What documentation is necessary for enrolling a group?
The group is required to submit the completed Group Application, Enrollment Forms and the first month’s premium.
What forms are necessary to enroll an employee?
A completed Enrollment Form is needed.
Can I email information to the plan?
What is needed to renew my coverage?
A completed group application and possibly Enrollment Forms, depending on what benefit changes are being made at renewal. If you have a broker, the group application must be signed by you and the broker.
Notification of Changes
Who do I contact with changes of address or other administrative changes?
Really, anyone at Piedmont can take these changes for you and distribute them to the other areas. It is generally best to contact the Eligibility/Enrollment Coordinator with all changes.
Can I make changes to the group contract during the year?
Only certain changes can be made to the group contract off renewal and only one such change to the group contract during the year is allowed.
Premiums/Rate and Quotes
Is payment required at the time of application?
The group’s first month’s premium is due at the time the group submits the initial group application for coverage. The premium is due the first of the month prior to the month of coverage throughout the year. The monthly premium statements reflect enrollment as of a given time and date. The premium obviously changes as members come on or go off of the plan so changes in enrollment and premium adjustments may be included on the statement the following month.
What percentage of premium does the employer have to contribute?
The employer is required to contribute at least 50% of the employee premium cost.
Are there participation requirements?
Yes, at least 75% of all eligible employees must be covered under the health plan. Eligible employees are those that meet the eligibility requirements and do not have coverage elsewhere such as through a spouse’s employer or through an individual policy.
Do I have to go through a broker to get a quote?
While there is no broker requirement, we do support the use of a broker. Whether you use a broker or not, we also encourage you to contact us directly with any questions or concerns. Rates on small groups (2-50) are not lower if you do not use a broker.
What products and services do you offer?
We offer an array of health insurance plans as well as self-insured arrangements. Plans generally include prescription drug coverage, preventive care coverage, disease and case management, and vision discounts. We also have COBRA administration, a wellness program, flexible spending account and health reimbursement arrangement administration, and some association value added benefits.
Can you please describe your provider networks?
The Piedmont Community Health Plan network includes almost all local providers in the Lynchburg and surrounding areas. It also includes providers in the Halifax/South Boston area as well as the Farmville/Prince Edward County area.
We also contract with other networks outside our area to accommodate employees that reside elsewhere or college students that attend school out of the area. These include networks that cover the rest of the state of Virginia and surrounding states such as West Virginia, North Carolina and South Carolina. In addition, we have a national network to cover the rest of the United States.
We specifically contract with the University of Virginia, the Medical College of Virginia, and the University of North Carolina for tertiary care. We also arrange for members to receive services outside the network when medically necessary.
Emergency care coverage is available anywhere all the time. Members are not restricted to network providers in emergency situations.
How often are your paper and on-line directories updated?
Directories are typically updated once a year or more frequently as needed. On-line information is kept current on a monthly basis.
Is there detailed benefit information for employees, if so, how do they get it?
Yes, employees should receive detailed information on their benefits that includes a certificate of coverage or summary plan document and schedule of benefits. We typically provide packets of materials for employees at the time of enrollment. These are generally provided through the broker or Piedmont during enrollment meetings.
Is there a pre-existing conditions waiting period? No
When traveling, can my employees receive coverage out-of-area?
Members are covered for emergency and urgent care anywhere in the world and at any time. We understand that emergencies and urgent situations happen while you are outside the service area. In these situations members should seek immediate care. Because the Piedmont network only covers certain areas, we do ask them to notify us when these situations happen so that we can help them get the proper treatment and the proper claims processing. So if something happens while one of your employees is on vacation or traveling for work, don’t worry - we are here to help.
What type of wellness or health promotion programs do you offer to your members?
We have a full scale wellness program that includes a health risk assessment, clinical testing and biometrics, and follow up with employee participants. We also have the disease, case, and lifestyle management components in place to compliment the program. For more information, contact your broker or our Marketing Department.
Are pharmacy benefits offered with each plan?
Typically pharmacy is offered with each plan, although you can have a plan with no pharmacy benefits included. Pharmacy includes the 30-day prescription coverage, as well as the 90-day mail-in prescription coverage. We also have certain pharmacies that you can walk into to receive the 90-day prescription coverage.
If a claim is denied, what should my employee do next?
The first step would be to contact Customer Service and have the issue researched by one of our representatives. If the claim was denied in error, they can resolve it. They can also explain the appeal process for a claim that your employee feels should not have been denied.
Do my employees have to file their own claims?
Contracted providers will file the claims for your employees.
What happens to a claim if an employee has more than one health insurance plan?
Benefits are coordinated with the other health insurance coverage. Typically your plan will be primary for your active employees, so your coverage will pay first. Then the claim will be sent to the secondary coverage plan. If the secondary would have paid more on the claim had it been primary, then the secondary coverage will pay up to that amount, otherwise the secondary coverage will not pay at all. Detailed information on the Coordination of Benefits is included in the member’s policy book.