualifying event” for
determining benefits.
■■ For marriages performed after July 7, 2009, the
date of the “qualifying event” for determining
benefits will be the date on which the legal
marriage took place.
CareFirst will extend the “qualifying event”
enrollment period for same-sex spouses so
notification of the benefit can be provided to
groups. Members will have 30 days to enroll
same-sex spouses from the date the contract
amendment is received by the group.
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Domestic Partnership Judicial Determination
of Parentage Amendment Act of 2009
Effective July 18, 2009, the District of Columbia
will recognize as domestic partnerships, those
relationships other than marriages, which are
recognized in other jurisdictions as having all
the rights and duties of marriage, regardless of
the description of the relationship. These include
civil unions and domestic partnerships. The D.C.
Department of Insurance, Securities and Banking
issued guidance for health insurers that states:
■■ Insurance products that cover the domestic
partner of a primary insurance policyholder or
employee of a group policyholder shall cover
the same-sex domestic partner of the insured
for those relationships recognized as domestic
partnerships in other jurisdictions.
■■ For same-sex couples who entered into a
domestic partnership in another jurisdiction on
or before July 18, 2009, the “qualifying event”
date for determination of benefits will be July
18, 2009.
■■ For same-sex couples who entered into a
domestic partnership in another jurisdiction
after July 18, 2009, the “qualifying event”
date for determination of benefits will be the
date in which the two persons entered into a
recognized domestic partnership in another
jurisdiction.
CareFirst will extend the “qualifying event”
enrollment period for same-sex domestic partners
so notification of the benefit can be provided to
groups. Members will have 30 days to enroll.
Insurance Coverage for Emergency
Department HIV Testing Amendment Act of
2008
Effective March 21, 2009, health benefit plans are
required to reimburse the cost of a voluntary HIV
screening test performed on its insured while the
insured is receiving emergency medical services,
other than HIV screening, at a hospital emergency
department. This is regardless of whether or
not the HIV screening test is necessary for the
CONTENTS
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Highlights of Small Group Legislation—DC, Va, Federal (continued)
treatment of the medical emergency which caused the
insured to seek emergency services. The mandated
benefits shall:
■■ Include at least one HIV screening test annually,
if performed in connection with an unrelated
emergency department visit.
■■ Reimburse the costs of administering the test, all
laboratory expenses to analyze the test, the cost
of communicating to the patient the results of the
test, and any applicable follow-up instructions for
obtaining health care and support services.
■■ Not be subject to any annual or coinsurance
deductible or any co-payment other than the copayment that the insured would have to pay for the
applicable hospital emergency department visit.
Enhanced BlueVision Plus Products in DC and VA
(Effective 6/1/12)
CareFirst is now offering new voluntary and employersponsored BlueVision Plus vision plans in DC
and Virginia. The vision plans mirror our existing
BlueVision Plus group plans in Maryland. Voluntary
benefits can offer added financial security to
employees with no direct costs incurred by employers.
There is no participation requirement for voluntary
vision. Employees gain access to enhanced coverage
that otherwise might not be available to them.
Removal of Prior Authorization for Inpatient
Maternity Admissions in VA, DC and MD
(Effective 12/1/12)
Most small-mid risk contracts require an inpatient
authorization for maternity admissions with a length
of stay longer than 48 hours (normal delivery) or 96
hours (caesarean delivery). Analysis shows claims
initially denied for lack of authorization are overturned
on appeal more than 99% of the time. When the cost
of the appeal, medical review and adjustment as well
as the impact to the member are considered, CareFirst
has determined authorization should no longer
be required for an inpatient maternity admission,
regardless of the length of stay.
New Pharmacy Benefit Manager (PBM)
(Effective 1/1/14)
CareFirst selected CVS CareMark* as the company’s
new PBM. Members will receive new ID cards.
Transitions of care will be made and member
communications will be coordinated.
Virginia
Virginia Prosthetic Parity Act
The Virginia Prosthetic Parity Act requires health
insurers to offer coverage for prosthetic devices
(i.e., arm, leg, foot or any portion of an arm, hand,
leg or foot), including the repair, fitting, replacement
and components to those mentioned devices. This
mandate is effective on January 1, 2010 and impacts
Virginia risk business only.
VA HB1075 (Effective 7/1/1998)
Virginia law requires every Health Maintenance
Organization (HMO) when offering a health plan
to a group contract holder to provide or include a
“point-of-service” (POS) benefit as an additional
benefit for the enrollee, at the enrollee’s option,
individually to accept or reject. In connection with its
group enrollment form, HMOs must make available
to the prospective group contract holder and to
all prospective enrollees, in advance of the initial
enrollment and each re-enrollment, a notice, approved
by the Commissioner, which completely and accurately
explains to the group contract holder and prospective
enrollee the point-of-service benefit and permits each
enrollee to make his or her election. Virginia approved
point of service offerings include CareFirst BlueChoice
Opt-Out Open Access, BlueChoice Advantage and
BluePreferred. CareFirst BlueChoice Opt-Out Plus
Open Access does not meet the requirements of VA
HB1075. (38.23407.12, 38.2-4319). Each enrollee
completes an enrollment form and a Point-of-Service
Selection form. The enrollee individually accepts or
rejects the POS options on the POS form.
* C VS Caremark is an independent company that provides pharmacy benefit
management services.
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Highlights of Small Group Legislation—DC, Va, Federal (continued)
Direct Reimbursement for Ambulance Providers
(Effective April 2012)
VA Code 38.2-3407.9 states that if a policy provides
coverage for ambulance services sand the ambulance
service provider presents an Assignment of Benefits
(AOB), the Insurer must pay the ambulance provider
directly. This legislation applies to Virginia Risk
Groups and Consumer Direct members residing in
Virginia only, in addition to any ambulance provider.
Enhanced BlueVision Plus Products in DC and VA
(Effective 6/1/12)
CareFirst is now offering new voluntary and employersponsored BlueVision Plus vision plans in DC
and Virginia. The vision plans mirror our existing
BlueVision Plus group plans in Maryland. Voluntary
benefits can offer added financial security to
employees with no direct costs incurred by employers.
There is no participation requirement for voluntary
vision. Employees gain access to enhanced coverage
that otherwise might not be available to them.
be required for an inpatient maternity admission,
regardless of the length of stay.
Revision to the Virginia Insurance Continuing
Education (CE) Program Requirements (Effective
1/1/13)
The Virginia General Assembly amended Article 7 of
Chapter 18, Tittle 38.2 of the Code of VA to streamline
the CE process for insurance agents subject to VA
Insurance CE requirements. These amendments
included the elimination of the provision that required
agents whose licenses had been terminated for failure
to comply with CE requirements to wait 90 days
before reapplying for a license.
Secondly, all resident insurance agents subject to
VA Insurance CE are required to complete 3 CE hours
of insurance ethics in lieu of the previously required
2 hours of insurance laws and regulations. These 3
credit hours of insurance ethics may include insurance
law and regulations applicable in VA.
VA HB1273 Parity of Coverage for Oral
Chemotherapy Medications (Effective 7/1/12)
New Pharmacy Benefit Manager (PBM) (Effective
1/1/14)
Requires individual and group health plans to provide
coverage for prescribed, orally administered anticancer medication on parity with coverage provided
for intravenously administered or injected cancer
medications. CareFirst has implemented the mandate
for all fully insured groups headquartered in Virginia.
Members in these groups, regardless of where they
reside, have a $0 copay for specific oral chemotherapy
drugs when dispensed at a pharmacy.
CareFirst selected CVS CareMark as the company’s
new PBM. Members will receive new ID cards.
Transitions of care will be made and member
communications will be coordinated.
Removal of Prior Authorization for Inpatient
Maternity Admissions in VA, DC and MD
(Effective 12/1/12)
Most small-mid risk contracts require an inpatient
authorization for maternity admissions with a length
of stay longer than 48 hours (normal delivery) or 96
hours (caesarean delivery). Analysis shows claims
initially denied for lack of authorization are overturned
on appeal more than 99% of the time. When the cost
of the appeal, medical review and adjustment as well
as the impact to the member are considered, CareFirst
has determined authorization should no longer
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CONTENTS
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Highlights of Small Group Legislation—DC, Va, Federal (continued)
Federal
Notice of Intent to Grandfather a Plan
The Patient Protection and Affordable Care Act
(PPACA), also known as the federal health reform law,
was enacted on March 23, 2010. This law established
new benefits that increase the coverage under many
health plans. This law also created the option for
groups to elect “grandfathered status” for their
qualified health plan, and be exempted from some
provisions under the law.
To be eligible for grandfathered status, a plan must:
■■ Have been in effect on or before March 23, 2010,
with at least one enrollee
■■ Have maintained continuous enrollment since then
■■ Not have undergone any changes that would
disqualify the plan, including increasing copays,
deductibles and employee contributions beyond
certain limits
■■ Provide certain disclosures to plan participants as
required by federal law
The decision and the responsibility for maintaining the
status of a plan belongs to the group, not to CareFirst
BlueCross BlueShield (CareFirst). Groups that wish to
maintain the grandfathered status of a plan will have
to maintain additional documents for inspection by
members, and by state and federal officials.
If a group intends to continue Grandfather status a
notice of intent needs to be submitted annually.
Federal Mental Health Parity
Federal Mental Health Parity states that there must
be parity between medical benefits and mental health
benefits which are offered to the member. The bill
does not require group health plans to offer mental
health or substance abuse disorder benefits. Rather,
it establishes parity requirements between medical/
surgical benefits and mental health or substance
abuse disorder benefits for group health plans that
provide mental health or substance abuse disorder
benefits.
Federal Mental Health Parity applies to:
■■ 51+ fully insured accounts in MD, DC, VA
■■ MD Parity groups
■■ Small groups in DC and VA with 51+ employees
(not enrollees or eligibles)
■■ Self-insured accounts with standard benefits
Medical Loss Ratio
Under the Patient Protection and Affordable Care
Act (PPACA), beginning in 2011, health insurers
must spend a minimum percentage of the premiums
they collect on health care services and quality
improvement activities for their members. This
percentage is called the Medical Loss Ratio (MLR).
In addition, insurers must publically report this
information each year.
The same calculation developed for Federal Mental
Health Parity will be used for MLR. This calculation is
referred to as the Federal Employer size and must be
updated annually.
Federal Employer Size = Number of Full Time Employees
+ Part Time employee hours worked Total annual hours for the employer
(52 weeks X 40 hours = 2, 080)
67 / DC/VA GROUP ELIGIBILITY / BROKER MANUAL
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Highlights of Small Group Legislation—DC, Va, Federal (continued)
Request for Group Size Data: Full-Time
Equivalent (FTE) Calculation (Effective
September 2013)
Based on recently published regulations from
both federal and state agencies, pursuant to the
Affordable Care Act, CareFirst BlueCross BlueShield
and CareFirst BlueChoice Inc. (collectively, CareFirst)
must use a new method to categorize groups as
either a small or large employer. To do this, we are
asking groups to calculate the average number of
employees—part-time, seasonal and full-time—using
a Full-Time Equivalent (FTE) calculation that classifies
an employee working a 30-hour work-week (120-hour
work-month) as full-time.
By having this information n on file, we will help
ensure that groups receive the appropriate plans
and correlating rates at renewal. Additionally, it’s
important that groups are categorized correctly
for purposes of Medical Loss Ratio calculation and
potential l future refunds.
The collection and reporting of FTE data by CareFirst
is required under federal mandate and is used to
determine the average number of all employees (not
just the number of covered lives) who worked for a
company in the calendar year prior to their renewal.
Employers with more than 50 full-time employees on a
temporary or seasonal basis will not qualify as a large
employer, unless the number of full-time employees
exceeded 50 for more than 120 days.
CareFirst BlueCross BlueShield is the business name of Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and
CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association. ® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.
CST2308 Broker Manual_DCVA (4/14)
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>