Plan Documents & Eligibility

The Employer/Plan determines who is actively at work and covered under the plan. This includes determinations for employees who have been furloughed or have reduced hours but will still considered actively at work for the purposes of plan coverage and stop loss premiums.

TMHCC will accept any notification of how the plan will address and administer their updated guidelines. TMHCC will allow retroactive changes to keep currently covered members on the plan. TMHCC will provide formal approval upon receipt of notification.

Layoffs & Furloughs

If a client chooses to allow furloughed / lay-off employees to remain on the benefit plan, THMHCC will follow the plan change to continue their stop loss coverage as well. TMHCC does not require a formal Plan Document Amendment, but does need something from the group documenting how they are handling the situation, such as an official notice to their employees, or if there is a plan amendment, a copy of that amendment.

If a certain percentage of a work force is laid off, standard underwriting requirements will apply with enrollment changes. Of course, in these unique times, communication is key and all enrollment variances will be considered on a case by case and situation by situation basis.

If an entire work force is laid off or furloughed, TMHCC's policy follows the Plan Document. Lay-offs would be governed by the employer and how they wish to
update their plan. If the company is not operating but still keeps the plan active, TMHCC's stop loss policy will continue to offer coverage when the plan is updated, via notice or amendment, for the continued eligibility and payment of stop loss premiums. If the company ceases to offer benefits and terminates the plan, TMHCC's Stop Loss Policy would also terminate.

COBRA Extension Guidelines

TMHCC understand the immediate impact the Rule has on our stop loss policyholders and the entire self-funded health market.

TMHCC views the outbreak period as an extension to normal timing requirements. Therefore, there is no rating impact to inforce policies nor any PD amendment requirements.

 

Actively at Work & No Scheduled Shifts

Determination of who is actively at work and covered under the plan will be made by the employer. This includes determination for employees who have been furloughed or have reduced hours but will still be considered eligible for the purposes of plan coverage.

TMHCC is agreeable to accepting any notification of how the plan will address and administer their updated guidelines. We will also allow retroactive changes that keep currently covered members on the plan for as long as employees are included in the census and the applicable stop loss premiums are paid.

Policy Administration & Wet Signatures

During this time, TMHCC agrees to forgo "wet" signatures on Policy Forms, Applications, etc. and will accept scanned signatures.

Claims Reimbursements & Timely Filing

Standard claims process will continue to apply. While TMHCC does not plan on changing required documentation due to effected entities, they are willing to work with SLIS and the clients on any extenuating circumstances.

TMHCC will not agree to extend timely filing limits at this time, however will work with SLIS and the clients on any extenuating circumstances.

Early Rx Refills

Policyholders who decide to allow covered participants to receive early prescription refills to ensure they have a 30-day supply will be allowed to apply these costs as eligible expenses under their Stop Loss policy without prior notification.

Telemedicine & Virtual Visits

Policyholders who decide to waive cost-sharing for telemedicine and virtual healthcare visits for covered participants will be allowed to apply these costs as eligible expenses under their Stop Loss policy without prior notification.

Cost Share

Policyholders who decide to waive the cost of deductibles, copays, and costsharing for COVID-19 testing for covered participants will be allowed to apply these costs as eligible expenses under their Stop Loss Policy without prior notification.

Regarding treatment, claim expenses related to the treatment of COVID-19 (Coronavirus) will apply under the Stop Loss coverage as any other illness as defined in the policyholder’s plan document. TMHCC is agreeable to accept any notification of how the plan desires to update their benefit plan. Such a plan change may result in changes to rates or aggregate factors on a case by case basis.