Group Administrator Manual (PDF) For Innova^SM and Engage^SM plans only

This guide will serve as your first resource in administering the coverage selected by your company. It has been designed to answer general questions about enrollment, billing, and appeals procedures for Innova^SM and Engage^SM plans.

Group Administrator Guide – For all other plans

This guide will help you to administer Regence BlueCross BlueShield of Oregon coverage for your group. We’ve included instructions for adding or updating employee and dependent information. If you can’t find answers to your questions in this guide or in your contract, please call your membership administrator or sales team. We’re here to help!

Please note that these are our standard information and administration guidelines.

• Who Can Apply
• Enrolling New or Newly Eligible Employees
• Exclusion Period for Pre-Existing Conditions
• Special Enrollment
• Member Cards
• Deleting Employees and Dependents
• Certificate of Coverage
• Leave of Absence
• Leave of Absence under the Family and Medical Leave Act (FMLA) of 1993
• Handling Returns from Layoffs
• Premiums
• Annual Group Listings (Groups with less than 50 employees)
• Annual Census
• Making Changes
• Filing a Claim
• If You Cover California Residents
• Member Satisfaction
• Changing the Terms of the Group Contract
• Fraud and Abuse
• Oregon State Continuation of Group Coverage (groups under 20)
• Washington State Continuation of Group Coverage (groups under 20)
• COBRA Continuation for Oregon and Washington (groups over 20)
• Portability Coverage/Conversion
• Step By Step Through Your Premium Invoice
• Important Telephone Numbers
• Customer Service

WHO CAN APPLY

Employees
A full time employee regularly working your group’s applicable hours per week is eligible for enrollment after satisfying your group’s eligibility waiting period. The employee’s coverage will begin on the first of the month following completion of the eligibility waiting period.

Please note, any employee hired as a temporary or seasonal employee cannot be offered coverage. (Please refer to the Eligible Employee provision in your contract for further details.) Employees whose hours increase and become eligible to enroll must satisfy the eligibility waiting period, which begins on the date the hours were increased.

Dependents
The following qualify as dependents of the enrolled employee:

• legal spouse;
• qualified domestic partner (if applicable);
• unmarried children under age 23 (under age 25 for Washington-based groups) if they are dependent on the employee for support (the age may vary depending upon the group contract). Eligible children include a natural child, an adopted child, a child placed for adoption, a stepchild living in the employee’s home or a nonresident stepchild with a qualified medical support order, and a child related to the employee by blood or marriage if the employee or qualified domestic partner is the legal guardian;
• children over age 23 (under age 25 for Washington-based groups) if incapable of self-support because of a mental or physical disability. The incapacitation must have occurred before the child’s 23rd birthday, and be approved by us.

Domestic Partners (if applicable)
The domestic partner of an enrolled employee is eligible for coverage if the domestic partnership meets qualifying conditions. The qualified domestic partner can be added by completing an Employee Enrollment Form and an Affidavit of Domestic Partnership.

ENROLLING NEW OR NEWLY ELIGIBLE EMPLOYEES

Notify Employee of Insurance Eligibility
About a month before the employee is due to be effective on coverage, give the employee a new hire packet (containing an Employee Enrollment Form, benefit summaries, and related materials). Advise the employee when you want the Enrollment Form returned to you to assure timely submission to us. Notify the employee what their expected effective date is and mention that they may receive their member cards before the coverage actually begins.

Determining the Effective Date
After serving the eligibility waiting period, eligible employees and dependents must enroll within 30 days of their eligibility.

The following example will help you determine the effective date. Your group has a 30-day eligibility waiting period and Subscriber1 is hired on April 20. Subscriber1's eligibility waiting period is over on May 20, so the effective date is June 1. To have coverage effective June 1, we need to receive Subscriber1's Employee Enrollment Form during the month of May.

Enrolling New Employees
Timely submission of the Employee Enrollment Form is very important. Employee Enrollment Forms received more than 30 days from an employee’s eligibility date will be returned to you. The employee and any eligible dependents won’t become eligible for coverage until your group’s next open enrollment date.

If you include completed Employee Enrollment Forms along with your premium payment, please submit only the amount shown on your current premium invoice. Your premium invoice for the following month will show the appropriate payment due for any eligibility changes made the previous month.

Enrolling Newly Eligible Employees
If you have an employee who hasn’t been working the number of hours necessary to be eligible for coverage, but the number of hours worked each week increase, the eligibility waiting period will begin on the date the hours were increased. For example, Company XYZ has a 60-day eligibility waiting period and employees must work 30 hours each week to be eligible for coverage. Subscriber2 had been working 25 hours each week, but beginning May 17 Subscriber2 is working 30 hours (the minimum required). Subscriber2’s eligibility waiting period ends on July 17 (60 days from the date the hours increased) and the coverage effective date will be August 1.

Please note, there are times when additional information may be needed, which is addressed in the remainder of this guide. Remember, this additional information should be submitted with the enrollment form.

Employee Declines or Waives Coverage
Your contract requires that a certain percentage of employees enroll in the plan. Your contract may allow a small percentage of employees to decline coverage. We’ll provide declination forms for the employee to sign and return to you to keep with your records, however, supervision of the participation level is your responsibility. There’s no need to return these forms to us.

Voluntary Dental
The “Information About Your Group” section will indicate if this provision applies to your group. If an enrollee declines coverage when first offered, they can’t enroll on the dental plan at a later date. Voluntary termination from the dental plan disqualifies the employee from future re enrollment.

Adding Newly Acquired Dependents to an Enrolled Employee’s Coverage
When an employee has a life event (marriage, new qualified domestic partner, birth of a baby, legal guardianship, or adoption or placement for adoption) and wants to add a dependent, an Employee Enrollment Form must be submitted within 31 days of the event.

New Spouse and Stepchildren
A new spouse and his or her children must be added and an Employee Enrollment Form submitted, within 31 days of the marriage. Refer to Who Can Apply for the list of eligible dependents. We may ask you to obtain and submit a completed Certificate of Marriage and/or Certificate of Dependency form. Coverage will be effective the first of the month following the date of marriage.

Newly Qualified Domestic Partner
A newly eligible qualified domestic partner (see Who Can Apply for details) becomes eligible on the date an an Affidavit of Domestic Partnership is completed. Please be sure to include the completed affidavit when the Employee Enrollment Form is submitted. Coverage for the newly eligible domestic partner will be effective the first of the month following receipt and acceptance of the forms.

Newborn Children - Oregon
An eligible newborn child will be covered as long as an Employee Enrollment Form is signed and submitted adding the child within 31 days of birth. Coverage will be effective on the newborn child’s date of birth. If additional premium is required, it will be reflected back to the date of birth on your next premium invoice.

Newborn Children - Washington
An eligible newborn child will be covered as long as an Employee Enrollment Form is signed and submitted adding the child within 60 days of birth. Coverage will be effective on the newborn child’s date of birth. If additional premium is required, it will be reflected back to the date of birth on your next premium invoice.

Newborn Grandchildren - Oregon
If the birth mother or birth father is an enrolled dependent child of your enrolled employee, the newborn child can be covered from the date of birth, as long as legal guardianship is established for the enrolled employee. In the case of a newborn of a male dependent, proof of paternity must also be provided. An Employee Enrollment Form must be signed and submitted, along with proof of application for guardianship, adding the child within 31 days of the child’s birth. The actual guardianship papers must be received within 90 days of the date of birth. If additional premium is required, it will be reflected back to the date of birth on you next premium invoice.

Newborn Grandchildren – Washington
If the birth mother or birth father is an enrolled dependent child of your enrolled employee, the newborn child can be covered from the date of birth, as long as legal guardianship is established for the enrolled employee. The exception is when the mother is receiving maternity benefits under this contract, in which case, the baby will be covered for 31 days regardless of eligibility. Please also note that in the case of a newborn of a male dependent, proof of paternity must also be provided. An Employee Enrollment Form must be signed and submitted, along with proof of application for guardianship, adding the child within 60 days of the child’s birth. The actual guardianship papers must be received within 90 days of the date of birth. If additional premium is required, it will be reflected back to the date of birth on you next premium invoice.

Adopted Children – Oregon
A newly adopted child will be covered as long as an Employee Enrollment Form along with the required legal documents are submitted to add the child within 31 days of placement. Coverage will be effective on the date of placement. If additional premium is required, it will be reflected back to the date of placement on your next premium invoice.

Adopted Children – Washington
A newly adopted child will be covered as long as an Employee Enrollment Form along with the required legal documents are submitted to add the child within 60 days of placement. Coverage will be effective on the date of placement. If additional premium is required, it will be reflected back to the date of placement on your next premium invoice.

• Employee Enrollment/Change Form
• Declination of Coverage
• Certificate of Dependency
• Certificate of Marriage
• Certificate of Placement – Oregon
• Certificate of Placement – Washington
  

Exclusion Period for Pre-existing Conditions
Beginning January 1, 2005, an exclusion period for pre-existing conditions applies to new and renewing groups in Oregon and Washington. For Oregon-based groups, an exclusion list of specific conditions and procedures will also apply. The waiting and lookback periods are defined based on contact issue state and group size.

Exclusion Period for Pre-Existing Conditions – The exclusion period for pre-existing conditions is the period of time that must pass before charges for covered services will be paid.

Pre-existing Condition – A pre-existing condition, regardless of the cause, for which medical advice, diagnosis, care, or treatment was recommended or received, or for which medication was prescribed or taken within the six-month period before the enrollment date.

Lookback Period – The period of time before coverage begins that Regence BCBSO will check to determine if a pre-existing condition(s) existed. The lookback period will be applied as follows:

• Six-month lookback period for all size Oregon-based groups, and Washington-based groups size 2-50.
• Three-month lookback period for all Washington-based groups size 51+.
• New employees – we will use full time (or eligible) hire date
• New dependents – we will use the effective date of coverage
• Late enrollees – we will use the effective date of coverage

Creditable Coverage – Creditable coverage means the exclusion period for pre-existing conditions is reduced one month for every month that the member had coverage in a previous plan as long as the gap in coverage between the termination of the previous plan and the employee’s date of hire with the Regence plan is 63 days or less.

IMPORTANT– The prior coverage section of the Employee Enrollment Form must be completed to ensure the employee’s prior coverage is credited correctly.

Exclusion list for Oregon-based groups includes the following conditions and procedures not covered during the exclusion period:

• Removal of tonsils and adenoids with or without myringotomy
• Otitis media
• Allergies
• Sterilization
• Elective procedures

Note: The exclusion list does not apply to Washington-based groups.

SPECIAL ENROLLMENT
(Your Employee Originally Declined Coverage, But Now Wants to Enroll)

Open Enrollment
Employees or family members who did not enroll when originally eligible may apply for enrollment at your group’s yearly open enrollment. The date for your open enrollment is listed on the first page of this guide.

Involuntary Loss of Coverage
If your employees and/or dependents(s) declined coverage when first offered, then changes their mind, they must wait for your group’s next open enrollment date.

However, there are exceptions:

• Involuntary loss of group or individual coverage. The Employee Enrollment Form must be submitted within 31 days of the loss of coverage along with a Certificate of Coverage (COC) from the old carrier. If the COC isn’t available, the Employee Enrollment Form still needs to be submitted within 31 days of the loss of coverage.
  • Example of involuntary loss of coverage: Subscriber3 was enrolled on their spouse’s group plan, but the spouse lost their job. The spouse's health insurance will end on August 31. We must receive Subscriber3's application for coverage by September 30 for a September 1 effective date.
  • Example of voluntary loss of coverage: Subscriber4 was enrolled on their spouse’s group plan, but their spouse’s payroll deduction increased and now this coverage is less expensive. Discontinuing other insurance because of a premium increase isn’t considered an involuntary loss of coverage. Subscriber4 wouldn’t be eligible to enroll for this coverage until the next open enrollment.
• Legal separation, divorce, death, termination of employment, reduction in hours, or termination of employer contributions, or involuntary loss of coverage under Medicaid, Medicare, CHAMPUS/Tricare, Indian Health Service, or a publicly sponsored or subsidized health plan such as Oregon Health Plan.

In these instances the employee becomes eligible to apply for coverage on the date the other plan ends. We must receive the Employee Enrollment Form within 31 days of the event.

Life Events
Even though the employee originally declined coverage when first eligible, if:

• he or she marries, the employee, new spouse or eligible domestic partner, and any eligible dependent children become eligible on the date of marriage or domestic partnership;
• he or she acquires a new dependent child by birth, adoption, or placement for adoption, the employee, new spouse, newly acquired child, and any eligible dependent children become eligible on the date of the birth, adoption, or placement for adoption; or
• a court issues an order that the employee provide coverage for a spouse or eligible domestic partner and/or dependent child, the spouse or eligible domestic partner and/or child becomes eligible on the date of the order.

We must receive the Employee Enrollment Form within 31 days of the event. Coverage will begin the first of the month following the event. Please note, the life events listed above don’t apply to freestanding or voluntary dental plans.

• Employee Enrollment/Change Form
  

MEMBER CARDS
New enrollees will receive member cards in the mail. If additional member cards are needed, you or your employee can use our Web site to order cards. You can also contact a customer service specialist. Employees and dependents should present their member cards at the time care is received. Information on the card gives providers essential data about the employee’s benefits, and helps the provider file claims directly with us.

Note: Employees may receive their member cards before coverage begins. The “issue date” printed on the card most often isn’t the coverage effective date. It is simply the date the card was printed. You should inform your employees of their actual coverage effective date.

DELETING EMPLOYEES AND DEPENDENTS

Termination of Employment
On your next billing invoice, under the section entitled “Terms,” list the employee’s name, identification number and the last day worked. We’ll cancel coverage on the last date of the month the employee stopped working. For example, if Subscriber’s last day worked is September 2, their last day of coverage is September 30. Depending on your group’s size, your employees may be eligible for COBRA continuation or state continuation. Refer to the “Continuation of Group Coverage” brochure (Lit. #4554 for Oregon and #4554wa for Washington), for more details. Your contract indicates your group’s current form of continuation.

Employee’s Child Becomes Ineligible for Coverage
Coverage for the employee’s child normally ends at the end of the premium payment period during which the child turns 23 (the age may vary depending on the group contract), marries, or is no longer dependent on his or her parent for support. The child may then be eligible to continue their group coverage through COBRA continuation, Washington state continuation (if Washington-based group) or may apply for a portability plan (Oregon state continuation is not available for over-age dependent children).

Divorce
The spouse may remain on coverage until the divorce decree is final. An Employee Enrollment Form must be completed, and the spouse will be deleted on the first of the month following the date the divorce decree is final. The spouse may be eligible to continue coverage through COBRA continuation or state continuation.

Note: If you have an employee who wants to remove his or her spouse before the divorce decree is final, we suggest you advise the employee to consult an attorney before ending the spouse’s coverage.

Death
Coverage for the employee’s spouse and covered children ends at the end of the premium payment period in which the employee dies. Please delete the employee on your next premium invoice. Covered family members may be eligible to continue their group medical coverage through COBRA continuation or state continuation. Upon the death of a dependent, an Employee Enrollment Form should be completed reflecting the change.

Employee or Spouse Eligible for Medicare
Groups with less than 20 employees: If an employee or spouse becomes eligible for Medicare and is actively working, Medicare automatically becomes the primary coverage and the group policy becomes the secondary coverage.

Groups of 20 or more employees: If an employee or spouse becomes eligible for Medicare and is still actively working, the group coverage remains the primary coverage and Medicare becomes the secondary coverage.

Retirees
Regence BlueCross BlueShield of Oregon offers several individual plans for Medicare-eligible individuals - the Companion Plans, First Choice Sixty-Five and Preferred Choice Sixty-Five. For more information about one of our individual plans, contact your Individual marketing representative.

• Employee Enrollment/Change Form
• COBRA Application
• Oregon Continuation Application
• Washington Continuation Application
  

CERTIFICATE OF COVERAGE
A certificate of coverage (COC) form will be mailed to each member that has terminated coverage with us. The member’s effective date and termination date with out company will be stated. This form can be used as proof of coverage when the member applies for insurance with another carrier.

LEAVE OF ABSENCE
A leave of absence can be approved for up to three months provided the enrollee is still considered an employee and is expected to return to work. Indicate on your monthly premium invoice that the employee is on an approved leave of absence. Continue to send in the necessary premium each month.

LEAVE OF ABSENCE UNDER THE FAMILY AND MEDICAL LEAVE ACT (FMLA) OF 1993
FMLA applies to groups with 50 or more employees. Indicate on the monthly premium invoice that the employee is on an approved FMLA leave of absence. Continue to send in the necessary premium each month. By law, you are required to continue coverage for up to 12 weeks. Employees must continue to submit premium to maintain coverage for eligible dependents during the leave.

If the employee and/or dependents elect not to remain insured during the leave, they can re-enroll with no new eligibility waiting periods when the employee returns to work. The employee must submit a new Employee Enrollment Form within 60 days of the return to work. Credit is applied for all eligibility waiting periods served prior to the FMLA leave.

HANDLING RETURNS FROM LAYOFFS

Re-enrollment
Send a completed new Employee Enrollment Form with your monthly premium invoice for the returning employee and indicate the rehire date on the premium invoice and the form.

Eligibility Waiting and Exclusionary Period Credits - Oregon
Groups with less than 20 employees with Oregon Continuation: An employee who returns to work with six months of a layoff will be credited for eligibility waiting periods already served.

Groups of 20 or more employees: An employee who returns to work after a layoff will be credited for eligibility waiting periods already served only if the employee had COBRA or state continuation coverage during the layoff period. If the returning employee chose not to continue coverage through COBRA or state continuation, he or she will be treated as a new hire.

Eligibility Waiting and Exclusionary Period Credits – Washington
An employee who returns to work after a layoff will be credited for eligibility waiting periods already served only if the employee had COBRA or state continuation coverage during the layoff period. If the returning employee chose not to continue coverage through COBRA or state continuation, he or she will be treated as a new hire. If dependents aren’t carried on continuation, they can only re enroll at open enrollment.

PREMIUMS
If an employee or dependent begins coverage on other than your group premium due date, the premium will be prorated unless your contract specifies otherwise.

ANNUAL GROUP LISTINGS (Groups with less than 50 employees)
The Oregon Department of Consumer Business Services requires that we provide periodic reports regarding the eligibility and enrollment of individuals in our small groups. In order to comply with this rule, each year upon request you are responsible for supplying us with a list of current employees.

ANNUAL CENSUS
For groups of 2 – 50 employees, an annual census questionnaire, which is required by Oregon Insurance Law and the Washington State Insurance Commissioner, will be sent directly to the group and must be returned by the due date for us to issue renewal rates. If the questionnaire is not returned, we won’t be able to renew your group’s health plan.

MAKING CHANGES

Name Changes
Have the employee complete an Employee Enrollment/Change Form. Submit it with your regular monthly premium invoice. We’ll issue new member cards.

Address Changes
There are a couple of ways to let us know your employee has an address change.

Your employee may change the address on our Web site on the member page, or fill out an Employee Enrollment/Change Form. If your employee chooses to fill out the form, please forward it to us with your monthly premium invoice.

Changing Medical Plans
If you offer a choice of medical plans, employees can elect to change to another available program only at your group’s open enrollment date.

Changing Dental Plans
If your group offers both a standard dental plan and a Dentacare plan, employees can elect to change from one plan to the other at your group’s open enrollment date. If the employee has Dentacare coverage and moves out of the service area but continues to be an active employee, he or she can change at that time to the standard dental program by submitting an Employee Enrollment/Change Form within 31 days of moving.

FILING A CLAIM (for services received in Oregon or SW Washington)

When an Employee Receives the Bill
When an employee receives a bill from a provider or hospital, he or she will need to examine it carefully to determine which steps below to follow.

• If the Provider Has Already Billed Us
  If the statement indicates the insurance company has been billed, there is nothing the employee needs to do. The employee will receive a statement from us showing the amount we paid and if there is any balance owed.
• If We Haven't Been Billed Yet
  If the statement says "Insurance Copy" or "For Insurance Purposes," have the employee send the bill to us for processing. No claim form is needed.
• If You Aren't Sure
  If the employee is unsure whether we have been billed, send us the bill anyway. We will determine the appropriate processing.
• When You Need to Send the Bill to Us
  When sending a bill to us, be sure that all of the following items are indicated on the bill:
  • Your group number and personal identification number. These are found on the employee's Regence BlueCross BlueShield of Oregon identification card.
  • Itemization of charges. The bill must clearly state all services provided and the charge for each service. We cannot make payments based on a "balance due" statement.
  • Any pertinent details. If services are the result of an accident, indicate the date of the accident, the type of injury sustained, and whether any other insurance company will be responsible (e.g., automobile, homeowner's liability, etc.).
  • Emergency room services. If the bill is for emergency room services, we will need a copy of the hospital emergency room report before we can pay benefits. If you cannot obtain this report, we will request the report from the hospital, which will cause a short delay in processing the bill.
  • Where to Send the Bill
    

    Traditional/PPO/BlueChoices Medical Bills Regence BlueCross BlueShield of Oregon P.O. Box 1271 Portland, Oregon 97207-1271

    HMO Medical Claims Regence HMO Oregon P.O. Box 900 Portland, OR 97207-1271

• Prescription Medications
  You can obtain reimbursement forms directly from us by calling our Customer Service department or visiting the forms section of our Web site. Complete the form, attach the receipts and send them to the address on the form.

Questions?
If you still have questions about filing a claim, call our Customer Service department at (503) 225-5336 or toll-free at 1 (800) 231-9027. Or, you can call the number listed on the back of your Regence BlueCross BlueShield of Oregon identification card.

IF YOU COVER CALIFORNIA RESIDENTS

Employees or Dependents Who Decline Coverage
California law requires the employer to keep on file waivers signed by both the California employee and spouse who decline coverage. (Note: There is a special waiver form for California residents, Form #3686.)

Late Enrollees
If the California employee or dependent signs the Coverage Waiver form and later requests coverage, he or she must wait 12 months from the date of the request before enrollment on the plan. After 12 months, the employee will be accepted for coverage without a health statement application.

MEMBER SATISFACTION

Member Grievance
This is used when a member would like to file a formal expression of dissatisfaction. The dissatisfaction can be with any aspect of care – policy, telephone wait times to speak with a customer service specialist, or an issue with the provider’s office.

Note: The grievance process is outlined in the member’s benefits booklet.

Member Appeals
An appeal is used if an enrollee wants to dispute a decision made by us. The dispute may be with the rejection of a claim or denial of preauthorization request.

Note: The appeals process is outlined in the member’s benefit booklet.

CHANGING THE TERMS OF THE GROUP CONTRACT
We’ll change the terms of the contract upon written request on the first of the month following receipt of the change.

Changing Your Eligibility Waiting Period
Let’s say you want to change your eligibility waiting period on May 1. Employees hired before May 1 will follow the old eligibility waiting period. Employees hired on May 1 or after will follow the new eligibility waiting period.

Changing the Eligibility Hours
Contact your sales team. It may necessary to re-rate your group premiums if several employees will be added or deleted because of the change.

Changing the Employer Contribution
Contact your sales team. It may necessary to re-rate your group premiums if several employees will be added or deleted because of the change.

FRAUD AND ABUSE
To help control the cost of health insurance, our Fraud and Abuse department works to identify fraudulent claims and ineligible employees or dependents that have enrolled. This team works diligently to recover thousands of dollars each year helping to keep your premium increases to a minimum.

OREGON STATE CONTINUATION OF GROUP COVERAGE (groups under 20)
Oregon state insurance law requires that group medical and integrated medical/dental (not stand-alone dental) policies allow people whose coverage would ordinarily end under their group plan to continue coverage for up to six months in certain situations. These continuation rules apply to groups not subject to federal COBRA continuation rules. Oregon state continuation applies to groups with fewer than 20 employees.

Qualifying Events

• The enrolled employee loses coverage because of termination of employment.
• The enrolled employee loses coverage because of loss of eligibility due to illness or injury for which a workers' compensation claim has been filed.
• An enrolled dependent spouse loses coverage because of divorce or legal separation.
• An enrolled dependent spouse and/or dependent children lose coverage because of the employee's death.
• An enrolled employee has a reduction of Hours.

Note: There is no dependent continuation for children who become ineligible for group coverage because of age or for dependents who lose coverage because the employee becomes eligible for Medicare.

How To Enroll
Continued group coverage is not automatic. First, the enrollee must complete a Continuation of Group Coverage Form (Form 9765). Then, the completed form must be given to the employee benefits administrator to include with the group's monthly premium payment.

Note: The enrollee must send the employee benefits administrator both the completed state continuation application and the first premium payment within 31 days of the date coverage normally would have ended.

State Continuation Premium Payments
The enrollee is responsible for paying the premium to the employee administrator each month in advance. The employee benefits administrator then sends the premium payment to us along with the group's regular monthly premium payment. We will only accept continuation premiums if they are received with the group's regular monthly premium payment.

Length of Coverage
The number of months a member may continue coverage under Oregon law is as follows:

• For termination of employment, continuation may last for up to six months.
• For death, dissolution of marriage, or legal separation of the covered employee, continuation may last up to six months. There is a specific Oregon Statute (applicable to only employers with 20 or more employees) that allows a spouse who is age 55 to 65 at the time of the qualifying event may remain on continuation until covered by another group health plan or until age 65 or eligible for Medicare, whichever happens first. Covered dependent children of the spouse may remain on the plan with the spouse as long as they are otherwise eligible under the terms of the plan.

Requirements for Continuation
All of the following requirements must be met in order to continue coverage:

• The enrolled employee must have been covered through the group for at least three months immediately before coverage would have ended.
• The person applying for continuation of coverage must not be eligible for Medicare or a group health plan through his or her spouse's or parents' employment not covering him or her when coverage would have ended.
• All eligible dependents covered through the group must also continue coverage.

Changes in Benefits and Premiums
If the group's benefits change during the continuation period, continuation coverage will also be changed in the same manner. Required monthly premiums may also change during the continuation period in the manner allowed under the law. You should notify the continuation applicant of any changes in benefits and/or premiums during the continuation period.

When Continuation Ends
In all cases, continuation coverage may be ended if any of the following events occur:

• The employer stops providing health plan coverage to its employees.
• Premium for continuation is not paid on a timely basis.
• An individual, after electing continuation, becomes covered under any other group plan or Medicare.
• An injured worker on continuation becomes a full-time employee with another employer.
• Dependents on continuation lose eligibility due to loss of dependent status.
• The applicable allowed number of months of continuation ends.

Oregon Continuation Application and Notice

WASHINGTON STATE CONTINUATION OF GROUP COVERAGE (groups under 20)
Washington state insurance law requires that group medical and integrated medical/dental (not freestanding dental) policies allow people whose coverage would ordinarily end under their group plan to continue coverage for up to six months in certain situations. These continuation rules apply to groups not subject to federal COBRA continuation rules and who have elected to have State Continuation of Coverage provisions in their medical contract.

Qualifying Events

• The enrolled employee loses coverage because of termination of employment.
• The enrolled employee loses coverage because of loss of eligibility due to illness or injury for which a workers' compensation claim has been filed.
• An enrolled dependent spouse loses coverage because of divorce or legal separation.
• An enrolled dependent spouse and/or dependent children lose coverage because of the employee's death.
• An enrolled dependent child no longer qualifies as a dependent under the terms of the plan.

How To Enroll
Continued group coverage is not automatic. First, the enrollee must complete a Continuation of Group Coverage Form (form 3243). Then, the completed form must be given to the employee benefits administrator to include with the group's monthly premium payment.

Note: The enrollee must send the employee benefits administrator both the completed state continuation application and the first premium payment within 31 days of the date coverage normally would have ended.

State Continuation Premium Payments
The enrollee is responsible for paying the premium to the employee administrator each month in advance. The employee benefits administrator then sends the premium payment to us along with the group's regular monthly premium payment. We will only accept continuation premiums if they are received with the group's regular monthly premium payment.

Length of Coverage
Continuation of coverage will end on the last day of the monthly premium period for any of the following reasons:

• The group medical policy is terminated.
• The premium for continuation is not paid on a timely basis.
• The six months continuation period has expired.
• Receipt of written notice that the terminated employee wishes to discontinue coverage.

Changes in Benefits and Premiums
If the group's benefits change during the continuation period, continuation coverage will also be changed in the same manner. Required monthly premiums may also change during the continuation period in the manner allowed under the law. The continuation employee will be notified by the group of any changes in benefits and/or premiums during the continuation period.

When Continuation Ends
In all cases, continuation coverage may be ended if any of the following events occur:

• The employer stops providing health plan coverage to its employees.
• Premium for continuation is not paid on a timely basis.
• An individual, after electing continuation, becomes covered under any other group plan. However, coverage under another plan will not cause continuation to end so long as the other plan excludes or limits coverage for a pre-existing condition of the qualified beneficiary in accordance with federal law.
• An individual on continuation becomes eligible for Medicare (except when the individual is on continuation due to Chapter 11 bankruptcy).
• The applicable allowed number of months of continuation ends.

Washington Continuation Application and Notice

COBRA CONTINUATION (Oregon & Washington groups over 20)
COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985) eligibility is based on employers who have 20 or more full-time or part-time employees on 50 percent of more of the employer’s typical business days in the preceding calendar year, whether enrolled in your health-care plan or not. If you group doesn’t meet this qualification, your continuation of coverage is state continuation. An employee must have been enrolled on the group health coverage for a minimum of three months to be eligible for state continuation.

It’s important to let us know if your continuation status has changed. The best time to notify us is in December so we can ensure your group contract reflects the correct continuation for the new year.

Qualifying Events

Insured Employee
An enrolled employee may continue coverage when he or she would otherwise lose coverage because of either of the following situations:

• Termination of employment (for reasons other than gross misconduct)
• Reduction in hours of employment

Spouse or Dependent Child
A covered spouse or covered dependent child (natural-born child or a child placed for adoption) may continue coverage when the spouse or dependent child would otherwise lose coverage because of any of the following circumstances:

• Divorce
• Termination of employment or reduction in hours of employment of the covered employee.
• Death of the covered employee or the covered retiree
• Loss of eligibility for dependents under the plan because the covered employee becomes covered under Medicare
• Loss of dependent child status under the terms of the plan
• Filing of Chapter 11 bankruptcy by the employer*

  *A covered retired employee or the covered surviving spouse of a retiree who died before this bankruptcy-related qualifying event may continue coverage. However, the coverage may only be continued when the retiree's coverage or surviving spouse's coverage would otherwise be lost or substantially eliminated due to the employer filing a Chapter 11 (reorganization) bankruptcy.

Medicare or Other Group Coverage
In certain cases, an insured employee or covered dependent may not be eligible for COBRA continuation. For instance, if he or she becomes enrolled in Medicare or covered under another group health plan after the time of COBRA election (unless the other plan limits or excludes coverage for a pre-existing condition of the qualified beneficiary in accordance with federal law), refer to the length of coverage section for the explanation on termination of COBRA coverage.

How to Enroll
First, the enrolled employee must complete the COBRA continuation form (Form 1800). Then, the completed form must be given to the employee benefits administrator within 60 days of receiving COBRA notification or from the date active coverage terminated, whichever is later. Payment of premium must be made to the administrator within 45 days of the election date. (We will accept continuation premiums only if they are included in the group's regular monthly premium payment.)

Premium Payments
Under the law, the employer may require that the qualified beneficiary pay the entire cost of continuation coverage. The applicable premium on insured plans is the cost to the plan for similarly enrolled beneficiaries with respect to whom a qualifying event has not occurred. There are special rules for determining the continuation premium on self-insured plans. COBRA allows the employer to charge an extra two percent of applicable premium to cover the cost of administering continuation. In addition, 148 percent of the applicable premium will be charged in the case of a disabled qualified beneficiary on the 11-month extended continuation. (See Length of Coverage section.)

Premium payments must be made on a timely basis and generally will be due according to the premium payment provisions of the plan with no less than a 30-day grace period after the due date. If continuation coverage is elected after the qualifying event, the plan must require payment for continuation coverage during the period preceding the election to be made within 45 days of the date of the election.

Notification Requirements

Employee or Dependent
In order to obtain the right to continue coverage, the law requires that the insured employee or covered dependent notify the employee benefits administrator (normally the person at the employer, association or trust office either named as employee benefits administrator or responsible generally for employee benefits administration) within 60 days in the event of either of the following:

• Divorce
• Loss of dependent child status under the plan

If notification is not made within 60 days, generally the dependents will lose their rights to COBRA continuation.

Employer
The employer is responsible for notifying the employee benefits administrator within 30 days of the date of any of the following qualifying events:

• Death of the insured employee
• Termination of the insured employee's employment or reduction of the insured employee's hours rendering him or her ineligible for coverage
• Medicare entitlement of the insured employee or retiree
• Filing of Chapter 11 bankruptcy

Employee Benefits Administrator
The employee benefits administrator must then notify the insured employee, spouse, domestic partner or dependent child of his or her rights to continuation within 14 days of the employee benefits administrator being notified. The insured employee, spouse, domestic partner or dependent child then has 60 days to elect continuation of coverage from either the date coverage would ordinarily have ended under the plan by reason of a qualifying event or the date of notification, whichever is later.

Length of Coverage
COBRA provides that each qualified beneficiary has a separate right to elect continuation of coverage. The number of months a qualified beneficiary who has elected continuation may continue coverage is as follows:

• For termination of employment or reduction of hours, continuation may last for up to 18 months. However, there is one exception. It applies when a qualified beneficiary is determined by the Social Security Administration to have been disabled at any time before or during the first 60 days of continuation coverage. Those individuals may have up to a total of 29 months of continuation, but only if the Social Security Administration makes the determination within the first 18 months of the continuation period. In addition, the qualified beneficiary must notify the employee benefits administrator both within that 18-month period and within 60 days of the determination. Thereafter, if there is a final determination of non-disability, the qualified beneficiary must notify the employee benefits administrator within 30 days. The extended continuation will end the month that begins more than 30 days from the final determination that the qualified beneficiary is no longer disabled.
• For Chapter 11 bankruptcy, continuation may last for the lifetime of the covered retiree or the surviving spouse of a retiree. On the death of the retiree, any of his or her covered dependents may continue coverage for an additional 36 months.
• For death, dissolution of marriage or termination of qualified domestic partnership of the covered employee, continuation of covered dependents may last for up to 36 months. There is a special Oregon statute (applicable to insurance policies issued in Oregon to employers of 20 or more employees). It allows a spouse who is age 55 or over at the time of the qualifying event to remain on the plan beyond 36 months - until covered by another group health plan or until age 65, whichever happens first. Covered dependent children of the spouse or qualified domestic partner may remain on the plan with the spouse or qualified domestic partner beyond 36 months as long as they are otherwise eligible under the terms of the plan.
• For a dependent child no longer eligible as a dependent under the plan, continuation may last for up to 36 months.
• For the covered employee or retiree becoming entitled to Medicare and thereby causing a loss of coverage for covered dependents, continuation may last for up to 36 months.
• In the case of multiple qualifying events (a qualifying event followed by one or more qualifying events), a qualified beneficiary may, upon proper notice to the employee benefits administrator, continue for up to 36 months from the date the original continuation began. However, in the case of a covered employee with covered dependents who becomes terminated and elects COBRA, the period of continuation for covered dependents for any subsequent qualifying event (such as the employee's termination of employment) may last for up to 36 months from the date of termination.

Note: Changes in plan benefits, premiums and administration of plan rules generally, such as at open enrollment periods, apply to those on continuation in the same manner as they apply to active employees.

Changes in Benefits and Premiums
If the group's benefits change during the continuation period, continuation coverage will also be changed in the same manner. Required monthly premiums may also change during the continuation period in the manner allowed under the law. You should notify the continuation applicant of any changes in benefits and/or premiums during the continuation period.

When Continuation Ends
In all cases, continuation coverage may be ended if any of the following events occur:

• The employer stops providing health plan coverage to its employees
• Premium for continuation is not paid on a timely basis
• A person, after electing continuation, becomes covered under any other group plan. However, coverage under another plan will not cause continuation to end so long as the other plan excludes or limits coverage for a pre-existing condition of the qualified beneficiary in accordance with federal law
• An individual, after electing continuation, becomes eligible for Medicare (except when the individual is on continuation due to a Chapter 11 bankruptcy)
• The applicable allowed number of months of continuation ends

COBRA Application and Notice

PORTABILITY COVERAGE/CONVERSION
When a Regence BlueCross BlueShield of Oregon member discontinues employment with an employer, he or she may be eligible to continue insurance benefits through a portability plan. Portability means that an individual, in Oregon, with at least 180 days of continuous group health insurance, may continue his or her health coverage by enrolling on an individual policy offered through the employer's insurer.

Portability Rights (Oregon)
A member will be notified by us of his or her eligibility for a portable individual product. Portability products are available to an individual terminating his or her group coverage if the following requirements are met:

• Must not be eligible for Medicare.
• Must not be eligible for coverage under any other group or individual health benefit plan.
• Must have been continuously covered for at least 180 days under group health coverage - with the most recent coverage under a Regence BlueCross BlueShield of Oregon plan.
• Must be a resident of the state of Oregon.

For more information, please visit our Portability section of the Member Web site.

Conversion (Washington)
If an enrollee and his or her dependents lose eligibility for coverage under Washington state continuation, the enrollee and/or his or her dependents may be entitled to convert to an individual conversion plan or the Medicare supplement plan we are offering at that time. The benefits under the conversion plan will be different than the benefits under state continuation.

The following individuals have the right to convert to the conversion plan:

• The enrolled employee and/or his or her enrolled eligible dependents who are terminating from the group.
• The enrolled employee’s surviving spouse, divorced spouse, or eligible dependents.
• The enrolled employee’s enrolled children who have lost eligibility as dependents under state continuation.

Note: Notice of the right to conversion must be given during the continuation period.

STEP BY STEP THROUGH YOUR PREMIUM INVOICE
This Guide walks you through:

• Invoice generation
• Understanding your premium invoice
• How to notify us of changes to your enrollment
• What to include with your premium payment
• Steps to reconcile your premium invoice

When Invoices Are Generated
We generate the next bill once we process payment of the current month’s premium invoice. As noted in the group contract, payments are due no later than the first of the month for which coverage is being purchased. Example: June health insurance coverage is due by June 1.

The contract provides a 15-day grace period and if payment has not been received, the group health insurance plan is terminated without further notice. We may mail a letter offering one opportunity to reinstate the coverage.

Please be aware that due to Oregon legislation, if we have not processed a payment by the third day of the month, letters must be sent to any employee and their provider for claims that are pended due to the group premium payment not being received. The letter will direct the employee to check about the status of their coverage.

If you have any questions about your invoice, please call the appropriate phone number shown in the upper right corner of your invoice entitled, “For Billing Questions.”

Understanding Your Premium Invoice

Group Billing Summary
The premium for the members listed on the roster, any amounts (debits or credits) carried forward, and adjustments to the previous invoice are displayed and totaled. The sum of these amounts is the total premium due for this billing period. We provide two summaries: one to return with your payment and one to keep for your records.

Eligibility Adjustments
Use this space to list any additions, cancellations, or changes to the enrollment. Record the subscriber's name, identification (ID) number, and the effective date of the change. (If your changes won't fit in this space, record the information on an eligibility adjustment form and submit with your premium payment.) Be sure that application forms are included with your payment for new enrollees or changes to existing enrollment (if you haven’t already submitted them).

Member Roster
Each subscriber currently covered for this billing period is listed. The contract type and the lines of business are shown for each subscriber. The roster also shows the number of members enrolled, the benefit package selected, and the total premium amount.

Auditing Your Premium Invoice
It is important to audit your invoice to ensure the changes you requested in the previous invoice are now reflected in the new invoice. Does the new invoice reflect new employees you added previously? How about terminations or package changes? What about dependents that were added or deleted, or name changes that were made? These are examples of what you will want to audit your invoice for.

Note: Enrollment changes to existing coverage made on your previous invoice will be shown under the “contract types”. Additions will show an increase in the number covered under the “no mbr”. Deletions, showing a decrease in the number covered, will be reflected in the same area.

Contract Type Counts
For each benefit package, the total number of contracts enrolled by contract type and lines of business are displayed.

***Contract Type Counts***