Employer Admin Guide

You know us by .
Employer Administrative Guide
Highlights of your health plans provisions, rules
and procedures.

Important Telephone Numbers and Addresses
Telephone Numbers
Member Services Department
For information about eligibility, ID Cards, benefits, claims, coverage, referrals and provider participation:
• Members call:
(860) 674-5757
1-800-251-7722
Group Premium Billing
For information regarding premium billing: 1-800-333-1733. Fax: 1-860-678-5255.
Enrollment Representative
For information about member/dependent eligibility and membership verification: 1-800-333-1733
Emergency Hospital Admissions
To notify ConnectiCare about emergency treatment within 24 hours of an emergency admission, if possible:
(860) 674-5870 or 1-888-261-2273
Pharmacy Services Department
For information about prescription drug benefits or our drug list: (860) 674-5757 or 1-800-251-7722
Behavioral Health Program
To arrange treatment for mental health or alcohol and substance abuse: 1-888-946-4658
(Note: this number may vary for employer groups who choose to carve out coverage for behavioral
health services.)
Corporate Wellness
For information about our employer-based wellness programs:
(860) 674-7015 or 1-800-666-1731.
Small-Group Sales
For information about small-group and individual products available and for information on renewals call
1-800-723-2986.
Large-Group Sales
1-800-923-2822
2

Addresses
General Correspondence:
ConnectiCare, Inc.
175 Scott Swamp Road
P.O. Box 4050
Farmington, CT 06034-4050
Premium Payments:
ConnectiCare, Inc. & Affiliates
P.O. Box 416191
Boston, MA 02241-6191
Enrollment Forms/
Correspondence:
ConnectiCare, Inc. & Affiliates
175 Scott Swamp Road
P.O. Box 4058
Farmington, CT 06034-4058
Medical Claims
Connecticut:
ConnectiCare, Inc.
175 Scott Swamp Road
P.O. Box 546
Farmington, CT 06034-0546
Massachusetts:
ConnectiCare of Massachusetts, Inc.
175 Scott Swamp Road
P.O. Box 522
Farmington, CT 06034-0522
Utilization Review Appeals
Connecticut:
ConnectiCare, Inc. & Affiliates
Member Appeals
175 Scott Swamp Road
P.O. Box 4061
Farmington, CT 06034-4061
Massachusetts:
ConnectiCare of Massachusetts, Inc.
Member Appeals
175 Scott Swamp Road
P.O. Box 4061
Farmington, CT 06034-4061
ConnectiCare of Massachusetts, Inc.
175 Scott Swamp Road
P.O. Box 522
Farmington, CT 06034-0522
ConnectiCare, Inc. Sales & Marketing
ConnectiCare, Inc.
175 Scott Swamp Road
P.O. Box 4050
Farmington, CT 06034-4050
Questions & Complaints
ConnectiCare, Inc.
Member & Provider Services
175 Scott Swamp Road
P.O. Box 4050
Farmington, CT 06034-4050
3

Table of Contents
In this Guide/Registration
6 In this Guide
7 Employer Registration
8 Member Registration
ConnectiCare Product Listing
9 FlexPOS (Point-Of-Service Plan)
Product Portfolio
11 ConnectiCare Dental Plans
11 ConnectiCare Dental Plans – Basic Plans
The ConnectiCare ID Card
12 Members Shouldn’t Leave Home Without It
12 Sample ID Card
The Primary Care Physician
13 Selecting a PCP
13 PCP Assignment
13 Changing a PCP
Rules & Guidelines for Receiving Benefits
15 Emergency Care
15 Urgent Care
Eligibility and Enrollment
16 Employees
16 Adding a New Hire
17 Who is Eligible for Membership under plans
issued in Connecticut?
18 Who is Eligible for Membership under plans
issued in Massachusetts?
19 Renewal/Open Enrollment
19 Coverage for the College Student
20 Sample Enrollment Form
21 Enrollment Materials
21 Subscriber/Member Materials
21 Changes in Coverage
21 Changes that Affect Eligibility
22 Adding Dependents to the Plan
23 Electronic Enrollment
Terminating Coverage
24 Group Coverage
24 Member-Initiated Termination of Coverage
25 Member and Provider Services
25 For Connecticut Employer Groups only
25 COBRA Continuation Coverage
26 The Right to Continue Coverage
26 Exceptions
Billing Procedures
27 Group Billing
28 The Premium Invoice
30 COBRA Billing
Claims and Reimbursements
31 Receipt and Processing
31 Care received from Participating Providers
31 Care received from Non-participating Providers
32 Foreign Claims
32 Coordination of Benefits
32 The Claim Summary
33 How to Read Your Claim Summary
Questions, Grievances and Appeals
35 Questions and Complaints
35 The Appeals Process
Special Benefit Programs
36 Prescription Drug Program
ConnectiCare Touchpoints
37 Driving Results
39 Manage Your Condition
39 Health Management Programs
40 Care Management Programs
43 Treatment Cost Calculator
43 College Tuition Rewards
44 LifeMart
45 Worksite Wellness
4

Caring About What’s Important
ConnectiCare has built a reputation as a leader in health care benefit services by providing
exceptional quality and service to employers and their employees. We’ve received high marks
when it comes to assuring access to routine office visits, immunizations, preventive cancer and
cholesterol screenings, prenatal care, mental health benefits and wellness programs to help
keep employees healthy.
So why is ConnectiCare the best choice for you and your employees?
Because we have industry-leading service capabilities, we specialize in high-quality care
management, and we’re responsive and accessible.
5

In This Guide/Registration
Welcome to the ConnectiCare Employer Administrative Guide! Be sure to keep this Guide handy and
refer to it when you have questions about your ConnectiCare health plans, plan provisions, requirements
and procedures. While the Guide is not intended to be an all-inclusive reference, it does provide basic
information on important administrative topics. Updates to the Employer Administrative Guide are made
available online at www.connecticare.com/Employer/.
If you need additional information:
• Check the contact list on the opening pages. You’ll find addresses and phone numbers that can connect
you with the information you need.
• Look it up in the Plan documents. The Membership Agreement, Certificate of Coverage or other Plan
documents have more details on many of the topics covered in this Guide.
• Visit our website, www.connecticare.com to process certain member transactions, view your group’s
Subscriber Roster, premium information and general information about ConnectiCare.
6

Employer Registration
Once you complete the online registration request form, as a registered employer you’ll be able to use the
secure features of the ConnectiCare website:
My Account — An up-to-date utility that provides you with detailed information about your employees.
My Account provides you with the ability to:
• view member Welcome Kits online;
• add subscribers and dependents quickly and easily online;
• check on eligibility;
• view benefit summaries;
• review rate tables and billing status;
• delete a subscriber and/or dependent(s);
• enter a new Primary Care Physician (PCP) for a subscriber or dependent;
• change a subscriber’s name and address;
• order new ID cards;
• print temporary ID cards;
• verify rates and account balances;
• view invoices and payment history;
• download member rosters to an Excel spreadsheet;
• download a variety of forms;
• search our provider directory;
• look up a specific drug on our drug list; and
• access a “how to” guide on electronic data interchange (EDI).
If your company has more than 50 eligible employees, access will be reviewed with the Account Management
team in order to ensure that only appropriate access is provided for your account information.
If your company has less than 50 eligible employees ConnectiCare only allows the primary contact of the group
to register to use the ConnectiCare Employer website.
To register using our easy online process:
• Log onto www.connecticare.com/register and click on the Employer button.
7

In This Guide/Registration
Member Registration
Once your employees become active members with ConnectiCare, they may register to access the
Managing Your Account section of our website. As a registered member he/she will be able to:
• make selections for e-notification on their Claim Summary;
• print a temporary ID card;
• view benefit summary;
• view his/her claim history;
• change his/her address;
• change his/her PCP;
• change her OB/GYN;
• order an ID card;
• download member forms;
• track and view a personal health record;
• view and/or download Health Care Financial Summaries — great for balancing HSA/HRA accounts;
• view Plan Deductible or Coinsurance information;
• complete a Health Risk Assessment; and
• access Pharmacy Center.
To register using our easy online process: Log onto www.connecticare.com/register and click on the
Member button: Fill in the requested fields with your information. (Make sure to have your 11-digit
member ID number and your 6- or 10-digit group number as displayed on your ID card handy.)
8

ConnectiCare Product Listing
FlexPOS (Point-Of-Service) Plan
FlexPOS plans allow members the choice of using any health care provider. A higher
level of benefits is paid for covered services when using ConnectiCare’s participating
providers in our service area, and PHCS Healthy Directions participating providers
when seeking care outside of our service area.
The in-network level of benefits will be paid when members use a ConnectiCare
participating provider and services are provided in the State of Connecticut or
Hampden, Hampshire and Franklin counties in Massachusetts. The in-network level of
benefits will also be paid when members use a PHCS Healthy Directions participating
provider for services provided outside of the State of Connecticut or the counties of
Hampden, Hampshire and Franklin in Massachusetts.
Descriptions of types of FlexPOS plans are listed below.
Types of ConnectiCare FlexPOS Plans
Copayment Plans
A copayment is a flat fee members pay for certain benefits. The copayment amount may vary by service
and whether that service is provided by a health care professional that belongs to our network of
providers. There is no deductible on in-network services.
Upfront Deductible Plans
An Upfront Deductible plan includes an amount of medical expenses that members must pay out of
pocket before plan benefits are paid. A deductible helps reduce the monthly health plan premium, and
deductible amounts vary by plan. Copayments and/or coinsurance may also apply.
Hospital Deductible Plans
A deductible applies only to inpatient and outpatient (ambulatory) services. After the hospital deductible
is met, benefits will be paid subject to the Member’s payment of his or her cost-share amount for
inpatient and outpatient (ambulatory) services. For most other covered health services, members have a
copayment cost-share.
High-Deductible Health Plans (HDHP) with HSA Features
An HSA works with a qualified HDHP to help employees save for medical expenses incurred before
their deductible is reached. Employees can fund an HSA with pre-tax or tax-deductible contributions.
The money saved in an HSA accumulates without tax. HSA withdrawals are also tax-free as long as the
money is used for qualified medical expenses. State taxes may vary. Unused balances roll over year
after year.
9

ConnectiCare Product Listing
Deductible and Copayment Plans
Depending on the service, some items, like office visits, are not subject to the deductible, however copayments
still apply.
Coinsurance Plans
Following satisfaction of a deductible, members pay a percentage of services until they reach their out of
pocket maximum, at which time the plan pays 100% for covered services. Visits to PCP are typically not
subject to the deductible with these plans.
HMO Plans
These plans require members to seek care from a participating practitioner and facility. Authorization is required
before seeking care when services are being provided outside of the network, which is only available under limited
circumstances. Members are encouraged to choose a Primary Care Physician (PCP).
Point-Of-Service (POS) Plans
These plans allow members the choice of utilizing any health care provider. Members who choose a
ConnectiCare participating practitioner or facility will receive a higher level of benefits. Members are
encouraged to choose a PCP.
ConnectiCare ® VIP Medicare Advantage Plans
ConnectiCare offers Medicare Advantage plans for Individuals and Employer Groups. These plans provide all
of the Medicare Part A and Part B benefits and generally offer extra benefits such as preventive care and
wellness programs. Our portfolio includes HMO and Point-of-Service (POS) plans which provide a range of
product and pricing options. Most of these plans include Medicare Prescription Drug coverage (known as Part
D). Our Medicare Advantage Plans can also be enhanced with our optional supplemental dental plan.
ConnectiCare ® SOLO Plans
ConnectiCare SOLO offers a wide selection of plans for individuals and their families. Designed to meet different budgets
and levels of coverage, our portfolio includes Point-of-Service (POS) plans and Consumer-Driven Health Plans.
Individual Plans sold through Access Health CT
(The State of CT Exchange)
ConnectiCare Benefits, Inc. offers standard bronze, silver and gold plans as well as two additional bronze level
plans, and a catastrophic plan. Plan designs offer a variety of cost share and premium options.
10

Product Portfolio
ConnectiCare Dental Plans
ConnectiCare offers familiar PPO-style dental plans with open access to broad participating provider
networks. Whether seeking dental benefits for employees of large- or small-groups, ConnectiCare Dental
Plans provide comprehensive plan designs, including out-of-network benefits and competitive rates.
We also offer two cost effective network options.
For large groups of more than 50 eligible employees, ConnectiCare can customize dental plan designs.
ConnectiCare Dental Plans also offers the option of self-funded dental plans for large-group sponsors.
ConnectiCare Dental Plans – Basic Plans
ConnectiCare has a convenient, effective way for small employers to introduce a dental plan into their
benefits package. ConnectiCare Dental Plans — Basic Plans. Our Basic Plans provide cost-effective
plan designs specifically targeted to meet the demands of small employers.
The Basic plans are available for small groups with 3-9 and 10-50 employees and provide a $0
deductible with a $1,000 annual maximum and coverage for preventive and basic services. There are
plan designs available for both networks — Plus and Premium.
ConnectiCare Dental Plus Network — the plan that adds improved provider access
ConnectiCare Dental Premium Network — the plan for those who want the broadest access and coverage
Either of the network options can be matched with any plan to provide a level of benefits and coverage
to fit employers’ needs.
11

The ConnectiCare ID Card
Members Shouldn’t Leave Home Without It!
Members should carry their ConnectiCare ID card with them at all times. They’ll need to show it whenever they
receive health care services — at the doctor’s office, in an emergency room, at the pharmacy or at any other
health care facility. Members also will need to provide their ConnectiCare ID number — shown on the card —
whenever they call our Member Services Department.
The member must destroy his/her ID card if coverage is terminated. If any claims are incurred once a member
is no longer eligible for coverage, the member will be responsible for paying the charges in full.
Sample ID Card
A
B
C
D
E
A
B
C
D
Member name
Member ID number
Group number
Pharmacy group number
E
Copayment amounts
F
Important phone numbers
HMO Open Access Plan
G
Mailing address
F
G
Reverse side of HMO Open Access Plan Card
REQUESTING
ADDITIONAL ID CARDS
Members can go online to request additional
cards or to print a temporary copy of their ID
card for themselves or their dependents. The
member will need to register at our website if
he/she hasn't already done so. These services
are available to members upon the effective date
of their coverage with ConnectiCare.
12

The Primary Care Physician
The Primary Care Physician serves as a member’s “health care manager,”
providing basic care.
Selecting a PCP
ConnectiCare requires that all members select a participating PCP at enrollment time. The PCP maintains the
member’s medical records and works with other health care providers to coordinate services, order X-rays,
lab tests and other services.
While members who enroll in any ConnectiCare plan are required to select a participating PCP, members
enrolled in the HMO Open Access and Point-of-Service Open Access plans aren’t required to obtain a PCP
referral to visit participating specialists or other providers. In the Open Access plans, a referral from the PCP is
recommended, but not required. Members may choose and visit a participating specialist or other provider on
their own.
PCP Assignment
Members who fail to select a PCP will have one assigned to them, usually based on the PCP they visited most
in the last 6 to 24 months.
CHANGING A PCP
In addition to calling Member Services, a member with Internet
access may also choose a new PCP on Find a Doctor, our online
Provider Directory, and verify the PCP’s network participation.
The online directory includes a feature that allows members to find
the most conveniently located PCPs. The member will need to
register at our website if he/she hasn't already done so. These online services are available
to members upon the effective date of their coverage with ConnectiCare.
13

Rules & Guidelines for Receiving Benefits
Mental Health/Substance Abuse
In the HMO Open Access and Point-of-Service Open Access plans, a referral from the PCP is recommended
but not required. However, members covered under all plan types must call the Behavioral Health Program at
1-888-946-4658 to request a referral before receiving mental health/substance abuse care.
Physician’s Orders
Certain services or supplies require a written physician’s order from a participating provider before they are
received. These services and supplies are listed in the Membership Agreement, Certificate of Coverage or other
Plan document, for your plan.
Pre-authorization & Pre-certification
Certain services require pre-authorization or pre-certification before they are received.
• Pre-authorization is the advance authorization required for certain types of medical services or supplies.
• Pre-certification is the advance review and approval of certain health care facility admissions.
Refer to the Membership Agreement, Certificate of Coverage, or other applicable Plan document for more
details about referral requirements, physician’s orders, and pre-authorization and pre-certification guidelines.
MEMBER AND PROVIDER SERVICES
ConnectiCare’s Member and Provider Services Department is
dedicated to helping members and administrators with information
and answers about eligibility, benefits, claims, ID cards and provider
participation. They should be the first point of contact when
information is needed.
For help and information, call (860) 674-5757 or 1-800-251-7722.
For members covered under self-funded plans, call (860) 674-2075
or 1-800-846-8578.
14

Rules & Guidelines for Receiving Benefits
Emergency Care
ConnectiCare covers emergency services at 100% after the emergency room copay or applicable plan
deductible, whether treatment is provided at a participating or nonparticipating hospital.
An emergency is generally defined as “the sudden and unexpected onset of an illness or injury with
severe symptoms whereby a prudent person, acting reasonably, would believe that emergency medical
treatment is needed.” In the case of mental health care, an emergency also exists when a member risks
suffering serious physical impairment or death, or becoming a threat to himself/herself or others, or
significantly decreasing his/her functional capability if treatment is withheld for more than 24 hours.
In the event of an emergency, we advise members to seek care as soon as possible. If possible, we urge
members to seek care from:
• a participating hospital emergency room. As soon as reasonably possible, the member should contact
his/her PCP or the Behavioral Health Program (as appropriate);
• the closest emergency room; or
• by calling 911, where available.
If the member is admitted to a non-participating hospital from the emergency room, he/she must notify
ConnectiCare or the Behavioral Health Program (as appropriate). If the member is unable to make this
call and there is no one who can make the call for him/her, notification must be given as soon as possible,
but no later than one business day after discharge.
Urgent Care
Sometimes an illness or injury isn’t quite an emergency, but does require urgent care. Urgent care is
generally defined as “services for the treatment of a sudden and unexpected onset of illness or injury
requiring care within 24 hours that can be treated in a physician’s office or in an Urgent Care Center.
Urgent care is covered; however, we recommend that members call their PCP before using an Urgent
Care Center.
Note: These are general definitions of “Emergency Care” and “Urgent Care”. For specific definitions,
please refer to the specific Membership Agreement, Certificate of Coverage, or other Plan document.
15

Eligibility and Enrollment
This section summarizes the rules and guidelines that apply to the eligibility
and enrollment of ConnectiCare Subscribers and dependents. More detailed
information is contained in the Membership Agreement or other Plan documents.
Employees
Employees are eligible for coverage if they work full-time, live or work in the service area and meet their
employer’s requirements for eligibility.
Adding a New Hire
If your company is a Small Group with 50 or less eligible employees/lives, your Small-Group Sales Representative
has set up the new hire eligibility rules in our system to reflect your company’s policy. The new hire eligibility rules
determine when a new hire’s coverage can become effective. If you want to confirm these rules or discuss any
other eligibility concerns, you may call your Group Account Service Representative or Group Sales Representative
(Small Groups only) or Group Account Manager (Large Groups), during regular business hours — 8:00 a.m. to
5:00 p.m., Monday through Friday.
If your company is a Large Group with 51 or more eligible employees/lives, we will enroll new hires on the
Effective Date stated on the Enrollment/Change Form, provided that:
• The Effective Date is the day your new employees become eligible for coverage.
• The Enrollment Application is completed and signed within 31 days of the date your new employee(s) became
eligible for coverage. To help expedite this process you can go online at www.connecticare.com and order
new enrollment packets (see page 21). Also, your Group Account Manager, (Large Group), Group Account
Service Representative or Group Sales Representative (Small Group) can provide you with a supply of
updated new hire packets to distribute to new employees.
Just call or write to us at:
ConnectiCare, Inc.
Sales & Marketing Department
175 Scott Swamp Road
P.O. Box 4050
Farmington, CT 06034-4050
16

Eligibility and Enrollment
Wondering who is eligible for membership? Besides you, your plan can cover eligible members
of your immediate family.
Who’s eligible for membership under plans issued in
Connecticut?
Subject to the Employer’s rules, here is a brief summary of who is eligible to enroll in the plan:
Connecticut employers may decide to offer benefits to part-time employees working 20 or more hours a week.
When an employer chooses to extend benefits to part time employees, all employees must be treated equally
with respect to:
• Participation • Eligibility • Contribution
If an employer does not extend benefits to part-time employees, then only those employees working 30-hours
or more are eligible. ConnectiCare must be made aware of an employer’s decision to extend coverage to parttime
employees. This decision can be made at the initial effective date or upon renewal.
Employees
• If enrolling in a HMO Plan, you must live or work in the Service Area.
• If enrolling in a POS, FlexPOS or PPO Plan, you do not have to live or work in the Service Area.
Spouses
• The spouse of an employee is also eligible for coverage if the employee and spouse are in a legally valid
existing marriage and the spouse resides with the employee, or in the service area.
• A partner under a legally valid civil union recognized by the State of Connecticut who resides with the employee.
Children
Children under age 26 who meet one of the conditions/criteria below. Some plans may end dependent child
eligibility if a child age 26 has his/her own employer-sponsored coverage.
• Natural children
• Adopted children who are legally adopted by the employee and meet the requirements for natural children
once the adoption is final. Before the adoption is final, the children are eligible for coverage when you
become legally responsible for at least partial support.
• Stepchildren who are natural or adopted children of your spouse, or for whom your spouse is appointed legal guardian.
• Children for whom the employee or spouse are appointed legal guardians.
Coverage for dependent children will end on the policy anniversary date that is on or after the date
the child turns 26.
For example, if a dependent turns age 26 in July and the parent’s policy renews on January 1st, the dependent
child is covered until the policy renewal date and the coverage will be terminated on December 31st.
Coverage for handicapped children may be extended beyond the age when it would normally end if the children:
• Reside in the Service Area or with the employee;
• Are unable to support themselves by working because of a mental or physical handicap as certified by
the children’s physician;
• Are chiefly dependent on the employee or spouse for support and maintenance due to the mental or
physical handicap; and
• Have become and continuously remained handicapped while they would have been eligible for dependent
children coverage if they were not disabled.
17

Eligibility and Enrollment
Who’s eligible for membership under plans issued in
Massachusetts?
Subject to the Employer’s rules, here is a brief summary of who is eligible to enroll in the plan:
Employees
• If enrolling in a HMO Plan, you must live or work in the Service Area
• If enrolling in a POS Plan, you do not have to live or work in the Service Area
Spouses
• The spouse of an employee is also eligible for coverage if the employee and spouse are in a legally valid
existing marriage and the spouse resides with the employee or in the Service Area.
Children
Children under age 26 who meet one of the conditions/criteria below. Some plans may end dependent child
eligibility if a child age 26 has his/her own employer-sponsored coverage.
• Natural children.
• Adopted children who are legally adopted by the employee and meet the requirements for natural children
once the adoption is final. Before the adoption is final, the children are eligible for coverage when you
become legally responsible for at least partial support.
• Stepchildren who are natural or adopted children of your spouse, or for whom your spouse is appointed legal guardian.
• Children for whom the employee or spouse are appointed legal guardians.
Coverage for children enrolled in Massachusetts Group Plans will end on the last day of the month in
which the child turns 26.
Grandchildren. Your eligible dependent children’s natural children may be covered, as long as your dependent
children continue to be covered as eligible dependents under your plan.
Coverage for handicapped children may be extended beyond the age when it would normally end if the children:
• Reside in the service area or with the employee;
• Are unable to support themselves by working because of a mental or physical handicap as certified by
the children’s physician;
• Are chiefly dependent on the employee or spouse for support and maintenance due to the mental or
physical handicap; and
• Have become and continuously remained handicapped while they would have been eligible for dependent
children coverage if they were not disabled.
Court-ordered child support: the employer must decide whether an employee or spouse may enroll a child for whom
health insurance is court-ordered.
18

Eligibility and Enrollment
Renewal/Open Enrollment
Your large-group account manager starts the renewal/enrollment process about 120 days
before your renewal date, working closely with you to determine which plan is best for your
employees and coordinating a smooth implementation.
Large Group
ConnectiCare wants to make sure the enrollment process goes smoothly for your company and its employees.
This is why your Account Manager and/or your broker starts the renewal/enrollment process well in advance of
your renewal date, working closely with you to determine which plan is best for your employees and coordinating
a smooth implementation.
For Large-Group Open Enrollment:
All applications must be received approximately 30 days before the Plan’s effective date for timely receipt of
ID Cards.
Electronic Enrollment:
If you are interested in receiving information on Electronic Data Interchange (EDI), please contact your
Large-Group Account Manager.
COBRA Participants:
Remember, it is your responsibility to notify any COBRA participants about your annual open enrollment.
The Enrollment Form:
We’ve included an enrollment form, with information on completing each section.
Small Group
Renewal packages are mailed to each
employer/broker 45 days prior to the effective
renewal date. Your broker/Small-Group Sales
Representative will work with you to recommend
alternative plan options if needed and to ensure
that your open enrollment is a smooth process.
COVERAGE FOR THE COLLEGE STUDENT
ConnectiCare has made it easier for college students to receive certain
services while out of ConnectiCare's service area. In addition to
emergency services, students are covered for allergy shots, behavioral
health services, and physical therapy, even when provided out-ofnetwork.
However, members will need to be sure to receive necessary
pre-authorization prior to obtaining these out-of-network services.
19

Sample Enrollment Form
A
B
A
B
At the top of the form, in the “Employee”
section, the subscriber checks the type
of plan for which he/she is enrolling.
Also in the “Employee” section, the
subscriber provides information needed
to process enrollment.
C
C
In the “Member(s)” section, the subscriber
selects a PCP for each family member
and fills in the PCP names, provider ID
numbers and other information requested.
The information is required for each
covered family member. PCPs are listed
in the Provider Directory and in Find a
Doctor, our online directory at
www.connecticare.com.
D
D
If the subscriber or any covered family
members have other medical coverage
— including Medicare or Medicaid —
this must be indicated in the “Other
health care coverage” section.
NOTE:
All enrollment forms are available online at www.connecticare.com
E
F
E
F
In the “Employer” section, specific
information must be filled out and the
signature of the employer is required.
The employer submits the white copies.
Donot complete the COBRA election
sections unless you are asking us to
enroll the former emplyee in COBRA.
The subscriber reads the section
marked “Important” as well as the back
of the form, signs and dates the form,
tears off the pink copy of the form and
keeps it until he/she receives a
ConnectiCare ID card. (This form may
also be used as Certificate of Coverage
if members need to seek services from
a provider, but they have not yet received
their ID card. Or, upon the effective date
the employee/member may register and
print a temporary ID card.)
For Connecticut-based Small-Group Employers, a Family Health Statement must be completed for
each new hire, and must accompany the enrollment form. For Massachusetts-based Small-Group
Employers, a Family Health Statement is not required for new hire employees.
20

Eligibility and Enrollment
Enrollment Materials
You can go online and order a variety of materials to fulfill your needs, including:
• enrollment kits;
• provider directories; and
• enrollment/change forms;
• out-of-plan reimbursement forms.
Subscriber/Member Materials
Once your employees have enrolled in the plan, they’ll receive the following materials at home:
• Identification Card(s)
• Benefit Summary
• The ConnectiCare Guidebook
• HouseCall, ConnectiCare’s member newsletter
• Member Welcome Kit which includes the Membership Agreement or Certificate of Coverage,
applicable riders and other Plan documents
• Prescription drug information and mail order forms
Employees also may obtain an updated Participating Provider Directory by calling Member Services at (860) 674-5757
or 1-800-251-7722. For members covered under self-funded plans, call (860) 674-2075 or 1-800-846-8578.
You can also visit our online provider directory Find a Doctor, at our website, www.connecticare.com.
Changes in Coverage
We know that change is inevitable in a member’s life, so we’ve made it easy to add or delete dependents
from the plan. Here are the important points to remember:
• Members complete an enrollment form and submit it to you for all additions and deletions, even in cases
where their payroll deduction will not be affected.
• If a dependent’s coverage ends automatically because he or she has become ineligible (for example, if the
dependent attains the maximum age for coverage under your plan), we will send a notice of termination
directly to the member. We also will send you a copy of the dependent’s notice of termination.
• Membership terminations can be processed retroactively for up to 60 days, subject to ConnectiCare’s approval.
Changes that Affect Eligibility
Members are required to notify ConnectiCare, in writing, within 31 days of any change that could affect
coverage. Examples include, but are not limited to, the following situations:
• a subscriber or dependent child marries;
• a subscriber gets divorced;
• a member gives birth;
• a dependent child reaches the maximum age for coverage under the plan;
• a member moves outside the service area; or
• a subscriber’s employment is terminated or his/her work hours are reduced.
21

Adding Dependents to the Plan
We know that change is inevitable in a member’s life, so we’ve made it easy to add or delete
dependents from the plan.
Adding a New Spouse, Civil Union Partner, or Domestic Partner
If a subscriber marries or enters into a civil union, he/she must add the new spouse to the plan within 31 days of
the marriage or civil union date. Then, the new spouse’s/partner’s coverage becomes effective on the date of the
marriage/civil union. If the subscriber misses this deadline, he/she must wait until the next Annual Enrollment
Period or the Special Enrollment Period*.
Adding a New Child
The following are general rules, some plans may vary. Check with your Account Representative if you have
additional questions.
• Newborn natural children must be added within 61 days of the birth date. If the subscriber misses this deadline,
the children must be added during the next Annual Enrollment Period or Special Enrollment Period*.
• Newly adopted children must be enrolled within 61 days of the adoption date or, if the adoption isn’t final, the date
the children start living with the subscriber or depending on him/her for support. If the subscriber misses this
deadline, he/she must wait until the next Annual Enrollment Period or the Special Enrollment Period*.
• Children newly under the subscriber’s legal guardianship must be added within 61 days of the date guardianship
becomes effective, or wait until the next Annual Enrollment Period or the Special Enrollment Period*.
• Stepchildren must be added within 61 days of the date the subscriber marries their parent, or wait until the next
Annual Enrollment Period or the Special Enrollment Period*.
*The Special Enrollment Period is the 31-day period that follows the end of the member’s coverage under another plan or the occurrence
of a Life Event. Refer to the Membership Agreement, Certificate of Coverage, or other Plan document for more detailed information.
22

Eligibility and Enrollment
Electronic Enrollment
ConnectiCare makes available to employers the option to conduct enrollment electronically. Employers are
encouraged to provide all additions, terminations and changes to ConnectiCare via Electronic File Transfer
(EFT), diskette, or on a CD. The benefits of electronic enrollment include:
• More timely processing; the whole process takes only 24-48 hours
• Routine audits of the client’s data compared to ConnectiCare’s records
• Improved controls to address privacy of information
To find out more about how to get started with electronic enrollment, call your Account Manager
or Account Service Representative, and make a change to an existing plan/division within a group.
You can also visit our website at www.connecticare.com.
New online enrollment process
ConnectiCare now provides a simple and secure self-service mechanism for employers to add new
employees and their dependents to existing groups, and make a change to an existing plan/division
within a group. We have developed an enhanced online enrollment system.
This new process will allow employers access to our website where they will be able to quickly and
efficiently add employees and their dependents and make plan changes. It will streamline paperwork
and reduce or eliminate potential delays in enrollment.
To find out more, contact your Account Manager or Account Service Representative or visit our website
at www.connecticare.com.
ConnectiCare Benefits, Inc. plans can only be chosen through the Access Health CT website:
www.accesshealthct.com.
TERMINATING COVERAGE
When your group or any of its subscribers or members need to
terminate ConnectiCare coverage, our primary concern is making the
process as easy and efficient as possible. In this section, we’ve
outlined some general termination guidelines and procedures for you
to keep in mind.
23

Terminating Coverage
Group Coverage
If your group wishes to terminate its group policy, you'll need to provide written notification 30 days before the
identified termination date. You must submit this signed notification on company letterhead with the signature of the
authorized group representative and include the date requested for termination of the group policy. Please note that
a group termination is effective the last day of the month requested. Termination requests should be sent to your
Large-Group Account Manager or Small-Group Billing Department.
In addition, your group policy will terminate on the earliest day that any of the following events occur:
1. At the end of the grace period, if the employer fails to make any premium payments that are due, or at
another date after the grace period that we specify in writing.
2. If the company commits fraud or willfully conceals or misrepresents any material fact or circumstance in applying
for coverage with ConnectiCare.
3. In the event the employer fails to comply with:
• service area requirements;
• employer contribution requirements;
• group participation rules pertaining to either the Health Insurance Portability and Accountability Act of 1996 (HIPAA),
if the group has between 2 and 50 eligible employees; or state law if the group has more than 50 eligible employees.
4. In the event that we terminate coverage for all employers in accordance with applicable state law.
5. In the event the employer’s membership ceases in a bona fide association through which coverage is provided.
6. On the date the company is liquidated, ceases to operate, or no longer covers or employs any eligible employees.
7. On the date agreed upon by the company and ConnectiCare. The above is a summary of group termination rules.
For more detailed information, please refer to the Membership Agreement, Certificate of Coverage, or other Plan
document for your plan.
Member-Initiated Termination of Coverage
Employees or dependents may only terminate coverage during the Annual Enrollment Period unless they have a
qualifying event. Employees or dependents that want to terminate their coverage outside the Annual Enrollment
Period must submit the request to their HR Department in writing within 31 days of the event effecting coverage.
The employer must:
• complete and sign an Enrollment/Change Form, or
• write a letter that indicates the member’s name, identification number, termination date and reason for termination.
The employer must then submit the enrollment/change form to ConnectiCare requesting termination or submit the
change on their electronic eligibility update file. Employers can also process employee terminations online at the
ConnectiCare website, www.connecticare.com.
Eligibility changes may not appear on your next bill if we do not receive the enrollment/change form before the next
bill is produced. Membership terminations can be processed retroactively up to 60 days, subject to ConnectiCare’s
approval. Remember, it is your responsibility to make sure the employee submits the appropriate documentation
(as described above) to you. These procedures must be used for all terminations whether or not the employee/
dependent is eligible for COBRA coverage. If the employee decides to continue coverage, it will be reinstated to the
date of termination once a Change Form indicating election of continuation coverage is submitted. The Small-Group
employer is required to collect and remit COBRA premium payments to ConnectiCare. For Large-Group cases,
where ConnectiCare handles COBRA billing, we will reinstate coverage once a COBRA election form is received.
We produce the first COBRA invoice when the next COBRA billing cycle is scheduled, and we mail the invoice to
the COBRA participant.
24

Terminating Coverage
Member and Provider Services
ConnectiCare’s Member Services Department is dedicated to helping members and administrators with
information and answers about eligibility, benefits, claims, ID cards and provider participation. They should
be the first point of contact when information is needed. For help and information, call (860) 675-5757 or
1-800-251-7722. For members covered under self-funded plans, call (860) 674-2075 or 1-800-846-8578.
You can also visit our website at www.connecticare.com.
For Connecticut Employer Groups only
Under a Connecticut law effective October 1, 2009, if an employee is terminated by their employer for any
reason other than a layoff, or if the employee voluntarily terminates their own employment, the employer may
decide not to pay the health insurance premium for the employee and their covered dependents, starting with
the day that is 72 hours after the termination of employment. Credits for any refundable premium amounts will
appear on your next premium statement that is processed after we receive your timely request. You must make
your request for the premium credit by completing ConnectiCare’s Premium Credit for Terminated Employees
form. To obtain a copy of this form, please visit our website at www.connecticare.com/employer/
OnlineForms.asp. ConnectiCare must receive this form within 72 hours of the employee’s termination or
you will not be eligible for the credit. When you request the credit, you will have to certify that the employee’s
termination falls within the legal requirements for receiving the credit. Please note that it is your responsibility
under the law to pay the former employee any part of the credited premium which they contributed
for their coverage. Also note that you are not permitted under the law to request a credit where a collective
bargaining agreement requires you to pay any premium beyond the date of termination.
Changes may not appear on your next bill if we do not receive the
enrollment/change form before the next billing cycle.
COBRA Continuation Coverage
In accordance with the federal Consolidated Omnibus Budget Reconciliation Act of 1985 and Connecticut and
Massachusetts State law (referred to here as COBRA), subscribers and members must be offered the opportunity
to continue their group coverage when it ends for certain reasons. Connecticut and Massachusetts state laws
also mandate that COBRA rights and privileges will apply to all employers covered by ConnectiCare, regardless
of the employer size or whether the employer’s plan is subject to ERISA or COBRA.
The employer is responsible for notifying members of their COBRA rights and administering the COBRA rules.
Note that some large-group employers have hired ConnectiCare to perform certain billing services for COBRA
premiums (see “COBRA Billing” in the Billing Procedures section.) [This is not available to small-group employers.]
We’ve outlined the COBRA provisions that pertain to continuing coverage. You’ll find a more detailed discussion
of COBRA rules and provisions in the Membership Agreement, Certificate of Coverage, or other Plan document.
Another viable alternative to COBRA may be ConnectiCare ® SOLO.
For more information see the information in the Product Portfolio section
on page 10.
25

The Right to Continue Coverage
COBRA gives subscribers and members the right to continue coverage when it ends due to the occurrence of a
“qualifying event,” such as a layoff, reduction in work hours or termination of employment, death, or divorce.
Coverage for subscribers and members may be continued for up to 18, 29 or 36 months, depending on the type of
qualifying event involved.
• Coverage may be continued for up to 18 months (30 months for subscribers and members enrolled in
ConnectiCare, Inc.) when it ends due to the subscriber’s reduction in work hours, leave of absence or his/her
employment is terminated for reasons other than gross misconduct.
• For a disabled person, coverage may be continued from 18 to 29 months as long as that person meets certain
requirements. See the appropriate Membership Agreement, Certificate of Coverage, or other Plan document
for more details.
• Coverage may be continued for up to 36 months for:
– a covered child who is no longer an eligible dependent;
– a covered spouse and dependents if the subscriber dies;
– a covered spouse if the subscriber and spouse divorce or separate;
– a covered spouse and dependents if coverage ends when the subscriber becomes eligible for Medicare.
• Subscribers or members enrolled on ConnectiCare Inc., who lose group health coverage at age 62 or older
who are eligible to get Social Security income at the time of termination may continue their group coverage
until they are eligible for Medicare, instead of the usual COBRA continuation period.
The employer is responsible for notifying members of their COBRA rights
and administering the COBRA rules.
Exceptions
Continuation of group coverage with ConnectiCare is not available for:
• Newborn children who are not properly enrolled in the plan within 61 days of their birth.
• Employees or dependents who were not eligible for coverage or waived coverage on the employer’s health plan.
States may have additional continuation of coverage rules. Members should review their Membership
Agreement or other Plan documents for more details.
26

Billing Procedures
Group Billing
Here are the important rules and guidelines to remember:
• You can access your premium invoice and payment history online. Just register your employer group at
www.connecticare.com to obtain your premium billing information (including premium rate information.)
• You will receive an invoice on a monthly basis detailing your premium due.
• Please remit the Total Premium Due by the Premium Due Date posted on the invoice.
• Premium payment is due and payable on the first of the month for which coverage is applicable.
• Your invoices are driven by your eligibility and therefore they will automatically debit and credit your account
retroactively, allowing us to keep your bill current. Eligibility changes may not appear on your bill if we do not
receive and process the Enrollment/Change form before the Invoice Date (the date the bill was produced.)
• Be sure to include only your payment coupon with your check for a prompt, accurate credit to your account.
Remit to: ConnectiCare, Inc., P.O. Box 416191, Boston, MA 02241-6191.
• Alternative Payment Options for Small Groups Only — Small Employer Groups can elect to have their
monthly premium automatically taken from their bank account on a monthly basis. Your premium invoice
payment voucher has a section on it to enroll in Electronic Funds Transfer. Simply sign the payment voucher
that you send with your premium payment and continue to pay by check until you receive your confirmation
letter with your effective date of EFT. (If you wish to cancel your EFT you must provide 30 days advance
written notice.)
Mail to: ConnectiCare, Inc.,175 Scott Swamp Rd., Farmington, CT 06032.
Please mail your payment along with the invoice’s payment voucher to the lockbox address noted on the voucher.
Premium payment may be sent via overnight mail (UPS, FedEx, DHL, USPS Priority, etc.) to Bank of America
Merrill Lynch Lockbox Services, Lockbox 416191, MA5-527-02-07, 2 Morrissey Blvd., Dorchester, MA 02125.
• Please allow 5-7 days for payment posting to your account.
• Mail enrollment forms separately. Please don’t send Enrollment/Change Forms along with your premium
payment. The Enrollment/Change Forms should be submitted as soon as possible to us at 175 Scott Swamp
Road, P.O. Box 4058, Farmington, CT 06034-4058.
• Wash Method. Our billing system works on a “wash method” for new hires, in accordance with the following
ConnectiCare new hire eligibility and termination guidelines:
– New hires and additions: If the effective date is on or before the 15th of the month, we will bill for the entire
month. If the effective date is after the 15th, there will be no premium charge for that month.
– Terminations: If the termination date is on or before the 15th of the month, there will be no premium charge
for that month. If the termination date is after the 15th, we will bill for the entire month.
• Auditing. Remember, you are responsible for auditing your monthly invoice to ensure that it is accurate.
Any eligibility discrepancies can be corrected through the submission of an Enrollment/Change Form or
updates to your Electronic Enrollment and will be reflected on the invoice following the corrective transaction.
• Retroactive changes will only be allowed up to 60 days.
27

Billing Procedures
The Premium Invoice
Summary
1
Premium payment address.
The same address appears on the
payment coupon.
2
3
Your company’s name and address.
Your company’s account number, the
billing period covered by the invoice, the
premium due date, invoice number and
date the invoice was produced (also
located on page three of your invoice).
You know us by .
2
1
3
4
4
5
Premium billing department phone
number.
Message box containing important
billing information.
5
6
8
9
11
7
10
6
The amount of premium owed for the
current billing period.
14
12
13
7
An adjustment code is assigned to any
adjustment made to the previous or
current billing period. The code appears
here and is explained in the itemized
portion of the invoice.
15
8
The current premium due after
adjustments.
9
The monthly administration fee,
if applicable.
10
Any outstanding balance carried over
from a previous billing period
appears here.
16
11
The amount of payment received since
the last bill posting.
12
The total amount due for the current
billing period.
13
Date premium payment is due.
14
Premium payment procedures.
15
All correspondences (other than
premium payments) should be mailed
to the address listed.
16
Premium due date and total amount due.
28

Billing Procedures
The Premium Invoice
17
17
Premium payment information
and requirements.
Itemized
18
19
20
21
22
23
24
Contact name, number and
contact type listed here.
Benefit plan description if your group
offers more than one benefit plan.
Current monthly premium billed.
Retro-active adjustments made to
your account will appear in this
section.
Itemized amounts are totaled on
each line for each contract holder.
This is where you’ll find the
adjustment code explained.
This box provides a summary of
premium dollars (current and
adjustments) by contract year.
Questions?
18
19
20 21
22
If you have questions about your
invoice, please feel free to reference
the Employer page of our website,
www.connecticare.com, or call us at
1-800-333-1733, Monday through
Friday 9:00 a.m. to 5:00 p.m.
23
24
29

COBRA Billing
(available for Large-Group Employers only)
If your group would like ConnectiCare to administer the billing for members with COBRA continuation coverage,
contact your Account Manager. We will execute a Contract Administration Agreement that outlines our mutual
responsibilities, and we will bill the member at 102% of the group rate.
The following are the group’s or the group’s TPA’s responsibilities
• Send us a change form or other notification to terminate an employee according to the terms of your policy
(for example, at the end of the month or on the date of termination.)
• Determine if plan is required to offer COBRA.
• Determine member eligibility for extension or continuation of COBRA coverage.
• Notify terminating members and any other eligible covered dependents of their right to continuation of coverage
in accordance with the provisions of COBRA.
• Determine duration of COBRA coverage.
• Communicate to employees of COBRA eligibility due to company closure or bankruptcy.
• Determine and/or advise of qualifying event(s) for employees, spouses and dependent children.
• Notify us within 60 days when an eligible employee elects COBRA continuation coverage. The member will
then have 45 more days to send payment.
• Notify existing COBRA participants of plan and rate changes affecting their coverage.
• Conduct any other duties or responsibilities assigned to the COBRA Administrator.
• Communicate COBRA election timeframes to eligible subscriber/member.
ConnectiCare’s Responsibilities for Large Group Only
When hired by an employer group as the COBRA billing administrator, ConnectiCare will perform the following duties:
• Bill the COBRA participant for the initial and any retroactive premium.
• Communicate premium payment timeframes.
• Monitor premium payment timeframes.
• Bill the COBRA participant for subsequent monthly premium.
• Distribute late notices as applicable to COBRA participants.
• Terminate COBRA participant for nonpayment.
• Distribute a termination of COBRA coverage notice to the participant 60 days prior to COBRA expiration date.
• Notify COBRA participant of conversion coverage where applicable.
• Upon request, but no more than twice a year, provide employer group with a list of members on COBRA,
complete with COBRA eligibility expiration dates.
Sometimes employer groups and COBRA participants have questions regarding COBRA eligibility, timeframes, terminations, etc.
IMPORTANT
When electing COBRA continuation coverage the member has 45 days from the date of the election to make the first
payment of premium. The first payment must include payment for coverage as of the member’s effective date of
COBRA election. For example, if the election to continue coverage is made 60 days following the Qualifying Event and
payment is made 45 days following the election, a total of three months premium must be paid on that date.
The following websites can help to answer questions that employers and members may have about COBRA.
• http://www.dol.gov/ebsa/faqs/faq-consumer-cobra.html – FAQ about COBRA continuation of Health Coverage
• http://www.dol.gov/ebsa/publications/cobra.html – Notice of changes under HIPAA to COBRA
30

Claims and Reimbursements
In this section, you’ll find the basics on claim filing, including information
about the Claim Summary and the Coordination of Benefits (COB) process.
The information that follows is an overview; for more details, refer to the
Membership Agreement, or other Plan document for your plan.
Receipt and Processing
We need to receive claims within 180 days from the date services or supplies were received; otherwise we will
not provide reimbursement.
Care Received from Participating Providers
In general, members should not receive bills from participating providers. This is because participating providers
bill ConnectiCare directly for their services, which eliminates paperwork for our members. If a member does
receive a bill from a participating provider, it probably means more information is needed. The member should
call the provider immediately to find out what is required. The participating provider will then bill us directly and
remove the member’s name from the billing system if the member has no financial responsibility.
If the member receives a second billing notice, he or she should call Member Services at (860) 674-5757 or
1-800-251-7722. For members covered under self-funded plans, call (860) 674-2075 or 1-800-846-8578.
You can also visit our website at www.connecticare.com.
Care Received from Non-participating Providers
Members may receive care from non-participating providers if:
• They are members of a Point-of-Service plan.
• They need emergency care (as defined under the Emergency Care section.)
These claims must be submitted to us within 180 days at the following address:
Massachusetts:
Connecticut:
ConnectiCare of Massachusetts, Inc. & Affiliates
ConnectiCare, Inc & Affiliates
175 Scott Swamp Road 175 Scott Swamp Road
P.O. Box 522 P.O. Box 546
Farmington, CT 06034-0522 Farmington, CT 06034-0546
Information Required
The claim should include:
• The subscriber’s name.
• The name and ConnectiCare ID number of the person who received the care.
• A complete, itemized bill that describes the services provided and the diagnosis. Note that charge card
receipts and “balance due” statements are not acceptable.
• A copy of the written pre-authorization letter issued by us or our Behavioral Health Program. If the care did not require
pre-authorization, an explanation of why care was sought from a non-participating provider (i.e., that the care was
emergency or urgent care received 30 miles outside the ConnectiCare service area) should be provided.
31

Foreign Claims
If the claim is for emergency or urgent care received outside the United States, the member will need to ensure:
• The itemized bill is written or translated in English, and
• It shows the amount paid in U.S. dollars.
It also can be helpful for the member to provide a charge receipt with the itemized bill.
Coordination of Benefits
If a member is eligible to receive benefits under another plan — including group HMOs, Medicare, Workers’
Compensation and employer-sponsored medical plans — Coordination of Benefits will apply. A member’s
ConnectiCare benefits will be coordinated with the other plan’s benefits.
When ConnectiCare is the secondary plan, the member must send us a copy of the Claim Summary statement
received from the primary plan, along with the claim form. If we receive a claim without an Claim Summary from
the primary plan, we will deny the claim. It is the member’s responsibility to ensure that the claim is processed
with the primary plan. If we are the secondary carrier, the member has 180 days from the date the primary plan
processed the claim to submit the claim to us. The rules and guidelines for Coordination of Benefits are described
in the Membership Agreement, or other Plan document for your plan.
The Claim Summary
Members will receive a Claim Summary statement according to the following guidelines:
1. For claims from in-network providers, a Claim Summary is issued whenever the member has financial
responsibility other than a fixed cost (e.g., coinsurance, deductibles, etc.)
2. All claims from non-participating providers will generate a Claim Summary.
32

Claims and Reimbursements
33

34
Claims and Reimbursements

Questions, Grievances and Appeals
The information that follows is an overview. For more details, refer to the
Membership Agreement, or other Plan document for your plan.
Questions and Complaints
Most questions or complaints can be resolved informally. If a member has a question or complaint, his/her first
step should be to call our Member Services Department at (860) 674-5757 or 1-800-251-7722. You can also visit
our website at www.connecticare.com.
Or you can write to us at:
ConnectiCare, Inc.
Member and Provider Services
175 Scott Swamp Road
P.O. Box 4050
Farmington, CT 06034-4050
Representatives are available Monday through Friday during regular business hours.
The Appeals Process
If the question or complaint can’t be resolved informally, the member may use the appeals process. This process
is available to members who disagree with a decision we’ve made regarding:
• covered health services,
• benefits,
• pre-authorization or pre-certification, or
• claims processing.
Details regarding the appeals process are provided within the Membership Agreement, Certificate of Coverage,
or other Plan documents. Representatives are available Monday through Friday during regular business hours.
35

Special Benefit Programs
In addition to medical and hospital benefits, ConnectiCare plans include
coverage for prescription drugs as well as certain value-added programs.
These special programs are outlined in this section. Some of them are
described more fully in the Membership Agreement or other Plan document
for your plan or The ConnectiCare Guidebook.
Prescription Drug Program
ConnectiCare has a prescription drug program which uses an incentive drug list. This helps to keep prescription
drugs and health insurance affordable without sacrificing quality. A drug list includes those medications that
have been chosen for their safety and effectiveness.
If your plan includes prescription drug benefits, coverage applies only to drugs obtained from a participating
pharmacy. If a member fills a prescription at a non-participating pharmacy, he/she must pay the entire cost of
the prescription.
How the Pharmacy Program Works
The ConnectiCare drug list is based on a tiered system and is designed to give members an incentive to use
drugs that are listed on the drug list on Tier 1 or Tier 2.
Prescription Drug Pre-authorization
Drugs that require pre-authorization are identified on the drug list with a “PA” or “ST” next to their names. Members
should make sure their physician contacts ConnectiCare before prescribing these medications.
Mail Order Medications
Most members covered under the Prescription Drug Program can order up
to a three-month supply of medications by mail. For details about mail order
medications, call 1-800-369-0675.
VIEW OUR
DRUG LIST
ONLINE
To review ConnectiCare’s
Prescription Drug List,
visit us online at
www.connecticare.com
and click on Pharmacy
Center.
36

ConnectiCare Touchpoints
DRIVING RESULTS
A wealth of ways to take a more hands-on approach to managing health care costs
At ConnectiCare we know that employees are the driver of any business. That’s why employers have always wanted to
provide them with the best health care coverage available. More recently, employers have realized that encouraging
employees to take advantage of the programs, tools and services available through their plans is equally important. That’s
why we’ve introduced ConnectiCare Touchpoints — to help your employees easily find and utilize everything their
ConnectiCare health plan offers so they can stay healthy and continue to drive the health of your business.
ConnectiCare Touchpoints is a comprehensive program of Health and Wellness tools, resources and services all designed
to help your employees — those in good health as well as those with health conditions — take a proactive role in their
health. As ConnectiCare members, your employees can take advantage of everything in the Touchpoints program at no
cost beyond their monthly premium — no matter which ConnectiCare health plan they are enrolled in.
Employee Health and Your Company’s Bottom Line
Health care costs in the United States continue to rise every year. The average annual premium in 2011 is $15,073 for
family coverage. Since 2010, average premiums increased 9% for family coverage. The 9% increase for family premiums
between 2010 and 2011 is significantly greater than the 3% family premium increase between 2009 and 2010. 1
There are a number of reasons for rising costs, but two stand out in particular:
• increased demand for medical services
• increased incidence of certain chronic conditions
How bad is the situation? Consider four conditions currently in the news, and their economic burden on the health care system:
CONDITION COST TO HEALTH CARE SYSTEM
Diabetes $ 174 billion
Obesity $ 147 billion
Heart disease $ 444 billion
Asthma $ 18 billion
Total $ 783 billion
• More than 25.8 million Americans have diabetes. 2
• In 2007-08, more than 34% of adults aged 20 years or older were obese, and 17.1% of children and adolescents
2-19 years of age were obese. 3
• More than 82 million Americans currently live with a cardiovascular disease. 4
• 29.9 million Americans have Asthma. 5
1 Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2011 2 American Diabetes Association 3 Centers for Disease Control and Prevention
4 American Heart Association 5 Centers for Disease Control and Prevention
37

Touchpoints
ConnectiCare is here to help
ConnectiCare understands the need for your business to control health care costs. Clearly the impact of poor
employee health has a tremendous effect on the bottom line.
Consider the following figures:
• At least 25% of employer health costs are associated with unhealthy lifestyles and modifiable risk factors
• About 70% of all health care costs are potentially preventable 6
The good news is that many people can live healthier lives if they have the right support — and that is exactly
why we’ve introduced ConnectiCare Touchpoints.
The ConnectiCare Difference
What makes ConnectiCare Touchpoints different from other Health and Wellness programs in the industry is how we
communicate it to your employees. Many Health and Wellness programs are generally collections of programs and
services laden with health care speak terminology that plan members find confusing and complicated. Such
program designs do not serve to increase member engagement; rather individuals are less likely to consistently
use these programs and services to full advantage.
As health care becomes more consumer-driven, ConnectiCare recognizes the need to communicate to your
employees in a way that engages them and encourages them to take a hands on role in their health. ConnectiCare
Touchpoints is built on a user-friendly and consumer-driven platform which allows your employees to interact
through health “calls to action” or steps they can take to lead healthy lives or get the care they need.
Profiles of Programs and Services Your Employees Will See
When your employees look to take an active role in their health they will find that Touchpoints has the programs,
tools, services and information that they’re looking for. For their benefit Touchpoints has been organized in the
following categories to help easily guide them on the path that best suits their health needs:
• Take stock and keep track
Through this offering your employees can take their own Health Risk Assessment, establish and maintain their
Personal Health Record and explore a range of preventive and health maintenance guidelines, information and
tools at www.connecticare.com. The more your employees know about their health, the easier it is for them to
stay healthy.
• Make healthy choices
With these tools your employees find information and guidance on ways to improve their health status
such as losing weight, quitting smoking and dealing with stress.
• Watch for reminders
Keeping track of preventive health immunizations and screenings is important for your employees’ health.
Through our preventive health programs, your employees will receive regular reminders, at least annually,
to get important preventive services such as mammograms, PAP smears, colon cancer screening and
influenza immunizations. We also send regular reports to physicians to encourage them to reach out to
their patients regarding needed preventive services.
6 James Fries, M.D., Stanford University School of Medicine
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Manage your condition
Health Management Programs
ConnectiCare assists your employees who are dealing with chronic conditions
through our comprehensive Health Management Programs. Our Health
Management Programs focus on each of the following conditions:
• BREATHE Asthma — Asthma prevention for all members with asthma
• BREATHE COPD — for members with Chronic Obstructive Pulmonary Disease (COPD), which includes
chronic bronchitis and emphysema
• DiabetiCare — for adult members with diabetes
• HeartCare CAD — for members with coronary artery disease
• HeartCare HF — for members with heart failure
• QuitCare — a smoking cessation program for all members
The primary goals of our Health Management Programs are to: reduce overall medical expenses,
improve process and outcome of care, improve member quality of life and to increase member, provider
and employer satisfaction.
A primary component of all health management programs is member intervention. Members in high-risk
groups are offered care management with a registered Nurse Care Manager who provides
individualized support and education. In addition, enrolled members receive informational postcards
and educational mailings.
Practitioner interventions are another important component. Primary care physicians and specialists
receive nationally recognized treatment guidelines and periodic patient reports.
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Touchpoints
Care Management Programs
ConnectiCare offers additional support for members with special or multiple
health conditions through our Care Management Programs.
Transplant Case Management Program
Our Transplant Case Management Program uses telephonic outreach to members and providers during the
pre-transplant, intra- and post-transplant phases. It provides them with education, support and advocacy.
Special Care Case Management Program
ConnectiCare offers the Special Care Case Management Program, which focuses on chronic illness and
its management challenges. This service is designed to help your employees understand and better
manage their health. It also provides information that can give them confidence when making health
care decisions. Once enrolled, a Nurse Case Manager will be assigned to help. He or she will call and
ask questions to get a picture of the member’s current health situation. Based on these answers, The
Nurse Case Manager may provide educational information about a specific health condition, or discuss
any questions or concerns that the member may have.
There are several ways to enroll in the Special Care Case Management Program:
• A member’s doctor or nurse can call us;
• A member can sign up on his/her own;
• Or, if our review of a member’s health care services indicates that he or she could benefit from the
program, we may call them.
Our experienced, caring Nurse Case Managers are here to help, and provide support. Members should
feel comfortable speaking with them.
Cancer Support Program
When someone is diagnosed with cancer, they have questions and need to make difficult decisions.
Our Cancer Support Program provides members with a single source of personal support from an
experienced cancer nurse. The nurse works with members and their loved ones as long as they have
needs regarding cancer. The program addresses all kinds of cancer from the earliest stages, and is
available at no additional cost.
Kidney Case Management Program
This program is designed to help ConnectiCare members with chronic kidney disease manage their
condition. A registered nurse with specialized training calls members to provide guidance and support —
and to monitor health conditions and complications that are commonly related to kidney disease.
For more information on Transplant, Special Care, Cancer Support or Kidney Case Management
Programs, members may call toll-free 1-866-897-1038.
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Specialty Pharmacy Programs
ConnectiCare contracts with pharmacies that specialize in prescription drug therapies that require unique
handling for the following conditions: Hemophilia, Hepatitis C, Multiple Sclerosis and Infertility. By doing
so we are able to provide our members, who use these products, a level of service not possible from a
local retail pharmacy. These pharmacies offer 24/7 nurse and pharmacist consultation for side effect,
administration and storage questions.
Neonatal Intensive Care Unit (NICU) Case Management Program
The NICU Case Management Program connects families with newborns who are admitted to the NICU
with case managers who have NICU experience. The NICU Case Managers, perform on-site and
telephonic case management. The goal is of the program is to provide support to your employee during
their newborn’s hospitalization and immediately after discharge, to provide information to help them
make decisions.
Hospitalization and Recovery
ConnectiCare’s Nurse Case Managers review inpatient stays in hospitals, as well as stays in sub-acute
and skilled nursing facilities. These reviews are done to see if members are receiving necessary
services, so that we’re able to coordinate physicians to determine the most appropriate steps in the
member’s treatment.
In addition, our Nurse Case Managers continue to provide support to help members with their recovery
so that the gains they made during their hospital/skilled nursing facility stay are not lost.
Discover the discounts
Through our Healthy Alternatives program your employees will find discounts on products and services
that are up to 30% of the provider’s usual and customary fee. This program offers a wide range of
sources to enhance the well being of your employees — from alternative therapies and nutritional
supplements to weight management programs and fitness centers.
Understand your benefits
Your employees have to know what coverage they’ve got in order to use it to their best advantage. In
this section we explain to them how they can access resources such as their Medical Benefits Summary
and Treatment Cost Calculator.
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Touchpoints
Find out about doctors and hospitals
We’ll provide your employees with the information they need, so they can choose the right doctor and
the right hospital for the type of care they need. Here they’ll learn about resources like Hospital Safety
Comparisons, Physician Profiles and the Participating Provider Directory.
Know your medicine
Sometimes understanding prescriptions and coverage for them can be confusing. We’ll give your
employees the information and tools they need to help sort it out. Through our online Pharmacy Center
they will find information on topics such as Mail Order Prescriptions, Generic Drugs, and Medication Safety.
Educate yourself
Mining the internet for health information is time-consuming unless Touchpoints is the first stop. In this
section your employees learn about our online educational resources like Daily Health News from
WebMD.
It’s all about helping your employees help themselves
In order to BE healthier, people have to DO healthier things. ConnectiCare Touchpoints is full of options
for your employees to help them take charge of their health. When they utilize the Touchpoints tools,
they’ll not only get the most out of their ConnectiCare health plan, they may take fewer sick days, and in
general, lead healthier, happier lives. With the help of Touchpoints, you and your company take the
management of health care costs into your own hands.
To do the best job, use the right tools
Please take a few minutes to scan through the breadth and depth of programs and services profiled in
this brochure, available to you and your employees through ConnectiCare Touchpoints. Your employees
have most of this same information in their member brochure entitled, “ConnectiCare Touchpoints —
The tools for a healthier life. Right at your fingertips.”
Right at your employee’s fingertips — that’s the key. Tools are just tools, sitting there on the shelf until
people put them to work. When your employees use the tools you see here, when they get proactively
involved in their health, that’s when you’ll start to see the improvements. Do everything you can to
encourage employees to take full advantage of ConnectiCare Touchpoints. We’ll do everything we can
to help. Together, we can improve health care and help control health care costs.
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Treatment Cost Calculator
Now you and your employees can be more informed and confident about your health care decisions with our
Treatment Cost Calculator. This online tool allows you to find information quickly about the three most important
factors involved in choosing a health care provider: cost, quality and convenience. You can research nearly 300
procedures in a variety of categories, from inpatient and outpatient services to X-rays and lab tests.
You can also:
• Find local providers
• Review cost estimates
• Compare provider quality, cost and location
• Select the treatment setting that’s right for you
Log in at www.connecticare.com/members.
College Tuition Rewards
As a ConnectiCare member you have access to College Tuition Rewards ® , a program that helps to address a
major source of stress for Connecticut families: the rising cost of higher education. ConnectiCare Specialty
Services, a ConnectiCare, Inc. affiliate, has an exclusive agreement with SAGE Scholars to offer the program.
Participants can earn college tuition discounts for their children or other family members — up to one full year’s
tuition — at more than 300 private colleges and universities across 45 states that participate in the SAGE
Scholars consortium. The maximum discount varies by college — but the average is currently more than
$40,000. There is no additional cost to participate in the program.
Participants will receive an initial 1,000 tuition points, which they may distribute among their enrolled children,
as well as grandchildren, and nieces and nephews. The children are then awarded between 500 and 1,000
additional points on each birthday that they participate in the program. The tuition points can be redeemed at
1 credit = $1 toward tuition at any of the participating schools.
For more information, watch an online video at www.brainshark.com/ConnectiCare/CTR or go to
www.tuitionrewards.com/cci.
ConnectiCare, Inc. does not insure or guarantee the College Tuition Rewards program.
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Touchpoints
Members-only discounts help support their overall well-being
At ConnectiCare, we care about both your employees’ physical health and their peace of mind. So, we work
hard to provide an exceptional level of service and caring. And, we provide extra ways to help manage the
stresses of everyday life and support their well-being.
Studies have shown that financial stress in particular can affect ones health 1 . We’re offering a members-only discount
program — LifeMart ® — which can help members manage this stress by making their personal finances go further.
This program is available at no additional cost through ConnectiCare Specialty Services, a ConnectiCare affiliate.
LifeMart — Online savings every day
LifeMart is one of the largest shopping platforms on the Internet. It offers discounts of up to 40% on millions of
products and services from a wide range of departments: wellness, family care, financial services, and many
more. The program is available to valued ConnectiCare customers, effective January 1, 2014.
LifeMart provides access to exclusive deals, everyday savings and limited-time offers. Why waste time scouring
the Internet? LifeMart can be your one-stop resource for everyday and major purchases from leading brands.
Below are just some of the categories and brands you can choose from:
• Wellness – fitness clubs, diet plans (Nutrisystem & Jillian Michaels), personal care products
• Family Care – child care (Tutor Time), senior care and needs (CareFamily), pet care
• Parent Deals – learning products, apparel, toys
• Travel – hotels (Wyndham Hotels), car rentals (Enterprise and Hertz), cruises (Carnival), vacation packages
• Entertainment Tickets – movies (Showcase Cinemas, AMC), theme parks (Disney and Six Flags),
sporting events (NFL Tickets)
• Electronics – cell phones (T-Mobile), computers (Lenovo and Dell)
• Food – printable coupons and local restaurants deals
• Flowers & Gifts – flowers (FTD, 1-800 Flowers), gift baskets, gourmet food
• Home & Auto – Home décor, appliances, auto care
• Financial – credit & legal services (Legal Zoom), home mortgages (Wells Fargo)
• And more!
Your employees can start using LifeMart by logging into www.connecticare.com with their ConnectiCare user
name and password, and clicking on the LifeMart button.
All goods and services provided through LifeMart are provided by independent third-party Discount Vendors. Neither Connecticare nor
LifeCare approves, endorses or recommends any particular Discount Vendor or any of their products or services. An evaluation of the
appropriateness and cost of any product or service must be made by the purchaser. Discount Vendors and their offerings are subject to
change or withdrawal by LifeCare at any time. Discount Vendors' coupons or offerings may be time sensitive
1 “Stressful Life Events and the Metabolic Syndrome,” Diabetic Care Journal, 2010: “…those reporting work- or finance-related events had
increased odds for having the metabolic syndrome.” This is a cluster of conditions — increased blood pressure, a high blood sugar level, excess
body fat around the waist and abnormal cholesterol levels — that occur together, increasing your risk of heart disease, stroke and diabetes.
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Worksite Wellness
ConnectiCare’s approach to a healthier workforce
ConnectiCare’s Worksite Wellness Program, established in 1990, helps employers encourage healthy
living among their most valuable asset: the employee. Our Worksite Wellness mission is to educate
employees about lifestyle behaviors and how they influence health, quality of life and use of health care.
We offer onsite education, with seminars and screenings. Our staff is experienced and knowledgeable in
the fields of nursing, exercise science and nutritional science.
Providing a comprehensive menu of wellness offerings to employees, our program is designed to have a
positive impact on the employer’s productivity and profitability. This type of diverse approach to worksite
wellness is supported by the 2002 Hewitt Associates study, Health and Productivity Programs Continue
to Grow in Popularity As Health Care Costs Rise. Our Worksite Wellness offerings include the following:
Large-group access
ConnectiCare offers all large, fully-insured employer groups an opportunity to receive three free wellness
programs as a new group. When the group renews with ConnectiCare, it receives two additional free
wellness programs during the course of the renewing year.
Small-group access
ConnectiCare will provide one free wellness group program to any employer group with 10 or more
employees that signs up for a ConnectiCare health plan.
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You know us by .
175 Scott Swamp Road, Farmington, CT 06034-4050
www.connecticare.com
Coverage is provided by and services are administered as follows: In Connecticut: Group HMO and POS coverage,
and Individual HMO coverage is underwritten by ConnectiCare, Inc.; Group coverage for coinsurance plans and
Individual POS coverage is underwritten by ConnectiCare Insurance Company, Inc; coverage for plans offered on
Access Health CT is underwritten by ConnectiCare Benefits, Inc.; In Massachusetts: Group HMO and POS coverage
is underwritten by ConnectiCare of Massachusetts, Inc. FlexPOS, PPO coverage, ASO/Self-funded services, and
Dental products are administered or underwritten by ConnectiCare Insurance Company, Inc.
EAG 12/13