Health Insurance

*NOTE: If you are doing extensive research you may want to download the Insurance Handbook. After downloading the Insurance Handbook, you may use it to examine the page numbers referenced by this document.

Health Insurance Enrollment

Employees must complete an enrollment form to enroll in coverage.  If the employee is enrolling in United, he/she must also submit a PCP card.

Eligibility
Employees who are regularly scheduled to work at least thirty hours per week in a non-seasonal, non-temporary position.  Page 5 of the Insurance Handbook*.

Beginning Date of Coverage for Employee
Employees have 31 days from the date of employment to submit an enrollment form. Coverage begins on the first day of the month after the enrollment/change application has been filed with Employee Benefits, provided the employee is in a positive pay status on that day.   If an employee fails to enroll by the end of the eligibility period, they will only be eligible by satisfying one of the special enrollment provisions on page 12 of the Insurance Handbook or by qualifying through the late applicant medical underwriting process.  Page 6 of the Insurance Handbook*.

Beginning date of Coverage for Dependents
Dependent coverage is effective on the same date as the employee unless newly acquired.  Newly acquired dependents will become effective on the date they were acquired if the employee is in the appropriate type of coverage. The employee may also choose to have coverage effective the first day of the following month.  Page 6 of the Insurance Handbook*.

Eligible Dependents

• Spouse (legally married)
• Natural or adopted children (regardless of where they live)
• Stepchildren, if employee or employee’s spouse has legal or joint custody or shared parenting
• Children living in the home for whom employee is the legal guardian
• Any dependent child living in employee’s home for 12 months a year who is dependent upon employee for support and maintenance as evidenced by being claimed as a dependent on employee’s federal income taxes
  
  

  Unmarried dependent children are eligible to continue health insurance coverage through the last day of the month of their 24th birthday.  A dependent child between the ages of 19 and 24 must be must be a full-time student or claimed on employee’s current year’s income tax return to be covered by the State of Tennessee Insurance System.  Proof of a dependent’s eligibility will be required.  

  When the dependent marries, graduates or can no longer be claimed on the employee’s current year federal income tax return the employee must notify the Employee Benefits Office of the dependent’s change in status.  Health insurance will be cancelled on the last day of the month the dependent no longer meets the criteria for dependent coverage.   All claims paid for the ineligible dependent will be recovered by the State of Tennessee Division of Insurance Administration.  The employee is responsible for reimbursing the Plan for incorrect claim payments.

  A child no longer meeting the criteria for dependent coverage maybe offered continuation of medical coverage under the provision of COBRA.  The Division of Insurance Administration will not offer COBRA if notification of loss of eligibility is received after 60 days from the change in status.  The Division of Insurance Administration will send a COBRA notification packet to the employee’s home at the address on file after being notified there has been a termination of coverage.

  Please note employees may receive letters from the State of Tennessee, the insurance Vendor (Blue Cross, United, & Cigna), and Knox County Schools asking whether or not their dependent is still a student or claimed on the employee’s tax return.  It is important that you respond to all three requests.  If you do not respond the dependent’s coverage can be cancelled.

• Adopted children, in connection with any placement for adoption of a child with any person, means the assumption of a legal obligation of total or partial support of a child in anticipation of adoption — the obligation may be determined by court records, federal income tax records or other appropriate documentation as determined by the Insurance Committee or its representative Page 9 of the Insurance Handbook*.

Special Enrollment Provisions

The federal law, Health Insurance Portability Accountability Act (HIPAA) allows employees and dependents to enroll under certain conditions. Exceptions will also be made for eligible employees or dependents if they lose their health coverage offered through the employer of the employee’s spouse/ex-spouse. The required documentation must be submitted to Employee Benefits and coverage applied for within 60 days of loss of health coverage.

Special Enrollment Provisions include:

• Employee NOT currently enrolled acquires a new eligible dependent (spouse, newborn or adoptee)
  • Copy of the birth certificate, marriage certificate or adoption documents
• Death
  • Copy of death certificate and written documentation from the employer on company letterhead providing names of covered participants and date coverage ended
• Divorce
  • Copy of the signed divorce decree and written documentation from the employer on company letterhead providing names of covered participants, date coverage ended and the reason why coverage ended
• Legal Separation
  • Copy of the agreed order of legal separation and written documentation from the employer on company letterhead providing the names of covered participants, date coverage ended and the reason why coverage ended
• Loss of Eligibility (this does not include a loss due to failure of the employee or dependent to pay premiums on a timely basis or termination of coverage for cause)
  • Written documentation from the insurance company on company letterhead providing names of covered participants, date coverage ended and the reason for the loss of eligibility
• Loss of TennCare (this does not include a loss due to failure of the employee or dependent to pay premiums on a timely basis)
  • Certificate of coverage from TennCare stating that coverage has been or will be terminated
• Termination of Employment (voluntary and non-voluntary)
  • Written documentation from the employer on company letterhead providing names of covered participants, date coverage ended and the reason why coverage ended
• The reduction in the number of hours that caused loss of eligibility
  • Written documentation from the employer on company letterhead providing names of covered participants, date coverage ended and the reason why coverage ended
• Employer’s discontinuation of contributions to the spouse’s insurance coverage (total contribution not partial)
  • Written documentation from the employer on company letterhead providing names of covered participants and verifying the employer’s discontinuation of total contribution toward health insurance coverage

The effective date of coverage for a participant approved through a special enrollment provision is either

(1) the first of the month in which other coverage was lost, if other coverage was lost in the middle of the month;

(2) the first of the month following loss of other coverage if other coverage was lost at the end of the month;

(3) the first of the month or subsequent month following approval by the Division of Insurance Administration;

(4) the day on which the event occurred, if enrollment is waived due to marriage, birth, adoption or placement for adoption;

(5) the first of the month following the 60-day period.  Page 12 of the Insurance Handbook

Medical Underwriting

If an employee or his/her dependents did not enroll during the eligibility period and do not qualify under a special enrollment provision of HIPAA, the employee may apply for health coverage by completing a health care evaluation application for the employee and every eligible dependent. The cost of the evaluation fee is currently $60.00 and is the employee’s responsibility. The application will be evaluated through the medical underwriting process for approval/disapproval and the employee will be notified by letter of the underwriter’s decision. The employee (head of contract) must be approved or already participating in the plan before any dependents can be added for coverage. You may apply for coverage as many times as you wish should your medical condition change by submitting a new application and paying the required non-refundable application fee. Denied applications cannot be appealed through the plan’s appeal process. The effective date of coverage shall be the first of the month or subsequent month following the date of the approval letter, or the first of the month following the 60-day period after the approval letter. Applications must be requested from the Employee Benefits Office. Applications that do not have the appropriate verification from Employee Benefits will not be processed by the underwriter. Page 13 of the Insurance Handbook.

Types of Coverage Available

Medical Options Comparison Chart
Medical Comparison chart

• Preferred Provider Organization (Blue Cross Blue Shield PPO) - A health insurance option where participants choose a network provider or a non-network provider.  A network provider accepts a pre-negotiated fee. The participant is responsible for a percentage of the maximum allowable charge and an annual deductible. When a patient utilizes a non-network provider, care is paid at a percentage of the maximum allowable charge and charges above the maximum allowable are the patient’s responsibility.  Annual out-of-pocket maximums apply.

• Point of Service (CIGNA) - A health insurance option where participants use in-network providers who have agreed to accept a fixed co-payment. The delivery of health care services must be coordinated by the participant’s primary care physician. Use of out-of-network providers is covered at a percentage of the maximum allowable charge. Charges above the maximum allowable amount are the patient’s responsibility. There are no deductibles or out-of-pocket maximums if in network providers are used.

• Health Maintenance Organization (UNITED HMO ) Health Options - A health insurance option where care is coordinated through a primary care physician. No benefits, other than approved emergency or urgent care, are paid apart from the HMO’s network. Co-payments are paid each time services are received. There are no deductibles.

Annual Transfer Period

During the fall of each year (usually October 15-November 15) employees have the opportunity to transfer from one plan to another health insurance plan if the employee is currently enrolled. If an employee decides to transfer to another healthcare option, coverage will be effective on the following January 1, and the employee must remain enrolled in that healthcare option until the next year unless the employee moves outside the HMO or POS service area.  This is not an open enrollment period. Employees must complete and submit an Enrollment Change form to transfer between plans.

Health Insurance Termination

An employee who wants to terminate their health coverage or the health coverage of a dependent must complete an enrollment/change application and return it to Employee Benefits.  The insurance will terminate on the last day of the month in which the form was received.  A dependent’s insurance will be canceled on the last day of the month when he/she becomes ineligible for coverage. All forms must be completed by the last day of the month to terminate coverage for the following month. For example, if an employee does not want coverage for the month of December, the employee must cancel the coverage in writing by the end of November. An employee cannot cancel coverage for the month of December once the month begins.

Please note that employees must have a change in status reason to cancel your insurance during the year.  The paperwork and the verification must be submitted within 30 days of the event.  Otherwise employees will only be able to cancel their insurance during open enrollment/annual transfer time.