FY2011 Health Benefits Booklet

58 s u m m a r y o f g e n e r a l b e n e f i t s j u l y 2 0 1 0 – j u n e 2 0 1 1
Important Notices and Information
Employee Fraud and Abuse
Fraud, abuse and unethical conduct in connection with the
benefits provided through the State Employee and Retiree
Health and Welfare Benefits Program is a serious issue. Fraud
and abuse can take many forms, including:
• Adding a dependent to your coverage who you know is not
eligible for coverage;
• Submitting false or altered affidavits or documentation as
part of adding or removing a dependent;
• Letting someone else who is not covered under your
enrollment use your insurance card to get health benefits or
services;
• Lying to get coverage or access to health benefits (such as
prescription drugs or treatments) that are not medically
necessary;
• Giving or selling your prescriptions to another person; or
• Submitting reimbursement requests for health benefits or
services that were not provided.
The Department of Budget and Management Employee
Benefits Division must investigate allegations of fraud and
abuse; each plan and benefit option has programs to look for
and eliminate fraud and abuse. If fraud or abuse is determined
to have taken place, there can be serious consequences,
including:
• Lock-down of your prescription benefits to only one doctor
or pharmacy;
• Termination of coverage; or
• Seeking repayment or reimbursement of any claims/
benefits that were inappropriately paid.
There may also be serious criminal or civil consequences.
Notice About Disclosure and Use of Your Social Security
Number
A federal mandatory reporting law (Section 111 of Public Law
110-173) requires group health plans to report, as directed
by the Secretary of the Department of Health and Human
Services, information that the Secretary requires for purposes
of coordination of benefits. Two key elements that will be
required to be reported are social security numbers (SSNs)
of covered individuals (or HICNs) and the plan sponsor’s
employer identification number (EIN). In order for Medicare
to properly coordinate Medicare payments with other
insurance and/or workers’ compensation benefits, Medicare
relies on the collection of both the SSN or HICN and the EIN,
as applicable. As a member (or spouse or family member of a
member) covered by a group health plan arrangement, your
SSN and/or HICN will likely be requested in order to meet
the requirements of this law. To get more information about
the mandatory reporting requirements under this law, visit the
CMS website at www.cms.hhs.gov/MandatoryInsRep.
In addition, because of the tax benefits of employer-sponsored
health benefits coverage, we need your SSN to make sure
that your income tax and other employment-related taxes are
calculated and withheld from your paycheck properly.
Leave/Continuation of
Coverage/COBRA
While on Leave of Absence
If you take a Leave of Absence Without Pay (LAW) you may
continue the same health benefits coverage by electing to enroll
and paying the full cost of your premiums.
If you take a leave of absence pursuant to the Family Medical
Leave Act (FMLA), special rules govern the continuation
of your health benefits. You have several options about
your health benefits coverage while you are on FMLA leave,
including whether to keep your coverage in place or drop it
and how to pay for health benefits coverage while you are
on FMLA leave. You should review the options and make an
informed decision. Contact your Agency Benefits Coordinator
for details, and visit the Employee Benefits Division website.
Short-Term LAW
If you are on short-term LAW (two pay periods or less for
Employees who are paid bi-weekly; up to 28 days), and it is
neither FMLA leave nor due to a job-related accident or injury
(LAW-OJI), you must pay the full cost (both Employee share
and State subsidy) of all missed premiums in order to continue
your benefits for the rest of the plan year. You will receive a
“No Pay” bill from the Employee Benefits Division for your
missed premiums. Deductions may resume if you return to
work before the due date on the “No Pay” bill. However,
payment for the missed premiums is still due. If you do not
pay by the due date on the “No Pay” bill, your enrollment and
benefits coverage will be cancelled for the rest of the plan year.
If your short term LAW is due to a job-related accident or
injury (LAW-OJI), or an approved FMLA leave, you are
entitled to the maximum State subsidy and are responsible for
the Employee’s share of the premium only. When you receive
your bill, please contact your Agency Benefits Coordinator,
who will complete a retroactive adjustment form and collect
your portion of the premiums. You must make up missed
premiums within the requested timeframe or your enrollment
and benefits coverage will be cancelled. There will be a
break in your coverage until you return to work and request
re-enrollment in health benefits. Payment deadlines are strictly
enforced.
Long-Term LAW
If you are on a leave of absence without pay for more than
two bi-weekly pay periods (more than 28 days), your leave is
considered a long-term LAW. If you are on an approved longterm
LAW, you may elect to continue or discontinue health
insurance for the duration of the LAW. You may elect to
continue your benefits during long-term LAW for up to two
years.
You must notify the Employee Benefits Division of your
coverage election within 60 days of beginning your long-term
LAW. You cannot retroactively terminate benefits and you
may be required to pay the full premium for any period of
coverage during your long-term LAW that has elapsed prior to
your notification to terminate benefits during your long-term
LAW.