Health Benefits Administration - PowerPoint Presentation

Slide1

Health Benefits Administration

An Introduction to the HR Professional’s

Role

California Department of Human Resources

Slide2

Describe the HR Professional’s role in health eligibility/enrollment

Locate and identify needed rules, procedures, and information

Make determination of eligibilityCategorize enrollment transactions

Learning ObjectivesSlide3

Health Benefits Pre-Quiz 1

Eligibility

1. Which of the following dependents are eligible for health benefits?a. Grandparentb. Live-in fiancéc. 25 year old child

d. Foster child

2. Which

of the following people are

not

eligible for health benefits?

a. Permanent

Intermittent that worked 470 hours

in a

control

period

b. Limited

Term employee that has a current 12 month position

c. Half-Time

employee that holds a permanent position

d. Full-Time

employee in

Bargaining Unit

12Slide4

Health Benefits Pre-Quiz 2

Permitting

Events3. Which of the following is not a permitting event?a. Domestic partnershipb. Voluntary cancelation of coveragec. Birth of a childd. Newly hired

employee

4. Which

of the following is

not

a permitting event that may prompt an individual to change health plans?

a. Household

move

b. Change

in employment location

c. Retirement

d. In

place promotionSlide5

Health Benefits Pre-Quiz 3

Bonus

Question5. How often are open enrollments required per the Public Employees’ Medical and Hospital Care Act (PEHMCA)?a. Annuallyb. Once every other yearc. Once every three years

d. PeriodicallySlide6

Your Role is

Essential:

Provide accurate information on enrollment, eligibility requirements, benefits, and costsEnsure that only eligible employees and dependents are placed on the rollRole of the HR Professional 1Slide7

Role of the HR Professional 2

Process enrollments timely

Retain all documentation in OPFProactively monitor continued eligibilitySlide8

Product

Rules

SystemThere’s a Lot to KnowSlide9

Web site—

www.calpers.ca.gov

Health Plan CalPERS-specific Web sitesHealth Program GuidesHealth Benefit SummariesHealth Plan Evidence of Coverage (EOC)

Know the CalPERS ProductsSlide10

Public Employees’ Medical & Hospital Care Act (PEMHCA)—

Government

Code §22750–22944CA Code of Regulations §599.500–599.517CalPERS State Health Benefits GuideCalPERS Circular LettersCalHR Policy Statements (Formerly PMLs)

State Collective

B

argaining

C

ontracts

Know the RulesSlide11

Take my|CalPERS Training

Use my|CalPERS Resources

Subscribe to my|CalPERS NotificationsKnow the SystemSlide12

The more you know, the easier your job becomes

Rising health benefit costs are a leading cause of anemic pay raises

WIIFMSlide13

An employee comes to you

expressing confusion

in selecting a health plan, and asks you which health plan is the best. What actions would you take and what information would you provide to assist them in making a selection?Discussion Question 1Slide14

Health Plan Chooser 1Slide15

Health Plan Chooser 2Slide16

Based on appointment tenure and time

b

ase:Tenure—More than 6 months Time Base—Half-time or moreSpecial Rules for:Permanent IntermittentsSeasonal FirefightersEligibilitySlide17

Permanent Full-Time

Permanent Part-Time (half-time

or more)Permanent IntermittentMust work ≥ 480 hours in control period or ≥ 960 hours in 2 consecutive control periodsMust requalify each control period

Eligible Employees 1Slide18

Limited Term of more than 6

months and:

Full-Time, orPart-Time (half-time or more)Eligible Employees 2Slide19

Employees whose

appointment is:

-Temporary (except for TAUs) -Limited Term, 6 months or less -Less than half-time -Intermittent, other than Permanent Intermittent

Ineligible Employees 1 Slide20

Temporary Authorization Utilization (TAU) 1

Current state employees:

TAU does not have to be more than 6 months.Time base must be half-time or more.Slide21

Temporary Authorization Utilization (TAU) 2

New state employees:

TAU must be more than 6 months.Time base must be

half-time or more

.

If

later

appointed Permanent Intermittent, cannot use hours

worked as

TAU to

qualify

for a

control period.Slide22

Only spouses, domestic partners, and disabled adult children, but not other adults?

Only natural, adopted, step/DP children, children in parent-child relationship, but not other children?

Dependent Eligibility—Why . . .Slide23

Dependent Eligibility Verification

Checklist (CalHR Form 781) 1

Required to:Verify dependents are eligible for health, dental, and premier vision benefits before enrollment.Annually recertify parent-child relationships (PCR).Slide24

Dependent Eligibility Verification

Checklist (

CalHR Form 781) 2Section 1—Required forms and acceptable documents to determine dependent eligibilitySection 2—Documents the employee knows their obligations by their signature Section 3—Documents HR staff took necessary steps by their signatureSlide25

CalPERS Circular Letter 600-045-12

CalHR Health Benefits Policy (formerly PML)

Required Enrollment DocumentsSlide26

Spouse

or

registered domestic partnerEmployee’s children, up to age 26:Natural childrenAdopted childrenStep children

Registered

domestic partner's

children

Eligible Dependents 1Slide27

E

mployee’s

disabled adult children—Must be incapable of self-support due to a mental or physical conditionMust be disabled and enrolled prior to age 26CalPERS approves : “Member Questionnaire for the CalPERS Disabled Dependent Health

Benefit

”

and

“Medical

Report for the Disabled Dependent

Benefit”

Eligible Dependents 2Slide28

Eligible

Dependents 3

Initial certification of disabled adult child must be:Within 60 days before and 60 days after child’s 26th birthday (employee and child currently enrolled) Or

Within

60 days of

newly

eligible employee’s initial

health enrollmentSlide29

Children up to age 26 for whom employee has:

“

assumed a parent-child relationship. . . by intentional assumption of parental status, or assumption of parental duties” [CA Code of Regulations §599.500(o)] PCR (parent-child relationship)Eligible Dependents 4Slide30

Employee must complete Affidavit of Parent-Child Relationship

and

provide documentations showing a current parent-child relationship.HR Manager and Health Benefits Officer must sign Affidavit. PCR Eligibility ProcedureSlide31

Employee submits:

A copy of the first page from the previous tax year’s income tax return, showing child is a dependent

OR Court order with employee as legal guardian Bank, credit card, tuition or insurance statement School records Bills or mail indicating common residency

Enrolling PCR Child Under

Age 19Slide32

Re-certifying PCR Child Under Age 19

Employee

must submit a copy of the first page from the previous tax year’s income tax return, showing child is a dependent.Slide33

Employee

submits:

A copy of the first page from the previous tax year’s income tax return, showing child is a dependent OROther documentation showing child

is financially

dependent, provided

that the child:

L

ives

with

employee for

more than 50

percent or

is a full-time

student,

AND

Is

more

than 50 percent dependent

upon

employee

Enrolling and Re-certifying PCR Child,

Age 19 to 26Slide34

Annual Recertification

Required

(Circular Letter 600-058-12)Employee must submit a new affidavit and documentations showing current parent-child relationshipHR Manager and Health Benefits Officer must sign Affidavit

PCR Annual RecertificationSlide35

Former spouses and former registered domestic partners are

not eligible

(even if a court orders the employee to provide health coverage)Children age 26 and olderDisabled adult children not enrolled and disabled prior to age 26

Ineligible Dependents 1Slide36

Grandchildren

, grandparents, parents, aunts, uncles

, nieces, nephews, etc.Foster children Spouses/domestic partners of adult children Ineligible Dependents 2Slide37

Live-in boyfriend/girlfriend

and his/her

childrenAnyone already enrolled in a CalPERS health plan on their own or as another subscriber’s dependentIneligible Dependents 3 Slide38

Benefit Entitlement

Government Code section 20128

allows CalPERS to require information it deems necessary to determine a member or beneficiary’s benefit entitlement. Slide39

Self-Only or

Self and

all eligible dependentsExceptions:Family member with other (non-CalPERS) coverageSpouse not living with employeeChildren over 18

Family member in military

Enrollment 1 Slide40

Enrollment 2

Failure to Enroll required Dependent(s):

Notice the employee in writing that all family members will be deleted from coverage effective the last day of the following month. If the employee does not comply timely, administratively disenroll all family members.CA Code of Regulations §599.502(a)(6)Slide41

Enrollment Types:

New Enrollment

Open EnrollmentSpecial EnrollmentLate Enrollment (HIPAA)Permitting Event—occurrence that permits an enrollment action

Enrollment 3 Slide42

New hires may enroll within 60 days of appointment

Permanent Intermittents may enroll within 60 days following completion of qualifying control period

Coverage effective the first of the month following the date HBD-12 is received in HR Office.New EnrollmentSlide43

Held each fall for approximately 30 days

Employees may enroll, change plans, cancel coverage, add, or delete dependents

Changes effective January 1 (start of new plan year)CalPERS issues Circular Letter in summer with open enrollment info & instructionsOpen EnrollmentSlide44

Triggered by permitting events, such as:

Marriage

Birth (Reference Circular Letter 600-007)Adoption or placement for adoptionInvoluntary loss of other coverage

Court-ordered

coverage

Must enroll within 60 days of event

Effective 1

st

of the month following

Special EnrollmentSlide45

Outside of open enrollment or more than 60 days following permitting event

90-day waiting period

Coverage effective 1st of the month following expiration of 90-day waiting periodReference Circular Letter 600-007Late Enrollment (HIPAA)Slide46

Mandatory

Permissive

Plan ChangesProhibitedReason Codes; Effective Date Methods www.calpers.ca.gov

TransactionsSlide47

Additions or deletions required by law from:

Court-ordered coverage

Divorce (deletion of ex-spouse and stepchildren)Death of a family memberDependent reaches age 26

Separation

from

employment or reduction

in

time

base (

Circular Letter

600-067-10)

Birth or

adoption

Mandatory TransactionsSlide48

Additions or deletions that are voluntary at the employee’s option.

Examples include:

Child reaches age 18Family member enters or leaves militaryFamily member obtains other coverage

Custody change for child under age 18

Permissive TransactionsSlide49

Triggers enabling a plan change:

Household move

Change in employment locationRetirementBecoming Medicare-eligible

Health Plan ChangeSlide50

Dual Coverage

Split Enrollments—dependents can’t be split between two CalPERS subscribers

Upon discovery, the employee’s health account must be corrected retroactivelyRetroactivity (Circular Letter 600-215-05)

Not PermittedSlide51

Circular Letter

600-050-14

Employee may direct pay premiums when off pay status, such as: leave of absence (LOA), pending approval of disability retirement, suspension.If employee declines to direct pay: must complete a HBD-12 to cancel coverageWhen an employee returns to work: update my|CalPERS and schedule resumption of payroll deductions

Off Pay StatusSlide52

Marriage/Domestic

Partnership

Divorce/Termination of Domestic PartnershipDeath of a member/family memberChange of residential addressMedicare-eligible due to age or disability

Employee Must Report TimelySlide53

What about the role of the HR professional in health eligibility/enrollment is most challenging?

What kinds of support would help most with these challenges?

Discussion Question 2Slide54

Separation and Divorce 1

If separated, but still married:

Cannot drop minor step-children.If court-orders coverage: If employee is not enrolled, must enroll.Health plan must provide coverage where dependents reside. If employee refuses, HR administratively enrolls family in PERS Choice.Slide55

Separation and Divorce 2

When divorce is final:

Disenroll ex-spouse and step-childrenCOBRA rightsA court ordering employee to provide ex-spouse with health coverage does not bind the state to provide it, or make the ex-spouse eligible for state benefits.Slide56

Check bargaining unit contract of the employee.

Dependent Health Vesting Slide57

Advise employees reaching age 65 and new-hires age 65 or

older to

contact Social Security Administration for their Medicare options, rights, and obligations.Lifetime penalty (premium surcharge) for late Medicare Part B enrollment. Medicare 1Slide58

Cannot

enroll Medicare-covered employees into FlexElect or CoBen Cash Option.Medicare 2 Slide59

Your

role is

important.Administering health benefits matters to the employees and the state.Organize and use reference materials online.SummarySlide60

Catbert: Evil HR Director