Brokers — Frequently Asked Questions
If your question is not listed below, please contact our Sales Department at (619) 228-2429 for assistance. We are here to help.
Grandfathered status under health care reform
Dependent coverage under health care reform
Contact information
| • | Whom do I contact with questions? |
| • | Whom can my customers contact with questions? |
Selling Sharp Health Plan
Grandfathered status under health care reform
What is a grandfathered health plan?
Essentially, a grandfathered health plan is one that maintains the same health coverage that was in effect when the health care reform law was enacted on March 23, 2010. A grandfathered health plan is exempt from the following changes otherwise required by health care reform:
| • | Coverage of preventive health services with no copayments. Sharp Health Plan already covers preventive health services, but our grandfathered benefit plans include some level of copayments for those services. Eliminating the copayments may increase premiums. |
| • | Restrictions on special benefit arrangements for highly compensated employees. Grandfathered health plans are able to maintain existing management carve-outs. |
| • | Other requirements that will go into effect in 2014. These include restrictions on premium differences based on age and tobacco use and require coverage of all “essential health benefits” with specified cost-sharing. These requirements may result in increased premiums in 2014 for benefit plans that do not maintain their grandfathered status. |
What kinds of changes would cause my benefit plan to lose its grandfathered status?
Changes that can cause an employer’s benefit plan to lose its grandfathered status include, but are not limited to:
| • | At renewal, selecting a benefit plan other than the one that was in effect on March 23, 2010. |
| • | A decrease of more than 5% in the percentage of premiums paid by the employer. |
| • | A change in insurance company or health plan. |
How do I keep my grandfathered health plan?
You may keep your grandfathered health plan as follows:
| • | For small group employers (2-50 employees) by renewing with the same Sharp Health Plan benefit plan you had in place on March 23, 2010. |
| • | For large group employers (51+ employees) by renewing either on your current Sharp Health Plan benefit plan, or alternative plans that also qualify as grandfathered that will be included in your renewal. |
| • | For both large and small groups you may change your provider network from Sharp Blue Choice to Sharp Gold Value and still maintain your grandfathered status. |
Will my grandfathered health plan always have a lower premium than a non-grandfathered benefit plan?
Not necessarily. Although grandfathered benefit plans are exempt from certain requirements under the law, you may choose a non-grandfathered benefit plan during your renewal that has a lower premium due to other benefit changes. Because the federal government has not released the final rules regarding the changes required in 2014 for non-grandfathered health plans, Sharp Health Plan cannot determine what impact there will be on premiums at that time.
Are there any health care reform requirements that apply to all benefit plans, including grandfathered plans?
Yes. All benefit plans, whether grandfathered or not, must provide the following benefits to their customers for plan years starting on or after September 23, 2010.
| • | No lifetime limits on the dollar value of “essential health benefits.” All Sharp Health Plan HMO plans already provide this benefit. |
| • | No coverage exclusions for children with pre-existing conditions. Sharp Health Plan HMO plans do not include any pre-existing condition clauses for children or adults. |
| • | No annual limits on the dollar value of “essential health benefits.” Sharp Health Plan HMO plans do not have any annual limits on “essential health benefits,” except on the optional small group chemical dependency rider , the $25,000 lifetime limit will be removed effective October 1, 2010. |
What does ‘essential health benefits’ mean? Which benefits are included in ‘essential health benefits’?
The definition of “essential health benefits” currently includes the following categories of services: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorders including behavioral health treatment, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services, including oral and vision care. The detailed benefits included under these broad categories have not been finalized. Therefore, benefits that may be considered “essential” may change as additional health care reform rules and regulations are released by the federal government.
Dependent coverage under health care reform
What changes does health care reform require for dependent coverage?
If you provide dependent coverage, effective with this plan renewal, you must offer coverage to dependents up to 26 years of age, regardless of marital or student status. However, a dependent that is eligible for health coverage through his or her employer should enroll in their own employer’s plan.
Does the change in dependent coverage apply to all benefit plans, including grandfathered plans?
Yes. All benefit plans that provide coverage to dependents must offer coverage up to age 26, regardless of grandfathered or non-grandfathered status.
Which of my employee’s dependents can enroll in Sharp Health Plan?
An employee’s child (naturally born or adopted), stepchild, or children for whom the employee is the legal guardian may enroll in Sharp Health Plan.
Does an employee’s dependent have to live with them in order to enroll in Sharp Health Plan?
No. An employee’s dependent does not have to live with them in order to enroll in Sharp Health Plan, but he/she must live within Sharp Health Plan’s service area (San Diego and Southern Riverside counties).
Can an employee’s child’s spouse and children enroll in Sharp Health Plan?
No. An employee’s child’s spouse and children are not eligible for enrollment in Sharp Health Plan.
If my employee’s dependent coverage ended because he/she was not a full-time student; can my employee’s dependent enroll in Sharp Health Plan?
Yes. Any dependent whose coverage ended or who was denied coverage due to age, student status or marital status will be eligible to enroll in Sharp Health Plan as of your group’s renewal date. Employees may request enrollment for such dependents during the group’s open enrollment period.
Contact Information
Whom do I contact with questions?
Your Sharp Health Plan account representative can answer your questions or connect you to the right person. See our Sales Contact List or you can use our Contact Us Form to send an e-mail.
Whom can my customers contact with questions?
Your employer customers may contact your Sharp Health Plan representative with questions about the administration of their health plan. See our Sales Contact List or they can use our Contact Us Form to send an e-mail.
Members may contact Customer Care at (619) 228-2300 or toll-free at 1-800-359-2002, or send an e-mail via our Contact Us Form. Customer Care representatives are available Monday through Friday, 8 am to 6 pm.
Selling sharp health plan
What is Sharp Health Plan’s service area?
Sharp Health Plan is San Diego’s only locally based commercial health plan. We serve employers based in San Diego and southern Riverside counties. Click here to see a list of all ZIP codes included in Sharp Health Plan’s service area.
Which providers and hospitals are available through Sharp Health Plan?
Sharp Health Plan connects members to thousands of physicians and 12 local hospitals. Your customers access providers through the Gold Value provider network or the Blue Choice provider network. Click here to view the Blue Choice and Gold Value Brochure.
Use our Find a Doctor search tool to determine if a specific physician is part of Sharp Health Plan’s provider network.
Which health plan products are available through Sharp Health Plan?
Sharp Health Plan provides a wide variety of HMO options, supplemental riders and value-added enhancements, as well as a partnership with national PPO vendors, to meet your customers’ health plan needs.
What are the group underwriting requirements for Sharp Health Plan?
Sharp Health Plan’s underwriting requirements are available here for your reference: Small Group Underwriting Matrix.
How do I become appointed with Sharp Health Plan?
In order to sell Sharp Health Plan, you are only required to maintain appropriate state licensing credentials. Please contact your Sharp Health Plan representative to review a group quote. See our Sales Contact List
How do I obtain a group quote?
Sharp Health Plan has teamed up with Health Connect to offer small group quotes for employers. Registration is required. Click here for more details.
You may also contact your Sharp Health Plan representative to get group quotes. In addition, you may review Sharp Health Plan quotes through several general agencies.
How do I order marketing materials?
Marketing materials are available through Sharp Health Plan’s Web site (Materials Request Form) or by contacting your Sharp Health Plan representative.
Which wellness programs are available to Sharp Health Plan members?
Sharp Health Plan members have access to a variety of wellness programs, including online self-management tools, trackers, workshops and telephone-based health coaching. For more information, members can visit us online.
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