The Significa Group Administrator Manual can help you when administering Significa coverage to your employees. It explains the processes necessary for certain situations, such as when enrolling new employees or changing employee coverage, as well as provides the necessary details on how to access covered benefits and services.

You can view the entire manual online by clicking here. Feel free to print the entire manual or you can view each section according to the table of contents by clicking below on your topic of interest.

Table Of Contents:

The Flexible, Innovative, Affordable Answer to Health Care Coverage

Unlike outdated plans steeped in inefficiencies and higher costs, Significa represents a fresh new approach to health and wellness coverage. One that’s dedicated to superior customer service, accurate and timely claim payment, and ease of doing business.

No paperwork:

Our preferred providers handle and submit claims and precertification paperwork.

No referrals:

Referrals are not needed to see a specialist.

Extensive network of quality providers:

We offer the most respected and capable health care providers.

Lower out-of-pocket costs:

Save when choosing in-network preferred providers. Yet have the freedom to choose out-of-network providers.

Coast-to-coast coverage:

Coverage anywhere in America.

Unique and comprehensive wellness programs:

All designed to improve health and your quality of life.

Prompt ‘can do’ service:

Friendly, knowledgeable customer service representatives who have your best interest at heart.

Performance…efficiency… and value. It’s the fresh new solution that makes everyone feel good about their health coverage. Again.

Customer Service at a Glance

Significa Customer Service
phone:	717-581-1300	mail:	Significa Insurance Group, Inc.
	800-796-7460		P.O. Box 7777
	weekdays from 8:30 a.m. - 4:30 p.m.		Lancaster, PA 17606-7777
website:	www.significa-ins.com
Significa Participating Providers
phone:	888-498-9648
	weekdays from 8:30 a.m. - 5:00 p.m.
website:	www.significa-ins.com
Precertification
phone:	717-581-1245
	800-432-8877
Prescription Drug Information
phone:	800-305-7926	mail:	Express Scripts, Inc.
	Express Scripts, Inc. (ESI)		P.O. Box 66773
	24 hours a day/7 days a week		Saint Louis, MO 63166-6773
website:	www.significa-ins.com

Customer Service

Telephone:

Customer Service telephone representatives are available weekdays:

8:30 a.m. to 4:30 p.m.

717-581-1300

800-796-7460

Feel free to leave a message after hours and we will return your call within 24 hours on business days.

Employees may call customer service if they have questions regarding:

Their benefits;
Status of a claim;
A bill from a physician or other health care professional or facility;
Correcting an error on their card; or
Coverage for a service or benefit.

Administrative office:

All correspondence should be sent to our administrative offices at:

Significa Insurance Group Inc.

P.O. Box 7777

Lancaster, PA 17604-7777

Website:

www.significa-ins.com

Our website is your and your employees’ best resource for information regarding Significa PPO health care coverage.

Use the site to:

Review benefits;
View claims history;
Find physicians, health care professionals and facilities who are part of the EHP-Significa network;
Review the prescription drug formulary;
Request a new or duplicate identification card;
Access a wide range of health care information and education;
E-mail customer service with questions; and
Access ‘My Health’ for health and wellness tools and information.

As a group administrator, you will also be able to:

View employee eligibility and coverage information such as enrollment and effective dates; and
Submit coverage terminations electronically

The website is continually improved to offer you more information and health care-related tools. We encourage you to visit the site often to get the most from your health care coverage plan and to keep yourself healthy

Online Health and Wellness with 'My Health'

With Significa, you and your employees have access to our online personal health and wellness management tool, ‘My Health.’ By visiting www.significa-ins.com and clicking on ‘My Health,’ you’ll find a wealth of health-related topics and information designed to help control and prevent medical conditions such as diabetes, heart disease, and obesity–all 100% secure and available 24/7.

You’ll have access to several online health resources including:

Lifestyle coaches.
Condition and fitness managers.
Health risk trackers, and much more!

To learn more about ‘My Health’ and all of the online programs and health resources offered, log on and encourage your employees to log on to www.significains. com and click ‘My Health’ today.

The first time you visit you will be asked to register. When prompted, simply enter this passkey: SIGB7WWW2. Then create your own userid and password to log on.

Group Participation and Eligibility Requirements

Who Is Eligible for Coverage

There are certain participation and eligibility requirements that your group must follow.

To maintain group status, your group must consist of at least two eligible employees.
If at any time your group falls below the minimum enrollment requirement, your broker/sales representative can provide you with information on other health plan options and will be happy to assist you in transitioning your coverage.

Employee eligibility

To be eligible for enrollment your employee must be:

An active employee eligible to participate in a health care plan offered by your business; and
Eligible in accordance with your group’s specific eligibility requirements.

Dependent eligibility

If an employee wishes to enroll a dependent, the dependent must be:

The spouse of the employee; or
The employee’s or employee’s spouse’s unmarried child(ren), including newborn children, stepchildren, children legally placed for adoption, legally adopted children and children required to be covered under a Qualified Medical Child Support Order or National Medical Support Notice.

Please note that we may require written legal documentation to verify the relationship between the employee and the dependent.

Dependent children must be either of the following:

Under 19* years of age. Coverage will continue until the end of the calendar month in which the dependent reaches age 19* or until the end of the month in which the dependent marries or becomes employed full time, whichever occurs first; or
Under 23* years of age and a full-time student, defined as an individual who is either a high school student or enrolled in a recognized, accredited or state approved college or university, carrying a minimum of 12 undergraduate credits per semester or nine graduate credits, or enrolled full-time in a trade or secondary school. The determination of eligibility will be made by Significa, whose decision will be final. Coverage will continue until the end of the calendar month in which the dependent reaches age 23,* the first of the month following graduation, or the end of the month in which the dependent marries or becomes employed full time, whichever occurs first.

Eligibility may continue past the limiting age for unmarried children who are incapable of self-sustaining employment due to mental retardation, physical handicap,mental illness, or developmental disability if the disability began while the child was a validly enrolled dependent on this policy and the child has been certified as disabled by Significa. If a disabled child is already covered under this policy, the disabled dependent will remain eligible for coverage under the policy as long as he/she is certified as a disabled dependent by Significa. Please complete the Disabled Dependent Application form. Medical documentation is necessary and would be reviewed by our medical director.

* Dependent and student age eligibility are specified in your benefits booklet/policy.

Contractual Underwriting Requirements

The following are Significa’s underwriting requirements. The requirements, as they specifically pertain to your group, are included in your policy and are also available on our website www.significa-ins.com.

For Groups with 2 to 9 Eligible Employees

May offer one Significa benefit package.
A minimum of 75% of the eligible participants must be enrolled in the group benefit program.
A minimum of two eligible employees must be enrolled in the benefit package offered.
Significa must be the exclusive provider of group health benefits.

For Groups with 10 to 50 Eligible Employees

May offer a maximum of two benefit packages.
A minimum of 75% of the eligible participants must be enrolled in the Significa group benefit program(s).
A minimum of three eligible employees must be enrolled in each benefit package offered by Significa.
If two products are offered, Significa must be the exclusive provider of group health benefits.

For Groups with 51 or More Eligible Employees

May offer a maximum of three Significa benefit packages.
A minimum of 75% of the eligible participants must be enrolled in the Significa group benefit program(s).
The group plan must maintain 51 or more eligible employees.
A minimum of 10 employees must be enrolled in each product, or upon renewal, the product(s) not meeting the minimum requirement may be cancelled.
If three products are offered, Significa must be the exclusive provider of group health benefits.

Determining Eligibility

It’s important to determine your group’s number of eligible employees and eligible participants. To do so, use these formulas:

Eligible employees

The total number of eligible employees is identified as the total number of employees, less the number of ineligible employees.

Employees not eligible for coverage include:

Part-time employees;
Temporary employees;
Seasonal employees;
Partners, owners, directors, officers.
If a group is a partnership or proprietorship, a partner or owner is a full-time employee if his or her main job is conducting the group’s business and he or she works the required number of hours as designated on the enrollment application to be full time, however can not be less than 30 hours per week. To become an eligible employee, a director or officer of a corporation must be a fulltime employee of the group, working at the location of the business.
Independent contractors, including 1099 contractors;
Unpaid workers;
Members of household staffs or personal employees;
Employees not having satisfied the group-imposed waiting period;
Retirees;
Employees on long-term disability;
Employees who have not worked for three months or less if the employer policies so state due to illness or injury or for three months due to leave of absence or temporary layoff;
Employees not scheduled to return to work; and
Employees enrolled in a Taft-Hartley Trust.

Eligible participants

The total number of eligible participants is identified as number of eligible employees, less the number of excluded employees.

Employees excluded from your number of eligible employees are those who waive coverage due to the availability of:

Medicare Supplement or Medicare Advantage coverage;
Medicaid coverage;
Coverage available to active or retired military personnel; or
Availability of Federal Employees Program group coverage (through spouse’s employer).

Eligible dependents

To be eligible to enroll as a dependent, a person must be the employee’s:

Spouse; or
Employee’s or spouse’s unmarried child(ren) as described by the master policy.

Ineligible dependents

Dependents ineligible for coverage include:

Ex-spouse, even if required by legal decree; and
Retirees.

Groups can be more restrictive in their own definitions of employee eligibility than that stated above, but not less restrictive without the written approval of Significa.

Changes in Enrollment

Whenever any group acquires or loses a significant number of enrolled employees (+/- 10 percent), the group’s coverage may be subject to review.

Minimum enrollment requirements not maintained

A group not meeting the minimum enrollment requirement will be terminated. Employees leaving a group for this reason may be eligible for continuous coverage under an individual conversion policy provided application is made and premium is paid within 31 days of the date of cancellation and the employee has been covered under the group policy for at least three months.

A group of 10 - 50 eligible employees offering two benefit packages that does not meet the required minimum of three employees in each benefit package will be converted to a single product offering.*

For groups of 51 or more eligible employees who offer another carrier and do not meet the required minimum of 10 employees in each product, the product that doesn’t meet the requirement may be cancelled.* You may choose to offer employees the other Significa product(s) being offered.

* Employees whose coverage is cancelled as a result of these situations will not be eligible for continuous coverage under an individual conversion policy.

Non-payment of premium

A group that fails to remit the premium prior to the expiration of the applicable grace period will be terminated.

Employees losing coverage for this reason may be eligible for continuous coverage under an individual conversion policy provided application is made, premium is paid within 31 days of the date of cancellation and the employee has been covered under the group policy for at least three months.

Should any group previously cancelled for non-payment of premiums or returned checks apply for coverage within 12 months of cancellation, the group must be approved by Significa and comply with any credit or collection policies in place before re-enrolling. These may include payment of any previously unpaid grace period premiums and advance payment of multiple months of premiums. Employees will be subject to medical underwriting.

If a group is cancelled for non-payment of premium, Significa is not obligated to reinstate coverage in the event that past due premium is later paid. However, the group may request reinstatement to Significa in writing. If approved for reinstatement, the group will be subject to premium payment terms that may include the payment of all past due premiums and advance premiums in the form of certified funds or another form of funds, as approved by Significa.

Employer goes out of business

A group whose originating organization (employer) goes out of business will have its group coverage arrangements terminated as of the paid-to date, provided Significa was notified.

Employees losing coverage for this reason may be eligible for continuous coverage under an individual conversion policy provided application is made and premium is paid within 31 days of the date of cancellation and the employee has been covered under the group policy for at least three months.

Employer requests termination

Employers requesting termination of their group must do so in writing. The written request must come from the group decision maker or the individual responsible for signing policies and must identify whether the group has obtained other coverage. Failure to notify Significa in writing in accordance with the policy will result in the group’s being liable for premiums covering the grace period. Employees will not be eligible for conversion to individual policies if the group has obtained other coverage.

Conversion to individual policies

Eligibility for continuous coverage under an individual conversion policy is limited to those who have been covered under the group policy for at least three months and who are not eligible for coverage (whether or not elected) under Medicare, Medicaid or another group policy. Renewal of an individual conversion policy will be subject to continued eligibility under these requirements and may be forfeited if the converted policyholder fails to certify same. Individual application must be made and premium paid within 31 days of the date of eligible group coverage cancellation.

Common ownership

Business owners sometimes own more than one legal business entity. When the owner initially enrolls his/her business, he or she has the choice of enrolling all businesses under one policy as an affiliated company, or enrolling each applicable business separately. If the businesses are enrolled separately, they will not be allowed to combine at a future time, unless there is a material change in the ownership structure. Likewise, if combined, the affiliated companies may not segregate, unless there is a material change in the ownership structure. This policy will have no bearing on our interpretation or administration of the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA).

Enrollments and Reporting Account Activity

The Enrollment Application

An Enrollment Application is required when joining any of our group health care coverage plans as well as when making changes to coverage. It is important to familiarize yourself with this form, since you are required to collect, sign and submit these forms to Significa, on behalf of an employee, as the administrator of your company’s health care plan.

You will notice the top of the form asks specific questions of you, such as the reason for the form’s submittal and coverage plan type the changes are being made to. Please make sure the form is filled out completely before submitting it to Significa. We cannot process application/ changes unless all necessary information is provided. If it is not, we will return the form to you and enrollment will be delayed.

The Supplemental Information for Dependent Enrollment Form

If your employee answered “yes” to the questions asked in section 2, Dependent Information of the enrollment application, he/she is required to complete the necessary sections of the Supplemental Information for Dependent Enrollment form.

New-Hire Enrollment

To assure the earliest possible effective date for coverage, offer coverage to all eligible new employees at the time of their hire. However, your company can establish your own eligibility date. New full-time employees, working a minimum of 30 hours per week, can join your group health care coverage, providing we receive their application within 30 days of their eligibility date. Every new employee must complete an Enrollment Application Form (see pages 26, 28 and 30). The form cannot be processed unless all information requested from the enrollee is provided.

Changes in Family Status

Significa provides special coverage arrangements for life events. Coverage can begin or end outside of timely enrollment periods for certain situations.

It’s important that your employees notify you of any changes in family status, including marriage, marriage of their dependents, death, divorce, or other life events affecting their own or their dependents’ eligibility. Complete an Employee Change/Termination Form. Submit the form directly to our administrative office

If an employee marries, please send us the form before the wedding date. We can process the change prior to the date of the wedding to expedite the spouse’s coverage.

Newborn Enrollment

When an employee has a child, the newborn will be covered as a dependent for 31 days immediately following the birth, as required under Act 81. If the employee would like to continue the child’s coverage beyond that date, an Enrollment Application (see pages 26, 28 and 30) must be completed and returned within the 31-day period.

An adopted child or child legally placed for adoption will be covered as a dependent for 31 days beginning on the date adopted or placed in the member’s home. Significa may require legal documentation. If the employee would like to continue the child’s coverage beyond that date, an Enrollment Application (see pages 26, 28 and 30) must be completed and returned within the 31-day period.

Changes of Address

If an employee changes his or her address, please notify us in a timely manner by completing an Employee Change/Termination Form (see page 33) and submitting it with the monthly invoice or sending it directly to us at our administrative office. Employees can also call Customer Service directly to facilitate the change. It is important that we have the correct address on file so your employees will receive any benefit information, identification cards or literature that we may send.

Coordination of Benefits

When your employee enrolls in one of our plans, he/ she is asked to indicate if he/she is covered by another health insurance plan (one from a spouse’s employer, for example). This is for coordination of benefits (COB) purposes.

Coordination of benefits occurs when an employee, spouse, or dependents are covered by more than one health plan at the same time. If the medical expenses are not covered in full by the primary plan, they can be submitted to the other plan. If a spouse is covered under two health plans, his/her expenses will be the responsibility of the primary plan. If a dependent child is covered under two health plans, his/her expenses will be the responsibility of the plan that covers the parent whose birthday (month and day) occurs earliest in the year. When expenses are submitted that were not paid by the primary plan, the employee will need to send the entire explanation of benefits received from the primary plan along with a claim form.

For information on coordinating benefits for parents who are separated or divorced, please refer to your policy or call our Customer Service Department.

Subrogation

Subrogation is an important provision of your group’s Significa product, which helps to manage your cost for health care. If an employee or eligible dependent receives Significa benefits for injuries caused by another person or company, we have the right to seek payment from the other party or their insurance company.

The employee is responsible for paying Significa all amounts recovered by suit, settlement, or otherwise from any third party or his/her insurer in the amount of the benefits provided or paid, and to the extent permitted by law.

The employee is responsible for taking such action, furnishing information and assistance, and executing any paperwork that Significa may reasonably require to facilitate enforcement of its rights. The employee shall take no action prejudicing the rights and interests of Significa.

These provisions shall not apply where subrogation is specifically prohibited by law.

Terminations and Reinstatements

Single Termination

You can visit the website at www.significa-ins.com or use an Employee Change/Termination form (see page 33) when terminating an employee or a dependent from your coverage because they have lost eligibility.

Complete the following information:

Employee’s name;
Employee’s Social Security number;
Employee’s address and home phone number;
Employer’s name and group number;
Section E. entitled “Termination notice and notice of conversion privilege.” Be sure to include the date and reason for termination; and
Your signature as the policy holder.

The form cannot be processed without this information.

You may use the Employee Change/Termination form to satisfy your obligation to notify your employee of his/her conversion privilege under the conversion policy. Please discuss the conversion privilege with your employee and have the employee sign the form. Make a copy of the form for the employee and for your file, then send the original to our administrative office.

Waivers

If a newly hired employee wishes to waive coverage for himself/herself or any eligible dependents, the appropriate Enrollment Application should be used (see pages 26, 28 and 30).

Complete the following information:

Employer section;
Applicant section 1;
Dependent section 2 only if the employee is enrolling a dependent;
Medical section only for individuals who are being enrolled; and
“To Decline Coverage” section for the employee and/ or any eligible dependents who are being waived.

If an employee who is already enrolled wishes to voluntarily drop coverage for himself/herself or a covered dependent, use the Employee Change/Termination form (see page 33).

Complete the following information:

Employee’s name;
Employee’s Social Security number;
Employee’s address and home phone number;
Employer’s name and group number; and
Section C. entitled “Coverage Waiver.” The employee must complete this section and sign the form where indicated at “Employee Signature.”

Waivers will be processed for an effective date equal to the end of the month in which it is received by Significa. No waivers will be accepted for a retroactive effective date. This form cannot be processed without the employee’s signature and all necessary information.

Mail the form(s) to:

Significa Insurance Group, Inc.
P.O. Box 7777
Lancaster, PA 17604-7777

It is important that you provide prompt notification of the effective date of any changes in your employee’s coverage status. For example, if an employee’s or dependent’s coverage is terminated, and the group fails to notify Significa on or before the termination date, the group is liable for premium payment if benefits are provided for covered services received by that employee or dependent after termination.

Rehires

Employees who are rehired after termination of employment may be required to satisfy a new waiting period. Please submit the appropriate Enrollment Application (see pages 26, 28 and 30). Be sure to check “Rehire” and provide the rehire date at the top of the form.

Adding Dependents

If an employee wants to add a dependent(s) for coverage after his/her initial enrollment, use the appropriate Enrollment Application (see pages 26, 28 and 30) and Supplemental Information for Dependent Enrollment Form, if applicable (see page 32).

Complete the same information as when enrolling an employee;
Complete Dependent Section 2; and
Complete Medical Information only for new dependent(s) being enrolled.

Continuing Coverage COBRA

Under specific circumstances, the employee, employee’s spouse, or employee’s dependents may elect to continue coverage under the employer’s policy if they are eligible for the federal COBRA program. If you have selected Significa Benefit Services to administer your COBRA coverage, please call policy administration at 717-581-1300 or 800-796-7460 for assistance.

If Significa Benefit Services is not administering COBRA for you or you have any questions about COBRA, send your concerns by letter to:

U.S. Department of Labor
Pension & Welfare Benefits Administration
Room M300 Gateway Bldg.
3535 Market St., Philadelphia, PA 19104.

You can also access the following websites:

www.benefit news.com or www.benefitslink.com.

Conversion

If an employee, employee’s spouse, or employee’s dependents become ineligible for coverage through your group, they may continue coverage through a direct-pay conversion plan with Significa. It is the group’s responsibility to provide employees with a notice of conversion privilege and its duration upon termination of the employee’s group health care coverage. This notice is required within 15 days prior to or 30 days following the date that the employee’s group health care coverage is terminated. The employee or the employee’s dependents have 31 days following the date that the employee’s group health care coverage was terminated to apply and pay for the conversion privilege, provided that the coverage terminated for one of the following reasons:

The group coverage terminated and was not replaced with continuous and similar coverage by the group.
The employee ceased to meet the eligibility requirements, in which case the employee and employee’s dependents, if any, are eligible to convert.
A dependent ceased to meet the eligibility requirements because of his or her age or the death or divorce of an employee.

The conversion privilege is not available if the employee or employee’s dependents have access to any other group health care coverage, or to those who have not been covered under a group policy for at least three months.

Medicare-Eligible Employees and Medicare Secondary Payer (MSP) Information

Reaching Age 65

Significa will notify you at least 30 days prior to the 65th birthday of your covered employees. It’s important that you respond to each notification because we will continue to bill for full group benefits until you notify us that:

Your employee/employee’s spouse has chosen Medicare; or
Your employee has retired.

Medicare Eligibility

Upon reaching age 65, an individual is normally eligible for Medicare health care coverage through the Social Security Administration (SSA). Eligible individuals should contact the local Social Security office for Medicare enrollment information.

Medicare consists of two parts:

Part A (Hospital Insurance)-

Part A is available without charge to an individual who meets certain requirements (e.g., 40 quarters of full-time employment) or may be purchased from the SSA if the individual does not meet the requirements.

Part B (Medical Insurance)-

Payment for Part B coverage is deducted monthly from the individual’s Social Security check once an individual is enrolled, or it may be purchased from the SSA if the individual does not receive a SS check. If an individual is eligible for Part A, then he/she is eligible for Part B.

An employee and/or an eligible spouse enrolled in a group health plan that is primary payer of his/her medical expenses will not be required to sign up for Medicare Part A and B. Such individuals will be allowed to enroll in Medicare during specified periods other than the “open season” when they are no longer eligible for your group coverage. Please advise the employee/spouse to check with the local Social Security office for Medicare enrollment information.

What is TEFRA?

The Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) made Medicare the secondary payer for certain employees and dependents. Under the TEFRA law and subsequent legislation, the group is the primary payer and Medicare is the secondary payer of claims for working-aged employees and certain dependents in employer groups with 20 or more full-time and/or part-time employees.

TEFRA criteria

When an employer has 20 or more full-time and/or parttime employees on its payroll for 20 weeks in a calendar year (known as the 20/20 threshold), the group becomes the primary payer and Medicare becomes the secondary payer for the remainder of the calendar year and the following calendar year for claims of working-aged employees and certain dependents.

The 20 weeks in a calendar year do not have to be consecutive to reach the 20/20 threshold. If your company reaches the 20/20 threshold at any time during the calendar year, please notify your broker or our Policy Administration Department to request another Allegation of the Employer Form, so you may furnish updated information.

OBRA criteria

The Omnibus Budget Reconciliation Act of 1993 (OBRA) made the group the primary payer and Medicare the secondary payer for certain claimants who are on Medicare because of disability in employee groups with 100 or more full-time and/or part-time employees.

If your company employs 100 or more full-time and/or part-time employees during 50 percent or more of the business days during the previous calendar year, the group is the primary payer and Medicare is the secondary payer for employees and dependents who are entitled to Medicare because of disability.

Common ownership/control

Companies that are under common ownership/control are treated as a single employer.* For example, John Smith owns two companies. Company A employs three full-time employees and one part-time employee. Company B employs six full-time employees and 11 part-time employees. For MSP purposes, John Smith has 21 employees. Therefore, the group is the primary payer and Medicare is the secondary payer for working-aged claims.

The need for your active participation

We depend on information you provide to make accurate claim payment determinations for individuals enrolled in Significa PPO. Federal law dictates when Significa is the primary payer and when Medicare is the primary payer.

To ensure the continuing accuracy of our files, it is your responsibility to notify us promptly of any changes in the size of your workforce or the status of your employees that might affect the order of payment under the MSP statute.

We will be using the information you provide us to update our files. We will also forward this information to the Centers for Medicare and Medicaid Services (CMS) on a quarterly basis so that the CMS can revise its file to reflect relevant changes in primary/ secondary status.

Please use the Allegation of the Employer Form (see page 34) to communicate with us. A form will be mailed to you annually. Complete and return the form to our Policy Administration Department.

Amendments to Medicare secondary payer statute and regulations

The MSP statute and regulations are frequently amended. As a result, it is important that you (your broker, if applicable) and your counsel continue to monitor changes in the law and assess the impact of such changes on your company. While we can assist you in meeting your statutory obligations by providing general information about the statute and gathering information that will detect potential problems in enrollment, it is ultimately your responsibility to ensure your company’s compliance with the MSP statute.

Consequences of non-compliance

Non-compliance with the MSP statute may result in serious financial consequences for an employer, which may include a fine and the IRS’ applying an excise tax of 25 percent of the group health plan expenditures for the calendar year.

Medicare as Primary Payer

If an employee or dependent is enrolled in a group health plan in which Medicare is the primary payer and is or becomes eligible for Medicare, he/she can remain in the Significa group.

If an employee or dependent who is covered by Medicare is in a group health plan that has attained the 20/20 threshold, the group health plan will be the primary payer. If an employee or dependent chooses Medicare as the primary payer, he/she cannot remain in the group with Significa coverage and you will be prohibited from providing him/her with any group health care benefits that would supplement Medicare.

A Medicare direct-pay supplemental plan may be purchased by the employee or dependent but the cost cannot be borne or supplemented in any manner by the group.

Active employees

If your group has fewer than 20 full-time and/or parttime employees, Medicare is the primary payer for all Medicare-eligible employees or dependents.

If your group has more than 20 full-time and/or parttime employees for more than 20 weeks in a calendar year, the group health plan is the primary payer for all Medicare-eligible employees or dependents.

Medicare secondary payer (MSP) demand letters

You may at some point receive a letter from CMS regarding an MSP debt. Such a letter is usually sent because Medicare may have made primary payments for services furnished to Medicare beneficiaries that it believes should have been the primary payment responsibility of the group health plan.

Please note that the law mak for payment under a group health plan jointly and severally responsible for resolving these debts. entities include the employer sponsoring the group health plan. However, CMS will only mail this information directly to employers. Significa can assist you should you receive such a letter for a subscriber who was covered under a Significa polic services were received.

We will research to determine if the group health plan or Medicare is the primary payer each claim to see if we already paid the pro the benefit and applicable precertification/referral information, and will either send a letter to CMS with our rebuttal (with full documentation) on why the debt is not owed, or we’ll process the claims to pay the CMS agency noted in the demand letter. This research and rebuttal/claims adjudication may take up to 60 days.

If you receive an MSP demand letter, please send us the full packet of information, including the letter, the MSP Summary Data Sheet, the Potential Savings Report, claims facsimiles and any additional notices/letters you may receive. Be sure to send both sides of all pages to ensure that all information is received. Mail the packet to:

Significa Insurance Group, Inc.
PO Box 7777
Lancaster, PA 17604-7777

If you have questions regarding MSP demands, please see the CMS website (www.cms.gov) and review the “Medicare Secondary Payer”manual or call the number listed within the demand letter.

Health Insurance Portability and Accountability Act (HIPAA)

Pre-existing conditions

HIPAA permits the pre-existing condition exclusion only if the exclusion relates to a condition, whether physical or mental, for which medical advice, diagnosis, care, or treatment was recommended or received within the six-month period immediately preceding a person’s enrollment date.

Restrictions based on pre-existing conditions

HIPAA provides that a plan may restrict the payment of benefits for a period not to exceed 365 days for a pre-existing condition. In the case of a “late enrollee” (i.e., an individual who enrolls later than he or she was first eligible to enroll, other than during a special enrollment period), the plan may limit benefits for a period of up to 365 days for a pre-existing condition. The period of a plan’s pre-existing condition exclusion must be reduced by periods of “creditable coverage.” Creditable coverage is continuous coverage under a previous health plan.

Portability

Portability allows the time an employee is enrolled under previous health insurance coverage to be credited toward the pre-existing condition exclusion of a new employer’s group health plan. This time is called “creditable coverage.” Credit is given for previous coverage that occurred without a break in coverage of 63 days or more. The law also guarantees that an employer’s health plan must accept a new employee, regardless of health status.

Certificate of Creditable Coverage

In order to provide a new employer with proof of prior coverage, the law requires that a Certificate of Creditable Coverage be issued when an individual leaves a group health care plan. To receive credit from a previous carrier, the Certificate of Creditable Coverage should be sent to Significa with the employee’s application.

Significa will automatically issue a Certificate of Creditable Coverage to participants who terminate their coverage. Some groups may elect to produce their own certificate. Any certificate that we issue will only reflect coverage with Significa.

Understanding Your Billing Invoice

You will receive a monthly group billing invoice from Significa. The bill will reflect the payment due date and premium amount.

We also provide access to electronic rosters and e-mail capabilities for administrative changes. To learn more about these services, or if you have additional questions, please contact a policy administration representative at 717-581-1300 or 800-796-7460, weekdays, 8:30 a.m. - 4:30 p.m.

Access to Benefits

Identification cards

When an employee enrolls in a Significa product, the employee will receive a membership identification card in the employee’s name. If other family members are enrolled, the employee will receive two identification cards, both cards in the employee’s name. Additional cards are available upon request. The cards include the employee’s name, policy identification number, group number, office visit copayment if applicable, and prescription drug identification number and group number

If any of the information on the identification cards is incorrect, if the cards are lost or stolen, or if a duplicate set is necessary, please advise your employees to visit www.significa-ins.com or call a policy administration representative at 800-796-7460.

Emergency care

When an emergency occurs, get care immediately! Medical expenses are covered as if were treated by a preferred provider—no matter where, even if away from home. Coverage includes services and supplies provided by a hospital or facility provider and/or professional provider for emergency treatment of a medical condition with acute symptoms, requiring immediate medical care. Emergency treatment of a bodily injury resulting from an accident will also be covered.

If admitted to a non-preferred hospital or facility, Significa must be notified within 48 hours of the emergency care or as soon as reasonably possible. Once the condition is stabilized, we may require a transfer of care from a non-preferred provider to a preferred provider. Transfer expenses will be covered by Significa.

Preferred Providers

Significa PPO offers a large network of quality physicians, hospitals and other health care providers. All network providers meet strict credentialing criteria. Best of all, Significa preferred providers will accept the Significa PPO allowance as full payment (subject to applicable copayments, coinsurance and deductibles) for covered services.

Choosing your health care provider is a personal decision. Significa offers two levels of benefits for most covered services, depending on the provider selected for care. While we encourage the use of Significa network preferred providers, we know there may be times one will elect to see a provider who is not within the network (a non-preferred provider). However, there are less out-of-pocket expense when using preferred providers.

When an insured uses a non-preferred provider, he/she is responsible for:

Requesting precertification;
Paying the difference in cost between the allowable charge and the provider’s actual charge; and
Paying all copayments, coinsurance and deductibles.

To minimize out-of-pocket health care expenses and obtain maximum payment levels from Significa PPO, be sure that all treating providers are in the Significa preferred provider network. For example, when scheduled for surgery, the insured should verify that the surgeon and all other providers, including the anesthesiologist, radiologist, etc., are network providers. It is important to note that even though a particular facility may be in the network, certain physicians providing services in that facility may not be.

To verify that a provider is in the Significa network, encourage employees to:

Simply ask the physician or health care provider;
Visit our website at www.significa-ins.com to review a directory of preferred providers; or
Contact Customer Service at 1-888-498-9648.

We understand there may be a special need and a preferred provider may not be available for the services required. Under certain circumstances we may make an exception.

When traveling outside of Significa’s service area, insureds will have access to covered benefits through arrangements we have made with other provider networks. Our Customer Service Department can assist with more information regarding care outside of the service area.

Medical necessity

Significa PPO provides benefits for services that are determined to be medically necessary. Medical necessity determinations are made based on diagnosis and current treatment standards from nationally established medical criteria.We will make this determination upon precertification. For services that do not require precertification, we will make the determination after services are rendered. Even after obtaining care, services may be denied.

A non-preferred provider is not obligated to accept our decision and may bill for services if we determine they are not medically necessary. The insured will be liable for the full cost of any services rendered. Avoid this simply by choosing Significa preferred providers for care.

Prescription Drug Coverage

If your group has prescription drug coverage and medication is obtained from a participating pharmacy, your employees should present their identification card and pay the applicable copayment, coinsurance and/or deductible. To find a participating pharmacy or to view the prescription drug formulary, call the Express Scripts Customer Service Call Center toll free at 800-305-7926 anytime, or go online at www.significa-ins.com.

If an employee is outside the service area and needs a prescription filled, he/she should ask if the pharmacy participates with Express Scripts. If the pharmacy is a member of the Express Scripts national network, the medication will be dispensed as described above. If your employee uses a non-participating pharmacy, he/she will be charged the full retail price for the medication. There is no coverage for prescriptions obtained from non-If an employee is outside the service area and needs a prescription filled, he/she should ask if the pharmacy participates with Express Scripts. If the pharmacy is a member of the Express Scripts national network, the medication will be dispensed as described above. If your employee uses a non-participating pharmacy, he/she will be charged the full retail price for the medication. There is no coverage for prescriptions obtained from nonparticipating pharmacies or for prescription drug claims not submitted electronically from participating pharmacies. In special circumstances, if your employees purchase a prescription drug from a pharmacy that was unable to submit their claim electronically, they can contact the Express Scripts Customer Service Call Center to obtain a pharmacy reimbursement form. Then they should submit the paid-in-full receipt and reimbursement form to:

Significa Insurance Group, Inc.
PO Box 7777
Lancaster, PA 17604-7777.

Significa may reimburse, subject to review, up to the price that would have been paid had the claim been submitted electronically, less the group-selected deductible, coinsurance and/or copayment.

Mail order prescription program

Your employees can receive up to a 90-day supply of medication according to your group-specific coverage. Employees may save costs by using mail order. The mail order service should be utilized for medication only when supplied in increments of up to 90 days.

To order the medication, the employee should contact his/her physician to obtain a written prescription for up to a 90-day supply of medication. A mail order form is included in each welcome kit or employees can visit www.significa-ins.com to obtain one.

Mail the completed form, the prescription, and payment to:

Express Scripts, Inc.
P.O. Box 66773
Saint Louis, MO 63166-6773

Allow up to 14 days for the medication to arrive. If there are medications that are needed immediately, those prescriptions should be filled by a local pharmacy.

If there are questions concerning the order, Express Scripts’ customer service representatives and pharmacists can be reached by calling 800-305-7926 anytime. They are available to answer questions regarding medications.

Significa PPO Claims Filing

How Payment Is Determined

Payment under Significa PPO is based on a preferred provider allowable charge.

It Is Important to Use a Significa Provider

Significa providers will file claim forms and handle most precertification requirements. They accept the Significa plan allowances as full payment for covered services. Your employees may be required to pay portions of the allowance if copayments, coinsurance or deductible amounts apply.

For services rendered by non-preferred providers, the patient is liable for all charges in excess of the allowable charge. Using Significa providers can significantly reduce your employees’ out-of-pocket expenses. For example:

Bill for Covered Services	Significa Provider	Non-Preferred Provider

Provider Charge	$1,000	$1,000
Significa Allowance	$800	$800
Annual Deductible	$250	$500
(subtracted from the allowance)
Coinsurance	None	$60
(subtracted from the allowance) (20% of $500)
Plan Payment	$550	$240

Employee’s Responsibility	$250	$760

In this example, those who utilize Significa providers are responsible only for the annual $250 deductible. Those who do not utilize Significa providers are responsible for the annual $500 deductible, 20 percent coinsurance, plus the $200 difference between the provider’s charge and the plan allowance.

Finding a Significa provider

There are several ways to find a Significa provider:

Check out our website at www.significa-ins.com.
Call Customer Service at 888-498-9648; or
Ask the provider.

Significa provider services

Employees should present their Significa PPO identification card at the time services are rendered. A Significa provider will submit a claim form directly to Significa on his/her behalf. The employee doesn’t need to fill out any claim forms. Payment will be sent to the provider and the employee will be sent an Explanation of Benefits notice that describes the services processed.

Non-preferred provider services

Most non-preferred providers will submit a claim to Significa on the employee’s behalf. However, if submitting a claim is required, the employee should request an itemized bill that shows:

Patient’s full name, date of birth and address;
Insured’s name, group number (if applicable) and identification number (as shown on your ID cards);
Date each service or supply was provided;
A description and/or procedure code for each service;
Diagnosis, illness or injury for each service;
Amount charged for each service;
Number of units for each service;
Name, address, fax and identification number of provider; and
Location where services were provided, if other than physician’s office.

Certain services may require additional information, such as medical notes from the provider, payment or rejection notices from other insurance carriers (including Workers’ Compensation, other health plans, Medicare, auto insurance, etc.), origin and destination points for ambulance transfers, or accident information. Delays in submitting this special information, when required, may result in a claim processing delay.

Claim form

You can obtain a claim form from our website at www.significa-ins.com or by calling customer service at 1-800-796-7460.

Claims must be submitted within one year from the date the service was rendered in order to be considered for payment.

For groups terminating coverage, or for employees whose coverage has terminated, please submit claims within 90 days of the service to ensure prompt and proper payment.

Significa PPO claims should be mailed to:

Significa Insurance Group, Inc.
P.O. Box 7777
Lancaster, PA 17604-7777

In accordance with the Employee Retirement Income Security Act (ERISA), Significa must notify insureds of any adverse benefit determination within a reasonable period of time, but not later than 30 days after receipt of the claim. Significa may extend this period for up to 15 days, one time only, provided that Significa determines that such an extension is necessary due to matters beyond the control of Significa. If an extension is necessary, Significa must notify the employee before the expiration of the initial 30-day period, of both the circumstances requiring the extension of time and the date by which Significa expects to make a decision.

If the extension is needed because the insured did not submit the information necessary to decide the claim, the notice of extension must specifically describe the required information. The employee will be given at least 45 days from receipt of the notice within which to provide the specified information.

If a Claim for Benefits Is Denied

Appeal Procedures for Insureds

Significa appeal procedures assure that your employees receive a full and fair review. The procedure for filing an appeal and for designating a representative to assist your employees is explained here. An appeal will be classified as either a complaint or grievance, depending on the issue being appealed. Your employees may submit written data or other information in support of their cases. They may also request copies of all documents, records, and other information relevant to their cases. All disputes involving denial of payment for a health care service based in whole or in part on medical judgment will be reviewed by qualified personnel with experience in the same or similar scope of practice and all notices of decisions will include information regarding the basis for the determination.

For any Significa claim, your employees have 180 days from the date of their receipt of the Significa decision to file a complaint or grievance.

Your employees may also designate a representative to act on their behalf. Significa must receive this designation in writing. A form is available for their convenience

Significa has established the following appeal procedures for your employees’ use if they are in any way dissatisfied with Significa or a preferred provider.

Complaint

If your employees have a dispute or objection regarding a preferred provider, coverage issues including policy exclusions, limitations and non-covered benefits, or the operations and management policies of Significa, they should contact our Customer Service Department at 800-796-7460. Your employees or their designated representatives may file a written or verbal complaint to Significa as well as written data or other information in support of the complaint. They also may request copies of all documents, records, and other information relevant to their complaint. A complaint does not include a grievance.

The complaint will be promptly investigated by a Review Committee comprised of one or more Significa employees who have not been involved in the prior decision to deny the complaint and are not subordinate to such individuals. If the complaint involves services that have not yet been rendered (pre-service), the Committee will provide the employee with a response within 30 days of receipt of the complaint. If the complaint involves services that have already been rendered (post-service), the Committee will provide the employee with a response within 60 days of receipt of the complaint. A written notification regarding the decision of the Review Committee will be mailed to the employee within five business days of the determination. The notice will include the basis for the decision and any additional rights your employee may have.

If your employees are members of an ERISA group, they have the right to bring civil action under section 502(a) of the Employee Retirement Income Security Act of 1974 once all administrative remedies have been exhausted, if the benefit determination is adverse to them. (This privilege does not apply to non-ERISA group members.)

At any stage of the complaint process, your employees have the right to request that Significa appoint a staff member who has had no direct involvement in the case to aid them in preparing their complaint. Such assistance may be particularly useful in preparing a succinct, factual, supportable presentation.

In the complaint process, your employees should be as specific as possible as to the remedy being sought from Significa.

Grievance

A grievance is a request by your employees or a provider with their written consent to have Significa review the denial of a health care service based on medical necessity and appropriateness. This includes cases in which Significa denies full or partial payment for requested health care services, approves the provision of a requested health care service for a lesser scope or duration than requested, or denies payment of the provision of a requested service but approves payment for the provision of an alternative health care service. A grievance does not include a complaint.

If your employees have a grievance request, they should contact our Customer Service Department. Significa will accept either oral or written grievance requests from your employees or their designated representatives as well as written data or other information in support of the grievance. Your employees also may request copies of all documents, records, and other information relevant to their grievance.

The initial grievance will be promptly investigated by a Review Committee composed of one or more persons selected by Significa who did not previously participate in the decision to deny payment for the health care service and are not subordinate to such individuals. This will include consultation with a licensed physician or, where appropriate, a licensed psychologist in the same or similar specialty that typically manages or consults on the health care service being reviewed. If the grievance involves services that have not yet been rendered (preservice), the Committee will provide the employee with a response within 30 days of receipt of the grievance. If the grievance involves services that have already been rendered (post-service), the Committee will provide the employee with a response within 60 days of receipt of the grievance. Written notification to the employee and provider regarding the decision will be mailed within five (5) business days of the determination. The notice will include the basis and clinical rationale for the decision and any additional rights your employee may have.

If your employees believe that the time frame for the standard grievance process could seriously jeopardize their life, health or ability to regain maximum functioning, they may request an expedited grievance. In order for a grievance to be expedited, the employees must provide Significa with a written certification from their physician stating that their life, health or ability to regain maximum function would be placed in jeopardy as a result of the delay occasioned by the regular review process. The certification must include a clinical rationale and facts to support the physician’s opinion. Significa will arrange to have the grievance reviewed by it’s medical director within 72 hours. Your employees will be orally informed of the decision within 72 hours followed by written correspondence within two days of the oral notification.

If your employees are members of an ERISA group, they have the right to bring civil action under section 502(a) of the Employee Retirement Income Security Act of 1974 once all administrative remedies have been exhausted if the benefit determination is adverse to them. (This privilege does not apply to non-ERISA group members.)

At any stage of the grievance process, your employees have the right to request that Significa appoint a staff member who has had no direct involvement in the case to aid them in preparing their grievance. Such assistance may be particularly useful in preparing a succinct, factual, supportable presentation.

In the grievance process, your employees should be as specific as possible as to the remedy being sought from Significa.

If your employees have any questions concerning the filing status of a complaint or grievance, your employers should call our Customer Service Department at 800-796-7460 weekdays, 8:30 a.m. - 4:30 p.m.

Confidentiality

As part of normal business operations Significa and its various business affiliates have access to your records that contain private and privileged information. We use this information to provide benefits, to ensure and improve quality and to identify health care needs. Maintaining the confidentiality of this information is very important.

We have adopted policies to ensure the confidentiality of employee information and records. Information contained in your medical records and received from physicians, other network health care practitioners, hospitals or health professionals instrumental in the doctor/patient relationship is kept confidential.

We will not release medical information without the employee’s written authorization except for payment, treatment and health care operations. We will obtain authorization in the following situations:regular text

When requests for information are received from someone other than the insured.
When insured-identifiable information will be shared with another organization or entity not involved in the provision of care of benefits.
For the release of any information related to mental health, substance abuse or AIDS.

Any information shared with you will be reported on the entire group, not on an individual basis, to maintain confidentiality.

Insureds have the right to access information contained in their medical records unless access is specifically restricted by the attending physician for medical reasons. If an employee needs a copy of his/her medical records, he/she should contact his/her treating physician to obtain a copy

If you or an insured have concerns regarding the confidentiality of information, you or the insured have the right to file a complaint with Significa.

Disabled Dependent Application

Enrollment Application Form for Small Group Coverage (2-50)

Enrollment Application Form for Large Group Coverage (50+)

Enrollment Application Form for Large Group Coverage (100+)

Supplemental Information for Dependent Enrollment

Employee Change/Termination Form

Allegation of the Employer Form

Certificate of Creditable Coverage

Claim Form

Mail Order Form

This website is continually being improved to offer you more information and health care related tools. We encourage you to visit the site often to get the most from you health care coverage plan.