NATIVE AMERICAN SCHOOLS HEALTH & WELFARE

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SELF FUNDING OVERVIEWELIGIBILITYENROLLMENT EFFECTIVE DATE TERMINIATIONBILLING ADJUSTMENTSAPPROVED LEAVE

How does How does Self-Funding Work?Self-Funding Work?

ContributionsContributions AdministrationAdministration

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EmployerEmployer’’s s General AssetsGeneral Assets

Employee Benefit PlanEmployee Benefit Plan

Fixed CostsFixed Costs

Actual ClaimsActual Claims

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Your Your ContributionsContributions

Native American Schools Health Plan©

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Stop Loss Specific Deductible

Member 1 Member 2 Member 3 Member 4 Member 5 Member 6

12 Month Policy Year

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Member Claims

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Eligibility Criteria - Employee

Generally employees must work 20 hours or more per workweek.

Understand that this does not apply to summer or scheduled breaks during school.

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Eligibility Criteria – DependentSpouse

1. Legal Spouse (State Law)

2. Common Law Spouse provided it meets legal requirements of Navajo Nation.

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Eligibility Criteria – DependentChild

1. Employee’s child to age 26:

a. Natural child,

b. Step child,

c. Legally adopted child,

d. Foster Child,

e. Guardian:

a) Not Power of Attorney

b) Legal guardianship through courts

- Emancipation at age 18

- To age 26, court document

must decree

2 Qualified Medical Child Support Order (QMCSO)

3. Disabled child over age 26—must provide proof every 2 years.

Eligibility Criteria – DependentChild

PRIOR TO PPACA, PLAN REQUIREMENTS FOR DEPENDENT CHILD

a) Lives with the employee

b) Unmarried;

c) To age 19;

d) If Full-time student, then to age 24

NO LONGER IN EFFECT

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Eligibility Criteria – Dependent

Dependent child does NOT include:

1. grandchildren

2. niece or nephew

Unless legal guardian

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Enrollment Timeline Employee—

a. New employee: within 31 days

b. annual “Open Enrollment”

Dependent—

a. at the time of employee enrollment, or

b. within 31 days of dependent acquisition

c. annual “Open Enrollment”

APPLIES UNTIL NEXT OPEN ENROLLMENT

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Open Enrollment– Employee not previously enrolled to enroll

for coverage

– Dependents not previously enrolled to enroll for coverage

– Enrolled dependents to be dropped from coverage

– Enrollment elections apply until next open enrollment

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HIPAA Special Enrollment

HIPAA Special Enrollment Period.

i.  Other coverage

ii.  Dependent acquisition

iii.Enroll within 31 days of the event

iv. CHIPS—60 day enrollment

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Special EnrollmentHIPAA Special Enrollment Period –

- Other Coverage

i.      Termination of the other coverage, including COBRA.

ii.     Cessation of employer contributions toward the other coverage.

iii.     Legal separation or divorce.

iv.     Termination of other employment or reduction in hours.

v.     Death of the covered person.

Enroll within 31 days of the event

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Special EnrollmentHIPAA Special Enrollment Period

- Dependent Acquisition

  i.  Marriage

     ii. Birth of a dependent child.

  iii. Adoption of a child

Enroll within 31 days of the event  

SPECIAL ENROLLMENTHIPAA Special Enrollment Period

• CHIP– Termination of Medicaid or CHIP Coverage

– Eligibility For Premium Assistance Under Medicaid or CHIP

– Enroll within 60 days

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Enrollment Form to Summit• Options:

– Fax: 480.505.0406– Email: monica@summit-inc.net– On-line enrollment: www.summit-inc.net– Snail Mail: P. O. Box 25160, Scottsdale, AZ

85255

• Retain enrollment form in Personnel file– Compare to next billing ensuring employee

is enrolled in the Plan

• Issue ID card to employee

Life Insurance Enrollment

• Life Insurance Enrollment is done on-line with Lincoln National

• Summit DOES NOT do Life Insurance enrollments

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Effective Date of Coverage

• Employee—1st of month following date of hire.

• Dependents, provided enrolled timely:– Date employee coverage is effective– Date dependent is acquired– Date adopted child is “placed for adoption”– Newborn

• Employee has family coverage = birth• Employee has single coverage = birth, provided

enrollment form is submitted within 31 days of birth

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Termination of Coverage

Employee:

The last day of the month in which the employee CEASES TO MEET THE ELIGIBILITY CRITERIA.

Note: this does not necessarily mean the employee terminates EMPLOYMENT.

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Certified & Contracted Employees:

Termination of Coverage

Certified or contracted employeeCertified or contracted employee

Signed the contract for next school year Signed the contract for next school year

SchoolSchool’’s Health Plan provides coverage s Health Plan provides coverage through the summer months. through the summer months.

The school continues to pay for employee The school continues to pay for employee coverage.coverage.

Termination of CoverageCertified & Contracted Employees

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DonDon’’t terminate teachers that are returning t terminate teachers that are returning next school year! next school year!

Keep them on the Health Plan. Keep them on the Health Plan.

Contributions for dependentContributions for dependent’’s coverage s coverage through the summer needs to be addressed through the summer needs to be addressed through payroll.through payroll.

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Termination of Coverage Dependents:

- The date an employee’s coverage terminates.

  - The date the person ceases to meet the eligibility criteria.1. Spouse: Divorce or legal separation.2. Child: Reaches the maximum age limit.

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Termination Notice to Summit

• Options:– Pull original enrollment form & note bottom

with termination information• Date of termination• Reason for termination (necessary for COBRA)

– On-line access: www.summit-inc.net– Notation on corrected census noting

termination date

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Termination Notice to Summit

Under Federal law, COBRA:

• Employer: 30 days to notify Summit– Notify Summit if due to “Gross Misconduct”

• Summit: 14 days to provide COBRA election

• Failure to provide timely notice:– could result in litigation and/or penalties– potential claims payments

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BILLING ADJUSTMENTSNew Enrollment/Billing

• If new employee is not on the billing:– Refax enrollment with notation “2nd

submission”

– Be aware of the “window”• Date of billing census vs. date enrollment sent

– Adjust the count on the bill to include employee

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BILLING ADJUSTMENTS Termination Notice/Billing

Compare the termination notice(s) sent to Summit to next billing

If term’d employee is still on the bill:– Be aware of the “window”– Make the # count adjustment on the bill– Provide documentation to Summit for the

adjustment with the check.– Resubmit term notice with “2nd submission

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BILLING ADJUSTMENTS Dependent Enrollment Audit

October billing/census will include all dependents covered by the employee

Verify against your records

Coordinate with Summit for corrections

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Leave of Absence Provisions

Conditions that allow continued coverage under the Plan after loss of eligibility:

a.    Administrative Leave

b. Family Medical Leave Act (FMLA)

c.     Leave of Absence (LOA) 

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Administrative Leave

• Coverage continued for enrolled employee and enrolled dependents

• School pays applicable contributions

• Coverage continues until investigation is closed

• If administrative action is suspension, coverage for 30 days of suspension.

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Leave of Absence (FMLA)

Employee must have worked for 1,250 hours in the preceding 12 months to be eligible for Leave of Absence under FMLA.

Employee must request leave under FMLA.

  

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Reason for leave must comply with FMLA criteria.

i. “Serious health condition”

ii. For self

iii. For immediate family members

Leave of Absence (FMLA)

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Employee remains covered under the health plan while on FMLA.

Employer pays the employee’s health plan contribution while employee is on FMLA leave.

Leave of Absence (FMLA)

Employee is granted leave of absence

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Leave of Absence (FMLA)

Serious Health Condition = 12 weeks

Military Caregiver Leave = 26 weeks

Qualifying Exigency = 12 work weeks

Leave of Absence (FMLA)

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Employee returns to work or is terminated from the Plan.

Last day of FMLA is qualifying event for COBRA.

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Leave of Absence, Regular

When employee does not qualify for FMLAMay be granted or denied LOAGenerally, employee pays the cost of health plan coverage

After 90 days of leave, the employee returns to work or is terminated from the Plan.

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The 90 days coverage under the Plan while on Regular Leave of Absence, applies to the maximum allowable coverage duration under COBRA.

Leave of Absence, Regular

If an employee is terminated from the Plan,

COBRA is offered.

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Employee was on leave for 90 days (3 months).

Employee elects COBRA.

Due to termination of employment, COBRA is offered for 18 months.

Three months have already been used, leaving 15 months of COBRA continuation of coverage.

Leave of Absence, Regular

ExampleExample

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Coordinating Paid Time Off with FMLA or Regular Leave

Each employer establishes the guidelines.

Variables include:

Requirement for employees to use up all available Paid Time Off before going on either FMLA or LOA

Allow an employee to use PTO concurrently with FMLA/LOA  

Claims FlowClaims Flow

Em

plo

yeeE

mp

loyee

Doctor VisitDoctor Visit

Payment

Payment

ClaimClaim

Your Your ContributionsContributions

Native American Schools Health Plan©

/\Summit

Stop Loss Specific Deductible

Member 1 Member 2 Member 3 Member 4 Member 5 Member 6

12 Month Policy Year

SpecificReimbursements

Member Claims

SpecificSpecific DeductibleDeductible

SELF FUNDING OVERVIEWELIGIBILITYENROLLMENT EFFECTIVE DATE TERMINIATIONBILLING ADJUSTMENTSAPPROVED LEAVE