Producers’ Administrative Guide
to Selling Individual Plans in Oregon
Spring 2014
Table of Contents
Eligibility and Enrollment Periods ... 2
Application Process Outside of the Exchange ... 4
Premium Payments and Due Dates ... 5
After Your Clients Are Enrolled ... 5
Canceling a Policy ... 6
Administrative Details for Producers ... 7
Thank you for partnering with LifeWise Health Plan of Oregon to provide quality healthcare coverage to individuals in Oregon. We value your business and want to make it easy for you to sell our individual plans. We also want to help you ensure that our current and prospective members receive the best service possible.
This guide summarizes key procedures pertaining to the sale and administration of LifeWise Health Plan of Oregon individual health plans, inside and outside of Oregon’s health insurance exchange. We strive to make benefits management and administration easier for you and our members.
We’re a local company that has been providing individual and family health coverage to more than 20,000 people in Oregon for the last several years. They look to us because we actively support and encourage members to live the healthiest lives possible through our coverage, programs, and services.
Eligibility and Enrollment Periods
Eligibility (applies inside and outside the exchange)
To be eligible to apply for individual health coverage, your client must:
• Currently be, and plan to remain, a resident of the state of Oregon. We may require proof of residency at any time during the life of the contract. Examples of proof of residency are a driver’s license issued by the state of Oregon or a utility bill showing a physical address in the state of Oregon.
• Not be enrolled in federal Medicare A or B (including entitlement due to disability), or a Medicare Choice or Medicare Advantage plan.
Eligible dependents who can enroll on a policyholder’s plan include: • Spouse or legally registered same sex domestic partner
• Birth, legally adopted, foster, or placed children under the age of 26 Open enrollment period (inside and outside the exchange)
Individuals may apply for enrollment in a LifeWise Health Plan of Oregon plan during an open enrollment period. The open enrollment period is set by the state of Oregon and may change from year to year. Refer to lifewiseor.com for the dates of open enrollment.
A completed application must be postmarked or received electronically before the end of this established open enrollment period in order to be eligible for coverage without a qualifying life event.
Special enrollment periods (inside and outside the exchange)
Individuals are eligible to apply outside of the open enrollment period only when they experience a qualifying life event. A 60-day special enrollment period (which starts from the date of the qualifying event) constitutes the timeline in which eligible individuals can sign up for individual health coverage.
Applicants must report the qualifying event within 60 days of the event’s occurrence either through the exchange or directly to LifeWise depending on how they choose to apply. LifeWise or the exchange will then determine whether they are eligible to apply with a special enrollment period. The exchange will allow qualified individuals and enrollees to enroll in or change from one qualified health plan to another as a result of the following triggering events:
• A qualified individual or dependent loses minimum essential coverage. (Note: This condition excludes loss of coverage due to non-payment of premiums by the individual, but includes loss of coverage due to non-payment of premiums by an employer.)
• A qualified individual gains a dependent or becomes a dependent through marriage, birth, adoption, or placement for adoption.
• An individual who was not previously a citizen, national, or lawfully present individual gains such status.
• An individual’s enrollment (or non-enrollment) in a qualified health plan is unintentional, inadvertent, or erroneous; and is the result of the error, misrepresentation, or inaction of an officer, employee, or agent of the exchange or the U.S. Department of Health and Human Services (HHS) or its instrumentalities as evaluated and determined by the exchange. In such cases, the exchange may take such action as may be necessary to correct or eliminate the effects of such error, misrepresentation, or inaction.
• An enrollee adequately demonstrates to the exchange that the qualified health plan in which he or she is enrolled substantially violated a material provision of its contract in relation to the enrollee.
• An individual is determined newly eligible or newly ineligible for advance payments of the premium tax credit or has a change in eligibility for cost-sharing reductions, regardless of whether such individual is already enrolled in a qualified health plan. The exchange must permit individuals whose existing coverage through an eligible employer-sponsored plan that will no longer be affordable or provide minimum value for his or her employer’s upcoming plan year to access this special enrollment period prior to the end of his or her coverage through such eligible employer-sponsored plan.
• A qualified individual or enrollee gains access to new qualified health plans as a result of a permanent move.
• An American Indian, as defined by Section 4 of the Indian Health Care Improvement Act, may enroll in a qualified health plan or change from one qualified plan to another one time per month.
Enrolling clients in a dental plan (applies outside the exchange only)
Adult dental coverage can be purchased directly through LifeWise Health Plan of Oregon. Applicants must be enrolled in a medical plan with LifeWise Health Plan of Oregon.
Applicants can chose to enroll in a dental plan at the time they purchase their medical plan. In addition, all members will be given the opportunity to add dental to their medical plan in June of each year, to be effective July 1. Members will be notified of this add-on period directly via letter. Changing from current plan (inside and outside of the exchange)
Outside the exchange: Plan changes can only be made during the open enrollment period. Plan change requests will be effective the first of the month following the receipt of a completed application. If you have specific questions regarding helping your client make a plan change, call the Producer Support team at 877-205-9725.
Inside the exchange: Plan changes can be made only during the open enrollment period. Plan change requests must be initiated through the exchange.
Adding dependents to a plan (applies inside and outside the exchange)
Dependents can be added to a policy during the open enrollment period or during a special enrollment period if they qualify. Refer to the Special Enrollment Qualifying Event document (https://www.lifewiseor.com/documents/030796.pdf) for more detailed information. A completed application and any required documentation must be submitted within the open enrollment period or within 60 days of the qualifying event in order to be added to the policyholder’s plan.
Application Process Outside the Exchange:
Paper process
Download and complete the individual enrollment application. (https://www.lifewiseor.com/documents/027138.pdf)
Mail the completed application and any required supporting documentation to LifeWise Health Plan of Oregon, P.O. Box 91120, MS 391, Seattle, WA 98111-9220 or fax to 425-918-5278. Electronic process
(https://lwor.inshealth.com/ehi/APLogin.ds?allid=Lif25313). Contact your account executive or Producer Support to learn how to set up your account.
Premium Payments and Due Dates
Premium due date
Premiums are due on the first day of each month, with grace periods noted below. If payment is not received by the end of the grace period, coverage will be terminated on the last day of the first month of the grace period. The member will not be eligible to re-enroll until the next open enrollment period.
Grace periods
• If the federal government is paying a portion of the premium as an advance payment of the premium tax credit, there is a three-month grace period. If we do not receive the full premium by the end of the grace period, coverage will be terminated on the last day of the first month of the grace period.
• If the federal government is not paying a portion of the premium, there is a 30-day grace period. If payment is not received by the 20th day of this grace period, we will let the
policyholder know in writing. If premium has not been received by the 30th day the policy will be terminated. The termination will be effective back to the last date of payment.
Important note! Premiums may not be paid or sponsored by an employer, provider, not-for-profit agency, or any other third party, except as required or allowed by law.
How to make payments
There are several ways for members to make their premium payments:
• Automatic funds transfer: Complete and submit the Automatic Funds Transfer Authorization form: https://www.lifewiseor.com/documents/012599.pdf
• Online: Log into their account and set up a one-time or recurring payment.
• By phone: Call 1-866-390-2742. Transfer payment from checking or savings account, or Visa/MasterCard credit or debit card.
• By mail: Send payment to LifeWise Health Plan of Oregon, Attention Payment Processing, P.O. Box 91060, Seattle, WA 98111.
After Your Clients Are Enrolled
Selecting a primary care provider (PCP)
Prior authorization policy
Members may be required to get advance approval for coverage of planned medical services and procedures. Prior authorization helps your clients:
• Find out if they’re covered by their benefits before they have a scheduled procedure • Save money and avoid extra costs
• Get an estimate of their out-of-pocket costs before they receive their service • Avoid unnecessary services
Providers should request a prior authorization on behalf of your clients. Providers are familiar with the process for obtaining a prior authorization, and they should do so for your clients/their patients. Providers have all of the medical information needed to seek review and approval of their requested medical services. If your client’s doctor doesn’t request a prior authorization and gives your client a service that requires a prior authorization, your clients may have to pay extra costs, such as:
• The full cost of their service
• A share of the cost of the service plus up to an additional $1,500
To avoid extra costs for your clients, inform them to always ask their provider to request a prior authorization before they have a planned medical service.
For a complete list of services that require prior authorization, visit
https://www.lifewiseor.com/documents/028862.pdf
Canceling a Policy
Plans purchased inside the exchange
Policyholders may cancel the policy by notifying the exchange in writing within 14 days prior to the termination date. If the member has enrolled through the exchange, all cancelations must be initiated by calling Cover Oregon at 1-855-268-3767.
The exchange will cancel the policy and notify LifeWise of the status. The policy will be canceled as of the last paid-to date of coverage.
Plans purchased outside the exchange
If the member has enrolled directly through LifeWise Health Plan of Oregon, cancelations must be received in writing by the policyholder or the producer. Cancelation requests can be emailed (only by the producer) to [email protected], or faxed (by the member or producer) to 425-918-3727. Retroactive cancelations are not allowed.
If the request to cancel is received within the first five business days of the month, coverage will end on the last day of the prior month. However, this does not apply if LifeWise paid for services received after the date the policyholder asked for coverage to end. In that case, coverage will end on the last day of the month in which we got the request. The plan will not pay for services received after the date coverage ends.
Administrative Details for Producers
Commissions
Commissions are paid on the first Monday of each month. Commissions are paid only on policies for which payment is current. Commissions will be paid on a per member per month basis for all members over the age of 21 and for up to three dependents under age 21. For questions regarding commissions, call Producer Support at 877-205-9725.
Producer of record for client
To become the producer of record on an existing policy, the policyholder must complete and sign producer of record change form. Producer of record changes will take effect the first of the month following receipt of the completed form. Forms can be downloaded at
www.lifewiseor.com/producer/forms Ordering supplies
Download an order form at www.lifewiseor.com/producer/forms. Fax the form to Producer Support at 425-918-3378 or email to [email protected]
Other resources
We are here to help you! Producer Support can be reached by phone Monday – Friday 8 a.m. - 5 p.m. Pacific time at 877-205-9725 or by email at [email protected]
For questions regarding providers or claim status, call Customer Service at 800-596-3400. Visit www.lifewiseor.com for more resources.
