SECTION 6.25 HEALTH INSURANCE
Health
insurance is provided through Wellmark Blue Cross and Blue Shield and several
managed care organizations (MCOs). Blue
Cross and Blue Shield coverage is available throughout the State. MCO coverage availability depends on the
employee’s geographic location. Contact
the personnel assistant for this information.
The State Police Officers Council (SPOC) has collectively bargained its own health and dental plan. Some of the information included here does not apply to employees covered under the SPOC collective bargaining agreement, however, the basic enrollment and eligibility rules would be applicable.
Blue Cross and
Blue Shield offers a traditional indemnity plan and a Preferred Provider
Organization (PPO) plan. The traditional
indemnity plans are Program 3 Plus and Deductible 3 Plus. The PPO plan is Iowa Select. These plans have an 11-month new employee
pre-existing condition waiting period.
This waiting period may be offset by proof of prior creditable coverage.
If an employee
chooses to participate in an indemnity or PPO plan, the plan they are eligible
for is based on their bargaining status.
AFSCME, AFSCME Judicial, PPME, and non-contract Judicial branch
employees are eligible for Program 3 Plus and Iowa Select. UE/IUP employees are eligible for Deductible
3 Plus and Iowa Select. Non-contract employees
(excluding the Judicial Branch) are eligible for Deductible 3 Plus and Iowa
Select.
Managed Care
Organizations (MCOs) provide medical and hospital services in defined
geographic areas of the State. There are
two types of MCOs – Primary Care MCOs and Open Access MCOs. Primary Care MCOs require that an employee
choose a primary care physician that must refer to participating
specialists. Open Access MCOs do not
require referral from a primary care physician.
Services may be obtained from any provider in the MCO network. Contact the personnel assistant for further
details.
Full-time and
part-time employees with probationary or permanent status who work 20 or more
hours a week are eligible for health insurance coverage. Employees working 20 to 29 hours per week are
considered part-time and the State’s share of the premium is one-half the
amount paid for full-time employees.
Employees who work 30 or more hours per week are considered full-time.
Temporary
employees are not eligible for health insurance.
Employees may enroll in a single or family coverage plan within the first 30 calendar days following employment. Dependents eligible for family coverage are the employee’s spouse, domestic partner, unmarried children under age 19, and unmarried children that are full time students regardless of their age. The age restriction is waived if the dependent is totally and permanently disabled prior to age 19.
Part-time
employees who initially elect not to have health insurance coverage and who
subsequently change to full-time employment may elect coverage at that
time. The employee will have the same
eligibility and effective dates of coverage as a new employee.
Insurance
becomes effective on the first day of the month following 30 days of continuous
employment (Example A). If the first day
of employment is the first working day of the month, coverage is effective the
first of the following month (Example B).
Example A
|
|
|
Date employed: |
June 22 |
|
Application signed before: |
July 20 |
|
Effective date: |
August 1 |
Example B
|
|
|
Date employed: |
September 3
(first working day in September) |
|
Application signed before: |
October 3 |
|
Effective date: |
October 1 |
The annual Open Health Enrollment and Change period is a 30 day period
normally beginning in October, with changes in coverage effective January
1. This is the one time of the year when
employees can enroll in a health plan, select a different carrier, or change
who is covered on their health plan.
When an
employee enrolls in benefits, the benefit elections remain in effect to the end
of the calendar year and they cannot make any changes until the next enrollment
and change period.
They cannot
make any changes until the next enrollment and change period unless
they experience a qualified life event and the benefit change requested is
consistent with the event. For example,
a marriage is a family status change that would allow a change from single
health coverage to family coverage because acquiring a spouse is consistent
with a gain in eligibility for health coverage.
Qualified
events are defined by Section 125 of the Internal Revenue Code, based on
individual circumstances and plan eligibility.
This list may not apply to every benefit plan.
EMPLOYEES MAY
BE ABLE TO CHANGE BENEFIT ELECTIONS IF…
·
They have a change in legal marital status.
·
They have a change in their number of dependents.
·
They have a change in their employment status.
·
Their spouse or dependent has a change in their
employment status.
·
Their dependent has a change in his or her eligibility
status.
·
They, their spouse or dependent has a change in
residence.
·
They, their spouse or dependent becomes entitled to
Medicare or Medicaid.
·
They are served with a judgment, order or decree.
·
There is a change in cost by the dependent care provider.
This list may
not apply to every benefit plan. For
specific information, see the Life Event Matrix, located at the following
DAS-HRE website: http://das.hre.iowa.gov/benefits/benefit_documents/life_events_matrix.pdf.
SPECIAL
ENROLLMENT UNDER HIPAA
Opportunities to enroll in coverage during the year – Under the
Health Insurance Portability and Accountability Act of 1996 (HIPAA), a special
enrollment period for health insurance is available in the following
circumstances. Employees may enroll in
the health plan within 30 days of any of the following events:
·
Adoption or placement for adoption
·
Birth
·
Loss of other health coverage
·
Marriage
Opportunities
to change coverage during the year – If already
enrolled in a health plan, HIPAA allows an employee to add eligible family
members to an already existing health plan AND enroll in a different health
plan within 30 days of the following events:
·
Adoption or placement for adoption
·
Birth
·
Loss of other health coverage
·
Marriage
·
Divorce or legal separation
·
Death of spouse or dependent
Other
opportunities to change health plans during the year – If already
enrolled in a health plan, the following life events allow an employee to enroll
in a different health plan regardless of whether they are adding eligible
family members.
·
Commencement of an unpaid leave of absence or FMLA leave
in excess of 30 days
·
Death of spouse or dependent
·
Decrease in work hours from full time (30 or more hours
per week) to part time (20-29 hours per week)
·
Return from an unpaid leave of absence or FMLA leave in
excess of 30 days
Changing Your Coverage
To change
coverage when a qualifying event occurs the employee must act within 30 days
of the event (60 days in the case of birth or adoption) for the change to
be accepted; otherwise, they will have to wait for the next enrollment and
change period in which they are eligible to participate and have the change
become effective the following January 1.
Employees may be asked to provide documentation of the change.
Employees who
leave state employment will continue to have coverage through the last day of
the month in which they separate.
Employees and
their dependents who are separated for other than gross misconduct are eligible
to continue coverage with the subsequent eligibility for conversion to a
private policy. (See COBRA explanation
that follows.)
The federal
Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986 requires that when
certain “qualifying events” occur, employers that offer medical and dental
benefit plans must provide covered employees, their spouses and dependents the
option to continue group health benefit coverage beyond the period when their
coverage would normally end. A
“qualifying event” is one which results in the State employee's loss of
employment, reduction of work hours to a level no longer eligible for benefits,
divorce, death of an employee, or a dependent reaches the maximum age for group
coverage. To be eligible for continued
coverage, the employee, spouse, or dependent of the employee must have been
covered immediately prior to the qualifying event.
Under these
circumstances, continued group coverage will be made available for a 36 month
period (18 months for separation or reduction of hours or 29 months if disabled
per the Social Security Administration at the time of termination).
This continued
coverage option does not apply to individuals who are discharged from
employment due to gross misconduct.
If an
employee’s spouse’s, or dependent’s benefit coverage ceases because of
separation or the employee’s death, the employee or the employee’s family will
be notified regarding benefit continuation rights. In instances where coverage is lost due to
divorce, legal separation, ineligibility of a dependent (i.e., the dependent
marries or is otherwise no longer a dependent or reduction of work hours to a
level that denies eligibility, it is important that the individual notify the
personnel assistant so that notice of these rights can be sent to the
individual(s). Individuals will have 60
days from the date of notification in which to elect continuation of coverage.
Individuals
electing coverage under COBRA will be provided with the same coverage as that
in effect at the time loss of coverage occurred. The full cost of the premium is the
responsibility of the employee, spouse, or dependent(s). Continued coverage will remain in effect for
the allowable 36, 29 or 18 month period, until cancelled by the covered
individual. Coverage may be terminated
prior to the allowed number of months, however, in the following instances:
1. The State no
longer provides group health coverage to any of its employees.
2. The premium for
continued coverage is not paid by the individual.
3. The individual
becomes covered under another group health plan unless there are pre-existing
conditions not covered by the plan.
4. The individual
becomes eligible for Medicare.
At the end of
the allowable continued coverage period, enrollment in a health conversion plan
is available.
Employees
approved for State group long term disability benefits, or employees leaving
the payroll as a retiree, are eligible to remain in the State health insurance
group as long as they assume responsibility for the total premium cost. Information and application procedures are
available from the personnel assistant in the agency.
When a husband and wife are employed by the State,
at the option of the couple, one family plan may be elected. The State's contribution to double-spouse
family coverage will be the full premium.
When a husband and wife are employed by the State and one spouse is a
full-time employee and one spouse is a benefits-eligible part-time employee, at
the option of the couple, one family plan may be elected. The State's contribution to the above stated
double-spouse family coverage will not exceed the full family premium. If both spouses are benefits-eligible
part-time employees, the State's share of the premium for each employee will be
one-half of the State’s share of the full-time double-spouse family
premium. When a husband and wife are
employed by the State, and one spouse is a non-Regents employee and the other
spouse is a non-merit Regents employee, at the option of the couple, one family
plan may be selected. The family plan
selected shall come from those plans administered by the Department of
Administrative Services.
Doctors and
hospitals who have contracts with Wellmark Blue Cross and Blue Shield (called
“participating”) file claims for the employee.
When necessary, forms for filing claims are available from the personnel
assistant in the agency or local Blue Cross and Blue Shield offices. Claims must be filed no later than one year
following the year in which services were received.
If employees
have questions concerning Blue Cross and Blue Shield coverage or payment of
claims they should call the Blue Cross and Blue Shield State Employee Service
Unit: in the Des Moines area (515)
245-5185; or toll-free at 1-800-622-0043.
For employees
enrolled in MCOs, it is not necessary to file claims, however, employees should
refer to the MCO plan materials for limitations regarding providers or
services.
For further
information contact the personnel assistant in the agency.