Employers — Frequently Asked Questions
If your question is not listed below, please call (619) 228-2429, or send an e-mail via our Contact Us Form. We’re here to help!
Grandfathered status under health care reform
Dependent coverage under health care reform
Contact information
| • | Whom do I contact with questions? |
| • | Whom do my employees contact with questions? |
| • | Whom do I contact regarding billing questions? |
About Sharp Health Plan
| • | Which providers and hospitals are available through Sharp Health Plan? |
| • | Which wellness programs are available to Sharp Health Plan members? |
| • | What are Blue Choice and Gold Value? |
Administration of Sharp Health Plan coverage
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. |
| • | 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. |
How do I keep my grandfathered benfit plan?
You may keep your grandfathered benefit plan by renewing with the same benefit plan you had in place on March 23, 2010. You may change your provider network from Blue Choice to 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 are ‘essential health benefits’?
The health care reform law lists the following categories as ‘essential health benefits’: 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 specific benefits included under these broad categories have not been finalized. Therefore, benefits that are considered 'essential’ may change as additional health care reform 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?
You may contact your Sharp Health Plan representative to ask questions about the administration of your health plan. See our Sales Contact List Use or use our Contact Us Form to send an e-mail.
Whom do my employees contact with questions?
Your employees can contact Sharp Health Plan’s dedicated Customer Care team Monday through Friday, 8 am to 6 pm, by calling (619) 228-2300 or 1-800-358-2002 or by e-mail at customer.service@sharp.com.
Whom do I contact regarding billing questions?
Log in to SharpConnect to view your most recent billing activity online. If you have any questions about your premium bill, you may contact your Sharp Health Plan representative. See our Sales Contact List or use our Contact Us Form to send an e-mail.
About Sharp Health Plan
Which providers and hospitals are available through Sharp Health Plan?
Sharp Health Plan connects your employees to thousands of physicians and 12 local hospitals throughout San Diego and southern Riverside Counties. Access will vary depending on the network you choose: Blue Choice or Gold Value.
Use our Find a Doctor search tool to determine if a specific physician is part of Sharp Health Plan’s provider network.
Which wellness programs are available to Sharp Health Plan members?
Sharp Health Plan members have direct access to a variety of wellness programs, including online self-management tools, trackers, workshops and telephone-based health coaching.
Visit the Health and Wellness area for more information.
What are Blue Choice and Gold Value?
Blue Choice and Gold Value are Sharp Health Plan’s two Plan Networks. Both networks include the medical groups affiliated with Sharp Community Medical Group, Sharp Rees-Stealy Medical Group, Children’s Physicians Medical Group, Greater Tri-Cities IPA, Primary Care Associates Medical Group and Arch Health Partners. The Blue Choice network also includes the doctors who are contracted directly with Sharp Health Plan, as part of the Independent Plan Medical Group.
Administration of Sharp Health Plan coverage
Does Sharp Health Plan provide administrative support to manage my health plan benefits?
Your Sharp Health Plan representative is available to address any questions you have about the plan. In addition, Sharp Health Plan issues a Group Administration Manual upon your group’s enrollment.
The manual includes information about:
| • | Enrollment cancellation procedures |
| • | Membership changes |
| • | Coordination of benefits |
| • | Continuation of coverage |
| • | Billing procedures |
| • | Terms and definitions |
Does Sharp Health Plan send detailed benefits information to my employees?
Sharp Health Plan provides a member kit to all new members, which includes:
| • | Member ID card(s) |
| • | Summary benefit matrices |
| • | Member Handbook |
How do I order new employee packets and additional forms?
You may contact your Sharp Health Plan representative to order additional employee packets. Use our Contact Us Form to send an e-mail or call (619) 228-2429 for assistance.
How do I enroll or disenroll an employee?
Log in to SharpConnect to complete enrollment and disenrollment online.
For paper enrollment, the new employee will need to complete the enrollment application once he or she has fulfilled your group’s waiting period. This form must be received by Sharp Health Plan within 30 days of the eligibility date.
To disenroll an employee on paper, you must complete the appropriate section of the enrollment application. The disenrollment form must be received by us by the end of the month in which coverage is to end. The following enrollment applications are available online for small and large groups:
Employee Application — HMO
Employee Application — Small Group PPO
or by contacting your Sharp Health Plan representative.
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