Insurance Procedure Manualfor the

Local Administration of the

Mississippi State and School Employees’Life and Health Insurance Plan

Mississippi Department of Finance and AdministrationOffice of Insurance

For distribution to and use by local Payroll/Personnel StaffRevised April 2019

CONTACT INFORMATION

Questions about premium billing and reconciliation, enrollment issues, COBRA, retiree forms and payments.

Blue Cross & Blue Shield of Mississippi3545 Lakeland DriveFlowood, MS 39232(888) 249-6132(601) 664-5246

Questions about medical claims, claim forms, claims issues and general correspondence.

Blue Cross & Blue Shield of Mississippi3545 Lakeland DriveFlowood, MS 39232(800) 709-7881(601) 664-5300

Questions about the State and School Employees’ Life Insurance Plan.

Minnesota Life Insurance Company, Securian Financial Group, Inc.P.O. Box 64114St. Paul, MN 55164-0114Phone: (888) 658-0193 Fax: (877) 494-8401

Questions about the Public Employees’ Retirement System (PERS) of Mississippi.

Public Employees’ Retirement System (PERS) of Mississippi429 Mississippi StreetJackson, MS 39201-1005(800) 444-7377(601) 359-3589

Questions about the State and School Employees’ Life and Health Insurance Plan, Minnesota Life (Securian) Claims Processing, ActiveHealth Management or Prime Therapeutics, requests for a printed copy of the Plan Document, or for additional information and issues that you are unable to resolve after first contacting Blue Cross & Blue Shield of Mississippi or Minnesota Life (Securian).

Department of Finance and AdministrationOffice of InsuranceEmail: knowyourbenefits@dfa.ms.govP.O. Box 24208Jackson, MS 39225-4208(866) 586-2781(601) 359-3411

Questions about pharmacy benefits, the formulary or the specialty pharmacy network.

Prime Therapeutics, LLC (Prime)P.O. Box 21870Lehigh Valley, PA 18002-1870(855) 457-0408

Questions about medical/disease management, health and wellness promotion, site champions and onsite wellness coaches.

ActiveHealth Management, Inc.4582 Ulster Street PkwyDenver, CO 80327(866) 939-4721

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TABLE OF CONTENTSINTRODUCTION .....................................................................................................................1KEY POINTS ................................................................................................................................................ 2

Updates ..................................................................................................................................................... 2

2019 Updates ............................................................................................................................................ 2

EnrollBlue .................................................................................................................................................. 2

Where to find forms ................................................................................................................................. 2

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) ............................................ 3

ELIGIBILITY AND ENROLLMENT ............................................................................................3INITIAL ENROLLMENT .............................................................................................................................. 3

NEW EMPLOYEE COMMUNICATIONS ..................................................................................................... 4

HEALTH INSURANCE ................................................................................................................................. 4

Applying for Health Insurance Coverage .................................................................................................. 5

Effective Date of Coverage for New Employees ....................................................................................... 5

Legacy and Horizon Employees ................................................................................................................ 5

Base Coverage and Select Coverage ......................................................................................................... 5

Dependent Coverage ................................................................................................................................ 6

Effective Date of Coverage for Dependents ............................................................................................. 6

Transferring Coverage ............................................................................................................................... 7

LIFE INSURANCE ..................................................................................................................................... 10

Applying for Life Insurance Coverage – New Employees ....................................................................... 11

Amount of Life Insurance Coverage – Active Employees ....................................................................... 11

Calculating Employee Life Insurance Coverage and Premiums .............................................................. 11

Designating a Beneficiary........................................................................................................................ 12

ENROLLMENT (OTHER THAN INITIAL) ................................................................................13HEALTH INSURANCE ............................................................................................................................... 13

Open Enrollment ..................................................................................................................................... 13

Special Enrollment Periods ..................................................................................................................... 13

Special Coverage/Cancellation Rules for to Schools, Community/Junior Colleges and Universities: .... 15

LIFE INSURANCE ..................................................................................................................................... 16

Applying for Life Insurance Coverage – Late Enrollees .......................................................................... 16

Filing Claims – Active Employees Only .................................................................................................. 16

Filing Claims – Retirees and/or Disabled Employees, Waiver of Premium Participants Only ................ 17

Other State-Sponsored Life Insurance – Policy Termination ................................................................. 17

CANCELING COVERAGE .......................................................................................................18CANCELING HEALTH INSURANCE COVERAGE ...................................................................................... 18

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CANCELING LIFE INSURANCE COVERAGE ............................................................................................ 18

CONTINUATION AND CONVERSION ...................................................................................19RETIREE AND DISABLED PARTICIPANTS ............................................................................................... 19

Retiree Eligibility ..................................................................................................................................... 19

Applying to Continue Coverage as a Retiree .......................................................................................... 19

Retiree Health Insurance – Service Retirement ...................................................................................... 20

Retiree Health Insurance – Disability Retirement .................................................................................. 20

Medicare-Eligible Retirement ................................................................................................................. 21

Surviving Spouses and Dependents ........................................................................................................ 21

Retiree Life Insurance ............................................................................................................................. 22

Life Insurance – Disabled Employees...................................................................................................... 22

Paying Premiums – Disability Retirement ............................................................................................... 24

Retirees Who Return to Covered Employment ...................................................................................... 24

Retirees Who Return to Employment as a School Bus Driver................................................................ 24

Canceling Retiree Coverage .................................................................................................................... 24

PORTABILITY AND CONVERSION OPTIONS FOR GROUP LIFE ............................................................ 25

Conversion Option .................................................................................................................................. 25

Portability Option .................................................................................................................................... 26

COBRA ...................................................................................................................................................... 27

Qualified Beneficiaries ............................................................................................................................ 27

Qualifying Events .................................................................................................................................... 27

Length of COBRA Coverage ..................................................................................................................... 27

Disability Extension ................................................................................................................................. 29

Termination of COBRA coverage ............................................................................................................. 29

COBRA Notification Requirements ........................................................................................................ 29

COBRA Election Requirements................................................................................................................ 29

EMPLOYEES ON UNPAID LEAVE ..........................................................................................30LEAVE WITHOUT PAY (LWOP) ................................................................................................................ 30

FAMILY MEDICAL LEAVE ACT (FMLA) .................................................................................................... 31

INVOLUNTARILY FURLOUGH .................................................................................................................. 31

WORKERS’ COMPENSATION .................................................................................................................. 32

ACTIVE MILITARY DUTY .......................................................................................................................... 32

Employees Called to Active Military Duty .............................................................................................. 33

Covered Dependents Called to Active Military Duty .............................................................................. 33

ENROLLBLUE REPORTS ........................................................................................................34

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Over Age Dependent Report .................................................................................................................. 34

Invalid Social Security Number Report ................................................................................................... 34

Invalid Address Report ............................................................................................................................ 34

Activity Report ........................................................................................................................................ 34

W2 Premium Information for Prior Tax Year .......................................................................................... 35

Tobacco Usage Report ............................................................................................................................ 35

PPACA 6055/6056 ................................................................................................................................... 35

BILLING AND PAYMENT PROCEDURES ...............................................................................35MONTHLY PREMIUM BILLINGS ............................................................................................................ 35

Premium Billing Reconciliations .............................................................................................................. 35

PAYMENT PROCEDURES ......................................................................................................................... 36

Payments Remitted by Check ................................................................................................................. 37

Direct Deposit Payments ........................................................................................................................ 37

FORMS AND NOTICES .........................................................................................................37HEALTH INSURANCE FORMS & NOTICES .............................................................................................. 37

Application for Coverage ........................................................................................................................ 37

Coverage Options Summary for State and School Employees’ Health Insurance Plan .......................... 40

Plan Document Notice ............................................................................................................................ 41

Health Insurance Portability and Accountability Act (HIPAA) Notice of Privacy Practices ..................... 41

Authorization of Release of PHI for Enrollment/Disenrollment Purposes ............................................. 41

LIFE INSURANCE FORMS & NOTICES .................................................................................................... 41

Enrollment/Change Request ................................................................................................................... 41

Evidence of Insurability ........................................................................................................................... 43

Notice of Death ....................................................................................................................................... 44

Notice of Disability .................................................................................................................................. 45

Notice of Disability Waiver of Premium Claim Employer’s Statement .................................................. 45

Notice of Accidental Dismemberment and Personal Loss .................................................................... 46

Notice of Claim for Accelerated Benefit ................................................................................................. 47

PORTABILITY AND CONVERSION GROUP LIFE ..................................................................................... 47

Conversion of Group Term Life Insurance .............................................................................................. 48

Option to Port Term Life Insurance Coverage ........................................................................................ 48

PAYMENTS & RECONCILIATION FORMS ................................................................................................ 48

Transmittal Form ..................................................................................................................................... 48

Transmittal Form – SPAHRS Payments .................................................................................................... 49

Premium Billing Reconciliation ............................................................................................................... 50

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INTRODUCTIONWe have prepared this Insurance Procedure Manual to assist you in handling the day-to-day local administration of the State and School Employees’ Life and Health Insurance Plan (Plan). The State and School Employees Health Insurance Management Board (Board) has approved the underlying policies contained within this manual.

This document is designed to provide you with a general source of information and serve as your primary reference for Plan administration. Periodic updates to this manual will be provided as new policies or procedures are added or revisions are made.

While the underlying rules and regulations in this document are derived from the Board approved Plan Document, the Insurance Procedure Manual is not intended to be a reference for participant benefit information. Employer units and/or participants seeking information on benefit issues should refer to the current Plan Document at http://knowyourbenefits.dfa.ms.gov/publications/.

In addition to the Plan Document, the Plan’s website provides access to other useful information on the health and life insurance programs administered by the Board. Contact information as well as links to related sites, can be easily accessed from this one location.

Note: Whenever a personal pronoun in the masculine gender is used, it will be deemed to include the feminine unless the context clearly indicates the contrary.

While every effort has been made to include information needed to help you with the local administration of the Plan, we recognize there will likely be instances in which you may have questions or want further clarification. In most instances, your first call should be to the Plan’s third party claims administrator, Blue Cross & Blue Shield of Mississippi (BCBSMS). The Jackson-area telephone number is (601) 664-5246. Employer units calling from outside the Jackson area should use the toll-free number (888) 249-6132. Please note that these numbers are for employer units only, as participants should use the contact numbers provided in the Plan Document.

Encourage all employees, once they receive their BCBSMS ID card to go online and register for BCBSMS online access where they can get more information about their policy and benefits, check their health insurance claims, and even view, enter or update their Minnesota Life, a Securian Company, beneficiary information. BCBSMS also has a mobile app that can be downloaded for free and provides many of these same functions. Go to the iTunes App Store or Google Play.

Additionally, employees should be encouraged to go online to Motivating Mississippi – Keys to Living Healthy and register with ActiveHealth Management which provides wellness information for all participants in the Plan.

Employees who elect health coverage will also receive information from Prime Therapeutics, the pharmacy benefit manager for the Plan. Once employees receive their Prime prescription ID card, they should be encouraged to register online with Prime and learn about the benefits, in-network pharmacies or opportunities for mail order prescriptions through Prime Therapeutics.

If you have general questions about the Plan’s life insurance policy, contact Minnesota Life at (888) 658-0193. While we encourage you to direct your inquiries to BCBSMS and Minnesota Life, you are also free to contact the Office of Insurance (OOI) on any issues that you are unable to resolve or for which you need additional clarification.

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KEY POINTSUpdatesAs future updates to the Procedure Manual are made, they will be posted here so you can readily know what changes have been made.

2019 UpdatesMinnesota Life has updated its claims customer service phone and fax number, and has provided a new mailing address for claims information. It is:

Securian Financial Group, Inc.Minnesota Life Insurance Company Benefits ServicesP.O. Box 64114St. Paul, MN 55164-0114Phone: (888) 658-0193Fax: (877) 494-8401

In addition to a new phone and mailing address, the procedure for submitting a death claim for active employees has changed. You will no longer be required to provide a certified death certificate. The Notice of Death form has been updated to reflect this change. See page 16-17, Filing Claims - Active Employee Only and page 44, Notice of Death.

EnrollBlueAll employer units utilize EnrollBlue, an Internet-based system developed by BCBSMS. This system allows employer units to enroll participants, make coverage changes, reconcile billings and access reports. EnrollBlue also allows you to enroll new retirees.

Where to find forms

This manual and other forms and notices referenced in this document can be found on the Plan’s website under the employer units section at http://knowyourbenefits.dfa.ms.gov/employer-units/. The username is insurance and the password is units1234. Links to most applications, forms and websites that do not generally change yearly have been included within the electronic version of this document.

All eligible employees must complete an Application for Coverage and Enrollment/Change Request to enroll in or waive participation in the State and School Employees’ Life and Health Insurance Plan. It is the employer’s responsibility to secure properly completed and signed forms from each eligible employee to indicate his desire to participate or waive coverage in the health and/or life Plan within 31 days of initial employment.

Appropriate Plan forms must be used to make coverage changes (e.g., additions, deletions, changes). Cafeteria election forms and/or other internal employer-provided documents are not acceptable substitutes to Plan forms.

As the employer, you are responsible to the Plan for the collection and remittance of all premiums for employee/dependent coverage elected by your employees. If an employee’s check is not sufficient for premiums to be payroll deducted, the employee must remit the premium to his employer who should deposit the check, and include the amount in the premium payment remitted to the OOI. Personal checks will not be accepted by the OOI for active employee premiums. If you are unable to collect the appropriate premiums from your employees, you should promptly terminate the employee’s coverage in EnrollBlue

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due to nonpayment of premiums. Until the appropriate termination transaction is entered in EnrollBlue and accepted by BCBSMS, the employer unit is still responsible for any unpaid premiums.

Premium payments are due in the OOI on the first day of each month and subject to a late payment fee if received after the 10th.

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)You should be aware of the importance of keeping certain information about employees confidential. With the passage of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, the federal government has mandated privacy standards.

Among other things, this federal law mandates the protection of personal health information, referred to as Protected Health Information (PHI). PHI is information about an individual’s health care that identifies the individual, or with respect to which there is a reasonable basis to believe the information can be used to identify the individual.

PHI includes information related to past, present or future physical or mental health or condition of an individual; information related to the provision of health care to an individual; and information related to the past, present or future payment for the provision of health care to an individual. PHI can be in any form, including verbal, written and electronic. The Plan is subject to the Standards for Privacy of Individually Identifiable Information (the HIPAA Privacy Rule). As such, information regarding a participant’s PHI for enrollment and disenrollment purposes can only be provided to authorized personnel within your employer unit. In order for BCBSMS and the OOI to discuss an employee’s medical information with you, he must first submit an Authorization of Release form to BCBSMS and to the OOI. You may refer the employee to the Plan Document for further information regarding HIPAA or visit http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/index.html.

ELIGIBILITY AND ENROLLMENT

INITIAL ENROLLMENTThe following employment classes are eligible to participate in the State and School Employees’ Life and Health Insurance Plan:

• Full-time public school district employees.• Regular nonstudent school bus drivers employed by a public school district (regardless of the number

of hours worked).• Full-time community/junior college employees. • Full-time library staff members in each public library.• Full-time state employees who work for and receive compensation as a direct payment from a

department, agency or Institution of Higher Learning.• Legislators, employees of the judicial and legislative branches of the state, full-time salaried judges,

full-time district attorneys and their staff, and full-time compulsory school attendance officers.• Full-time employees who work for a university-based program authorized under state law for deaf,

aphasic and emotionally disturbed children.

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For the purpose of defining eligibility, any employee making contributions to the Public Employees’ Retirement System (PERS) is considered full-time. Eligible employees, as defined above, are guaranteed by state law the right to participate in the Plan and cannot be denied this right by any department, agency, Institution of Higher Learning, public school district, community/junior college or public library.

NOTE: Retirees who return to work as school bus drivers while continuing to receive their PERS retirement benefits are not considered active employees eligible for employer-paid insurance. Refer to the section on school bus drivers for more information.

NEW EMPLOYEE COMMUNICATIONSAt a minimum, the following information must be provided to all new employees applying for or waiving coverage. Some information may be given out at orientation, while certain pieces of information must be mailed to an employee’s home address.

The information and/or forms listed below may be given to employees at orientation, but must be provided within the first 31 days of employment. The following may also be downloaded from http://knowyourbenefits.dfa.ms.gov/employer-units/.

• Application for Coverage • Enrollment/Change Request • Plan Document Notice• ActiveHealth Brochure• Coverage Options Summary – Base/Select• Health Insurance Marketplace Coverage Options• Active Employee Life Insurance Designation Handout• State and School Employees’ Life Insurance Plan Certificate The following information must be mailed by first class mail to each new employee at his home address. The envelope should be addressed to both the employee and the employee’s spouse if the employee elects dependent coverage. One notice to the home address is sufficient if all dependents reside at the same address.

• HIPAA Notice of Privacy Practices• COBRA Initial Notice Continuation of Coverage• Notice of Enrollment RightsIf an employee waives coverage, only the Notice of Enrollment Rights must be sent.

HEALTH INSURANCEHealth insurance is available to eligible employees when they enter full-time employment provided application is made within the first 31 days of employment. New employees eligible for coverage must either apply for or waive coverage during this time. These employees may also elect dependent coverage during their initial 31 days of employment. Employees who waive coverage will not be allowed to enroll until the next Open Enrollment Period, with an effective date of coverage beginning January 1 of the following year unless they experience a qualifying event for a Special Enrollment Period.

NOTE: It is your responsibility to secure a completed and signed Application for Coverage from every new employee meeting the eligibility requirements within the first 31 days of employment even if the employee declines coverage. Retroactive effective dates are not allowed.

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Employer units are not required to submit the completed Applications for Coverage to BCBSMS, but should instead maintain the signed forms in their office. Employer units are responsible for reviewing the forms for proper completion and entering the appropriate transactions into EnrollBlue timely, whether the employee is enrolling or waiving coverage. The employer unit should maintain all forms and related support documentation as they may be subject to review by the OOI and the Mississippi Office of the State Auditor to ensure that enrollment requirements are met.

Applying for Health Insurance CoverageAn employee enrolls for health insurance by completing an Application for Coverage when he enters full-time employment. Be sure that the employee completes the Application for Coverage and returns it to you. Employees should not send forms directly to BCBSMS. If a new employee is already covered under the Plan as a dependent of another employee, he must be canceled as a covered dependent, and enrolled as an enrollee with his own identification number to maintain coverage. Please ensure that employees properly complete and sign all applicable sections of the form within the first 31 days of employment, even if they choose to waive coverage.

Remember: If you do not have the employee complete an Application for Coverage to either apply or waive coverage when initially eligible, your employer unit could be liable for any claims incurred by the employee.

Effective Date of Coverage for New EmployeesFor a new employee, coverage becomes effective on the first day of employment, provided the employee completes an Application for Coverage within 31 days of the first day of employment. Applications completed after the initial 31 days of employment are considered late and are generally not accepted. It is your responsibility however, to ensure that all new eligible employees make application or waive coverage in the Plan within their initial 31 days of employment. Remember, employees who waive coverage will not be allowed to enroll until the next Open Enrollment Period unless they experience a qualifying event for a Special Enrollment Period. If the new employee is already a covered participant (active, dependent or COBRA), please refer to Transferring Coverage for guidelines regarding coverage effective dates for transfers.

Legacy and Horizon EmployeesFull-time employees are classified as either Legacy or Horizon.

• A Legacy employee is one who was initially hired before January 1, 2006. This includes all of your current employees as of January 1, 2006, as well as any subsequently hired new employees that were ever employed before January 1, 2006 in a full-time position by a community/junior college, public library, public school district, state agency or university.

• A Horizon employee is a full-time employee initially hired on or after January 1, 2006.

Base Coverage and Select CoverageEmployees have two medical coverage options: Base Coverage and Select Coverage. Base Coverage is available to all full-time active employees (Legacy and Horizon) at no cost. Employees must pay a portion of their premium if they choose Select Coverage. Premiums for dependent coverage under either option must be paid entirely by the employee. The premium rates for employee and/or employee and dependent coverage vary based on the coverage option selected. Currently enrolled employees may change their option for themselves and their dependents during Open Enrollment or during a Special Enrollment Period. For detailed information about these coverage options, employees should be referred to the Plan Document.

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Dependent CoverageHealth insurance coverage is also available to the following dependents of a participating employee:

• Legal spouse, unless the spouse is also an eligible employee under the Plan. If the spouse is an eligible full-time employee of a covered employer unit, he can only have coverage as an employee and cannot be covered as a dependent.

• Children to the end of the month that they turn age 26. If the dependent child is also an employee under the Plan, he may be covered as either an employee or as a dependent of his parent but not both.

• Dependent children who are permanently mentally or physically disabled, so incapacitated as to be incapable of self-sustaining employment, and dependent upon the employee for 50 percent or more support may be covered under the Plan regardless of their age, so long as they otherwise continue to meet dependent eligibility requirements and their incapacity began before their 26th birthday. A properly completed Request for Coverage for a Mentally or Physically Disabled Dependent form, along with written proof of the dependent child’s incapacity, must be provided at the time of enrollment (or within 31 days of the date the already-covered child would cease to be covered in the Plan due to age) in order for the dependent child to be eligible for coverage. If approved, the dependent child is eligible to continue coverage for as long as the incapacity continues and the employee (parent) is covered by the Plan. Request for Coverage for a Mentally or Physically Disabled Dependent forms and completion instructions may be obtained by contacting BCBSMS.

A dependent child of an employee includes a natural child, legally adopted child, stepchild, foster child, a child placed in the employee’s home in anticipation of adoption, a child for whom the employee has legal custody, a child for whom the employee is the legal guardian, and a child for whom the employee is required to cover by reason of a Qualified Medical Child Support Order (QMCSO).

If an employee is enrolling an adopted or legally placed child, a copy of the adoption, foster, placement or guardianship papers is required with the application. The employee with a child in a placement situation is also required to submit a copy of the adoption decree upon finalization of the adoption.

Effective Date of Coverage for DependentsFor dependents of new employees, coverage becomes effective the same day as the employee’s effective date, provided that an Application for Coverage including dependent information is completed within 31 days of the first day of employment. A new employee applying for coverage for his eligible dependent within the initial 31 days of employment cannot choose a different effective date for his dependent. If the employee does not want his dependent’s coverage to start at the same time the employee’s coverage becomes effective, the employee must wait until Open Enrollment or until a Special Enrollment Period occurs to apply for dependent coverage.

Example: An employee hired on October 11 cannot add dependents effective November 1. The effective date for dependent coverage is October 11 if the application is completed within the first 31 days of employment. If the dependent is already a covered participant, see Transferring Coverage.

New employees who experience a qualifying event for a Special Enrollment Period during their initial 31 days of employment may elect to enroll their dependents with an effective date the day following the date of a qualifying event instead of their date of hire. A separate Application for Coverage must be completed within 60 days of the event and the qualifying event must be indicated on the form.

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If an employee hired during the month of October wishes to add an eligible dependent for the current Open Enrollment Period, the effective date for the dependent will be January 1 of the following year. This will also require a separate Application for Coverage for the January 1 effective date.

Transferring CoverageWhen you hire a new employee that is already participating in the Plan (active employee from another employer unit, dependent of an active employee or COBRA participant), the rules regarding the effective date of coverage differ somewhat from the manner in which you process new employees.

If you hire the covered new employee on the first day of the month, his effective date of coverage as your employee will be his date of hire. If, however, the covered new employee’s date of hire is any time after the first day of the month, his coverage as your employee will become effective on the first day of the month following his date of hire. An exception to this occurs whenever a COBRA participant is hired into full-time employment.

The following scenarios describe various coverage transfer situations and how you should handle them. The transferring employee must sign and submit his Application for Coverage within 31 days of his hire date.

Dependent to Active Employee – first of the month employment date

When a covered dependent of an employee begins eligible employment on the first day of the month, his coverage as an employee will be effective the same day. His coverage as a dependent will be canceled the last day of the previous month. When a covered dependent becomes an active employee, he will also be able to enroll his eligible dependents and choose Base Coverage or Select Coverage.

Example: Jan, a full-time employee, has health insurance coverage in the Plan for herself and her husband, Alan. On October 1, Alan begins full-time employment and becomes eligible for employee coverage in the Plan. Alan’s coverage as an employee becomes effective October 1, and his coverage as Jan’s dependent is terminated September 30. As a new employee, he may select Base Coverage or Select Coverage and can enroll eligible dependents, all with an October 1 effective date. Jan will need to complete and submit to her employer an Application for Coverage to drop her coverage of Alan and any other dependents for which she wishes to terminate coverage. Alan is responsible for his dependent’s premium and his employer is responsible for his premium effective October 1.

Dependent to Active Employee – employment date after the first of the month

When the covered dependent of an employee begins eligible employment after the first of the month, the dependent’s effective date for coverage as a new employee is the first day of the following month, regardless of his actual hire date. His coverage as a dependent is canceled effective the last day of the current month. The new employee will be able to add coverage for his eligible dependents and can choose Base Coverage or Select Coverage.

Example: Don, a full-time employee has health insurance coverage in the Plan for himself and his wife, Linda. On July 10, Linda begins full-time employment and becomes eligible for employee coverage in the Plan. Linda’s coverage as an employee is effective August 1, and her coverage as Don’s dependent is terminated July 31. As a new employee, she may select Base Coverage or Select Coverage and can enroll eligible dependents, all with an August 1 effective date. Don will need to complete and submit to his employer an Application for Coverage to drop his coverage of Linda and any other dependents for which he wishes to terminate coverage. Linda is responsible for her dependent’s premium and her employer is responsible for her premium effective August 1.

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Employee Transfer – transferring from one employer unit to another within the same month

When an employee transfers from one employer unit to another within the same month, the effective date with the new employer unit is the first day of the following month, with health insurance coverage as an employee of the old group to be canceled the last day of the current month. The new employee will be able to add coverage for his eligible dependents and can choose Base Coverage or Select Coverage at this time.

Example: Bill resigns from employer unit A on March 12 and begins working with employer unit B on March 13. Employer unit A will terminate Bill’s health insurance coverage on March 31. Bill’s effective date of coverage with employer unit B is April 1. Bill will need to complete and submit to employer unit B an Application for Coverage to maintain coverage.

Employee Transfer – transferring from one employer unit to another during consecutive months

When an employee leaves one employer unit at any time during a given month and begins employment with another employer unit during the next consecutive month, the cancellation date under the old employer unit is the end of the month in which his employment terminated.

The effective date of coverage with the new employer unit is the first of the next consecutive month. The new employee will be able to add his eligible dependents and can choose Base Coverage or Select Coverage at this time.

Example: Paul resigns from employer unit A on February 28 and begins working with employer unit B on March 19. Coverage under employer unit A is canceled the last day of February. Although Paul’s actual hire date of March 19 should be indicated on his application, his effective date of coverage with employer unit B will be March 1. Paul will need to complete and submit to employer unit B an Application for Coverage to maintain coverage.

COBRA to Active Employee

When a COBRA participant begins eligible employment, the effective date of coverage as an active employee will be the first day of the month of his employment, regardless of his actual date of hire. His coverage under COBRA will be canceled the end of the previous month. He should complete and submit to BCBSMS an Application for Coverage to cancel his COBRA coverage. If he has paid a COBRA premium for the initial month of his employment, he will be entitled to a refund of the premium. The employee should contact BCBSMS to initiate the refund. The new employee will be able to add coverage for his eligible dependents and can choose Base Coverage or Select Coverage at this time.

Example: Anne is a COBRA participant who begins full-time employment with employer unit A on February 22. Her effective date of health insurance coverage as an active employee will be February 1, and her coverage under COBRA is terminated effective January 31. If she has already paid her COBRA premium for February, she can contact BCBSMS to request a refund.

COBRA to Dependent of Retiree

A COBRA participant whose spouse is a retired participant may transfer to the retiree’s policy at any time during COBRA coverage as a dependent and doesn’t have to wait for COBRA to be exhausted. The retiree must complete an Application for Coverage to add his spouse to his coverage, and the effective date will be the first of the following month.

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Dependent Coverage Transfer – from COBRA policy to active employee’s policy

When the covered dependent of a COBRA participant begins eligible employment, the effective date of coverage as an active employee is the first day of the month of employment regardless of his actual hire date. Dependent children covered under the COBRA participant’s policy may be transferred to an active employee’s policy provided Application for Coverage is completed by both the COBRA participant to drop the dependents and the new employee to add the dependents. If application is made for dependent coverage for any eligible dependents (including dependents who were not covered under the COBRA participant’s policy) during the initial 31 days of employment, the dependents will have the same effective date as the active employee.

Example 1: Cathy is a COBRA participant who has family coverage. Her spouse, James, begins eligible employment on May 17 and applies for health insurance coverage for himself and their children currently covered under Cathy’s COBRA policy.

His effective date of coverage as an active employee will be May 1. Cathy should also complete and submit to BCBSMS an Application for Coverage to drop coverage for the dependents. Cathy may also be covered as a dependent, provided James applies for her coverage when he begins eligible employment. In that instance, Cathy should submit to BCBSMS an Application for Coverage to cancel her COBRA coverage. If Cathy has paid her COBRA premium for May, she can contact BCBSMS to request a refund.

Example 2: Mike is a COBRA participant who also has coverage for Sandra, his spouse. Sandra begins eligible employment May 17 and applies for health insurance coverage for herself and their child who was not previously covered under Mike’s COBRA policy. Sandra’s effective date of coverage as an active employee, and her dependent child’s effective date of coverage, will be May 1. Mike may also be covered as a dependent, provided Sandra applies for the coverage when she begins eligible employment. In this instance, Mike should submit to BCBSMS an Application for Coverage to cancel his COBRA coverage. If Mike has paid his COBRA premium for May, he can contact BCBSMS to request a refund.

Dependent Coverage Transfer – from retiring employee to active spouse’s policy

If the spouse of a covered active employee has his own coverage in the Plan as a retired employee, any dependents covered under the retired employee’s coverage may be transferred to the active employee’s coverage at any time provided there is no break in coverage. The appropriate Application for Coverage must be completed by the active employee and given to his employer (to add the dependent) and the retired employee must complete and send to BCBSMS the Application for Coverage to process the transfer. Effective dates for the coverage changes will be the first of the following month.

Dependent Coverage Transfer – active employee to dependent of retiree

When a covered active employee, whose spouse is a covered retired employee, terminates his employment, he and any of his covered dependents may transfer to the retired employee’s policy. Such transfer is allowed provided there is no break in coverage. The retired employee must complete and send to BCBSMS an Application for Coverage to add the eligible dependents within 60 days of the date that the active employee’s coverage terminates. The effective date of the dependents’ coverage will be the first of the month following the active employee’s termination.

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Dependent Coverage Transfer – employee to employee

If both husband and wife are covered as active employees, dependent coverage can be transferred between spouses at anytime, provided there is no break in coverage. The Application for Coverage must be completed by both employees to add the dependent coverage to one and to drop the dependent coverage from the other. Effective dates for the coverage changes will be the first of the following month.

Retiree/Surviving Spouse to Active Employee

When a covered retired employee or surviving spouse returns to full-time employment, the effective date of coverage as an active employee will be the first day of the month of employment. Coverage as a retiree will be canceled effective the end of the previous month. The appropriate Application for Coverage should be completed to cancel the retiree coverage and to enroll the individual as an active employee.

If the individual has already paid a retiree premium for the initial month of his employment, he can contact BCBSMS to request a refund. The “new” employee will be able to add coverage for his eligible dependents and can choose Base Coverage or Select Coverage.

Example: Anne is a covered retired employee who begins full-time employment on February 22. Her effective date of coverage as an active employee will be February 1, and health insurance coverage as a retiree is terminated January 31.

If she has already paid her retiree premium for February, she can contact BCBSMS to request a refund. She will be able to add coverage for her eligible dependents and can choose Base Coverage or Select Coverage effective February 1.

NOTE: An employee’s status as Horizon or Legacy does not change because of a transfer from one employer unit to another. Assuming that the employee is already properly classified as Horizon or Legacy, transfers will have no effect on his status. Dependents and COBRA participants who subsequently become active employees but were never full-time employees before January 1, 2006, should always be classified as Horizon employees regardless of how long they may have been covered in the Plan.

LIFE INSURANCENOTE: This section only applies to the State and School Employees’ Life Insurance Plan. If your employer unit participates in an approved private policy in lieu of the State Plan, please refer to that specific policy’s provisions regarding enrollment and coverage.

Group term life insurance in the State and School Employees’ Life Insurance Plan is available to eligible employees when they enter full-time employment with a covered employer unit. New employees who are eligible for coverage must either apply for or waive coverage during the initial 31 days of employment.

New employees applying within 31 days of their initial employment are guaranteed coverage regardless of their health status so long as the appropriate premiums are paid. The effective date of coverage for new employees applying within their first 31 days of employment will be their date of hire (unless they happen to be ill or injured and away from work on this date, in which case, coverage would not take effect until they return to full-time work one full day).

Employees who initially waive coverage may apply to enroll at a later date; however, enrollment will be subject to medical evidence of insurability, as determined by Minnesota Life. For a complete description of the benefits and policy provisions, participants should refer to the State and School Employees’ Group Life Plan Certificate.

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Applying for Life Insurance Coverage – New EmployeesYou should have each new eligible employee complete and sign an Enrollment/Change Request within their initial 31 days of employment. Please ensure that employees complete all applicable sections of the form and return it to you within their first 31 days of employment, even if they choose to waive coverage. Once the form has been properly completed and signed, you will enter the information in EnrollBlue and retain the form in your personnel files.

Be sure to provide a copy of the Enrollment/Change Request, both front and back, to the employee so that he has the information he needs to designate his beneficiary by either online via BCBSMS or contacting Minnesota Life for a Beneficiary Designation and Change Request form.

NOTE: It is your responsibility to provide an Enrollment/Change Request to every new employee meeting the eligibility requirements. A new employee must either apply for or waive coverage within the first 31 days of full-time employment. Information should be entered into EnrollBlue even if coverage is waived.

Amount of Life Insurance Coverage – Active EmployeesParticipating active employees receive life insurance coverage equal to twice the amount of their annual salary rounded up to the next $1,000. The minimum amount of life insurance available for active employees is $30,000 and the maximum amount is $100,000. The Plan also includes Accidental Death and Dismemberment benefits at no additional cost.

Calculating Employee Life Insurance Coverage and PremiumsThe amount of an active employee’s life insurance coverage is calculated by multiplying his annual salary by two and raising the amount to the next higher thousand. An employee’s coverage amount is fixed based on his salary. The employee is not allowed to choose any other coverage amount. As his employer, you must contribute half of the premium and the employee must pay the other half. The current monthly premium is 18 cents (18¢) per $1,000 of life insurance coverage, with the employer and employee each paying 9 cents (9¢) per $1,000.

Example: Life insurance for a participating employee with an annual salary of $23,100 will be $47,000 ($23,100 x 2 = $46,200 - raised to the next higher thousand = $47,000). The current monthly premium for $47,000 in life insurance coverage is $8.46, with the employer and the employee each contributing $4.23. (ex. 47 x .18/2)

If a covered employee’s annual salary changes (increases or decreases), this could result in a change in the amount of his life insurance coverage. However, variations in an employee’s wages due to overtime or any other nonpermanent compensation generally should not be considered in determining the annual salary base for calculating the life benefit amount.

Any change in the amount of an employee’s life insurance brought about by a change in that employee’s annual salary is effective on the first of the month following the change. To be eligible to receive an increase in the amount of life insurance, the employee must be actively at work. If the employee is not actively at work on the date coverage would otherwise begin, or on the date the increase would otherwise be effective, HE WILL NOT BE ELIGIBLE FOR INCREASE UNTIL HE RETURNS TO ACTIVE WORK FOR ONE FULL DAY. However, if the increase is on a non-work day, coverage will not be delayed provided he was actively at work on the workday immediately preceding the non-work day.

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Example: An employee earning $30,000 per year with $60,000 in life insurance receives a $1,500 raise on July 1. The employee’s life insurance benefit amount is increased to $63,000 ($31,500 x 2) effective August 1. However, if the employee dies during the month of July, the higher benefit, $63,000, would be the life insurance benefit amount his beneficiary would receive.

Designating a BeneficiaryThe day after your employee’s information has been entered in EnrollBlue and accepted, he will be able to register on the BCBSMS website, and enter his beneficiary information. If the employee does not have Internet access, you can provide a Beneficiary Designation form that he can mail direct to Minnesota Life.

BCBSMS also offers a robust website and a free mobile app which can be downloaded for both Apple and Android devices that offers the option to view health claims, benefits and also elect or change the beneficiary designation. The app is available through both the App Store and Google Play. You should ensure your employees are aware of how to log on to the BCBSMS site so they can view their Explanation of Benefits and other claims information.

Other State-Sponsored Life Insurance

If your school district or community/junior college was approved by the Board to choose a private group term life insurance policy in lieu of participating in the Plan, the aforementioned policies and procedures do not apply. Although the basic benefit structure and eligibility requirements must be the same as those provided in the Plan, enrollment and premium payment procedures for those private policies will differ from the Plan instructions included herein.

Life insurance enrollment forms for private policies should be submitted to the private carrier, not to BCBSMS or the OOI. BCBSMS does not maintain any information in its eligibility system regarding private life insurance policy participation. Accordingly, the BCBSMS Premium Billing Reconciliation Form cannot be used to report any changes relative to private policy coverage. Participant change notifications, such as benefit increases, beneficiary designations and address changes should be forwarded to the private life insurance company. Premiums are to be paid to the private carrier and should not be sent to the OOI. Likewise, life insurance claims under these policies should be filed with the specific life insurance company, not the OOI or Minnesota Life.

NOTE: BCBSMS, Minnesota Life and the OOI can only respond to life insurance inquiries relative to the State and School Employees’ Life Insurance Plan and cannot answer questions regarding other state-sponsored life insurance policies. Any such questions should be referred to the specific life insurance company.

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ENROLLMENT (OTHER THAN INITIAL)

HEALTH INSURANCEIf certain changes (qualifying event) in a covered employee’s family status occur after the initial eligibility period, the employee should complete an Application for Coverage if he would like for his health coverage to reflect those changes, and submit the form to his payroll/personnel office. The applicable changes in family status include:

• Marriage • Death• Divorce • Address change• Newborn, placement (pending adoption),

adoption, foster child, legal guardianship, legal custody, or Qualified Medical Child Support Order (QMCSO)

• Change in dependent eligibility

If an employee wants to apply for health insurance coverage, add dependents or change coverage options (Base or Select) after the initial eligibility period, he may only do so during an Open Enrollment Period, unless he experiences a qualifying event for a Special Enrollment Period.

Open EnrollmentIf an employee waives health insurance coverage for himself and/or his dependents at the time of initial eligibility or does not apply for coverage during a Special Enrollment Period, he may apply for coverage during the annual Open Enrollment period in October. The effective date of coverage will be January 1 of the following year. If application is not made during the month of October, the employee/dependent is not eligible to apply until the next Open Enrollment unless a qualifying event for a Special Enrollment Period occurs. Employees may choose either Base Coverage or Select Coverage during Open Enrollment.

NOTE: The appropriate effective date must be indicated on the Application for Coverage. Retroactive effective dates are not allowed. Always complete the “For Employer/Administrator Use Only” section of the Application for Coverage for verification/audit purposes.

Special Enrollment PeriodsSpecial Enrollment Periods are only allowed in the specific circumstances described in this section. Participants may change coverage options (Base or Select) during a Special Enrollment Period.

Special Enrollment Periods are:

Loss of Coverage

An eligible employee or an eligible dependent of a covered employee who loses coverage under another health plan may be eligible to enroll under this Plan subject to the following conditions:

• The employee must have declined coverage for himself and/or his dependent under this Plan when initially eligible because the eligible employee or eligible dependent was covered under another group’s health plan or health insurance coverage.

The loss of coverage must be due to one of the following qualifying events:

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• The employee or dependent must become ineligible for coverage under another group health plan or health insurance coverage. Loss of coverage due to nonpayment of premiums does not constitute a special enrollment event; or

• The employee or dependent lost other coverage due to divorce; or• The employer ceased to contribute toward the cost of the other group health plan and it was

terminated; or• The employee or dependent’s COBRA continuation coverage has been exhausted.The eligible employee must submit a completed Application for Coverage within 60 days of the loss of other health insurance coverage. The employee will be required to provide proof of prior coverage. The effective date of coverage will be the first day following loss of other coverage, provided the application is received within 60 days of losing other coverage and proper premiums payments are made.

Gaining a Newly Eligible Dependent

A dependent acquired as a result of marriage, birth, adoption, legal guardianship, foster placement, placement in anticipation of adoption, legal custody or QMCSO may be eligible to enroll in the Plan subject to the conditions below:

The covered employee must complete and submit a completed Application for Coverage within 60 days of the qualifying event. If an employee is applying for coverage for a newborn, the Application for Coverage must be submitted within 60 days of the child’s date of birth even if a Social Security number for the newborn is not available at the time.

Once the Social Security number is received from the Social Security Administration, the number must be provided for the dependent.

For adoptions, legal guardianships, legal custody, placement in foster care, or placements in anticipation of adoption, a copy of the legal papers is required with the application. In other cases, proof of the qualifying event may be requested.

The effective date of coverage for a newly eligible dependent will be the date of the qualifying event, provided the application is received within 60 days of the qualifying event and proper premiums payments are made. The employee may also apply for coverage for any other eligible dependent.

An eligible employee not already covered by the Plan at the time of this qualifying event may enroll himself and any other eligible dependents.

When you receive a QMCSO (Department of Human Services - Notice of Enrollment) for an employee, you have 60 days from the date of the Notice of Enrollment to complete and/or acquire from the employee an Application for Coverage to add the dependent(s).

You should request that the employee complete and sign the application. If the employee refuses to complete and/or sign the form, you may complete it yourself. In all cases, the effective date will be the first of the month following the date of the Notice of Enrollment.

NOTE: If application is not made within 60 days of any of the Special Enrollment Periods described above, the change cannot be made until an Open Enrollment Period. Also, if a covered employee or dependent elects at any time during a calendar year to drop health insurance coverage, and then chooses to reapply, the earliest date coverage can begin is January 1 of the year following the next Open Enrollment Period or during a Special Enrollment Period. Employees who lose coverage due to termination of employment may reapply for coverage as a new employee the month they are rehired by any department, agency, Institution of Higher Learning, public school district, community/junior college or public library.

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Adding Newly Eligible Dependents

Employees may apply for health insurance coverage for newly eligible dependents by following the procedures:

• Marriage – If an employee marries and wishes to add his spouse, an Application for Coverage must be completed. If the application is completed within 60 days of the date of marriage, the spouse’s effective date of coverage will be the date of marriage. If the application is not completed within 60 days of the date of marriage, application cannot be made until an Open Enrollment Period or during a Special Enrollment Period.

• Newborn – A newborn child can be covered from date of birth if an Application for Coverage to add the newborn is completed and submitted within 60 days of the date of birth.

• Other Newly Eligible Dependent Children – This applies to children acquired through placements, adoptions, legal guardianships, QMCSO, and stepchildren acquired through a new marriage. An Application for Coverage must be completed within 60 days of the event.

Special Coverage/Cancellation Rules for to Schools, Community/Junior Colleges and Universities:• A covered employee (teachers or instructional staff) currently enrolled and returning to work in the

fall is entitled to continuous insurance coverage during the summer months.• A covered employee (teachers or instructional staff) who leaves one district or college at the end

of the contract/employment period and is not required to work during the summer, then becomes employed by another school in August should be covered by the new district effective August 1. Coverage with the old district or college would end July 31, and the employee would be removed from your August billing.

• A covered employee (all other employees who work year-round) leaving one district or college at the end of the contract/employment period and is required to work during the summer, then becomes employed by another school during the summer, should be covered by the old employer through the end of the month in which the transfer occurred. Remove the employee from your billing the next month after the transfer. The effective date with the new employer would be the first of the following month.

A covered employee leaving employment at the end of the contract/employment period with no indication of returning to any district or college should be terminated from your billing as follows:

• Employee receiving final check June 30; coverage will end June 30.• Employee receiving final check July 31; coverage will end July 31. • If an employee is terminated or resigns before the end of the contract/employment period, then

coverage ends the last day of the month in which employment was ended. Should the employee return to work with another district, coverage will begin on the date of employment, provided a timely application is filed.

• An employee who is eligible to retire and continue insurance as a retiree should be removed from your billing at the end of the month in which employment ends.

• A retiree returning to work while retaining retirement benefits is still considered a retiree for insurance purposes and is still responsible for the premiums. The retiree would not be eligible for employer-paid insurance coverage, and therefore must not be listed on your premium billing as an active employee.

• A retiree returning to work and terminating/suspending retirement benefits will become an active employee eligible for employer-paid insurance if the eligibility requirements are met. They may reapply for retiree insurance within 31 days of resignation/termination.

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Note: Employees who receive retirement benefits through PERS from entities or municipalities not participating in the Plan may be enrolled as active employees if eligibility requirements are met.

LIFE INSURANCEIf your employer unit participates in an approved private policy in lieu of the Plan, please refer to that specific policy’s provisions regarding late enrollment and canceling coverage.

Applying for Life Insurance Coverage – Late EnrolleesEmployees who apply for life insurance after the first 31 days of employment must provide medical evidence of insurability and be approved by Minnesota Life before coverage is allowed. Minnesota Life is the sole authority for evaluating late enrollment applications. There is no open enrollment period for life insurance.

Late enrollee applicants should complete and submit to their employer unit an Enrollment/Change Request. You will need to hold the Enrollment/Change Request in a pending file until Minnesota Life makes a determination of eligibility. To initiate the determination process, you will need to complete the sections designated for employer information on the Group Life Insurance Evidence of Insurability, make a copy of the form and give the original to the employee for completion of the remainder of the form.

Upon completion, the employee should sign and date the form in the space provided then submit it directly to Minnesota Life.

NOTE: The Enrollment/Change Request is not needed by Minnesota Life and should be retained by the employer until a response has been received from Minnesota Life regarding the Evidence of Insurability.

If requested by the employee, you can copy and mail the completed form to Minnesota Life on his behalf. If the employee needs to contact Minnesota Life concerning his late enrollment application, he can do so by calling (877) 348-9217.

Minnesota Life will evaluate the request, make a determination and advise the employee and his employer of their decision in writing. Coverage will be effective the first day of the month following or coincident with the date of Minnesota Life’s approval. Once the approval letter is received, the information should be entered in EnrollBlue.

If coverage is not approved by Minnesota Life, the Enrollment/Change Request and denial letter from Minnesota Life should be filed and retained by the employer.

NOTE: You should not deduct or pay premiums for late enrollee coverage nor enter transactions to add life coverage for late enrollees until Minnesota Life’s approval is received.

Filing Claims – Active Employees Only Death and/or Accidental Death and Dismemberment (AD&D) claims on behalf of active employees participating in the Plan should start at the local employer’s level. It is your responsibility to collect the available information from the beneficiary, complete the Notice of Death, and send it to the Office of Insurance, Attention: Life Insurance Claims Processing. Since inconsistencies and/or incomplete submissions will delay benefit payment on a life insurance claim, it is important that you submit complete and accurate information when filing a claim. You may mail, email or fax the information once you are notified of the loss. You should retain a copy of any and all documents submitted to the OOI for your records. The email address for claims is knowyourbenefits@dfa.ms.gov.

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Once the claim has been received, the OOI will verify coverage and input the claim into the Securian electronic system processing.

If an employee suffers a loss (other than death) under the AD&D provisions of the Plan, please have the employee complete a Notice of Accidental Dismemberment and Personal Loss Claim. Refer to the Group Life Certificate for additional information on types of qualifying events.

NOTE: Additional information may be requested by the OOI or Minnesota Life in order to process a claim. All claims for active employees should be filed through the employer. Claims should not be filed directly with Minnesota Life as this will only delay the claims process.

The Plan contains an accelerated benefits provision, whereby a terminally ill participant may apply to receive an advance payment of his death benefit equal to 50 percent of his total coverage amount. The Notice of Claim for Accelerated Benefit may be downloaded from the Plan’s website. Any requests for accelerated benefits should first be submitted to the OOI for validation. Once coverage has been verified, the OOI will forward the claim to Minnesota Life for determination of benefits.

Filing Claims – Retirees and/or Disabled Employees, Waiver of Premium Participants OnlyAs the former employer, you are not responsible for filing claims for retirees and/or disabled former employees. If you receive notice of a loss by one of your former employees, you should refer the beneficiary and/or other party wishing to file a claim to the OOI.

Other State-Sponsored Life Insurance – Policy Termination If your employer unit was approved by the Board to continue with a private group term life policy and subsequently decides to drop the private policy, you must then offer the State Life Plan to your employees. If an employee was participating in the private policy when it was dropped and chooses coverage in the Plan within the initial 31 days, he will be considered a “new employee” for life insurance purposes and will not be subject to underwriting. If, however, the employee was not participating in the private policy when it was dropped and applies for coverage in the Plan, he will be considered a “late enrollee” applicant and will be subject to the medical evidence of insurability requirements.

Note: Any of your employees who have retired on service or disability retirement before your district joined the Plan are not be eligible to purchase life coverage in the Plan under any circumstances.

Employees retiring from a district that does not participate in the Plan are eligible to continue coverage under the private policy as a retiree. Similar to the Plan, retirees can elect benefit levels of $5,000, $10,000 or $20,000, and will be responsible for their entire premium. Such retirees can make arrangements directly with the private policy carrier for payment of their premiums or contact the Public Employees’ Retirement System (PERS) to set up payroll deduction.

In the event your district or the private insurance company terminates the policy, your district will be eligible to rejoin the State Life Plan but;

1. The Board may assess charges in addition to the existing State Life Plan premium rates to employees to any district re-enrolling in the State Life Plan; and

2. Employees retiring on service or disability retirement prior to their district re-enrolling will not be eligible to purchase life insurance coverage in the State Life Plan.

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CANCELING COVERAGE

CANCELING HEALTH INSURANCE COVERAGEEmployee Coverage

Coverage should be terminated at the end of the month in which the employee becomes ineligible. You should promptly enter the appropriate EnrollBlue transaction to terminate the coverage. Coverage will also end if any required contributions are not paid or if the Plan is terminated for some reason. Dependent coverage ends at the same time or at the end of the month in which the Plan is made aware that a dependent is no longer eligible.

An Application for Coverage is not required to terminate coverage for an employee who is no longer eligible (i.e., terminated employment, changed from full-time to part-time). If a covered employee (who is not terminating employment) requests to cancel his coverage under the Plan, he must complete an Application for Coverage to do so. Coverage will be terminated at the end of the month in which the form is signed or any subsequent month, as requested by the employee. Requests to retroactively terminate employee coverage will not be considered.

Dependent Coverage

An Application for Coverage must be completed to terminate dependent coverage. Coverage is terminated at the end of the month in which the form was signed or any subsequent month, as requested by the employee. Requests to retroactively terminate dependent coverage will not be considered.

Retiree and COBRA Coverage

Retirees and COBRA participants may cancel their health coverage by sending a written request to BCBSMS. Coverage will be terminated at the end of the month in which the request is received by BCBSMS or any subsequent month, as requested by the participant. Requests to retroactively terminate coverage will not be considered.

CANCELING LIFE INSURANCE COVERAGEEmployee Coverage

A covered employee may cancel his life insurance at any time by completing sections A of the Enrollment/Change Request, and marking “Cancellation of Coverage” in section E. Coverage will be terminated at the end of the month in which the form was signed. Requests to retroactively terminate life insurance will not be considered. You should promptly enter the transaction in EnrollBlue to cancel the coverage and keep the signed copy for your records. Active employees who cancel their life insurance coverage may reapply at a later date; however, application will be subject to medical evidence of insurability and coverage may be denied.

Retiree Coverage

Retirees may cancel their life coverage by sending a written request to BCBSMS. Coverage will be terminated at the end of the month in which the request is received by BCBSMS or any subsequent month, as requested by the participant. Service and disability retirees who cancel their life insurance will never be allowed to re-enroll for coverage. Requests to retroactively terminate coverage will not be considered.

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CONTINUATION AND CONVERSIONHealth and/or life insurance coverage in the Plan ends at the end of the month in which an employee is terminated from full-time employment (exception – see Special Coverage/Cancellation Rules Applicable to School Districts, Community/Junior Colleges and Universities). An employee resigning or retiring on the last day of the month should not be payroll deducted for the next month’s premium for employee or dependent coverage on his last paycheck. If the employee notifies you of termination after payroll deductions for dependent health premiums have been made, you will take a credit on the subsequent billing provided the termination has been entered promptly. Opportunities for terminated employees and covered dependents to apply for continuation of coverage are described in this section.

RETIREE AND DISABLED PARTICIPANTSEmployees may continue health and life insurance coverage in the Plan upon retirement from employment. Continuation of coverage as a retiree can be elected only at the time of retirement.

Retiree EligibilityThe eligibility requirements a covered active employee must meet to continue coverage as a retiree are:

• Must be a participant in a retirement plan approved by PERS; and• Must be a participant in the Plan for four years or more (unless retiring due to work-related disability); and• Must qualify for service retirement benefits under the applicable PERS regulations; or• Must be approved for disability retirement benefits by PERS; or • Must be an elected state or district official who does not run for re-election or who is defeated.

NOTE: Creditable service can include any combination of an Optional Retirement Plan (ORP) and regular PERS retirement plan service.

Mississippi State Law, Section 25-15-3 defines a retiree as any person retired under the Mississippi retirement plan. The law further states that retired employees shall be eligible to continue life insurance coverage in an amount of $5,000, $10,000 or $20,000 into retirement. If an employee is approved for disability benefits through PERS, he is eligible for both health insurance and service retiree life insurance ($5,000, $10,000 or $20,000), provided he had health and life coverage as an active employee.

Applying to Continue Coverage as a RetireeAn employee should apply for retiree coverage at least 31 days before their retirement date to avoid a temporary lapse in coverage. An Application for Coverage and Enrollment/Change Request must be received by the employee’s Human Resources Office within 31 days of losing coverage as an employee. If the forms are received more than 31 days after coverage as an employee has terminated, the right to continue coverage as a retiree will be forfeited. The retiring employee must submit the following to his payroll/personnel office for entry in EnrollBlue:

• Completed Application for Coverage and Enrollment/Change Request. (These forms are not required if the retiree did not have coverage as an active employee. Otherwise, the retiree is required to complete both forms, even if waiving coverage. If the employee refuses to complete the forms, make a written record of his refusal, provide him with a copy, and keep the original in his personnel file.)

• One month’s premium made payable to State/School Insurance Fund (no postdated checks accepted). If the participant elects to continue health and life coverage, both premiums may be paid with one check for the total premium amount due.

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Please ensure that both the premium payment and the Retiree Payment Voucher are forwarded to the OOI. Employer units are not required to submit Application for Coverage and Enrollment/Change Request to BCBSMS or the OOI, but should instead maintain the forms in their office. Employer units are responsible for reviewing the forms for proper completion and entering the appropriate transactions in EnrollBlue timely, whether the employee is enrolling or waiving coverage. The employer unit should maintain all forms and related support documentation as they may be subject to review by the OOI and the Mississippi Office of the State Auditor to ensure that enrollment requirements are met.

Retiree Health Insurance – Service RetirementAs the employer, it is your responsibility to collect from the retiring employee the required forms along with the initial premium payment. You will enter the application into EnrollBlue and then forward the Retiree Payment Voucher and initial premium payment to the OOI. Once you have entered the application into EnrollBlue and forwarded the Retiree Payment Voucher and initial premium payment to the OOI, your responsibilities regarding the retiring employee’s insurance will end.

Although it is not recommended, the employee who is otherwise eligible for retirement health insurance under the Plan may elect coverage under COBRA. If the employee chooses coverage under COBRA instead of retiree insurance when he leaves active employment, he will only be eligible for 18 months of coverage under COBRA. If he subsequently decides to apply as a retiree during his COBRA continuation period, he must make application within the 18 months of COBRA, and pay a conversion fee. The same documentation regarding his retirement eligibility will be required and, as his former employer, you may be asked to assist him with the application process. The application and conversion fee should be sent to the OOI for proper handling.

An employee eligible for retirement insurance may instead elect to become a covered dependent, if his spouse is a covered employee under the Plan. If he elects to be covered as a dependent rather than maintaining coverage as a retiree, he will not be eligible to apply for retiree insurance at a later date. If the spouse dies before becoming eligible to retire, the dependent retiree is only eligible for 36 months of coverage under COBRA.

Retiree Health Insurance – Disability RetirementA covered employee who has been approved by PERS for disability benefits and wants to continue his health insurance in the Plan should apply for coverage as a disabled retiree within 31 days of the date coverage ceases as an active employee. An ORP retiree must likewise be adjudged disabled by PERS to qualify as a “disabled retiree” for insurance eligibility purposes, even though he will not actually receive disability benefits from PERS. To apply, the retiring employee should complete an Application for Coverage, marking the “Retiree” block in Section C, and submit it, along with the appropriate premium and the PERS Disability Approval Letter to the OOI. If the employee retiring on disability is on Medicare and is under age 65, he should also send a copy of his Medicare card.

If the covered employee has not yet been approved by PERS for disability retirement and is not otherwise eligible for service retirement benefits through PERS at the time he leaves employment, you should terminate his coverage and BCBSMS will mail him a COBRA application packet. If he desires to continue his health insurance coverage, the employee should complete the COBRA election form and submit it to BCBSMS along with the appropriate premium. He can also enroll electronically through the COBRA self-enrollment web portal and then submit the COBRA confirmation along with the appropriate premium to BCBSMS.

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If the participant is subsequently approved for disability by PERS before the expiration of his COBRA coverage, he should contact the OOI within 30 days of approval. He must complete a new Application for Coverage, marking the “Retiree” block in Section C, and submit it, along with the appropriate premium and his PERS Disability Approval Letter to the OOI. If the participant is ultimately not approved for disability before the expiration of his COBRA coverage, he will not be eligible for health insurance coverage as a retiree in the Plan. His coverage in the Plan will terminate at the end of his COBRA eligibility.

If the covered employee has not yet been approved by PERS for disability retirement and is eligible for service retirement benefits through PERS at the time he leaves employment, you should provide him with an Application for Coverage. If he desires to continue his health insurance coverage, the employee should complete the application indicating his enrollee type as “Retiree,” and follow the same procedures for service retirement. The participant will be set up as a service retiree pending resolution of his disability application with PERS. If the covered participant is subsequently approved for disability by PERS, he should provide to the OOI a copy of PERS Disability Approval Letter within 31 days. The OOI will convert his coverage from service retiree to disabled retiree. If the participant is ultimately not approved for disability, his coverage in the Plan may continue as a service retiree.

Medicare-Eligible RetirementWhen a retiree reaches age 65 or becomes covered by Medicare due to disability, Medicare is deemed to be his primary insurance. When an enrolled retiree reaches age 65, BCBSMS will automatically convert his coverage to reflect that Medicare is his primary policy. Medicare disability beneficiaries (under age 65) must notify BCBSMS by submitting a copy of their Medicare card in order to have their coverage updated. Retroactive coverage changes due to Medicare status are not allowed.

Surviving Spouses and DependentsIf an employee is covered in the Plan and is not eligible for retirement at the time of his death, his covered family members are eligible for COBRA for 36 months. BCBSMS will send a Continuation Coverage Election Notice to the dependents when notified of the death. If a covered surviving spouse is on Medicare at the time of the employee’s death, he will be eligible to continue coverage for up to 36 months under COBRA. If coverage is desired, you should have the surviving spouse send a completed Application for Coverage and Continuation Coverage Election Notice along with one month’s premium to BCBSMS within 60 days of the employee’s date of death. If the surviving spouse acquires Medicare at any time during the COBRA continuation, coverage in the Plan will terminate.

If a surviving spouse’s coverage includes dependents, BCBSMS will notify them of their rights to continue COBRA as Medicare ineligible dependents at the time the surviving spouse’s coverage is canceled.

If a covered retiree or a covered employee who is eligible for retirement dies, the surviving covered dependents may be eligible to continue health insurance coverage in the Plan. The surviving spouse may apply to continue coverage under the retiree group for the remainder of his lifetime. Covered dependent children may be eligible to continue coverage under the surviving spouse’s coverage until they reach age 26. If coverage is desired, the surviving spouse must complete an Application for Coverage and send it along with one month’s premium to the OOI within 60 days of the employee’s date of death. If there is no covered surviving spouse at the time of death, covered dependent children are eligible to continue coverage under COBRA for 36 months.

Covered surviving spouses who begin eligible employment with an employer unit under the Plan should be covered as active employees. Upon termination of employment, they may transfer back to the retiree group as surviving spouses provided there is no break in coverage and timely application is made.

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Any Application for Coverage received more than 60 days after the employee/retiree’s date of death will be returned, and coverage will not be available. The surviving spouse may contact BCBSMS to receive an Application for Coverage.

Retiree Life InsuranceAn employee must be enrolled in the Life Insurance Plan as an active employee as of the date of his retirement to be eligible for retiree life insurance. A retiring employee may elect to continue his life insurance coverage in the Plan by completing an Enrollment/Change Request and making the appropriate premium payment.

As with retiree health insurance, life coverage must also be elected at the time of retirement. To ensure uninterrupted coverage, application should be made 31 days before the date of retirement, but cannot be made later than 31 days after retirement. Enrollment/Change Requests submitted later than 31 days after retirement will not be accepted. If a participant elects retiree coverage, he must choose a retiree benefit level of $5,000, $10,000 or $20,000, and will be responsible for the appropriate monthly premiums. Premiums are variable based on the retiree’s age until age 70, at which time a flat rate per thousand applies regardless of the retiree’s age.

Life Insurance – Disabled EmployeesCovered employees who become totally and permanently disabled may apply for disability life insurance coverage within 31 days of losing coverage as active employees. If approved, the participant will be able to keep the amount of life insurance he had as an active employee until he reaches age 65, or is no longer disabled. He will be required to make a one-time payment for the full premium amount (currently 18 cents [18¢] per $1,000) for the first nine months of coverage as a disabled participant. After that, his premiums are waived until he is no longer disabled, or reaches age 65, whichever occurs first.

All applications to continue coverage under the disability waiver of premium (DWOP) provision of the Plan must be evaluated by Minnesota Life, who is the final authority on whether or not such coverage continuation is approved. Decisions made by PERS regarding disability retirement benefits have no bearing whatsoever on an employee’s application to continue life insurance under the DWOP provision.

To apply for continuation coverage under the DWOP provision, the covered employee should submit completed Enrollment/Change Request and Notice of Disability Claim to you as soon as possible after the onset of the disability but no later than within 31 days after losing life insurance coverage as an active employee. As the employer, you should complete a Notice of Disability Waiver of Premium Claim Employer’s Statement.

Once the Enrollment/Change Request, Notice of Disability, and Notice of Disability Waiver of Premium Claim Employer’s Statement have been completed and properly signed, you should submit all three forms to the OOI and retain a copy for your records. Once the claim has been received, the OOI will review the claim to verify coverage and ensure that the appropriate support documentation is included, validate the benefit amount, and resolve any discrepancies between the submitted coverage information and enrollment data maintained by BCBSMS. Once coverage has been verified and any discrepancies have been resolved, the OOI will be responsible for forwarding the claim to Minnesota Life for final processing. As part of the determination process, Minnesota Life will send an Attending Physician’s Statement to the participant-authorized physician to complete. Once completed, the form should be submitted directly to Minnesota Life for review.

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Note: Due to the confidential nature of the information on the Attending Physician’s Statement, it should never be sent to the employer unit or to the OOI.

Minnesota Life will evaluate the request, make a determination and advise the employee, the employer unit, and the OOI of their decision. If additional medical information is needed by Minnesota Life during their review, they will contact the employee and/or his physician directly.

If coverage is approved, it will become effective on the first day of the month following the date in which the participant’s coverage terminated as an active employee, subject to payment of the appropriate premium. The OOI will contact the participant by letter, advising him of the premium amounts due and request that he remit the initial nine-month premium payment within the time frame stated in the letter. Once the appropriate premium payment has been received, the OOI will have the DWOP coverage initiated. After payment of the initial nine-month premium amount by the disabled employee, premiums are waived for the duration of the coverage period until such time as the participant reaches age 65 or is deemed by Minnesota Life to no longer be disabled, whichever comes first.

If coverage is not approved by Minnesota Life, they will contact the participant and close the application file. If the participant needs to contact Minnesota Life concerning his DWOP application, he can do so by calling (877) 348-9217.

If the employee is eligible for service retirement benefits through PERS at the time he leaves employment, he may want to elect to continue life insurance coverage as a service retiree and apply for DWOP coverage while awaiting a decision on his disability application. By doing so, he will ensure that he will be able to retain at least retiree coverage regardless of the outcome of his disability application.

Note: Employers should urge employees who are eligible for service retirement to strongly consider making dual application in order to guarantee retiree coverage in the event their disability applications are not approved.

To make dual application, the participant must complete an Enrollment/Change Request, and check both “Retired Employee” and “Disabled Employee.” In the block for “Retired Employee,” he should select a benefit level of $5,000, $10,000 or $20,000 and attach the initial month’s premium for the selected coverage amount. He must also include a completed Notice of Disability and submit the forms along with the initial month’s premium for retiree life insurance to his employer. The employer will then forward the forms and the payment to the OOI. If Minnesota Life subsequently approves his application, any premiums paid for retiree coverage will be refunded to the participant upon activation of his coverage as a disability participant.

NOTE: If a terminating employee makes application only for disability coverage and his disability coverage application is subsequently denied by Minnesota Life, he will not be allowed to make late application as a service retiree.

Employees who are approved for DWOP coverage may be periodically required to furnish proof of continuous disability. This requirement applies to those disabled participants approved by Minnesota Life on or after January 1, 2009, as well as any disabled participants who were grandfathered in from previous policies. If the required proof is not submitted in a timely manner, or if Minnesota Life determines that the disability has ceased, Minnesota Life reserves the right to terminate the coverage. If such action is taken, written notice of the termination will be sent to the participant, with a copy to the OOI. If eligible, the participant will be offered the opportunity to continue coverage under the retiree provision of the policy. Such offering and any subsequent application process will be coordinated by the OOI similar to the procedures for any other retiree applicant.

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If the DWOP is terminated because the participant no longer qualifies as a disabled employee, the participant may elect to continue coverage ($5,000, $10,000 or $20,000) as a service retiree and remit monthly premiums himself if eligible.

Paying Premiums – Disability RetirementThe first month’s or any subsequent month’s health and/or life insurance premium is submitted to the OOI with the retiree insurance enrollment forms and PERS disability approval letters. Once application has been made and coverage is approved, premiums will be deducted from the retiree’s monthly PERS benefit payment. For retirees participating in a PERS-approved Optional Retirement Plan (ORP) (applies to certain university employees only) and/or those PERS retirees whose benefit payment is insufficient, monthly premium payments must be made by check, money order or bank draft. The retiree does not have the option of paying by direct bill if his PERS benefit is sufficient to cover the premium.

Participants have the option for their premiums to be direct billed or paid through a monthly bank draft. Once premiums have been set up as direct bill, (not deducted from their retirement checks) BCBSMS will send the direct bill notification and authorization form to participants. Participants should complete the authorization form and return it to BCBSMS for processing.

Retirees Who Return to Covered EmploymentRetirees who continue to receive benefits from PERS and return to covered employment under Mississippi Code Section 25-11-127, are considered retirees for insurance purposes. If the individual currently has coverage through the Plan, he will remain on the retiree group and must pay full premiums himself. If the individual ceases receiving benefits from PERS and returns to full-time employment with a covered employer unit, his employer will be responsible for paying the employee’s health insurance premiums. At the time of any subsequent resignation, he may convert back to the retiree group. Re-employed retirees are likewise eligible to participate in the Plan’s life insurance program if they so desire.

Retirees Who Return to Employment as a School Bus DriverRetirees who return to work as school bus drivers while continuing to receive their PERS retirement benefits are not considered active employees eligible for employer-paid insurance. In order to maintain coverage under the Plan, they must remain covered as retirees, and are responsible for the full amount of their health and life insurance premiums. However, this does not include those who retired from entities or municipalities that do not participate in the Plan. Employees receiving retirement benefits through PERS after retiring from entities not under the Plan may be enrolled as active employees if eligibility requirements are met.

Canceling Retiree CoverageRetirees may cancel their health and/or life insurance coverage by sending a written request to BCBSMS. Coverage will be terminated at the end of the month in which the request is received by BCBSMS or any subsequent month, as requested by the participant. Coverage will also end if any required contributions are not paid or if the Plan is terminated for some reason. Dependent coverage ends at the same time or at the end of the month in which the Plan is made aware that a dependent is no longer eligible. Retirees who choose to cancel their health and/or life insurance coverage are not eligible to re-enroll at a later date. Requests to retroactively terminate coverage will not be considered.

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PORTABILITY AND CONVERSION OPTIONS FOR GROUP LIFEEmployees who are no longer eligible for life insurance as an active employee due to voluntary or involuntary termination of employment (including retirement), have the option to continue their life insurance coverage without providing evidence of insurability.

Minnesota Life has provided a Portability and Conversion website that employees can access to learn more about the options available to them including: determine eligibility to convert or port coverage; calculate the cost of premiums; download and print forms directly; and view or download a Conversion FAQ document.

Employees should go to lifebenefits.com/continue and enter policy number 33683 and access key MSSE. Once the employee has downloaded the forms, he should verify coverage options with you.

Conversion OptionIf an active employee’s group term life insurance coverage in the State and School Employees’ Life Insurance Plan terminates, he may have the right to convert his coverage to an individual life insurance policy issued by Minnesota Life.

Eligibility for Conversion Option

To qualify, the coverage termination must be due to employment termination, retirement, layoff, nonmedical leave or medical leave, or because the employee is no longer considered to be a full-time employee. To be guaranteed coverage without being subject to medical evidence of insurability, the participant must apply for conversion within 31 days from the date he loses coverage as an active employee in the Plan. The amount of coverage for which a participant may apply to convert is limited to the amount of coverage that the individual is losing in the Plan.

Retiring employees who elect to remain in the Plan at the $5,000, $10,000 or $20,000 coverage levels may also apply to convert to an individual life policy up to the amount of coverage they are losing due to their retirement.

Example: John is an active employee with $75,000 in life insurance coverage in the Plan. He wants to retire, but wants to have more than the maximum $20,000 retiree life insurance coverage offered by the Plan. John can elect to keep the $20,000 in term life insurance as a retiree, and also convert to an individual life policy with Minnesota Life for up to $55,000 ($75,000 - $20,000 = $55,000 - the amount of coverage he is “losing” due to his retirement). As an alternative, John could also decide to decline retiree coverage in the Plan, and instead convert to a $75,000 individual life policy. Under either scenario, John is guaranteed coverage regardless of his health or any underlying medical conditions as long as he applies within 31 days of losing coverage as an active employee.

Applying for Conversion

To apply for a conversion policy, the participant will need to either go online or contact Minnesota Life directly at (866) 365-2374. It is very important that the terminating employee complete and submit the application no later than 31 days from the date he loses active employee coverage. Late applications (received after 31 days) are not guaranteed coverage and may be denied due to medical underwriting.

Once Minnesota Life receives the application, they will contact the OOI for verification of coverage, which will confirm coverage status and amount with BCBSMS, coordinate the resolution of any discrepancies, and notify Minnesota Life once coverage is confirmed. Minnesota Life will then complete the conversion request application process, advise the terminating employee in writing and will provide him with his

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policy and any related coverage information.

Any such converted policies issued by Minnesota Life to terminating employees are between Minnesota Life and the policyholder, and are not affiliated with or covered under the State and School Employees’ Life Insurance Plan. As such, any questions or issues that may arise on a Minnesota Life-issued conversion policy should be addressed directly to Minnesota Life at (866) 365-2374.

Employer’s Responsibility

It is important that you promptly report coverage terminations to BCBSMS so that the OOI can verify and confirm to Minnesota Life the loss of coverage in the plan.

Portability OptionActive employees participating in the Plan who terminate their State employment have the option to continue some or all of their term life insurance coverage through Minnesota Life. Unlike the conversion option which allows participants to “convert” to an individual life policy, this provision allows qualified terminating employees to “port” to a more affordable term life insurance coverage with no evidence of insurability requirements.

Eligibility for Portability Option

To qualify, the participant must be under age 70, and his coverage termination in the Plan must be due to his employment termination, retirement, layoff, nonmedical leave or medical leave, or loss of eligibility (i.e., no longer a full-time employee). The participant must apply within 31 days from the date he loses coverage as an active employee in the Plan, and medical evidence of insurability will not be required. The minimum amount of coverage for which a participant may apply to port is $10,000, while the maximum amount of ported coverage is limited to the lesser of the actual amount of coverage that the individual is losing in the Plan or $100,000.

A retiring employee may elect to port coverage, or continue coverage in the Plan as a retiree ($5,000, $10,000 or $20,000), or both, with the total amount of coverage (Plan and ported) not to exceed the amount of coverage he had as an active employee or $100,000. A participant age 65 or older is limited to a maximum of 65 percent of the coverage he had as an active employee, with all such ported coverage to terminate at age 70. All premiums for ported coverage are the responsibility of the participant.

Applying for Portability Election

To apply for ported coverage, the employer must complete the bottom portion of the Portability Election application and give to the employee for completion, and then submit the application to Minnesota Life. Before ported coverage can be approved, Minnesota Life must verify with the OOI the participant’s coverage loss in the Plan. Once Minnesota Life approves the ported coverage, they will bill the participant for the appropriate premium. The participant can authorize monthly bank draft premium payments at the time he applies for coverage by attaching a voided check to his application. Retirees electing to port coverage will have the option of paying their premiums by bank draft or check, but will not be able to have such premiums for ported coverage payroll deducted from their monthly PERS retirement benefits.

Once Minnesota Life receives the application, they will contact the OOI for verification of coverage, which will confirm coverage status and amount with BCBSMS, coordinate the resolution of any discrepancies, and notify Minnesota Life once coverage is confirmed. Minnesota Life will then complete the application process, notify the terminating employee in writing of coverage decisions, and provide him with his policy and any related information.

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Employer’s Responsibility

As the employer, your responsibility consists of providing terminating/retiring employees with a life insurance Portability Election form at the time of their termination/retirement. After you complete the “Employer Certification” section, you should have the employee complete the top portion of the form, and send the signed application to Minnesota Life. Ensure you keep copies of forms for your records. It is likewise very important that you promptly report coverage terminations to BCBSMS so that the OOI can verify, and confirm to Minnesota Life the loss of coverage in the plan.

COBRAThe Consolidated Omnibus Budget Reconciliation Act (COBRA) was signed into law in 1986 requiring certain employers who sponsor group health plans to offer their employees and their families (qualified beneficiaries) continuation coverage at group rates under certain circumstances (qualifying events).

When a covered employee leaves employment, his insurance stops at the end of the month in which his employment terminates. Under COBRA, the employee may elect to continue his health insurance coverage, as well as coverage for any of his already covered dependents in the Plan at his own expense. Continuation of life insurance coverage is not authorized under COBRA.

Qualified BeneficiariesA qualified beneficiary is an individual covered under the Plan the day before a qualifying event occurs (i.e., the employee, employee’s spouse and employee’s dependent children). Children born to or placed for adoption with covered employees participating in COBRA are also qualified beneficiaries. This does not include children born to a former spouse or dependent(s) on COBRA.

Qualifying EventsA qualifying event is a specified event that results in the loss of group medical coverage. Qualifying events include:

• Termination of employment for any reason other than “gross misconduct.”

• Divorce or legal separation.

• Reduction in hours of employment. • Entitlement to Medicare.• Death of the enrollee. • Loss of dependent eligibility under the Plan.

Length of COBRA CoverageCoverage under COBRA may last for varying periods depending upon the specific qualifying event and/or the participant’s status and eligibility. The specific coverage durations under COBRA are:

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Qualified Beneficiary Loss of Coverage Due To: Length of COBRA Coverage:

Covered employee

Termination of employment for reasons other than gross misconduct.Reduction in hours of employment.

Up to 18 months

Active military duty. Up to 24 monthsCovered spouse

Termination of employee’s employment for reasons other than gross misconduct.Reduction in employee’s hours of employment.

Up to 18 months

Employee being called to active military duty. Up to 24 monthsDivorce or legal separation.COBRA participant becomes entitled to Medicare.

Up to 36 months

Death of the enrollee. Up to 36 months if the enrollee was an active employee not eligible to retire at the time of death

Covered dependent children

Termination of employee’s employment for reasons other than gross misconduct.Reduction in employee’s hours of employment.

Up to 18 months

Parent being called to active military duty. Up to 24 monthsDeath of the enrollee. Up to 36 months unless

eligible for coverage as a dependent of a surviving spouse

Parent’s divorce or legal separation.COBRA participant becomes entitled to Medicare.No longer eligible as a dependent under the Plan.

Up to 36 months

If another qualifying event occurs during an 18-month continuation coverage period, then the period of continuation coverage can be extended, but not to exceed 36 months from the date of employment termination or reduction of hours of the employee.

A qualified beneficiary who has elected continuation coverage can choose to cover a newborn child, adopted child, or a new spouse acquired on or after the date of the qualifying event, subject to Plan enrollment period provisions. Coverage of new family members ceases at the same time as the continuation coverage of the qualified beneficiary. New family members, except children born to the covered employee or placed for adoption with the covered employee, do not become qualified beneficiaries.

NOTE: The employee or the qualified beneficiary is responsible for notifying the employer unit within 60 days in the event of divorce, separation or the ineligibility of a dependent child.

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Disability ExtensionAn 11-month extension of health insurance from 18 to 29 months may be granted to qualified beneficiaries who were disabled (as defined and determined under the Social Security Act) at the time of the qualifying event or at any time during the first 60 days of COBRA continuation coverage. A copy of the disability determination notice from the Social Security Administration must be received by BCBSMS within 60 days of the qualified beneficiary receiving the notice, and before the end of the 18-month period of COBRA continuation coverage to be eligible for this extension.

Termination of COBRA coverageContinuation coverage will terminate at the expiration of the specific maximum coverage period, but may end earlier in case of any of the following:• The qualified beneficiary fails to pay the applicable premium. Note: If the initial premium payment is

not received within the 45-day period from the date of election, coverage will terminate retroactively to the date of the qualifying event.

• The State of Mississippi no longer provides group health coverage to any of its employees.• The qualified beneficiary becomes covered by another group health plan, unless the health plan

contains any exclusion or limitations relating to any pre-existing condition.• The attainment of Medicare entitlement by the qualified beneficiary.• Coverage was extended for up to 29 months due to disability, and there has been a final determination

that the qualified beneficiary is no longer disabled.

COBRA Notification Requirements The employer will provide a Continuation Coverage Rights Under COBRA (Initial Notice) to covered employees, their spouses, newly hired employees and any newly covered spouse informing them of their rights under COBRA and describing the provisions of the law. The notice will be mailed to the employee’s home address via first class mail. It will NOT be sent return receipt requested or via email. Providing the employee the notice during employee orientation does not satisfy the federal notification responsibility.

BCBSMS sends the Continuation Coverage Election Notice to any covered employee leaving employment and to surviving spouses/dependents of deceased employees. This notice will be sent via first class mail or email (if the employee or qualified dependent has a registered personal email address) within 14 days of receiving information that a qualifying event has occurred. It is the qualified beneficiary’s responsibility to submit the Continuation Coverage Election Notice to BCBSMS within the specified time frame if they wish to maintain health insurance coverage.

If an employee retires and does not submit his retiree health election information to the employer, a COBRA notice will be sent. If an employee goes on leave without pay and does not pay his health insurance premiums to his employer, the employee should be removed from employer’s monthly reconciliation and terminated in EnrollBlue so a COBRA notice can be generated.

Once notified of a qualifying event, BCBSMS will send a Continuation Coverage Election Notice to qualified beneficiaries in such case of divorce, an ineligible dependent child, and Medicare ineligible spouse and/or children. BCBSMS is responsible for generating and mailing COBRA billing notices.

COBRA Election RequirementsThe employee or qualified beneficiary must submit the following to BCBSMS in order to apply for continuation of coverage as a COBRA participant:

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• A completed Continuation Coverage Election Notice within 60 days of the date coverage ended or the date of the notice, whichever is later.

• A COBRA Confirmation Page if the employee or qualified beneficiary chooses to self-enroll through the online COBRA Self-Enrollment Portal.

• The first premium payment and any arrears payments within 45 days from the date of election.

NOTE: The first payment must include all premiums due for the coverage period beginning with the COBRA coverage effective date through the current date.

EMPLOYEES ON UNPAID LEAVE

LEAVE WITHOUT PAY (LWOP)An employee who temporarily no longer receives pay and has been given an approved leave of absence by his employer may be eligible to remain on his employer’s billing and continue his health and/or life insurance coverage for a maximum of 12 months, provided the appropriate contributions are made.

If the employee fails to pay the appropriate premium, or has not returned to work by the end of 12 months, the employer should promptly terminate him from the premium billing by using the appropriate transaction code in EnrollBlue so a Continuation Coverage Election Notice can be generated and mailed to the employee. The procedures listed below should be followed for employees on approved LWOP.

• The employee is responsible for paying all monthly premiums, including the entire health premium and both the employee and employer’s share of the life insurance premium, to the payroll/personnel office by the first of each month for which coverage remains in force. Checks and/or money orders should be made payable to the employer, who should deposit the payment, and include the amount in with the employer’s total premium payment remitted to the OOI. Personal checks and/or money orders from employees should not be sent to the OOI.

• Premium payments from the employee are considered timely if they are received within 10 days of the date due. If the employee does not remit his premiums by the 10th of the month, he should be terminated from the premium billing.

• If the employee does not elect COBRA or remit premiums to the employer, he will be eligible to apply for health and life insurance coverage when he returns to full-time employment provided the following conditions are met:o The employee may apply for life insurance coverage as a new employee by completing an

Enrollment/Change Request, and for health insurance coverage for himself and any eligible dependents by completing an Application for Coverage. If these forms are completed within 31 days from the date he returns to full-time employment, the effective date will be the date the employee returned to work. The date the employee returns to work should be indicated in the Date of Employment block on both the Application for Coverage and the Enrollment/Change Request.If application is not made within 31 days of returning to full-time employment, the employee will not be allowed to make application for health insurance coverage until the next Open Enrollment Period or until he experiences a qualifying event for a Special Enrollment Period. If application for life coverage is not made within 31 days of returning, the employee may apply as a late enrollee and approval will be subject to evidence of insurability.

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IMPORTANT – If his coverage is terminated for any reason during his leave without pay period, the returning employee must complete new applications (Application for Coverage and/or Enrollment/Change Request) upon his return in order to reactivate his health and/or life coverage in the Plan. Coverage cannot be reinstated without new applications.

FAMILY MEDICAL LEAVE ACT (FMLA)An employee is entitled to the continuation of health insurance coverage during the FMLA leave period on the same terms as if the employee had continued to work. As the employer, you must continue to pay your portion of health insurance premiums for the employee for up to 12 weeks. The following procedures should be applied for employees on FMLA:

• During the FMLA leave period, the employee must continue to pay whatever portion of health insurance premiums that the employee paid before the FMLA leave. However, if the employee has life insurance when FMLA begins, he is responsible for the entire life premium. o Premium checks and/or money orders from employees on FMLA should be made payable to the

employer unit, deposited, then included in the total premium remitted to the OOI. No personal checks and/or money orders from active employees should be sent to the OOI.

• If the employee’s premium payment is more than 30 days late, the employer may terminate the employee’s health and/or life insurance coverage unless the employer has a policy of allowing a longer grace period.o In order to terminate insurance coverage for an employee whose premium payment is late, the

employer MUST provide written notice to the employee that the payment has not been received, and that his insurance coverage will end at a specified date (at least 15 days after the date of the notice). The notice must be mailed to the employee at least 15 days before coverage is to cease.

o If payment has not been received by the specified date in the termination of coverage notice, the employer should enter the transaction in EnrollBlue to terminate health and/or life insurance coverage with the appropriate reason code.

• An employee may choose not to retain health and/or life insurance coverage during the FMLA leave period. However, when an employee returns from leave, he is entitled to be reinstated on the same terms as before taking leave, including family or dependent coverages, without any qualifying event. The employee should complete an Application for Coverage within 31 days of returning to work, and the effective date will be the date the employee returned to work. The transaction should be entered in EnrollBlue using the appropriate reason code.

INVOLUNTARILY FURLOUGHIf an employee is placed on involuntary furlough for a period that extends past the end of the month in which it began, you should not pay any portion of the employee’s premium for the subsequent months during which the furlough continues. However, the employee can pay the entire premium and maintain coverage in the Plan until he resumes full-time employment. The procedures listed below should be followed for employees on involuntary furlough:

• If an employee is placed on involuntary furlough without pay, you should send him a written notification indicating the amount of premiums due (including the life premium) and that the premiums are due on the first of each month. At your discretion, a 10-day grace period may be allowed. Premium checks and/or money orders should be made payable to the employer, who should deposit the payment and include the amounts with their monthly premium payment submitted to the OOI.

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• If an employee retains coverage by paying premiums to the employer, the employee will remain as a covered employee on the employer invoice. The employee should remit the entire monthly premium to the employer. When the employee returns to full-time employment, you should resume paying the premium for “employee only coverage” and your appropriate portion of life premiums.

• If the employee does not pay the entire premium at any time during involuntary furlough, you must terminate the employee in EnrollBlue so a COBRA Coverage Election Notice can be generated.

• If an employee retains coverage through COBRA, he must reapply for employer paid coverage by completing an Application for Coverage within 31 days of returning to full-time employment. You should then resume paying the premium for “employee only coverage.”

• Because life insurance is not authorized under COBRA, employees who retain coverage as COBRA participants should complete an Enrollment/Change Request and indicate “New Employee” within 31 days of returning to full-time employment.

• If the employee does not retain coverage through COBRA or remit premiums to his employer while he is on furlough, he is eligible to apply for health and life coverage when he returns to full-time employment provided application is made within 31 days of returning. If application is made within 31 days, the employee’s effective date will be the date he returned to work. If application is not made within 31 days of returning to full-time employment, the employee will not be allowed to enroll until the next Open Enrollment Period, and the effective date of coverage will be January 1 of the following year unless the employee experiences a qualifying event for a Special Enrollment Period.

WORKERS’ COMPENSATIONThere is no such thing as Workers’ Compensation leave. Employees on approved leave due to a workers’ compensation injury or illness who have exhausted all of their personal and/or medical leave, and who are not receiving compensation from their employer, are considered to be in a leave without pay (LWOP) status.

Consequently, they are required to pay the full amount of their health and life premiums in order to remain covered. You are not required and are not authorized to pay health or life premiums for employees on unpaid leave due to workers’ compensation injuries, regardless if the leave is approved or not. The procedures described under LWOP would apply for maintaining coverage for these employees.

Please remember that leave due to a Workers’ Compensation injury or illness and FMLA can run concurrently provided the employee’s leave meets the criteria for FMLA, and the appropriate FMLA notification requirements are met.

ACTIVE MILITARY DUTYEmployees or covered dependents who are called to active military duty have the option to maintain their health and life insurance coverage in the Plan while on military leave, or to drop the coverage and re-enroll upon their return to work. The following procedures apply for covered employees on leave due to active military duty:

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Employees Called to Active Military DutyWhen a covered employee communicates to you that he has been called to active military duty, you should find out whether he wishes to participate in the Plan while on military duty so that his coverage can be handled accordingly. If he chooses to maintain his health and/or life coverage under the Plan, he will be responsible for the full premium.

He must remit the premiums to the employer unit by the first of each month in which coverage is in force. If he elects not to keep health coverage while on active duty, he and any covered dependents should be offered coverage under COBRA. He may choose to maintain life coverage under the Plan while on active duty, even if he does not keep his health coverage. He must complete applicable forms dropping health and/or life coverage and attach a copy of the military orders. Retroactive cancellations will not be considered. If the employee leaves for active duty and does not express to you his desire to maintain his coverage while he is on military duty, and does not remit premiums for his coverage, you should apply the procedures under LWOP.

When the employee returns to work, he may re-enroll in the Plan by completing an Application for Coverage and/or an Enrollment/Change Request. If application is made within 31 days of returning, the new effective date will be the employee’s date of return to employment. Any other eligible dependents may be added at this time. The employee will be considered a “New Enrollee” for life insurance.

If the employee is still covered under group coverage through the military, he may re-enroll in the Plan within 60 days of losing the coverage. The new effective date will be the day following the loss of the other coverage.

The procedures for health and life insurance in the Enrollment (Other Than Initial) Section should be followed if:

• Application for re-enrollment is not made within 31 days of returning to work; or • The employee does not apply for coverage within 60 days of losing group health coverage through

the military; or• The employee was not enrolled with health and/or life insurance before leaving for military duty.Some participants may be released but not discharged from military duty and placed on leave by the active force. These individuals remain under military orders for pay purposes and for purposes of expending leave accrued while on active duty. Therefore, the employee may return to work before official military discharge. The same re-enrollment procedures apply for these employees as for participants who have been discharged, however the employee will have to attach another copy of his military orders instead of release papers. The orders will provide proof that the employee had been away from work due to his military status. The new effective date will be the employee’s date of return to employment provided application is made within 31 days of returning to work.

Covered Dependents Called to Active Military DutyAn employee whose covered dependent is called to active military duty may terminate the dependent’s coverage while he is on active duty. The employee must complete an Application for Coverage to cancel the health insurance for the dependent and attach a copy of the military orders. Retroactive cancellations will not be considered.

When the dependent returns from active duty, he may be re-enrolled (providing the dependent still meets eligibility requirements) as a covered dependent within 60 days of his return. If application is not made within 60 days of the dependent’s return, he will not be allowed to enroll again until the next Open Enrollment or a Special Enrollment Period.

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ENROLLBLUE REPORTSEnrollBlue, the Internet-based enrollment system developed by BCBSMS, provides a secure, efficient and service-oriented system that includes many features to help you facilitate your responsibilities under the Plan. In addition to immediate access to enrollment, changes and billing, you have access to several different reports. Please be sure to review these reports often to ensure that changes are made as needed.

Over Age Dependent ReportDependent children are eligible for coverage up to age 26 regardless of student or marital status. Dependents will be listed on the Over Age Dependent Report approximately two months before dependents reach age 26. BCBSMS sends a COBRA packet and letter to the participant two months before the dependents’ birthday month.

• Employers should contact the employees listed on the Over Age Dependent Report to notify employees of their dependents who will be ineligible due to age. The employer should terminate the dependent(s) the month of his 26th birthday unless the employee wishes to continue coverage for the dependent as a mentally or physically disabled adult. If the employee choose to continue coverage, he should contact BCBSMS for a Request for Coverage for a Mentally or Physically Disabled Dependent form and submit it before the dependent’s 26th birthday.

• Employers should make any necessary payroll deduction changes.

Invalid Social Security Number ReportAll employees and dependents are required to provide Social Security numbers at the time their coverage becomes effective. There are some exceptions for a dependent to be added to coverage without a Social Security number.

• Dependent is not a United States citizen; or• Dependent is not a United States citizen but is in the country on a student visa; or• Dependent is in the process of being adopted.If one of these exceptions apply, the dependent may be added to the employee’s coverage without a Social Security number.

The Invalid Social Security Number Report is a cumulative listing of all dependents for which a Social Security number is required and is either missing or invalid. Contact the employees listed on the report and request the needed Social Security number. You can then update the dependent’s Social Security number directly from the report in EnrollBlue.

Invalid Address ReportThe Invalid Address Report provides the employer unit with a cumulative listing of employees with incorrect or undeliverable addresses.

Contact the employees listed on the report and have the employee complete an Application for Coverage for the address change. You can then update the invalid address directly from the report in EnrollBlue.

Activity ReportThe Activity Report provides the employer unit with all additions, changes and terminations performed in EnrollBlue within a specified date range.

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W2 Premium Information for Prior Tax YearThe W2 Premium Information Report provides the employer unit with information necessary for completion of the employees’ W2 forms. The report is made available in January and can be accessed through April for the prior tax year.

Tobacco Usage ReportThe Tobacco Usage Report provides the employer unit with all employees who have been updated through EnrollBlue from the Tobacco Attestation Form.

PPACA 6055/6056The PPACA 6055/6056 Report provides the employer unit with information on whether or not an employee had coverage and if so, for how long.

BILLING AND PAYMENT PROCEDURES

MONTHLY PREMIUM BILLINGS BCBSMS prepares a monthly premium billing for health and life insurance premiums to each employer unit. Your monthly billing includes several sections:

• Group Billing Statement includes remittance information and a summary of your current amount due and any past due amount.

• Premium Billing Section includes a current list of employees participating in the Plan, the last 3 digits of each Social Security number, payroll location (if used by your entity), and the life insurance face value and premium amount, health premium and the total premium for each employee.

• Monthly Summary of Activity Section includes all additions, deletions and changes made to employees since the previous billing statement.

• Past Due Detail Analysis Section lists information regarding any past due amounts.

Premium Billing ReconciliationsIt is your responsibility to enter transactions in EnrollBlue for any and all changes in the enrollment status of your employees and their covered dependents. A key component of this process is the prompt and accurate reconciliation of your monthly premium billing. You must reconcile the monthly billing with your payroll deduction records and complete the online Electronic Reconciliation. Allowing differences in these two records to go unreconciled can result in inaccurate eligibility files, the Plan paying claims on ineligible persons, claims being delayed and/or rejected for eligible persons, and premium overpayment/underpayment.

The Electronic Reconciliation should be completed in EnrollBlue and electronically submitted to BCBSMS on or before the 10th of the month. BCBSMS will not make any changes from your reconciliation and it should not be sent to the OOI unless specifically requested.

Reconciliations must be electronically submitted to BCBSMS every month. Even if the monthly billing is correct and there are no additional amounts or credits due, you must complete the reconciliation and electronically submit it to BCBSMS by the 10th of the month.

Upon receipt of your monthly billing:

1. Check the Premium Billing Section of your billing against your payroll records to verify that all eligible employees are listed with the correct coverage. List any differences on your electronic reconciliation

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by making the appropriate adjustments. This includes the current month’s changes and any changes that were not made from your previous month’s reconciliation. Since the Premium Billing Section is comprised of employees’ current coverage levels and premiums, any adjustments done to make changes to this section should be made in the Participant Adjustments Section of the reconciliation. Before completing your reconciliation, you may also enter any enrollment transactions in EnrollBlue for any current month’s changes and they will automatically upload to your reconciliation in the Unbilled Activity Section.

2. Review the Past Due Detail Analysis Section. In order to completely reconcile your billing, you must either pay the past due amounts or make adjustments to not pay those amounts in the Past Due Adjustment Section of your reconciliation. Transactions (premiums due and credits) will remain in the Past Due Detail Analysis Section until they are resolved. To avoid a sizable past due amount, you should take steps to resolve these items as quickly as possible. If there are any items listed that you do not understand or agree with, you should contact your account representative at BCBSMS for assistance.

Remember, the Total Amount Due on your billing includes the amounts in the Past Due Detail Analysis Section.

3. Submit your completed reconciliation to BCBSMS, and remit your premium payment to the OOI.

NOTE: If enrollment and billing reconciliation activities are handled by separate offices and/or personnel within your employer unit, you must ensure that these parties coordinate their efforts in communicating insurance information to BCBSMS. Regardless of how you distribute reconciliation and enrollment duties within your office, the overall responsibility for complying with these procedures rests with your employer unit.

PAYMENT PROCEDURESAs the employer, you are responsible for remitting health and life insurance premiums for your covered employees and their covered dependents. The employer unit pays a flat premium for each employee’s health coverage. If an employee chooses Select Coverage, his portion of the premium is paid through payroll deduction. Premiums for dependent coverage are paid 100 percent by the employee through payroll deduction. Life insurance premiums are paid 50 percent by the employer and 50 percent by the employee through payroll deduction. Employees whose paychecks are not sufficient to pay their dependent coverage or their portion of the life premiums through payroll deduction must remit the premiums to their employer (e.g., personal check, money order). Remittances should be made payable to the employer, who should deposit the payment and include the amount with their monthly premium payment to the OOI. Personal checks and/or money orders from active employees should not be sent to the OOI.

Premiums are due in advance at the first of each month. If a new employee begins full-time employment on or before the 15th of the month, a full month’s premium should be paid for the month of enrollment plus the following month’s premium. If an employee begins full-time employment on the 16th or after, a one-half month’s premium should be paid for the month of enrollment plus a full month’s premium for the following month. This applies to both life and health insurance premiums (including premiums for dependent health coverage).

NOTE: If new employees are already participating in the Plan, either as an employee, a dependent or under COBRA, please refer to Transferring Coverage Section.

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Payments Remitted by CheckPremiums are due in advance at the first of each month. Your check must be made payable to the State/School Insurance Fund, and mailed to the OOI, along with a Transmittal Form or the remittance coupon from your billing. Personal checks and/or money orders from employees should be deposited into your bank account or Treasury fund, and included in the overall premium payment your employer unit sends to the OOI.

Regardless of an employer unit’s payroll frequency, insurance premiums are always due in advance. Payments from entities that remit monthly are due on the first day of the coverage month. Payments from employer units that remit semimonthly are due on the first and 15th of the coverage month. Employer units whose premiums are not received in the OOI by 5 p.m. on or before the 10th (or the 25th for semimonthly payrolls) day of the month will be assessed a late payment penalty of 2 percent of the late/unpaid premiums. If the last day to remit premiums without incurring a late payment penalty falls on a weekend or holiday, the deadline is extended until the next working day.

If during any payment period, you determine that you will not be able to remit your premiums before the 10th and/or 25th – semimonthly of the month, you should contact the OOI as soon as possible to request an extension. Extensions are granted when properly justified; however, vacations, holidays and other foreseeable events are not justifiable excuses for late payment of premiums.

Remember: Premium payments are to be sent to the OOI and not to BCBSMS.

Direct Deposit PaymentsPremium payments that are payroll deducted through the Statewide Payroll and Human Resources System (SPAHRS) are paid to the OOI by Electronic Funds Transfer (EFT) on the Pay Date for payroll runs. A Transmittal Form – SPAHRS Payments will be required for EFT payments to provide information needed to accurately apply your agency’s payment information. Completed Transmittal Form – SPAHRS Payments should be emailed to InsuranceTrans@dfa.ms.gov.

Since the EFT will be made on the Pay Date, a completed transmittal should be emailed before the Pay Date in order to ensure proper credit of your agency’s premium payment.

When you receive a Deductions by Vendor report from SPAHRS that lists payroll deductions for health and/or life premiums, you should promptly complete and submit a Transmittal Form – SPAHRS Payments using information provided on the report. Transmittal Forms – SPAHRS Payments include spaces for the Pay Date, Payroll Run Number(s), and each Warrant/EFT Number on the corresponding Deductions by Vendor reports. Since payments will be made by direct deposit per Pay Date, a separate Transmittal Form – SPAHRS Payments must be submitted for each Pay Date for your agency. Multiple Payroll Runs may be included on the same transmittal provided they have the same Pay Date. Remember, it is important that this information is received in advance of the payment deposit.

FORMS AND NOTICES This section contains instructions for completion of the forms and notices referred to in this manual. Forms and notices are available online at http://KnowYourBenefits.dfa.ms.gov/.

HEALTH INSURANCE FORMS & NOTICESApplication for CoverageIMPORTANT: All eligible employees must sign up for or waive health insurance coverage within 31 days

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of employment. Please make sure that the enrollee completes the form and signs Section B checking the appropriate box to either add, continue or change their coverage, or to waive coverage. It is the responsibility of the payroll/personnel office to review the Application for Coverage to ensure that all information is accurate. After reviewing the completed forms, you should promptly enter the information in EnrollBlue and keep the original form in your files.

NOTE: The form online is a “fillable” form and can be completed online, then printed for the employee’s signature. The process for completing the form is as follows:

SECTION A: Enrollee Information – Every box in this section should be completed by the enrollee regardless if he is applying for or waiving coverage.

Employer Name – Employer unit name

Social Security number of the enrollee.

Enrollee First Name, MI, Last Name – Full legal name of the enrollee, no nicknames.

Home Address, Email Address and Telephone numbers – Enrollee should provide complete contact information including his home mailing address with ZIP code and, if applicable, apartment number. Contact information should also include a personal email address and phone numbers if provided.

Marital Status of enrollee – Married or single.

Gender – Gender of the enrollee.

Date of Birth of the enrollee – The month, day, year in MMDDYYYY format.

Date of Employment/Retirement – The date the employee actually began working and went on payroll, not the day his contract was signed or became effective. This includes the date of rehire or the date the employee returned from leave without pay if he did not keep his policy active – month, day, year. For retirees, this is the last day of the month in which your employment ended.

Were you ever a full-time employee of a covered entity under the Plan before 1/1/06? If no, the employee is a Horizon Employee. If yes, the employee is a Legacy Employee and must list his most recent (pre-1/1/06) employer and dates of employment.

If married, is your spouse a participant in the State and School Employees’ Health Insurance Plan? If yes, the enrollee should give the name and Social Security number of the spouse. If both husband and wife are eligible employees participating in the Plan, they must each be covered as an employee, and not as a dependent of their spouse’s policy.

SECTION B: Health Insurance Membership Agreement Authorization

Apply to add, continue, and/or change coverage – The enrollee must check here after reading this section if electing, continuing or changing coverage for himself and/or any dependents.

Waive coverage – The enrollee must check here after reading this section only if waiving coverage for himself.

All eligible employees must sign and date this section and check the applicable box (not both boxes)

Note: Section A must also be completed even if coverage is waived. Also, any employee wishing to cancel his (employee only) health insurance coverage should complete and sign this section, and check waive coverage.

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SECTION C: Coverage – The enrollee should complete all applicable boxes in this section.

Enrollee Type – Denote participant type: Employee – Legacy, Employee – Horizon, Retiree, COBRA or Surviving Spouse.

Coverage Type – The type of coverage elected by the enrollee. If the enrollee checks Enrollee + Spouse, Enrollee + Child, Enrollee + Children, or Enrollee + Spouse & Child(ren), the dependents to be covered must be listed in the space provided.

Coverage Option – The enrollee must choose either Base Coverage (High Deductible) or Select Coverage.

Do you have Medicare? – If the enrollee (employee, retiree or COBRA) has Medicare, he should indicate Part A, Part B, or both and the effective date of each. He should also indicate if the Medicare Entitlement was due to Age, ESRD (End Stage Renal Disease), or Disability by checking the appropriate box.

SECTION D: Other Coverage Information – If any dependent listed on the application has other insurance coverage, the enrollee should check “yes” and give complete information regarding the other coverage.

SECTION E: Dependents – If the enrollee is applying for dependent coverage, each dependent to be covered must be listed. He should list the spouse and/or children to be covered and indicate the relationship to the enrollee, Social Security number, date of birth, dependent’s address if it is different from the enrollee (this is a requirement of federal law), and current status (employment status for spouse; child under 26 or disabled status for children). He should complete the information for each dependent listed. If more space is needed to list additional dependents, enrollee should complete an additional Application for Coverage and indicate Page 1 of 2 on the first form and Page 2 of 2 on the second form.

Note: Social Security numbers are required for covered dependents when they are enrolled. The only exception is newborns less than 60 days old. Social Security numbers are not required for newborns at the time of enrollment, but must be reported as soon as they are acquired.

Are any of the dependents listed above covered by Medicare Part A or Part B? If any dependent listed in Section E is also enrolled in Medicare, he should list the dependent’s name, Medicare Number, effective date of Part A and Part B and list the reason for Medicare entitlement (Age, ESRD or Disability).

SECTION F: Change Information – This section should be completed by enrollees who want to apply for coverage after the initial enrollment period has passed or to make changes in their current coverage.

Add Enrollee: – The enrollee must check the appropriate reason and give the requested effective date (date of the event).

Add Dependent(s): – The enrollee should check if adding dependents, indicate the applicable reason, and give the requested effective date (date of the event). He should list each dependent to be covered including the dependent being added in Section E of this form.

Change Coverage Option: – If the enrollee wishes to change his Coverage Option, and has experienced a qualifying event to do so, he should indicate the type he desires. Changes to an enrollee’s coverage type can only be made during certain qualifying events.

Drop Dependent(s): – The enrollee should check if canceling dependents and indicate the reason. He should list the dependent(s) to be dropped, the Social Security number(s) and the requested termination date (cannot be retroactive). The appropriate effective date should also be listed in the space provided at the bottom of this form.

Other Changes – The enrollee should check this block if he is making any change other than one of those specified above. He should indicate the reason if he is canceling his (employee only) coverage. If the

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enrollee is making a name or address change, he should check here, and list the former name or address. The new information should be shown in Section A.

The enrollee should sign and date Section B after indicating all requested changes.

FOR EMPLOYER/ADMINISTRATOR USE ONLY – This section should be completed by the appropriate payroll/personnel staff, not the enrollee.

Group Number – Indicate the individual number assigned to your employer unit. This number is located on the monthly premium billing.

New Legacy Employee – Check if enrollee is a new or rehired employee who was ever a full-time employee with a covered employer unit before January 1, 2006 (the information requested in Section A). The requested effective date should be the same date as the date of employment in Section A.

New Horizon Employee – Check if enrollee is a new employee who has never been a full-time employee with a covered employer unit before January 1, 2006 (the information requested in Section A). The requested effective date should be the same date as the date of employment in Section A.

Retiree – Check if the enrollee is applying for retiree coverage as a service retiree or disability retiree. Give the effective date of retirement.

COBRA – Check if the participant qualifies for COBRA and indicate the date of the qualifying event.

Surviving Spouse – Check and give the effective date if the enrollee is the surviving spouse of an employee who, at the time of his death, was eligible to retire.

Change(s) – Check if the employee is applying for coverage for himself or for dependents after initial eligibility, or canceling dependents. Give the appropriate effective date for the requested change.

Entered By, Date – This space should be initialed and dated by the person entering this information in EnrollBlue.

Verified By, Date – This space should be initialed and dated by the person reviewing the form and/or the information submitted in EnrollBlue.

IMPORTANT: Please make every effort to ensure that your employees understand how to accurately complete the Application for Coverage. After the form is reviewed, you should promptly enter the appropriate transactions (including those waiving coverage). Employees waiving health insurance coverage in the Plan should be reminded that application for future enrollment can only be made during an Open Enrollment Period (each October) or during a Special Enrollment Period. All eligible employees must complete and sign an Application for Coverage indicating whether they are accepting or waiving coverage in Section B.

Coverage Options Summary for State and School Employees’ Health Insurance PlanNew employees should be provided a Coverage Options Summary to assist them in their coverage option selection. You should advise them to refer to the Plan Document for complete information regarding coverage options since this notice is only a brief summary.

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Base Coverage

Base Coverage meets the federal government’s criteria of a qualifying high deductible health plan under Section 1201 of the Medicare Prescription Drug Improvement and Modernization Act of 2003 in regard to establishing a Health Savings Account. Base Coverage includes a combined medical and pharmacy deductible. Allowable charges for prescription drugs are applied to the calendar year deductible. After the calendar year deductible has been met, participants will pay applicable prescription drug copayments.

Select Coverage

Select Coverage has separate medical and prescription drug deductibles. For more information, go to the Plan Document at http://knowyourbenefits.dfa.ms.gov/publications/ or download a copy of the Coverage Options Summary in the Employer Unit Section of the website.

Plan Document NoticeTo ensure that new employees are aware of the Plan Document, and informed on how to access it electronically or request a paper copy, you should provide them with a Plan Document Notice at orientation.

Health Insurance Portability and Accountability Act (HIPAA) Notice of Privacy PracticesThe Plan is required by law to maintain a notice of privacy practices. This notice describes how the Plan may use and disclose protected health information and also explains participants’ legal rights regarding this information. Employers must send this notice to new participants by first class mail.

Authorization of Release of PHI for Enrollment/Disenrollment PurposesThis form should be completed and signed by the payroll/personnel supervisor who authorizes an employee or employees to receive information regarding participant Protected Health Information (PHI) for Enrollment/Disenrollment purposes for your employer unit. After the form is completed, it should be submitted to BCBSMS. If this responsibility is reassigned to another employee, you must submit another authorization form to BCBSMS. To complete the form: Section A: Indicate the group number and name of your employer unit, the name of your human resource/payroll officer, mailing address, telephone number and fax number.Section B: Indicate the person(s) responsible for the maintenance of enrollment and disenrollment information.Signature: The supervisor of the payroll/personnel office should sign and date the form, print his name and indicate his title.

LIFE INSURANCE FORMS & NOTICESEnrollment/Change Request

NOTE: The life insurance forms in this manual only apply to the State and School Employees’ Life Insurance Plan. If your entity participates in an approved private policy in lieu of the State Plan, please refer to that specific policy’s enrollment instructions.

BCBSMS maintains all life insurance amounts relative to this coverage. Beneficiary information is maintained by Minnesota Life. It is the responsibility of the payroll/personnel office to review the Enrollment/Change Request to ensure that the form is complete and accurate before entering information in EnrollBlue. After reviewing the completed forms, the process for completing the Enrollment/Change Request is as follows:

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IMPORTANT: All eligible employees must apply for or waive coverage within 31 days of employment. Please make sure that the form is signed by the enrollees either in Section D to apply for coverage or in Section E to waive coverage, but not both.

SECTION A: Employee/Employer Information – Every box in this section should be completed by the enrollee.

Employee/Retiree Last Name, First Name, MI – Full legal name of the enrollee, no nicknames.

Social Security number of the enrollee.

Birthdate of the enrollee – The month, day and year in MMDDYYYY format.

Employee/Retiree Home Address – The complete home mailing address of the enrollee including ZIP code and, if applicable, apartment number.

Home Telephone No. – The enrollee’s home phone number.

Email Address – The enrollee’s personal email address (if provided).

Employer Name – The name of the employee’s employer unit. Retired applicants should write “Retiree” in this space.

Employer Address – Mailing address of the enrollee’s employer unit. Retirees should disregard this space.

Employer Telephone No. – The enrollee’s work phone number. Retirees should disregard this space.

SECTION B: Coverage

Active Employee – The enrollee should check New Employee if he is applying for coverage during the initial 31 days of employment. He should check Late Enrollee Applicant if he is applying for coverage after his initial 31 days of hire. A Group Life Insurance Evidence of Insurability form must also be completed for late enrollee applicants. If approved for coverage, the effective date for the late enrollee applicant will be the first of the month after or coincident with the date of approval by Minnesota Life. The enrollee should indicate his Date of Employment in the space provided in this section.

Retired Employee – The enrollee should enter his Date of Retirement in the space provided and check the life benefit Coverage Amount Requested.

Disabled Employee – The enrollee should list date of total disability in the space provided. If coverage is approved by Minnesota Life, the amount of life insurance will be the amount that he had as an employee.

At the top of the back page, the enrollee should fill in his name, Social Security number and daytime phone number in the space provided.

SECTION C: Beneficiary Instructions

This section explains the process for online beneficiary designation. If the employee does not have Internet access, he can call Minnesota Life at (877) 348-9217 to request a paper copy of the beneficiary designation form, or you can provide the employee a copy of the current Beneficiary Designation Form that the employee can complete and mail directly to Minnesota Life.

SECTION D: Authorization and Certification

After reading this section, the enrollee must sign and date in the space provided if electing life insurance coverage. The enrollee should not sign here if waiving or canceling coverage.

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IMPORTANT: Employees waiving life insurance coverage in the Plan should be reminded that application for future enrollment will be subject to review of evidence of insurability, and may be denied. All employees must complete and sign an Enrollment/Change Request indicating whether they are accepting or waiving coverage.

SECTION E: Waiver/Request to Cancel Coverage – This section must be completed and signed by the enrollee only if he wishes to waive or cancel coverage in the Plan.

Waiver of Coverage – Should only be checked by the enrollee if he is declining to participate in the Plan during his initial 31 days of eligibility, or if he is a covered employee who is retiring and does not want to continue life insurance coverage in the Plan.

Cancellation of Coverage – Should only be checked by the enrollee if he wishes to cancel his coverage in the Plan.

For Personnel/Payroll/Administrator Use Only – This section should be completed by the appropriate payroll/personnel staff, not the enrollee.

Coverage Amount – If the enrollee is a new employee or late enrollee applicant, indicate the life benefit amount based on the enrollee’s salary. Retiring applicants should indicate the life benefit amount chosen. List the amount of life insurance the disabled employee had as an active employee.

Requested Effective Date – Indicate the new employee’s date of hire, the effective date of cancellation for enrollees requesting to cancel their life coverage, or the retirement date for retiree applicants. Remember, no requests for retroactive cancellations will be considered. For late enrollees, list as the effective date the first day of the month following or coincident with the date coverage is approved by Minnesota Life.

Group Number – Indicate the group number assigned to your employer unit for premium billings in this space.

Information Verified – Once the appropriate staff reviews this form, this block must be initialed and dated to confirm its verification.

Evidence of InsurabilityLate enrollee applicants must submit a completed Group Life Insurance Evidence of Insurability to Minnesota Life, who determines eligibility for all late applicants. The employer should have an Enrollment/Change Request completed by the employee on file pending approval of life insurance coverage by Minnesota Life.

The Group Life Insurance Evidence of Insurability is completed partially by the employer, and partially by the employee applying for life coverage. The instructions below specify which sections each should complete.

NOTE: The form will not be considered complete unless the information required from the employer unit is provided including the employer unit signature.

The employer should complete the employer unit name and employer unit number spaces by providing the employer unit’s name and group number. The group number is shown on the monthly premium billing from BCBSMS.

In the For Employer Unit Office Use Only section on the back, the employer should restate the name and group in the spaces provided. On the next line, insert the amount of coverage the employee will have if approved. The amount should be twice his annual wages to the next $1,000 – minimum of $30,000 and maximum of $100,000. Then indicate whether the employee is eligible for coverage and sign the form in the space provided.

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At this point, you should make a copy of the form and give the original to the employee. The employee should be advised to complete the Employee Information and Health Questions sections on the front of the form. If the employee answers “yes” to any questions in the Health Questions section, he will need to complete the Additional Health Information section on the back.

Upon completion, the employee should sign and date the form in the space provided, then mail it directly to Minnesota Life.

If requested by the employee, you can mail the completed form to Minnesota Life on his behalf. If the employee needs to contact Minnesota Life concerning his late enrollment application, he can do so by calling (877) 348-9217.

Minnesota Life will evaluate the request, make a determination, and advise the employee and his employer of their decision in writing. If coverage is approved, enter a transaction in EnrollBlue. The effective date of coverage will be the first day of the month following or coincident with the date of Minnesota Life’s approval. If coverage is not approved by Minnesota Life, the Enrollment/Change Request and denial letter from Minnesota Life should be filed and retained by the employer.

Notice of DeathAfter a loss of an active employee has occurred, the employer should complete a Notice of Death and submit it to the OOI which will verify coverage status with BCBSMS, and input the claim into the electronic Securian Financial system processing.

For losses incurred by retirees and DWOP participants, the OOI, upon request/notification by the beneficiary or other interested party, will verify coverage status with BCBSMS, and input the claim into Securian for processing. Former employers who are contacted about retirees or DWOP participants should advise the beneficiaries to contact the OOI for assistance.

The following guidelines should be followed to file a claim and for completing the Notice of Death:

The employer unit’s name and group number should be inserted. Provide the employee’s name, address, Social Security number, date of birth, phone number and date of hire. Indicate the employee’s original effective date of coverage and whether the employee was actively at work on that date.

You should provide information concerning the employee’s last date at work and the reason he stopped working. Indicate the employee’s date of death, and the date to which life premiums were paid (should be the last day of the month in which his coverage ended). If the employee’s death was due to an accident, check “Yes.”

Insert the actual amount of insurance as of the date of the loss and the employee’s current salary on date last worked. Insert the effective date of last salary change.

The payroll/personnel contact completing this form should print his/her name, and provide a contact phone number and address. This person should sign and date the form and indicate his/her title.

The payroll/personnel contact should forward the completed, signed Notice of Death to the Office of Insurance, Attention: Life Claims Processing. The form can be mailed, faxed, or scanned and emailed to knowyourbenefits@dfa.ms.gov.

Remember, all claims must be submitted through the OOI. Any claims sent directly to Minnesota Life will have to be returned, thus delaying issuance of any benefit payments. If the beneficiary needs to contact Minnesota Life concerning a filed claim, he can do so by calling (888) 658-0193.

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Notice of DisabilityTo apply for continuation coverage under the Disability Waiver of Premium (DWOP) provision, the covered employee should complete an Enrollment/Change Request and Notice of Disability. These forms should be completed and submitted to the employer, who is responsible for completing a Notice of Disability Waiver of Premium Claim Employer’s Statement and the “For Personnel/Payroll Use Only” section of the Enrollment/Change Request.

Application should be made as soon as possible after the onset of the disability but no later than within 31 days after losing life insurance coverage as an active employee.

The employee should enter the personal information requested in spaces 1 – 7. Please ensure that the employee inserts 33683-G in space 8 for the group policy number and his name as the group policyholder name. In spaces 11 – 14, the employer unit’s name and address should be provided, along with a telephone number for the person indicated in space 12. Advise the employee to sign and date the completed form in the space provided on the back.

Once the Notice of Disability has been completed and properly signed, the employer should submit it along with the Enrollment/Change Request and Notice of Disability Waiver of Premium Claim Employer’s Statement to the OOI. The OOI will confirm the applicant’s coverage status and coverage amount with BCBSMS, resolve any discrepancies, and forward the forms to Minnesota Life.

As part of the determination process, Minnesota Life will send an Attending Physician’s Statement to the participant-authorized physician to complete. Once the participant receives the completed Attending Physician’s Statement from his physician, he should submit it to Minnesota Life for review. Due to the confidential nature of the information on the Attending Physician’s Statement, it should never be sent to the employer unit or to the OOI.

Minnesota Life will evaluate the request, make a determination and advise the employee, his employer, and the OOI of their decision. If additional medical information is needed by Minnesota Life during their review, they will contact the applicant and/or his physician directly.

If coverage is approved, it will become effective on the first day of the month following the date in which the applicant’s coverage terminated as an active employee, subject to payment of the appropriate premium. The OOI will contact the applicant, advising him of the premium amounts due, and request that he submit the initial nine-month premium payment.

Once the appropriate premium payment has been received, the DWOP will be initiated. After payment of the initial nine-month premium payment by the disabled employee, premiums are waived for the duration of the coverage period until such time as the participant reaches age 65 or is deemed by Minnesota Life to no longer be disabled, whichever comes first.

If coverage is not approved by Minnesota Life, the OOI will contact the applicant to confirm Minnesota Life’s decision, and close the application file. If the applicant needs to contact Minnesota Life concerning his disability application, he can do so by calling toll-free (877) 348-9217.

Notice of Disability Waiver of Premium Claim Employer’s StatementThis form is part of the disability life insurance application process for employees who become totally and permanently disabled. Once the employee has completed an Enrollment/Change Request and Notice of Disability, he must submit those forms to you. You should complete a Notice of Disability Waiver of Premium Claim Employer’s Statement and submit all three completed forms to Office of Insurance, Attention: Life Insurance Claims Processing.

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The following guidelines should be followed for completing this form:

Provide the employee’s name, gender, address, date of birth, date of employment, Social Security number and job title. Indicate the date of the employee’s last day of work, his salary on that date and whether the amount is an hourly, weekly, monthly or annual rate. Indicate the status of the employee applying for DWOP.

In the Amount of Employee’s Insurance space, insert the actual amount of coverage the employee currently has. The Effective Date of Coverage should be the employee’s original effective date of coverage.

Under EMPLOYER CERTIFICATION, indicate the employer unit name and address. Insert 33683-G in the space for Policy number. Employer unit number will be your group number from your BCBSMS premium billing. The payroll/personnel contact completing this form should print his/her name under Name of authorized representative, provide a contact phone number and email address, then sign and date the form in the spaces provided.

Remember to retain copies of any and all documents submitted to the OOI.

Notice of Accidental Dismemberment and Personal Loss Accidental Dismemberment and Personal Loss coverage is provided to active employees as a component of the life coverage under the Plan. Please refer your employees to the Your Group Plan Certificate for a list of the losses covered under this benefit. Should a covered employee experience one of the covered losses, the employer unit may submit a Notice of Accidental Dismemberment and Personal Loss Claim along with a copy of the employee’s current Enrollment/Change Request to the OOI which will confirm coverage status with BCBSMS, resolve any discrepancies, and forward the appropriate information to Minnesota Life for final claims processing and benefit issuance. As with all documents submitted, you, the employer, should retain copies of these forms for your records.

This form is to be completed in three parts: Part 1 by the employer, Part 2 by the employee, and Part 3 by the employee’s physician. The following guidelines should be followed for completing this form:

In PART 1, the employer should indicate employee’s name, Policy Number 33683-G, date of birth, date employed, current salary and whether the amount is an hourly, weekly, monthly or yearly rate, and status on last day worked. In the Amount of Employee’s Insurance space, insert the actual amount of coverage the employee currently has.

The Effective Date of Coverage should be the employee’s original effective date of insurance coverage.

Under Employer Certification, indicate the employer unit’s name, address and telephone number. The payroll/personnel contact completing this form should sign and date the form in the space provided.

PART 2 must be completed by the employee or an authorized representative of the employee. If a representative will be signing the form on the employee’s behalf, you must obtain a certified copy of the legal authorization papers (e.g., guardianship, power of attorney). Please advise the employee to completely answer every question in this section. The employee must sign and date PART 2 in the space provided.

After the employee has his physician complete and sign PART 3, he should return the form to the employer unit. The payroll/personnel contact should forward the completed and signed Notice of Accidental Dismemberment and Personal Loss Claim to the Office of Insurance, Attention: Life Insurance Claims Processing.

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Notice of Claim for Accelerated BenefitThe Accelerated Benefit Option is available to participants in the State and School Employees’ Life Insurance Plan who are enrolled with at least $10,000 life coverage. This includes active employees, retirees and DWOP participants. If the eligible participant has transferred ownership of his life insurance policy to someone else by assignment or otherwise, and no longer owns the policy, he is not eligible for this benefit.

For benefit information and requirements, please refer to the Your Group Life Plan Certificate. Should an eligible participant meet the requirements and would like to request an accelerated benefit, you should provide the participant with a Notice of Claim for Accelerated Benefits.

This form is to be completed in two parts: Part 1 by the employer and Part 2 by the participant or authorized representative (attach certified copy of official designation). In addition to the instructions on the form, the following guidelines should be followed:

In PART 1, the Effective date of insurance in space 4 should be the participant’s original effective date of coverage. The Date to which premiums were paid in space 7 should be the last day of the month in which his coverage ended. The Employee’s amount of insurance in space 8 will be the actual amount of coverage the employee currently has. The Amount of insurance available for acceleration in space 9 will be 50 percent of the employee’s actual amount of coverage shown in space 8.

Indicate the employer unit name, address, and phone number in spaces 10 – 12. The payroll/personnel contact completing this form should print his/her name in space 13, indicate his/her job title in space 14, and sign and date the form.

PART 2 must be completed and signed by the participant or an authorized representative. If a representative will be signing the form on the participant’s behalf, a certified copy of the legal authorization papers (e.g., guardianship or power of attorney papers) must be attached to this form. The requested policy number in space 3 of this section will be the same number in space 2 of PART 1.

The completed and signed Notice of Claim for Accelerated Benefits to the Office of Insurance, Attention: Life Insurance Claims Processing.

Employers should retain copies of all forms for their records before submitting them to the OOI who will review the claim to verify coverage and resolve any discrepancies between the submitted coverage information and enrollment data maintained by BCBSMS. Once coverage has been verified, and any discrepancies resolved, the claim will be forwarded to Minnesota Life for determination of benefits.

As part of the determination process, Minnesota Life will send an Attending Physician’s Statement to the participant-authorized physician to complete.

Once the participant receives the completed Attending Physician’s Statement from his physician, he should submit it to Minnesota Life for review. Due to the confidential nature of the information on the form, it should never be sent to the employer unit or to the OOI.

Portability and Conversion Group LifeEmployees who are no longer eligible for life insurance as an active employee due to voluntary or involuntary termination of employment (including retirement), have the option to continue their active life insurance coverage without providing health questions.

Minnesota Life has provided a Portability and Conversion website that employees can access to learn more about the options available to them including: determine eligibility to convert or port coverage; calculate the cost of premiums; download and print forms directly; and view or download a Conversion FAQ document.

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Employees should go to lifebenefits.com/continue and enter policy number 33683 and access key MSSE. Once the employee has downloaded the forms, he should verify coverage options with you.

Conversion of Group Term Life InsuranceWhen a covered employee’s life insurance coverage decreases or ends due to leaving employment or becoming ineligible for the coverage (i.e., change from full-time to part-time employment), he may convert the amount of life insurance he had as an active employee to an individual life insurance policy under Minnesota Life. For more information on the conversion policy, refer to Your Group Life Plan Certificate.

To convert, the employee can go online or call Minnesota Life at (866) 365-2374. The completed application and first month’s premium must be made within 31 days after life insurance ceases under the Plan. The employee will send the Conversion Application to Minnesota Life which will confirm coverage status and amount with the OOI and resolve any discrepancies. Minnesota Life will correspond directly with the applicant regarding approval of the conversion application.

Option to Port Term Life Insurance CoverageWhen an active employee’s group term life insurance coverage in the Plan terminates due to employment termination, retirement, layoff or nonmedical leave, or loss of eligibility, he may elect to continue some or all of his term life insurance coverage through Minnesota Life under the portability rider.

To make application, the employee can go online or complete the Option to Port Term Life Insurance Coverage within 31 days of losing life insurance coverage under the Plan. He must have his employer complete the Employer Certification Section of the form who will then submit it to Minnesota Life. They will confirm coverage status and amount with the OOI which will resolve any discrepancies. The payroll/personnel must complete the Employer Section of this form.

Note: Please ensure that applicants who are retiring fully understand the difference between the Plan’s retiree life insurance and the Minnesota Life portability coverage.

Payments & Reconciliation FormsTransmittal FormThe Transmittal Form should be submitted with each employer unit’s monthly premium payment. Payments should be remitted to the Department of Finance and Administration, Office of Insurance at the address on the Transmittal Form. If a payment includes more than one check, complete one Transmittal Form for the total payment. Checks for premium payments should be made payable to the State/School Insurance Fund and are due on the first day of each month. Payments received after the 10th are assessed a 2 percent penalty.

Note: This form is to report the actual amount(s) of payments being remitted. You should not include any amounts on this form that are not being remitted with its mailing.

Below are instructions for completing the Transmittal Form:

Group Number – Indicate the number assigned to your employer unit.

Date – The date that the payment is remitted to the OOI.

Employer Name, Emp. Address – Name and address of your employer unit.

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Contact Person – Name of the employee to contact with questions regarding your premium payment.

Telephone, Email, Fax – Contact information for the above-referenced person.

Insurance Period – Period covered by current premium payment. It is important that the insurance period is correctly reported. Insurance premiums pay for coverage for the period following the payroll deduction period.

Payroll Period – Payroll deduction period for the current premium payment.

Check No., Amount – Itemize checks for the payment being remitted. The total of the itemized checks should equal the total remittance.

Total Health Premiums Remitted – Total amount remitted for health insurance only.

Total Life Premiums Remitted – Total amount remitted for life insurance only. (NOTE: This only applies to the State and School Employees’ Life Insurance Plan. If your employer unit participates in an approved private policy in lieu of the State Plan, please do not remit/report life insurance premiums to the OOI.)

Total Remittance – Total amount remitted for health and life insurance premiums. This amount equals the total of your checks.

IMPORTANT: Please make sure that the Total Health Premiums Remitted and the Total Life Premiums Remitted equal the Total Remittance. The Total Remittance must equal the premium payment sent with this form.

Transmittal Form – SPAHRS PaymentsAgencies on the Statewide Payroll and Human Resource System (SPAHRS) should complete Transmittal Forms – SPAHRS Payments for health and life premium payments. Premium payments that are payroll deducted through SPAHRS are paid to the OOI by Electronic Funds Transfer (EFT) on the Pay Date for the payroll run.

Even though no paper warrants for health and life premiums will be generated from your payroll runs, transmittals are still required in order to provide information needed to accurately apply your agency’s premium payment information, and should be received by the OOI before the Pay Date for the payment.

You should complete a Transmittal Forms – SPAHRS Payments using the information provided on the Deductions by Vendor report generated with each payroll run in which premiums are deducted. Information you will need from the report includes the Pay Date, Payroll Run Number, and totals for health and life premium deductions for the payroll run.

In order to keep deposit records accurate, a separate Transmittal Forms – SPAHRS Payments must be submitted for each Pay Date for your agency. Multiple Payroll Run Numbers may be included on a single transmittal only if they have the same Pay Date.

Note: This form is to report the actual amount(s) being paid. You should not include any amounts on this form that are not included in the payment.

For further information regarding premium payments, see Billing and Payment Procedures. Below are instructions for completing the Transmittal Forms – SPAHRS Payments.

Group Number – Indicate the number assigned to your agency.

Employer Name, Emp. Address – Name and address of your agency.

Contact Person – Name of the employee to contact with questions regarding your agency’s premium payment.

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Telephone, Email, Fax – Contact information for the above-referenced person.

Insurance Period – Period covered by the corresponding premium payment. It is important that the insurance period is correctly reported.

Pay Date – Date indicated on the corresponding Deductions by Vendor report for the payment(s). This will be the date the payment will be made by direct deposit to the bank.

Payroll Run No.(s) – Number indicated on the corresponding Deductions by Vendor report(s) for the payment. Remember, if multiple Payroll Runs are listed on a single transmittal, they must have the same Pay Date.

Warrant/EFT No. – Itemize the EFT payments for the remittance. These numbers are shown on the corresponding Deductions by Vendor report(s) for the payment. The total of the itemized EFT’s should equal the total remittance.

Total Health Premiums Remitted – Total amount remitted for health insurance only.

Total Life Premiums Remitted – Total amount remitted for life insurance only.

Total Remittance – Total amount remitted for health and life insurance premiums. This amount equals the total of your payment.

IMPORTANT: Please make sure that the Total Health Premiums Remitted and the Total Life Premiums Remitted equal the Total Remittance. The Total Remittance must equal the premium payment for the reported Pay Date.

Premium Billing ReconciliationAn integral part of the reconciliation of your employer unit’s health and life insurance billing each month is Electronic Reconciliation. Electronic Reconciliation is used to reconcile your health and life insurance coverage records to the enrollment information being maintained by BCBSMS. It must be submitted every month to BCBSMS via EnrollBlue no later than the 10th of the month that the reconciliation is due. Electronic Reconciliation is for reconciliation purposes only. All enrollment activity (i.e., adds, changes and terminations) will continue to be processed via EnrollBlue. If your premium billing is correct and there are no credits or additional amounts due, you should only add your payment details via the Total paid link, make copies, then submit the reconciliation electronically using the Submit Reconciliation to BCBSMS button. If your reconciliation also requires adjustments, you should use the Participant Adjustments, Past Due Amounts or Other Adjustments link.

Electronic Reconciliation is available via EnrollBlue

(NOTE: Instructions regarding life insurance procedures apply only to the State and School Employees’ Life Insurance Plan. If your entity participates in an approved private policy in lieu of the State Plan, please refer to that specific policy’s provisions regarding reconciliation/change reporting.)

Below are instructions for accessing Electronic Reconciliation in EnrollBlue:

Log in to myAccessBlue at http://www.myaccessblue.com the same way as if you were logging into EnrollBlue.

Click Transactions located in the left navigation pane and then click Electronic Reconciliation to go to the Bill Reconciliation Review screen. Note: Before you reconcile your bill, you should access and review your monthly billing statement by clicking on View Your Bill located in the left navigation pane.

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The Review screen is the central screen for Electronic Reconciliation. From here you can click the:

• Unbilled Enrollment Activity link to review premium amounts related to enrollment activity processed after the billing cutoff that impacts the current bill or a prior bill.

• Participant Adjustments link to enter any necessary adjustments to amounts due or credits for individual participants (either billed, unbilled or both).

• Past Due Amounts link to review or enter an adjustment to past due amounts or credits.• Other Adjustments link to enter other adjustments in cases where the adjustment cannot be made

in participant adjustments or past due amounts.• Total Paid link to enter payment(s) and payment information.After you have completed your reconciliation, you should view and print a copy of the Bill Reconciliation Review page and the View Adjustment Summary page for your records. Once this is complete, you should submit the reconciliation.

Below are recommended steps for completing the Electronic Reconciliation in EnrollBlue.

Review your monthly premium bill.

Review prior monthly balance report, if applicable.

Identify premium differences between your payroll system and the monthly premium bill.

• Enter payment amounts by clicking the Total Paid link. • You will be directed to the Bill Payment Details screen. • Click the Add Payment Details button to enter your payment details. • Enter the check/warrant date, the check/warrant number, the medical premium payment amount,

and the life premium payment amount in the indicated fields. • Click the Save Payment Detail button when finished. You can enter multiple payments by clicking the

Add Payment Details button as many times as necessary for each payment. • Click on the Date link to view or edit payment information that you have already entered.

• Click the button to the right of a payment to delete it. • Click the Review button to return to the Review screen. Note: Payments can be entered at the beginning

of the reconciliation or once the reconciliation is complete.• Review unbilled enrollment (Following the Unbilled Enrollment Activity link).• If necessary, enter adjustments to amounts due for individual participants - billed and unbilled (follow

the Participant Adjustments link).• Review and, if necessary, enter adjustments to past due amounts or credits (follow the Past Due

Amounts link).• If necessary, enter any other adjustments (follow the Other Adjustments link).• Carefully review and print the adjustment summary (follow the View Adjustment Summary button).• Print a copy of the electronic reconciliation (click the Print/Save PDF or Excel button). Verify that you

have the copies.• Submit the reconciliation to BCBSMS by 6 p.m. on the 10th of the month.

Note: Groups are encouraged to be proactive in reconciling their monthly bill and entering necessary transactions through EnrollBlue. You should not enter electronic transactions without properly completed required forms

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