Frequently Asked Questions
How do I enroll a new employee?
How do I make changes to a current employee’s coverage (i.e., address change,
dependent changes, terminations, etc.)?
What is the enrollment/cancellation wash rule?
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?
Who is considered a dependent?
How long are dependents eligible to have coverage?
Full-time student dependents—To what age is my child eligible to be a
full-time student dependent?
What are the reasons for a dependent to lose eligibility?
What insurance options are available for dependents who lose their
eligibility for benefits?
How can members manage their account?
How can employers manage their group’s account?
What is COBRA?
Coverage when traveling out of the area—The BlueCard® Program
How do I start 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?
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.
Email 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
Please call us if you need a supply of enrollment forms. These forms are also available
under the Forms / Resources section of this website.
Return To Top
How do I make changes to a current
employee’s coverage (i.e., address change, dependent changes, terminations, etc.)?
Simply call or email 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 it to us for processing.
Please call us
if you need a supply of change forms. These forms are also available under the Forms/Resources section of this website. All completed forms should be mailed, emailed, or faxed
to the Pennsylvania Medical Society Insurance Agency. If you choose to fax or email
your forms, it is not necessary to also mail the originals.
Return To Top
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.
Return To Top
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).
Return To Top
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 7-15 business days. Employers
may order duplicate cards by logging on to 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.
Return To Top
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.
Return To Top
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.
Return To Top
Full-time student dependents—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 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 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.
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.
Return To Top
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 credits 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/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.
Return To Top
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.
Return To Top
How can members manage their account?
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.
Return To Top
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
send an email; 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.
Return To Top
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.
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 website 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.
Return To Top
Coverage when traveling out of the
area—The BlueCard® Program
The BlueCard® Program is best defined as a very
large and extensive Blues network. 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.
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.
Return To Top
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 (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.
Return To Top
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.
Medicare due to Disability:
- Medicare
due to disability is primary and the group coverage is secondary when the group
has less than 100 employees.
- 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 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.
Return To Top
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 make the change.
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.
Return To Top
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, we will gladly assist you. Please
contact an agent.
Return To Top