Policy on Retroactive Transactions of Health Plan Membership
BACKGROUND and FACTS:
Group Benefits Strategies (GBS) provides each Participating Governmental Unit with a monthly bill for health plans that includes a list of enrollees by health plan.
CCMHG requires each Participating Governmental Unit to (1) pay as billed, (2) review the membership lists each month and (3) inform GBS’s Manager of Enrollment & Billing of any disputed enrollments.
Health plans permit retroactive changes up to 60 days following the event (termination or enrollment).
HPHC makes capitation payments to physicians as well as fee payments. These capitated amounts cannot be recovered once paid.
CCMHG’S POLICY (does not include Medicare Advantage plans which are governed by the Centers of Medicare and Medicaid Services):
The CCMHG’s policy is 60 days retroactivity for enrollment transactions. The CCMHG will consider exceptions in 3 cases. In all cases reimbursements to governmental units will be net of any expenses that cannot be recovered from health plans, healthcare providers, reinsurer, or other.
No exceptions will be made to the 60-day retroactive except for the following –
1. Terminations because of death
Health plan terminations will be made beyond the 60-day retroactivity period to the date of death of the member when the Participating Governmental Unit provides Group Benefits Strategies (GBS) with a valid death certificate. Fees and payments withheld by the health plan, healthcare provider, and/or reinsurance premiums will be subtracted from the amount owed to the governmental unit. In the case of health plans with monthly capitation payments to providers, the CCMHG will make an estimate of these payments made on behalf of the member since his/her death and will subtract this from the premium credited to the governmental unit. The estimate will not be a subject of dispute.
2. Member enrolled with two CCMHG employers for the same period (BCBS only)
A governmental unit may request an exception to the 60-day retroactivity if it has failed to terminate a member who is then simultaneously covered with the same health plan through another CCMHG employer. The unit must put its request in writing to GBS explaining the circumstances. No such request will be processed with retroactivity beyond 6 months, and any fees withheld by the health plan and claim payments along with reinsurance premiums will be subtracted from the amount credited to the CCMHG employer requesting the relief.
3. Member simultaneously enrolled with a non-CCMHG employer (BCBS only)
If the member was enrolled through the same health plan with an employer that is not part of the CCMHG while erroneously remaining enrolled with the CCMHG employer, the CCMHG employer may make a written request to GBS for retroactive termination beyond 60 days but not exceeding 6 months. The CCMHG employer making the request will bear the burden of documenting that the member has coverage on the same plan through another employer. Any fees withheld by the health plan and claim payments will be subtracted from the amount credited to the CCMHG employer requesting the relief.