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Frequently Asked Questions — Highmark Blue Shield

Health Enrollments/Changes

• How do I enroll a new employee?
  How do I enroll a new employee?

  An enrollment form must be completed and then signed by the employee and employer. These forms should be mailed, emailed, or faxed to the Pennsylvania Medical Society Insurance Agency. If you choose to email or fax your forms, it is not necessary to also mail the originals.

  E-mail address:	admin@pamedinsurance.com
  Fax number:	717-561-6077 (HIPAA compliant)
  Mailing Address:	Pennsylvania Medical Society Insurance Agency P.O. Box 69067 Harrisburg, PA 17106-9067

  Please call us if you need a supply of enrollment forms. These forms are also available under the Health & Dental Forms section of this website.

• How do I make changes to a current employee's coverage (i.e., address change, dependent changes, terminations, etc.)?
  How do I make changes to a current employee's coverage (i.e., address change, dependent changes, terminations, etc.)?

  Simply call or e-mail the Pennsylvania Medical Society Insurance Agency with the necessary information, and we will complete the required paperwork. Because a change form does not require a signature by the employee or employer, we will be glad to complete these forms for you. Or, if you prefer, you may complete the form and return to us for processing.

  Please call us if you need a supply of change forms. These forms are also available under the Health & Dental Forms section of our website. All completed forms should be mailed, emailed, or faxed to the Pennsylvania Medical Society Insurance Agency. If you choose to fax or e-mail your forms, it is not necessary to also mail the originals.

• What are the rules for group and member effective dates?
  What are the rules for group and member effective dates?

  Group Level:

  • Group name, address, and contact changes - anytime
  • Group Enrollment and Group Plan Changes - 1st of the month
  • Group Terminations - 1st of the month. If you wish to CANCEL your group’s health insurance plan, you must provide 30 days notice (e.g. you must notify us by 12/1/2010 in order to cancel coverage for 1/1/2011).

  Member Level:

  • New Employee Enrollments - Date of eligibility, usually the 1st of the month or date of hire
  • Current Employee/Dependent Enrollment (due to life status change) - Date of event/loss of coverage (however, the change must be reported to the Pennsylvania Medical Society Insurance Agency/Highmark within 31 days of the life status event or the change cannot be made until open enrollment).
  • Termination of Employee/Dependent - Date chosen by group (if timely notice is sent).
  • Retroactive terminations (adds and terminations) cannot exceed the current month less 60 days.
    
    
• Should I ever adjust my premium invoice/bill?
  Should I ever adjust my premium invoice/bill?

  Please always pay your invoice as billed, even if the practice has made or is making changes that will ultimately affect the group's invoice. Highmark Blue Shield's invoicing system automatically credits/charges adjustments as soon as the change is recorded within its system. For further clarification of the rules regarding enrolling and terminating dependents, please contact the Pennsylvania Medical Society Insurance Agency at (866) 441-2392.

• What is the enrollment/cancellation wash rule?
  What is the enrollment/cancellation wash rule?

  If a member is enrolling with an effective date of the 1st through the 15th of the month, they are charged for that entire month's premium. If a member is enrolling from the 16th through the end of the month, they are not charged for that month's premium.

  If a member is cancelled with an effective date of the 1st through the 14th of the month, they are not charged for that month's premium. If a member is cancelled from the 15th through the end of the month, the full month premium is charged.

• What changes can a group make during their health insurance open enrollment period?
  What changes can a group make during their health insurance open enrollment period?

  During your group's annual open enrollment period, which occurs approximately 60 days prior to your renewal date, you may make the following changes:

  • Enroll eligible employees or dependents who do not currently have coverage
  • Change your group's product selection
  • Change a member's product selection
  • Cancel employees or dependents who currently have coverage

  These changes will become effective on your renewal date. Benefit elections (including waiver of coverage) remain in effect throughout the year, unless the applicant experiences what the Internal Revenue Service (IRS) defines as a "change in family status." If your employee has a change in family status, they can change certain benefit elections without having to wait until the next open enrollment period. Examples of family status changes or life status changes are as follows:

  • marriage;
  • divorce or legal separation;
  • birth or adoption of a child;
  • death of spouse or child;
  • loss of dependent status;
  • loss of coverage through a spouse; or
  • coverage becoming available through a spouse due to a new job or the spouse's open enrollment period.

  
  
• How do I get a Highmark Blue Shield health insurance ID card?
  How do I get a Highmark Blue Shield health insurance ID card?

  ID cards for new employees will be mailed to the member's home address within 7-10 business days. Employers may order duplicate cards by logging onto www.highmarkblueshield.com and clicking on the Employers tab. Employees may order duplicate cards by logging on to www.highmarkblueshield.com and clicking on Log in under "Manage Your Plan." If you need assistance ordering additional ID cards, please call the Pennsylvania Medical Society Insurance Agency

• How can members view their account information?
  How can members view their account information?

  Members have an on-line resource to view their account information. They are able to find a provider or pharmacy, view benefit booklets, view their drug formulary, view their medical and drug claims, and request ID cards. Just log onto www.highmarkblueshield.com, click on the Members tab, and register to log on. If you need assistance or have questions regarding any of your account information, please contact the Pennsylvania Medical Society Insurance Agency.

• How can employers manage their group's account?
  How can employers manage their group's account?

  Employers have a simple and convenient way to manage their Highmark health insurance account and customer service information from anywhere, at anytime. They have on-line access to currently enrolled members; their group's benefits, group numbers, and rates; forms, resources, and member account management tools; customer service area to email us; frequently asked questions; educational pieces; and additional insurance needs. Just visit our secure site at www.pamedinsurance.com/highmark and log in with your username and password. Please contact the Pennsylvania Medical Society Insurance Agency to receive your username and password.

Health Benefits

• Who do I call if I have a question about a member's claims or prescriptions?
  Who do I call if I have a question about a member's claims or prescriptions?

  Please direct all questions regarding claims or prescription issues to Highmark's customer service (the number on the back of your ID card - 866-871-7579).

• What is COBRA?
  What is COBRA?

  COBRA provides certain former employees, retirees, spouses, former spouses, and dependent children the right to temporary continuation of health coverage at group rates. This coverage, however, is only available when coverage is lost due to qualifying events.

  Federal COBRA
  Group health plans for employers with 20 or more employees for more than 50 percent of its typical business days in the previous calendar year are subject to COBRA. Both full- and part-time employees are counted. Part-time employees are counted as a fraction of an employee – please access website address below for details.

  Please go to http://www.dol.gov for additional information about Federal COBRA coverage.

  Pennsylvania Mini-COBRA
  Mini-COBRA, or Act 2 of 2009, gives employees of small businesses (2-19 employees) who receive health insurance from their employers the right to purchase continuation health insurance after they leave employment. The act went into effect July 10, 2009. It allows eligible employees and dependents to purchase health insurance for up to nine months after their employment ends as a result of a “qualifying event” that would result in the loss of coverage for the covered employee or eligible dependent.

  Please go to http://www.ins.state.pa.us for additional information about PA Mini-COBRA coverage.

• Coverage when traveling out of the area - The BlueCard® Program
  Coverage when traveling out of the area - The BlueCard® Program

  The BlueCard® Program is best defined as a very large and extensive Blues network and the creation of this program was facilitated by the National Blue Cross/Blue Shield Association. When traveling anywhere in the United States, if you need medical care and use the services of a Blue Shield provider that participates in the same network as your coverage, the procedure will be treated as an in-network service.

  The key is to ensure that you go to a Blues provider that participates in the same network. For example, if you are insured through a PPO product, make sure that the out-of-area physician or hospital participates in its regional Blues PPO network.

  Follow these five (5) steps for health coverage when you're away from home in the United States:

  1. Always carry your current Blue Shield Plan ID card.
  2. In an emergency, go directly to the nearest hospital.
  3. To find names and addresses of nearby doctors and hospitals, visit the BlueCard® Doctor and Hospital Finder or call BlueCard Access® at 1-800-810-BLUE.
  4. Call your Blue Plan for pre-certification or prior authorization, if necessary (refer to the phone number on your Blue Plan ID card).
  5. When you arrive at the participating doctor's office or hospital, simply present your Blue Plan ID card.

  As a PPO member, the doctor will recognize the logo which will ensure that you will get the PPO level of benefits.

  *Coverage may vary for each Blue Cross and/or Blue Shield Plan, so be sure to check with your Plan before traveling.

  After you receive care, you will not have to complete any claim forms or pay up-front for medical services other than the usual out-of-pocket expenses (non-covered services, deductible, co-payment, and co-insurance). You will be sent a complete explanation of benefits after your claims are processed.

  If you need to access a provider outside the United States, call the BlueCard Worldwide Service Center at 1-800-810-BLUE or call collect at 804-673-1177 for information on hospitals and doctors. If you are hospitalized, you must call the Service Center in order for them to arrange cash-less access with the hospital. In an emergency, go to the nearest hospital and then call the BlueCard Worldwide Service Center if you are hospitalized. Contact your Blue Cross and Blue Shield Plan for pre-authorization, if necessary.

• How do I start the mail order prescription benefits?
  How do I start the mail order prescription benefits?

  Highmark Blue Shield uses Medco as its Pharmacy Benefits Manager (PBM). The home delivery pharmacy service provides convenience and cost savings. For example, you pay a two-month co-payment amount for three months of prescriptions.

  For new prescriptions, ask your doctor for a script for 90 days, plus refills (if appropriate) for up to one year. The member should mail the prescription along with payment in a postage-paid envelope (please contact the Pennsylvania Medical Society Insurance Agency for these envelopes). Payments can be made by check, money order, or credit card. Members can also ask their doctor to call 1-888-EASYRX1 for instructions on faxing a new prescription. You have the option to place a refill order on Highmark Blue Shield's website, by telephone at 1-800-4REFILL, or by mail. Please note it takes 10 to 14 days for delivery after notification to the PBM is made.

Dependents

• Who is considered a dependent?
  Who is considered a dependent?

  	Spouses
  	Dependent children, up to the age of 26, of an employee may be considered eligible for group coverage. Eligible dependent children include the following: Newborns All children regardless of student status Stepchildren Children legally placed for adoption. Adopted children of the employee or their spouse. Children awarded coverage pursuant to an order of a Court. Children of a domestic partnership if such coverage is elected by the employer. Children of a legal guardian who has assumed the financial responsibility for the children.
  	Dependent eligibility requirements: The dependent is not required to live with their parents. The dependent does not have to be a dependent on their parents’ tax return The dependent can be a student. The dependent can be married. If the dependent has coverage available through their employer, they are not eligible to enroll as a dependent of the parent.

• What are the reasons for a dependent to lose eligibility?
  What are the reasons for a dependent to lose eligibility?

  Reaching the dependent age limit of 26 – coverage is cancelled the first of the month following the dependent’s 26th birthday.

• Can coverage be extended for dependents once they reach age 26?
  Can coverage be extended for dependents once they reach age 26?

  Employers have the option to extend health insurance coverage beyond the limiting age to dependents of employees up to the age of 30 under Pennsylvania law Act 4 of 2009. The employer must elect this coverage at initial enrollment or at renewal. To be eligible for coverage under Act 4, an adult child must meet ALL of the following requirements:

  • Be unmarried;
  • Have no dependents;
  • Be a Pennsylvania resident or is enrolled as a full-time student at an institution of higher education; and
  • Not have coverage under any other group or individual health care policy or enrolled in or entitled to benefits under any government health care program.

  To enroll an adult child, the Dependent Verification Form must be completed, signed and attached to the contract holder’s member application. The dependent will be enrolled under their own contract and pay the applicable group individual premium.

Medicare

• What are the Medicare Secondary Payor Rules?
  What are the Medicare Secondary Payor Rules?

  Medicare due to Age:

  • Working individuals of Medicare eligible age in groups of less than 20 employees are required to sign up for the Medicare supplement plans that are available. The individual must be enrolled in Medicare Parts A and B. Non-compliance will result in cancellation of all medical coverage for the employee.
  • Working individuals of Medicare eligible age in groups of 20 or more employees will have the group health plan as primary. These individuals are not eligible for the Medicare supplement plans through the Pennsylvania Medical Society Insurance Agency.
  • Please refer to the Medicare Secondary Payor Manual, Chapter 2-MSP Provisions, 10.3 - the 20-or-More Employees Requirement available on the Medicare website.

  Medicare due to Disability:

  • Medicare due to disability is primary and the group coverage is secondary when the group has less than 100 employees.The employee may elect to maintain the PPO plan as their secondary coverage or move to S65 for secondary coverage.
  • Medicare due to disability is secondary and the group coverage is primary when the group has more than 100 employees and the employee is actively working.
  • Medicare due to disability is primary and the group coverage is secondary when the group has more than 100 employees and the employee is not actively working and/or retired.
  • The small employer exception that the Pennsylvania Medical Society filed does not apply to persons entitled to Medicare due to disability or End Stage Renal Disease.
    
    
• How do I enroll in the Medicare supplement plan(s)?
  How do I enroll in the Medicare supplement plan(s)?

  An employee who is Medicare eligible and eligible to enroll in the Medicare supplement plans must first enroll in both Medicare Part A and Part B. Once they receive confirmation that they are enrolled in Medicare Part A and Part B, contact the Pennsylvania Medical Society Insurance Agency to obtain the forms needed to move to the Medicare supplement plans(s).

  Changes to the Medicare supplement plan can only be effective the first of the month. Completed paperwork must be received prior to the anticipated effective date.

Other Insurance Needs

• How can the Pennsylvania Medical Society Insurance Agency assist physician groups with additional insurance needs?
  How can the Pennsylvania Medical Society Insurance Agency assist physician groups with additional insurance needs?

  It is our mission and privilege to meet the insurance needs of Pennsylvania Medical Society members. Our commitment to service is of great importance, and we are always looking for new and unique ways to assist and meet the evolving insurance needs of physicians. In this regard, if you have additional insurance needs such as long-term care, disability (group or individual), life (group or individual), business liability, or professional liability, please feel free to contact us.