We have revised the exceptions process to better serve your needs and turnaround times. Delays in approving exceptions occur when we receive inadequate information to make an exception determination. Acquiring the needed information requires additional time and research, thus delaying the entire exceptions process. The attached exception request form was created to capture the needed information resulting in faster turnaround times. Going forward the exception request form will be required to process your exception request. Completed forms, along with the Change or Enrollment form for paper agencies should be sent to HBRinquiries@shpnc.org. Only completed forms will be processed. Forms missing required information will be returned.

 

Important Reminders

To ensure consistency and adherence to both State and Federal legislation it is important that all transactions for enrolling newly eligible dependents and the processing of terminations are completed within 30 days.

 

HBRs are responsible for understanding and applying the eligibility, enrollment and termination rules and requirements of the State Health Plan and ensuring that transactions are processed within the required timeframe.

 

Enrollment Rules

• New employees - Must enroll themselves and their dependents within 30 days from their date of hire. Enrollment past 30 days is allowed, but employee/dependents over the age of 19 may be subject to a pre-existing conditions waiting period. For late enrollees, coverage will be effective the 1st of the month following the written request. Requests after 30 days require approval by the State Health Plan. If approved, any premium deducted from the employee's paycheck must be payroll deducted on a post tax basis.
• Adding dependents - Must occur within 30 days from a qualifying life event. Requests after 30 days require approval by the State Health Plan.
• Employee terminations - To ensure members receive timely COBRA notifications, terminations should be processed within 30 days after the termination or reduction in hours. Requests after 60 days require approval by the State Health Plan.
• Dropping dependents - If dropping a dependent due to a qualified life event, such as gaining other coverage, the employee has 30 days from the event to remove the dependent. Terminations beyond 30 days require approval by the State Health Plan.

The enrollment/termination rules are in place to protect the members and provide consistency in administering the Plan. Members should have timely access to the care they need. In addition, late enrollments and terminations lead to retroactive premium adjustments, reconciliation issues and claims paid for members who are no longer eligible.

 

For more information on the requirements for enrolling or making changes to health coverage, please review the "When Coverage Begins and Ends" section of the Benefits Booklet on the Plan's website.

 

New Process Workflow: