Administering your Healthcare Plan

By self-funding your healthcare plan, you take on special responsibilities. Use these documents to guide you through legal and procedural requirements to make the administration of your plan run smoothly.

Informing Employees
Enrollment and Eligibility
Claims
Flexible Benefits

Informing your Employees

The success of your plan depends on effective communication with your employees. There are several methods you can use to effectively explain the provisions and requirements of the plan.

What Your Employees Need to Know
How Do You Keep Your Employees Informed?

What Your Employees Need to Know
ERISA requires that you provide the employees who participate in your health plan with a detailed description within 120 days after the plan first becomes subject to ERISA. The description should include an explanation of the eligibility requirements, the benefits offered and the limitations of the plan.

Ensure that your employees understand the following:

• Plan coverage
• Enrollment or re-enrollment procedures
• Eligibility requirements
• Health care management requirements, procedures and non-compliance penalties
• Claim handling and filing procedures
• Identification cards
• Plan provisions
• PPO requirements (if applicable)

Ensure that your newly hired employees understand the following:

• The pre-existing condition provision in your plan and the impact of prior creditable coverage under HIPAA
• Their monetary contributions to the plan
• Their effective dates of coverage
• Any waiting periods (if, for example, an employee must work full time for three months before becoming eligible for coverage)

How Do You Keep Your Employees Informed?

You can inform your employees of your plan's provisions, requirements and procedures by offering them a description of your plan, conducting meetings and distributing internal communication. In addition to your communication efforts, encourage your employees and their covered dependents to use their Benesight accounts to review their benefits and answer their questions.

• Description of Plan

  All employers are required to provide each of their employees who participate in their plan with either a plan document or a summary plan description that fully explains eligibility requirements, benefits and limitations of the plan. When there is a change to the plan, you must provide your employees with an explanation of that change.

• Meetings

  You may elect to conduct meetings with your employees to educate them on the benefits of the plan, changes to the plan, procedures for filing claims or clarification on any related topic. Meeting with your employees allows them an opportunity to voice any concerns and you an opportunity to respond.

• Internal Communication

  You may elect to distribute internal communication pieces to educate them on the benefits of the plan, changes to the plan, the procedures for filing claims and you may want to indicate on the communication who the employees contact if they have any further questions or need clarification.

• Electronic Disclosure

  The Department of Labor (DOL) Interim regulations (required under HIPAA) permit the disclosure of Summary Plan Descriptions to participants and beneficiaries through electronic media. The information disclosed via electronic media must be consistent with the style, format and content requirements applicable to SPDs under ERISA and the Plan Sponsor must notify participants, through electronic or other means that the disclosure documents have been furnished electronically.

  The following are the responsibilities of the Plan Sponsor regarding the disclosure requirements through electronic media:

  1. The Plan Sponsor must take appropriate and necessary measures to ensure that the system for furnishing documents results in actual receipt by participants of transmitted information and documents (e.g. uses return-receipt electronic mail feature or conducts periodic reviews or surveys to confirm receipt of transmitted information).
  2. Electronic documents must conform to the style, format, and content requirements for non-electronic documents.
  3. Each participant is provided notice, through electronic means or in writing, apprising the participant of the documents to be furnished electronically, the significance of the document and the participants right to request and receive, free of charge, a paper copy of each such document; and
  4. Upon request of any participant, the administrator furnishes, free of charge, a paper copy of any document delivered to the participant through electronic media.
  5. Participants (employees and former employees) must have the ability at their worksites to receive documents in electronic form and to convert documents from electronic form to paper form free of charge.

  
  

  By using electronic media, plans may only satisfy a portion of the ERISA disclosure requirements. Plans cannot satisfy the ERISA disclosure requirements with respect to spouses and dependents through electronic media. Plans using electronic media to provide plan information will still have to provide plan information to beneficiaries in a paper format.

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Enrollment and Eligibility

Accurate eligibility is an integral piece of the claims adjudication process. All eligible employees and dependents must be enrolled in RIMS (Resource Information Management System) in order for any type of claim to be processed on their behalf.

Your summary plan description (SPD) outlines all of your company's enrollment and eligibility requirements.

• The Eligibility, Effective and Termination section of the SPD defines who is an eligible employee and dependent under your plan, when coverage takes effect and when coverage terminates.
• The COBRA Continuation Options explains when a person's coverage under the Plan ceases and the continuation options which are available.
• Your employees may also make enrollment changes if they have had a qualifying event.

Please review these sections as you enroll employees and dependents.

Traditional Enrollment

An employee must enroll for coverage by filling out and signing an enrollment form. The covered employee is required to enroll for dependent coverage if coverage for dependents is desired. If the covered employee already has dependent coverage, a newborn child will be automatically enrolled from birth; otherwise separate enrollment for a newborn child is required.

Who should complete an enrollment form?

• Employees wishing to enroll in the benefit program or to waive benefits
• Employees or dependents who have changes in eligibility and/or benefits (at Open Enrollment or due to a qualifying event.
• Employers on behalf of employees or dependents who experience a termination event.

Note: Changes received by Benesight after the 10th of each month will appear on the following month's statement.

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Claims

Claims Processing Information
Claim Forms
Explanation of Benefits
Pending Claim Information
Flex Benefits

Claims Processing Information

• Group number and the employee's social security number identify all claims. Claims submitted should always include this information or they may need to be returned to the sender for identification, which would delay claims processing.
• Claims should be sent to the address(es) listed on the member's ID card. If your plan includes a PPO network, some claims may need to be sent to the PPO for repricing before they are sent to Benesight for processing. Filing claims according to the instructions on the ID card will avoid processing delays.
• Benesight performs daily random audits of claims processed, and audits of all claims in excess of a certain dollar amount. Audits are performed before the payment is issued; audit errors can be corrected before you fund the claim.
• A check and Explanation of Benefits (EOB) is generated for every claim that is processed for payment. The employee and the provider receive a copy of the EOB unless you instruct us otherwise. Payment is issued to the provider unless the bills clearly show no balance is due.
• Payment will be issued to the provider of service if the plan includes a Preferred Provider Organization (PPO). If the payment has not been assigned directly to the physician and the bill(s) clearly show the bill has been paid, the payment will be issued to the employee.
• Benesight uses an output distribution vendor to produce and mail checks, EOBs and pending letters.
• Benesight notifies you of the amount of paid claims after the checks have been generated so that you can fund the claim payment account. Additionally, you receive a monthly report showing the claims paid for each participant.

In most cases, the provider will submit the claim to Benesight on behalf of the patient. If this has not happened, submit the necessary information to Benesight.

Pending Claim Information
Benesight processes claims according to the requirements outlined in your Summary Plan Description (SPD). To determine whether or not a claim meets those requirements, we sometimes need more information than what appears on the bill.

The claims processor sends a letter requesting the necessary additional information for a specific claim. This letter is usually sent to the patient for a response, although occasionally the doctor or provider will be asked for additional information. Two attempts will be made to obtain the requested information and if a response is not received, a third and final letter will be sent indicating no further action will be taken until the requested information is received by Benesight.

The most common reasons for requesting more information are:

1. To determine if the patient has other health coverage. If a patient is covered under two health plans, Benesight must determine which plan is the primary payer. This information is usually requested only once or twice a year.
2. To obtain accident information. Some plans provide higher benefits for accident claims, and some injuries (such as worker's compensation claims) may not be covered under the health plan. To determine the benefits available, we need to know when, where and how the accident occurred.
3. To determine student status. Most plans cover unmarried, full-time college students. Benesight must have documentation showing that a child is a full-time student during each college quarter or semester for which a claim is incurred.

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Flexible Benefits

Flexible Spending Account Benefit Plans help provide your employees a way to pay for certain benefits with tax-free dollars. This will also reduce federal, state and Social Security taxes for your organization. Flexible Spending accounts can also help minimize other proposed benefit plan changes which shift more costs to the plan participants.

Benesight offers Flexible Spending Accounts for Medical/Dental expenses and Dependent Care. The plan year is determined by you, the Employer.

Enrollment

Employees must enroll annually to participant in the Healthcare Reimbursement account or for the Dependent Care account. Participants covered by your Employer sponsored benefit plan will automatically be enrolled in the Premium Only account unless they specifically elect to not participate. View and Print Flex Enrollment Form

Change of Elections

Employees must make their election within 30 days of their eligible effective date. Their election will be in effect for the entire year. They will only be able to make an election change for certain qualifying events.
View and Print Change of Elections Form

Flex Claim Filing Instructions

Claim forms are required for Flexible Spending Account claims. The completed claim form should be submitted to Benesight. Claims incurred during the Flex Plan year must be submitted to Benesight within 90 days of the plan year-end.

Dependent Care claims should include

1.  Name and date of birth of the Dependent
2.  Nature of services (Date range of Child Care services) and the cost of such services
3.  Relationship (if any) of the person performing child care services
4.  If child care services provided by a child of the participant, the age of that child must be provided
5.  Statement as to where child care services provided
6.  If services performed in a day care center, a statement that a) day care center complies with all applicable laws and regulations; b) the day care center provides care for more than six (6) individuals (non-residents); and c) the amount of compensation paid to the center.

Medical/Dental claims should include

1.  Name of patient
2.  Relationship of patient to participant
3.  Nature of medical/dental services
4.  Date of service for medical/dental services
5.  Amount of charges not reimbursed by medical/dental benefit plan

Qualifying Events

1.  Change in Marital Status by marriage, divorce, death of a spouse, legal separation or annulment.
2.  Change in number of dependents by birth, adoption, placement for adoption, or death of a dependent.
3.  Change in Employment Status by termination, reduction of hours, or commencement of employment by spouse or dependent.
4.  Change in dependent status by attainment of student status or attainment of age ineligible for coverage.
5.  Change in residency or worksite for employee, spouse or dependent.

Flex Reporting

Benesight processes Flexible Spending Account claims weekly. Benesight will provide you with periodic (monthly or annual) reports.

Annual elections, contributions to date, amount available for reimbursement, and expenses reimbursed are some of the items indicated on the reports.

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