December 2009

In This Issue


NCMS Plan Coverage of H1N1 Flu Vaccine Administration

To encourage NCMS Plan members to get the H1N1 vaccine, the NCMS Plan will pay 100% of eligible charges for the administration of the H1N1 vaccine. Our decision to cover the H1N1 vaccine is based on guidance from the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices, which predicts widespread H1N1 outbreaks this fall and winter.

Please note that the H1N1 vaccine should not replace the seasonal flu vaccine. We encourage our members to get both vaccines.

If you have additional questions, please contact your NCMS Plan representative, visit our Group Administrator's flu Web page (, or call us at (800) 662-7917.

BCBSNC Revises Upfront Collection Policy

Effective October 1, 2009, Blue Cross and Blue Shield of North Carolina revised its policy for upfront collection from a member enrolled in a non-copayment benefit plan. The provider can collect the estimated patient responsibility for applicable coinsurance and/or deductible amounts subject to certain guidelines. Under the previous guidelines, providers were limited to collections of up to $50 for professional services or up to $500 for services received at a facility from members with non-copayment plans (i.e. HDHP plans). Members having a copayment as part of their benefits make-up (i.e. traditional PPO plans) are only required to pay the member copay amount at the time of receiving service.

In order to collect the member's estimated responsibility, the provider, among other things; must have an established policy and assist member with payment options; not refuse necessary treatment if member is unable to pay; payment requested follows provider's negotiated BCBSNC fee schedule; staff must have access to fee schedule; and provider must be able to calculate member responsibility based on fee schedule and member's benefit year deductible and co-insurance status.

Members enrolled in non-copayment plans seeking care at the ER cannot be required to pay any charges until provider has received an explanation of payment (EOP) from BCBSNC. Urgent care providers have the option to follow the revised guidelines but should not deny urgent treatment prior to payment.

For more information about this policy change and the applicable guidelines, visit

Group Dental Insurance Through the NCMS Plan

Did you know the NCMS Plan offers group dental insurance underwritten by MetLife? Employers participating in the NCMS Plan can choose one of four dental plans with the option to add orthodontia to several of those plans. All plans give your employees the freedom to choose any dentist even if the dentist does not participate in MetLife’s Preferred Dental Program (a network of dentists offering discounted pricing for MetLife members).

The NCMS Plan dental plan year runs from August to August and we are currently offering a rate guarantee through August 2011. 75% of eligible employees must enroll in the chosen plan and a contribution of 25% of employee premium is required by the employer.

For more information about NCMS Plan dental coverage please contact your account representative, call 800-662-7917, or visit

New Look for NCMS Plan Website

As a service to NCMS Plan participating practices, was created to be a resource for practice administrators and others responsible for benefits administration. Why keep a file of printed applications and forms, when you can visit to obtain the forms exactly when you need them?

Recently, the NCMS Plan website underwent some re-design. If you have not visited, you should familiarize yourself with the resources available, including:

  • Benefit Highlights
  • Applications
  • Forms
  • and Wellness Resources

We hope you find the website to be a good resource and easy to use. If you have any questions or comments about the website, e-mail Gary Bossert at [email protected].

Ask George

Question: I just hired a new employee who has not had health insurance for the last six months. What does she need to know about her coverage?

Answer: Most importantly, since it's been six months since the employee had health coverage - she needs to be aware that she will be subject to a waiting period for pre-existing conditions. For the purposes of health coverage, HIPAA regulations define pre-existing conditions as those conditions for which medical advice or treatment was received or recommended within the six-month period immediately preceding the effective date of the participant's coverage. As an example, the employee may have had arthritis for many years before she came to your practice. If she did not have medical advice, diagnosis, care, or treatment – recommended or received – in the 6 months before she enrolled in the NCMS Plan, then the prior condition cannot be subject to a pre-existing condition exclusion. If she did receive medical advice, diagnosis, care, or treatment within the past 6 months, then the NCMS Plan imposes a pre-existing condition exclusion for that condition (arthritis). In addition, HIPAA prohibits plans from applying a pre-existing condition exclusion to pregnancy, genetic information, and certain children.

If the employee had any prior coverage, also known as "creditable" coverage with no lapse of longer than 63 days, then the waiting period for pre-existing conditions could be reduced or eliminated.

HIPAA requires that group health plans reduce any waiting period for pre-existing conditions by the length of any prior creditable coverage. Creditable coverage includes prior coverage under either group or individual insurance. Prior coverage is considered creditable only if there is no lapse in coverage of longer than 63 days. Probationary periods do not count toward any lapse so this time is included as "prior coverage" to reduce a waiting period for pre-existing conditions. So, if your new employee was covered for at least 12 months under another group or non-group health plan within 63 days of the date her new coverage starts, the waiting period for pre-existing conditions does not apply. If she was covered less than 12 months without a break in coverage of more than 63 days, her waiting period for pre-existing conditions will be reduced by whatever length of time was spent with the prior coverage.

Remember, a pre-existing condition exclusion relates only to benefits for your employee's (and your employee's family’s) pre-existing conditions. If the employee enrolls, they will receive coverage for the plan’s other benefits during that time.

Medicare Part D Prescription Drug Notification Requirement

The Medicare Modernization Act of 2003 added a prescription drug program to Medicare, and created notification requirements for employers. These notice requirements apply to employer groups that cover Medicare eligible individuals, even if they do not offer retiree drug coverage. The requirement means that employers must disclose whether their coverage is “creditable prescription drug coverage”. Generally, prescription drug coverage is creditable if, on average, it is at least as generous as Medicare prescription drug coverage. For more information on creditable drug coverage, please see the Centers for Medicare and Medicaid Services (“CMS”) website at

Employers must determine which of their Medicare beneficiaries must receive the “creditable coverage notice”. Employers that offer prescription drug coverage on a group basis must provide the notice to Medicare beneficiaries who are active or retired employees, as well as Medicare beneficiaries who are covered as spouses under active or retiree coverage. You may choose to satisfy this requirement by providing the notice to all employees. You should review the CMS website to determine any on-going notice requirements, as well as any requirements for disclosure to CMS. The CMS website also provides samples of the “creditable coverage notice” that you may want to utilize.

Employers are also responsible for determining if prescription drug coverage under its plan(s) is creditable. You can find instructions for making this determination on the CMS website. The NCMS Plan mailed a letter including a chart indicating which of its prescription drug plans are creditable. This information was provided as a courtesy to employers that participate in the NCMS Plan. If you did not receive the letter dated November 15, 2009, please contact Crystal Taylor at [email protected] to request a copy.

About the North Carolina Medical Society

As the largest physician organization in the state, the North Carolina Medical Society (NCMS) is devoted to representing the interests of physicians and protecting the quality of patient care. The NCMS Plan, sponsored by the NCMS, is the only statewide employee benefits plan designed specifically for North Carolina physicians.

For more information about many other benefits of NCMS membership, visit

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