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
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 (www.bcbsnc.com/memberservices/public/flu/h1n1-flu.cfm),
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.
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 www.bcbsnc.com.
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
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 www.ncmsplan.com.
New Look for NCMS Plan Website
As a service to NCMS Plan participating practices, ncmsplan.com 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 www.ncmsplan.com to obtain the forms
exactly when you need them?
Recently, the NCMS Plan website
underwent some re-design. If you have not visited www.ncmsplan.com, you should
familiarize yourself with the resources available, including:
- Benefit Highlights
- 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].
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
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.
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 www.cms.hhs.gov/creditablecoverage.
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.
information about many other benefits of NCMS membership, visit www.ncmedsoc.org.