Frequently Asked Questions
Health Enrollments/Changes
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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.
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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.
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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 - Last day of the month
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.
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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.
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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.
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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.
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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
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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.
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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
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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).
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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. The federal stimulus law also known as ARRA (the American Recovery and Reinvestment Act of 2009) provides that employees eligible for continuation coverage under comparable state Mini-COBRA laws may also be eligible for premium assistance.
Please go to http://www.ins.state.pa.us for additional information about PA Mini-COBRA coverage.
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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:
- Always carry your current Blue Shield Plan ID card.
- In an emergency, go directly to the nearest hospital.
- 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.
- Call your Blue Plan for pre-certification or prior authorization, if necessary (refer to the phone number on your Blue Plan ID card).
- 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.
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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
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Who is considered a dependent?
• Spouses
• Unmarried children under 19 years of age, including:
- Newborn children
- Stepchildren
- Children legally placed for adoption
- Legally adopted children or children for whom the employee or the employee's spouse is the child's legal guardian
- Children awarded coverage pursuant to an order of court
- Unmarried children up to the age of 25, provided they are full-time students (see description of full-time student below).
- Unmarried children over age 19 who are not able to support themselves due to mental retardation, physical disability, mental illness, or developmental disability.
- Domestic partners and their children. The group is responsible for determining if a person is eligible for coverage as a domestic partner and for reporting such eligibility.
- Newborn children of an eligible dependent automatically have coverage for the first 30 days after birth but are not eligible to remain on the coverage unless they meet the requirements listed above for an unmarried child under 19 years of age.
• Full-time students
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How long are dependents eligible to have coverage?
Dependent children are eligible for coverage until the first of the month following their 19th birthday, unless they marry or become employed full time prior to age 19.
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To what age is my child eligible to be a full-time student dependent?
Dependents are eligible as full-time students from age 19 until the first of the month following their 25th birthday. Dependents are not able to be listed/categorized as student dependents until the age of 19. Being a student dependent requires enrollment as a full-time student (defined as 12 credit hours per semester) in an accredited school, college, or university and solely dependent upon the employee for support.
The member must contact the Pennsylvania Medical Society Insurance Agency to have the dependent certified as a student (upon their 19th birthday).
Following initial certification, Highmark Blue Shield conducts an annual full-time student certification process each June. The purpose is to verify that the dependent is still a full-time student. The notice is sent to the member/contract holder. If this certification is not completed and returned to Highmark Blue Shield verifying continued student status, the dependent student's coverage is cancelled effective July 1.
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What are the reasons for a dependent to lose eligibility?
• Reaching the dependent age limit - coverage is cancelled the first of the month following the dependent's 19th birthday, unless they are enrolled as a full-time student (defined as 12 credit hours per semester) in an accredited school, college, or university and solely dependent upon the employee for support.
• Reaching the student age limit - coverage is cancelled the first of the month following the student's 25th birthday, even if they are still attending classes as a full time student.
• Graduation - coverage is cancelled the first of the month following graduation.
• Medical leave of absence – Under Michelle’s Law, full-time college students are able to take up to 12 months medical leave. Michelle’s Law applies to students who are covered under their parent’s health insurance plan. “Medical leave” can mean that the student is absent from school or reduces his/her course load to part-time. The date the medical leave begins is determined by a student’s physician. Please go to http://www.michelleslaw.com/history.php for additional information about Michelle’s Law.
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What insurance options are available for dependents who lose their eligibility for benefits?
Thirty days prior to the dependent's cancellation date, or once the cancellation date is entered in Highmark's system if less than 30 days notice, a Conversion Notice is sent to the member/dependent with an offer to purchase guaranteed issue direct-pay coverage from Highmark Blue Shield.
You may also contact the Pennsylvania Medical Society Insurance Agency to apply for one of Highmark Blue Shield's individual medically underwritten products that can be very affordable.
Medicare
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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.
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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
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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.
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