Frequently Asked Questions
- How do I enroll a new employee?
- What is the enrollment/cancellation wash rule?
- How do I make changes to a current employee's coverage?
- Who do I call if I have a question about a member’s claims or prescriptions?
- How do I get a Highmark Blue Shield health insurance ID card? eBDS
- How do I get a Highmark Blue Shield health insurance ID card? Non eBDS
- Who is considered a dependent?
- How long are dependents eligible to have coverage?
- Full-time student dependents — between what ages is my child eligible to be a dependent as a full-time student?
- What are the reasons for a dependent to loose eligibility?
- What insurance options are available for dependents who lose their eligibility for benefits?
- How can members manage their account?
- What is COBRA?
- Coverage when traveling out of the area – The BlueCard® Program
- How do I go about starting the mail order prescription benefits?
- What are the Medicare Secondary Payor Rules?
- How do I enroll in the Medicare supplement plan(s)?
- How can the Pennsylvania Medical Society Insurance Agency assist physician groups with additional insurance needs?
Q: How do I enroll a new employee?
A: 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
Mailing Address:
Pennsylvania Medical Society Insurance Agency
PO Box 69067
Harrisburg, PA 17106
Please call us if you need a supply of enrollment forms. These forms are also available under the Forms section of our website.
Q: What is the enrollment/cancellation wash rule?
A: 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.
Q: How do I make changes to a current employee’s coverage (i.e. address change, dependent changes, terminations, etc.)?
A: 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, the group may complete the form.
Please call us if you need a supply of Change Forms. These forms are also available under the 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 your forms, it is not necessary to also mail the originals.
Q: Who do I call if I have a question about a member’s claims or prescriptions?
A: 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).
Q: How do I get a Highmark Blue Shield health insurance ID card? eBDS
A: ID cards for new employees will be mailed to the member’s home address within 10-15 business days. Please call the PA Medical Society Insurance Agency if you need an additional ID card. Employers may also order duplicate cards by logging onto www.highmarkblueshield.com and clicking on the Employers tab. Employees may also order duplicate cards by logging on to www.highmarkblueshield.com and clicking on Log in under Manage Your Plan.
Q: How do I get a Highmark Blue Shield health insurance ID card? Non eBDS
A: ID cards for new employees will be mailed to the member’s home address within 7-10 business days. Please call the PA Medical Society Insurance Agency if you need an additional ID card. Employers may also order duplicate cards by logging onto www.highmarkblueshield.com and clicking on the Employers tab. Employees may also order duplicate cards by logging on to www.highmarkblueshield.com and clicking on Log in under Manage Your Plan.
Q: Who is considered a dependent?
A: Dependents are considered to be:
- 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.
Q: How long are dependents eligible to have coverage?
A: 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.
Q: Full-time student dependents — between what ages is my child eligible to be a dependent as a full-time student?
A: Dependents are eligible as full-time students from age 19 through 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 credits 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 student certification process each June. The purpose is to verify that the dependent is still a 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.
Parents or Employers may also contact the Pennsylvania Medical Society Insurance Agency to verify the dependent is a full time student each year in June.
Q: What are the reasons for a dependent to loose eligibility?
A: Student dependents are no longer eligible for dependent coverage for the following:
- Graduation or completion of schooling — coverage is to be cancelled the first of the month following completion of school.
- Reaching the limiting age — coverage is cancelled the first of the month following the students 25th birthday even if they are still attending classes as a full time student.
- Medical leave of absence/disenrollment from classes — students are not eligible to take a medical leave of absence from college and remain on the insurance coverage as a full time student dependent. If a student does not maintain full time status with an accredited school, college, or university, they are not eligible to maintain coverage. Coverage is to be cancelled the first of the month following the start of the leave of absence.
Q: What insurance options are available for dependents who lose their eligibility for benefits?
A: 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 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 medically underwritten products.
Q: How can members manage their account?
A: Members have an on-line resource to manage their account. 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.
Q: What is COBRA? ?
A: 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.
Group health plans for employers with 20 or more employees on 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 count as a fraction of an employee – access web-site address below for details.
Groups with less than 20 employees are not able to enroll individuals in COBRA.
Please go to http://www.dol.gov/ebsa/faqs/faq_consumer_cobra.html for additional information about COBRA coverage.
Q: Coverage when traveling out of the area – The BlueCard® Program
A: 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 should not have to complete any claim forms; you should not have to pay up-front for medical services other than the usual out-of-pocket expense (non-covered services, deductible, co-payment, and co-insurance); and you will be sent a complete explanation of benefits.
If you need to access a provider outside the United States, you can call the BlueCard Worldwide Service Center at 1-800-810-BLUE or 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.
Q: How do I go about starting the mail order prescription benefits?
A: 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 the copayment in a postage-paid envelope (please contact the Pennsylvania Medical Society Insurance Agency for these envelopes). Members can also ask their doctor to call 1-888-EASYRX1 for instructions on faxing a new prescription. For refills, you have the option to order on Highmark Blue Shield’s website (www.highmarkblueshield.com), 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.
Q: What are the Medicare Secondary Payor Rules?
A: Medicare due to Age:
- The small employer exception, that the Pennsylvania Medical Society filed, prohibits groups with fewer than 20 employees to be exempt from the working aged provision but does not apply to persons entitled to Medicare due to disability or End Stage Renal Disease.
- Working individuals of Medicare eligible age who purchase health insurance through the Pennsylvania Medical Society Insurance Agency are required to sign up for the Medicare supplement plans that are available. Non-compliance could constitute 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.
Medicare due to Disability:
- Medicare due to disability is secondary and the group coverage is primary when the group has more than 100 employees when 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 when the employee is not actively working or retired.
- Medicare due to disability is primary and the group coverage is secondary when the group has less than 100 employees.
Q: How do I enroll in the Medicare supplement plan(s)?
A: 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 benefit information on the supplement plans and the forms needed to make the change.
Changes to the Medicare supplement plan can only be effective for the first of the month and cannot be back dated. Completed paperwork must be received prior to the anticipated effective date.
Q: How can the Pennsylvania Medical Society Insurance Agency assist physician groups with additional insurance needs?
A: 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 insurance (group or individual), business liability, or professional liability, we will gladly assist you. Please contact an agent by clicking here.