Get answers to your frequently asked questions. Please Note: The following information does not apply to Senior Blue, Medicare PPO, Healthy New York, Child Health Plus, Family Health Plus, and Medicaid HMO.
BlueCard® and BlueCard® Worldwide Programs
The BlueCard® and BlueCard® Worldwide programs enable members to access doctors and hospitals throughout the U.S. and nearly 200 other countries and territories when they travel or live away from home. Members can use the Blue National Doctor & Hospital® finder at bcbs.com or call BlueCard Access at 1-800-810-BLUE (2583) to find a provider.
With BlueCard, members have access to:
Coverage may be limited to urgent and emergent care based on the plan you offer. Members should contact customer service for specific benefit information.
Away From Home Care® - Guest Membership
Members enrolled in HMO or POS managed care products (except high-deductible products) may have access to health care in most states and the District of Columbia when temporarily residing away from home for at least ninety (90) days.
This service is available for:
Pharmacy benefits remain with the home plan (us). Individuals with a Guest Membership should call Express Scripts® at 1-800-939-3751 to locate participating pharmacies where they are residing.
Coverage may be limited to urgent and emergent care due to plan design. Your employees should contact customer service for specific benefit information.
The following guidelines are not intended as legal advice.
COBRA Administration is the sole responsibility of the employer.
What is COBRA?
COBRA requires employers with 20 or more full-time and/or part-time employees to continue offering group health insurance to employees and their dependents upon the occurrence of a qualifying event.
COBRA Qualifying Events
The following are some examples of COBRA qualifying events.The following guidelines are not intended as legal advice.
|Qualifying Event||Qualifying Beneficiary||Duration of Coverage|
|Death||Spouse and/or dependent children who were covered prior to qualifying event||36 months|
|Termination of employment||Covered member, spouse and/or dependent children if covered under plan||18 months|
|Reduction in hours of employment||Covered member, spouse and/or dependent children if covered under plan||18 months|
|Medical or military leave||Covered member, spouse and/or dependent children if covered under plan
|Divorce or legal separation||Spouse and/or dependent children if covered under plan||36 months|
|Entitlement to Medicare||Spouse and/or dependent children if covered under plan||36 months|
|Dependent child reaching maximum coverage age, marriage, etc.||Child(ren) if covered under plan||36 months|
|Disability of a covered member||Covered member, disabled at the time of qualifying event or disabled within first 60 days of continued coverage||29 months|
COBRA Notification Requirements
Administrators of group health plans must ensure that each covered employee, spouse and dependent receives written notice, by mail, of his or her right to continuation of coverage.
What is a Complaint?
A complaint is an oral or written expression of dissatisfaction. For example: the member or provider may describe a criticism of the Plan, a provider contracted with the plan or one of the Plan's benefit or service delivery sub-contractors.
Resolving a Complaint
Unresolved Complaints on First Contact
Prescription Drug Coverage
BlueShield of Northeastern New York offers a Three-Tier Prescription Program as well as a mail order option to provide you with access to a wide selection of prescription products, while helping you manage your prescription drug costs. These products, administered by BlueShield and Express Scripts (formerly Medco), our pharmacy benefit manager, provide both coverage and convenience for our members.
Three Tier Prescription
Prescription Copayments Based on a Three Tier Program
What is a Formulary?
The BlueShield of Northeastern New York Medication Guide or Formulary is a preferred list of the quality, cost-effective medications that can be prescribed by your physician and are covered under your prescription drug rider. Using a formulary helps us keep premiums as low as possible by controlling the rising cost of prescription drugs. For more information on formularies please refer to the "Pharmacy Services" section of this web site.
Express Scripts - Home Delivery of Prescription Drugs
Why Use Express Scripts By Mail?
BlueShield offers the Express Scripts By Mail pharmacy service to all of our employer groups. The advantages for members using Express Scripts By Mail are:
When members use Express Scripts By Mail for medications taken on an ongoing basis, they enjoy greater convenience as demonstrated by the following:
Members save money and time through the use of mail order as demonstrated by the following:
QUALITY AND SERVICE
Express Script's mail-order pharmacy has been recognized by third party research groups and by its own members for the highest quality and service.
For more information and instructions on how to start using Express Scripts By Mail, members can call the Express Scripts Member Service department toll free at 1-800-939-3751 or access the Express Scripts web site through our secure member portal.
BlueShield of Northeastern New York offers group plans to employers with two or more eligible employees. When a business has multiple locations in and outside of our service area, employees will be combined to determine the size of the group.
Please refer to our Participation Requirements (Underwriting Guidelines) for details about eligibility requirements for groups.
Enrollment applications must be submitted within thirty calendar (30) days of the eligibility date, which is determined by your probationary (waiting) period. After thirty calendar (30) days, employees must wait for the open enrollment period to submit their applications.
Health plans that provide dependent coverage are required by law to make this coverage available until age of 26, regardless of group size or funding arrangement.
Dependent coverage is available to young adults up to age 26 even if they:
Grandfathered health plans are not required to make this Age 26 coverage available to their employees' dependents until January 1, 2014 (per Health Care Reform law) if they are eligible for coverage aside from their parent's plan. If and when you do offer the coverage, confirmation of the young adult’s eligibility for their own employer-sponsored coverage is your responsibility.
New York’s Age 29 Law
Revisions to New York State insurance laws in 2009 provide the following coverage opportunities for young adults who are 29 years of age or younger, when they meet specific criteria.
You must submit a Medicare Certification form within ninety (90) days of a member’s Medicare effective date. This applies to anyone on Medicare regardless of age, including disabled individuals. Please submit this information on an enrollment application with a copy of their Medicare card.
Employees who do not enroll in Part B may incur more out-of-pocket expenses. For more information, visit medicare.gov
Contact your dedicated account specialist or call our Billing and Enrollment Department at 1-800-430-7984.
OBRA, TEFRA and DEFRA are laws that enable active employees and their spouses, enrolled in a group health plan, to make their BlueShield coverage primary to Medicare.
Affects employers with 100 or more full-time and/or part-time active employees.
Affect employers with 20 or more full-time and/or part-time employees and that offer health insurance through the group.
OMNIBUS BUDGET RECONCILIATION ACT - FEDERAL (OBRA)
OBRA Specifications. This law affects employers with 100 or more employees.
When an active employee/dependent is covered by his/her employer enrolled in the active group and has Medicare due to a disability other than End Stage Renal Disease, the group coverage is primary to Medicare.
End Stage Renal Disease
If an employee (and/or dependent) is diagnosed with ESRD, the group health insurance remains primary for the 30-month period, after which Medicare becomes the primary carrier.
Tax Equity and Fiscal Responsibility Act of 1982 - Federal (TEFRA)
Deficit Reduction Act of 1984 - Federal (DEFRA)
TEFRA and DEFRA Specifications affects employers with 20 or more employees and that offer health insurance through that group.
If either the employee or his or her spouse chooses Medicare as the primary insurance carrier, that individual must be removed from the employer's group insurance plan. When the contract holder retires, TEFRA no longer applies, Medicare becomes primary and BlueShield classes should be changed to Over 65.
If a member is changing his or her coverage to Medicare primary, please submit a copy of the Medicare card showing Part A and Part B effective dates.
The preceding summary is not intended as legal advice or intended to be a legal analysis upon which you can rely for a definitive explanation of the statute. BlueShield recommends you contact your attorney and accountant to advise you of the applicability of the law to your group and the provisions and the penalties for noncompliance.
During an Open Enrollment Period, your employees can:
Employee Meetings & Information Sessions
Employee meetings and information sessions should be held six to seven weeks prior to the effective date. This allows for timely processing of Enrollment Application & Change Forms and Subscriber ID cards.
BlueShield representatives are happy to visit your location to present updated benefit information and to answer any questions you or your employees may have.
To coordinate an onsite meeting, please call your dedicated representative or our Marketing Services Unit at 1-800-342-5258.
The anniversary date of your group contract:
Suggested Timeline for Open Enrollment
Although the schedule may vary from employer to employer, the following is a recommended time frame for your Anniversary Date/Open Enrollment Period.
|Before Your Anniversary Date||Enrollment Activity|
|8 - 10 weeks||Group Administrator works with a BlueShield account manager to determine the group benefit package for the upcoming year.|
|6-7 weeks||Presentations are made to employees regarding benefit alternatives.|
|5-6 weeks||Decision-making period for employees.|
|4 weeks||Enrollment Application & Change Forms are submitted to BlueShield of Northeastern New York.|
All members with Point of Service contracts have the option to seek care from non-participating ("out-of-network") providers, at a higher out-of-pocket cost.
If a member's plan requires referrals to visit a participating specialist, the member's Primary Care Physician needs to issue a referral before the member sees the specialist in order to be covered.
Urgent care is treatment for medical situations that require prompt attention but are not life threatening.
Examples of urgent care situations include:
Urgent Care Within the Service Area:
(For members with HMO and POS coverage)
Urgent Care Outside the Service Area:
(For members with HMO and POS coverage)
Members are covered for urgent care while traveling outside the home service area through a network of BlueShield providers participating in the BlueCard® program.