Eligibility Review

Policy

100

What does the policy define?

what is the class of employee and the required amount of hours worked per week.

200

How do you determine the class?

What is reviewing employer statement form or FCS.

300

What is the definition of a member?

• Resides in the United States 
• Is a U.S. Citizen or legally working in the United States 
  • Their permanent address is in the U.S.
  • They have been in the U.S. for 6+ months within a 12 month period
• Work is at the Policyholder's usual place of business…to perform his or her regular duties
• Seasonal, temporary, contracted, or part time basis employee

400

Where do you find eligibility requirements in the policy?

Part III - Eligibility - Member insurance 

500

What is used to calculate the eligibility date?

What is the waiting period and the timing. 

Enrollment

100

What do we use to locate enrollment?

What is FCS, content navigator, and compass. 

200

What is the difference between contributory and non-contributory policies? 

Contributory = employee pays some or all of premium

Non-contributory = employer pays STD premium

300

Where do you find if a policy is contributory or non-contributory? 

What is on the employer information form and FCS under calculation parameters. 

400

What is the difference between Self-bill and List-bill? 

Self- bill = employer keeps the records (enrollment, EOI)

List-bill = Principal pulls the records they can be found in our databases

500

What do you need if a contributory employee enrolls late?

What is need EOI forms. 

Effective Date

100

What is the effective date?

What is the same as eligibility date. 

200

What do we look to determine the effective date?

What is using the policy information, eligibility date, contribution type, and enrollment information. 

300

Where do you find the definition of effective dates in the policy?

What is Part III Section B - Effective dates.

400

When is the effective date for non-contributory policies?

What is the effective date will always be the same as the date they are eligible. 

500

How do you determine the effective date for contributory policies?

• If they enrolled on or before the date they were eligible, their effective date is the same as     the date they are eligible
• If they enrolled after they were eligible, but within 31 days from their eligibility date,     their effective date will either be the day they enrolled or the first of the following month after they enrolled. This will be outlined in their     policy.
• If they enrolled more than 31 days after their eligibility date, you'll need to determine when     (and if) we approved their coverage

Termination

100

Why is it important to determine if an employee has been terminated? 

What is to determine if they fall under continuation rules.  

200

What do we look at to determine if an employee has been terminated?

What is the policy information and employer claim form. 

300

Where do you find individual requirements and rights?

What is Part III of the policy. 

400

What does the termination section outline?

What is 

• when their individual coverage will terminate 
• if and how long their coverage can be continued if they cease active work

500

What does continuation requirements include? 

What is the member has to have the right to continue premiums, and must also continue the payment of premiums.

Actively at work

100

Where do you find the definition for Actively at work? 

It is found in Part I - Definitions. 

200

When do we complete an AAW review?

• If there is less than 3 months between the calculated effective date and the incurred     date

AND/OR

• there is concern that there could be possible interference with their active work at the time their coverage went into effect

 

300

When do we need AAW documentation?

• A member has been insured for a short period of time and / or
• Documentation supports a possible interference of or with Active work

400

What are key information you can request from an employer to determine if someone is AAW? 

Timecards as long as they list out Sick pay, vacation, pto- emails, work logs, receipts, account records & sales slips

500

When is AAW documentation not necessary?

The disability is result of an injury or accident there is no indication or reason to believe the claimant was not Actively working.