Plan Administration

1: What happens if I do not provide a beneficiary?

A: If the beneficiary is not designated on the enrollment and signed in original ink, it will default to the estate of the employee.

2: What is the Waiting Period?

A: This is the period between the time that an employee was hired and the time that they are eligible to receive benefits. It helps to ensure that you are only covering those people who you know will stay with your company long term. It also helps to protect against high claims from employees who do not stay with the company.

3: Can I Waive the Waiting Period?

A: Most contracts do allow you to waive the waiting period for key employees. If you choose to waive the waiting period you must waive ALL of the waiting period and the enrollment card must be submitted when the person is hired. To waive the waiting period send a cover letter stating your intentions along with the enrollment card.

4: What happens if I forget to enroll an employee?

A: If the enrollment card for an employee is not received within 31 days of the employee's eligibility date, the employee is considered a late applicant and will be required to submit evidence of insurability (medical questionnaire). Their coverage can be restricted or even declined based on this medical information. It is always important to submit enrollment card in a timely manner.

5: How do I add a dependent?

A: Submit a change form to the insurance company as soon as you can (within 31 days) of the change of family status. If your spouse has coverage elsewhere, you must still inform the insurance company so that if your spouse's coverage terminates in the future, they will not be considered a late applicant.

Each carrier has its own form for making such a change. These can be found in your administration kit or at the carrier's website. If you are unsure of which form to use, contact your GMS associate.

6: Can I cover my common-law spouse?

A: Yes, common-law spouses and same sex spouses are eligible dependents under your group insurance plan. Most plans have a 12-month co-habitation clause meaning that if you live together for 12 consecutive months, your partner is considered a spouse and is eligible for the plan. Some plans do not have a co-habitation period - check your contract to verify. In all cases you must enroll your spouse within 31 days of their becoming eligible.

7: Do I have to take coverage if my spouse has coverage?

A: Yes. You must be enrolled for all insured benefits (ie Life, AD&D, Dependent Life, STD, and LTD). You may waive health and dental benefits provided you have coverage through your spouse's plan.

8: What do I do if an employee who has previously waived coverage for him/herself or his/her spouse now wants coverage?

A: If an employee or their spouse has previously waived coverage, they will be required to submit evidence of insurability unless they were previously covered elsewhere and have lost that coverage.

9: What is Co-ordination of Benefits?

A: This is an option for employees whose spouse's employer also offers benefits. In this case both spouses would apply for family benefits. Each would submit their own claims through their own employer's plan. Any portion that was not covered under the first plan can be submitted under the other plan for payment.

10: What is a non-evidence maximum (NEM)?

A: This applies to Life, Accidental Death and Long Term Disability benefits. It represents the amount of insurance an employee is eligible for without submitting evidence of insurability (non medical questionnaire). Evidence of insurability is required when the employee's salary entitles them to a higher amount of benefit than the NEM allows.

11: I have been charged for premiums after I terminated an employee. Why?

A: This could be because the notice of termination and the billing crossed paths. Each carrier runs their billing at approximately the middle of the month for the following month's statement. If the termination is not received and processed prior to this time, it will miss the current statement. It is best to pay the billing as you receive it and watch for a credit adjustment on the next month's statement.

This could also be because the insurance company was not notified of the termination until a while after the termination date and have paid out claims during that period. It is always important to notify the insurance company as soon as possible and to collect the drug card from the employee.

12: How long can we extend benefits for terminated employees?

A: Any employee who has been terminated should have benefits extended for the legislated notice period according to the Employment Standards Act (ESA). If you are offering a severance package, it is important to apply for the extension of benefits before making the offer to the employee. Benefits will generally be extended for a maximum of 18 months.

13: What happens when an employee goes on maternity/paternity leave?

A: If the benefits are 100% employer paid, you must continue all benefits except disability benefits. If there is a cost sharing between the employee and the employer, the employer only has to keep the employee on the plan for as long as the employee continues her/his contributions.

14: How long do I have to extend benefits for disabled employees receiving disability benefits?

A: Employees off work on disability should still be entitled to employee benefits. It is important for each company to have their own policy in place clearly stating the length of time that these benefits will continue. Your GMS representative can help you set up such a policy and develop a plan to communicate it to your current employees and future hires.

15: My drug card does not work. Why?

A: There are many possibilities for this. Try to get as much information as possible from the pharmacist to help us determine the cause. Frequent problems include:

• Date of birth or name is input incorrectly by the pharmacist or at the insurance company - the pharmacist can call the drug company and get approval if this is the problem. The change can be made later.
• Spouse tries to use the drug card when co-ordination of benefits is set up on the plan. Claims for the spouse must go through their own plan first.

16: How do I know if my specific claim is covered?

A: The best way to handle this is to submit a pre-determination. This is just like a claim but no receipts are required. The insurance company will notify you of what is/is not covered.

Send your predetermination in just like a claim but indicate PREDETERMINATION at the top of the claim form. It is best to treat all large dollar claims in this manner.