People First Service Center As Is Requirements. -- updated Oct. 2, 2015

Transcription

1 People First Service Center As Is Requirements -- updated Oct. 2, 2015 Table of Contents Benefits Definitions... 2 Benefits Processes Listing... 3 Carrier Discrepancy Listing and Instructions Payroll Payroll Processes Listing Human Resources Administration/Organizational Management Human Resources Admin/Organization Management Processes Listing Performance Management Performance Management Processes Listing Recruitment Recruitment Processes Listing... 36

2 I. Benefits A. Definitions: 1. ecase the proprietary case tracking program used by the incumbent service provider. 2. Division of State Group Insurance (DSGI) the Department s Division of State Group Insurance is responsible for offering and managing a comprehensive package of health and welfare insurance benefits for active and retired state employees and their families. 3. Human Resource Specialist (HR Specialist) - a Service Provider employee who handles Covered Population contacts and administers HR Functions through the Service Center. 4. People First Service Center (PFSC) the Service Provider location(s) staffed with HR Specialists that provide service support for the Covered Population. 5. Tier 0 - a State of Florida employee performed action, either online or via the Interactive Voice Recognition (IVR) system. 6. Tier 1 - PFSC telephone agent action PFSC action via a submitted case/request. ITN No.: DMS-14/ Page 2 of 40

3 B. Benefits Processes Listing 1 2 Acceptable Vs. Non- Acceptable Payees Adjust Posted Premium Payment 3 Agent Balance 4 Appeals In order for payments received at the People First lockbox to be processed and deposited into the appropriate State bank accounts, they must be made payable to an acceptable payee. Those payments that are made payable to a payee other than those identified to be acceptable will be returned. The People First Fiscal Administration System includes an adjustment feature that allows the complete reversal of a posted premium payment transaction due to an incorrect payment application to a Coverage period, person, or plan. This feature (application of adjustment indicator) is opened only to the PFSC Fiscal Administration Team Leader, PFSC Operations Manager and PFSC Senior Operations Manager. The PFSC Fiscal Administration Specialists are responsible for balancing any and all payments entered into SAP. Payments cannot be applied to a member s account until balanced by both the PFSC Specialist responsible for the entry and the PFSC Fiscal Administration Manager. The Balance is run after entering all payments received. The PFSC Fiscal Administration Specialist must do a manual count of the number of checks processed for the batch and the total payment amounts via a 10 key calculator prior to running the Balance. The Balance will only show those payments that the PFSC HR Specialist requesting the report has processed, but has not balanced. The Balance can be run at any time. The Balance must match the PFSC HR Specialist s 10 Key calculator total (manual count) before it can be considered balanced. Most issues can be resolved online. However, in the process of calls relative to enrollment, eligibility, or policy issues, members of the covered population may not be in agreement. A Level I Appeal is a request that is made by the member of the covered population, in letter format, typed or hand written. The appeal may be received by mail or fax and must be signed by the member of the population. The member of the population should send any documentation relevant to support the appeal. The PFSC receives requests for Level I Appeals and will approve or deny an appeal within 5 business days and sends a response in a letter. If the member of the population does not agree with the decision, they can submit a Level II appeal to DSGI and the instructions are in their Level I Appeal letter. If the appeal decision requires more than 5 business days, the appeal is pended and an acknowledgement letter is ITN No.: DMS-14/ Page 3 of 40

4 5 6 7 Approve Manual Adjustment Process Back-end System Updates Carrier Discrepancies 8 Case Processing Certify Eligibility of Over- Age Dependent Change Entered Payments COBRA - Continuation of Benefits sent out indicating the appeal has been received and is under review. All pended appeals must be resolved within 20 business days from receipt. Appeal decisions can only be relayed by letter. The Approve Manual Adjustment process is used by PFSC managers to approve manual adjustments. The following guidelines apply when approving manual adjustments. Only a PFSC manager can approve manual adjustments. PFSC managers must approve manual adjustments before a PFSC HR Specialist will be able to view the adjustment in the system. All manual adjustments are tracked on an Audit Log. The log can be viewed and printed as needed. A back-end plan / coverage change in the system requires the PFSC to use the Override event in order for the system to generate a confirmation statement to the member. The purpose of this process is to outline the steps that are taken to send, receive, research and process Carrier Discrepancy s through the PFSC. The case team completes transactions, processes, research, and problem solving that cannot be completed over the phone. A case should be created only after all online resources have been exhausted for a specific issue and a resolution has not been reached. DSGI provides to the PFSC the Certification of Over- Age Dependent Eligibility form. In November of each year, the PFSC sends this form and accompanying letter to members. Once returned, PFSC takes appropriate action based on the responses on the form. If no response is received within three weeks from initial notice, a second notice is sent out. If no response is received after second notice is sent, the dependent is removed from the coverage. When a payment is entered incorrectly, the PFSC Fiscal Administration Specialist may make changes to correct the payment amount. Payments may cover multiple plans. Each plan must be processed as a separate line item. Changes can only be made to payments that have been entered but not balanced in the system. Once a PFSC HR Specialist balances a batch the payment information is locked. Federal law requires that most group health plans give members the opportunity to continue their health care coverage when there is a "qualifying event" that would result in a loss of coverage under the State s plan. This plan is referred to as COBRA, Consolidated Omnibus Budget Reconciliation Act of Continuation of coverage depends on the type of qualifying event. Continued coverage is the same coverage that the Plan ITN No.: DMS-14/ Page 4 of 40

5 12 Create a Temporary Account 13 Death gives to active members covered under the State s plan. A COBRA packet detailing eligibility is mailed to eligible members once the system is updated with the qualifying event that caused termination of coverage. This information must be sent within 14 days of the PFSC receiving notification of the qualifying event or the date coverage is lost (whichever is later). This notice will also be sent when a second qualifying event is experienced by a COBRA member. For dependent children turning age 26, a COBRA packet will automatically be generated. Enrolled members pay 102% of the Plan cost. Payments must be received by check or money order. The PFSC creates a temporary account to record and track advanced payments received for a member prior to the member existing in the system. For death of an active employee, a death Personnel Action Request (PAR) must be processed in the People First system. Once the death PAR is entered in the system, a query is pulled by the PFSC the next day to review all the death PARs to determine if a Surviving Spouse Package needs to be created and mailed out. If needed, a Surviving Spouse package is sent certified mail within 3-5 business days from the date the death was processed in the system. If the death was reported outside the QSC timeframe, any coverage level changes will be prospective Dependent Care Reimbursement Account (DCRA) Dependent Documentation For death of a retiree, the death is reported to the service center via multiple sources (e.g., death report, family member). If retiree had family coverage, a surviving spouse package is mailed out to the spouse. The retiree s coverage is terminated the first of the month following the death. A Dependent Care Reimbursement Account (DCRA) is an IRS tax-favored account that can be used to pay for eligible dependent care expenses to ensure the member s qualified dependents (child or elder) are taken care of while the member and their spouse (if married) are working. These funds are set aside from the member s salary before taxes are deducted, allowing the member to pay for eligible expenses tax free. Claims for reimbursement from the DCRA can be made as often as members would like; however, their approved expense will not be reimbursed until the last date of service for which they are requesting reimbursement has passed and the member has sufficient funds available in their DCRA. The state does not contribute to the DCRA. Documentation that is required can be submitted to the PFSC by mail or fax. If required documentation is not ITN No.: DMS-14/ Page 5 of 40

6 Dependent Eligibility with Exceptions Dependent Eligibility Tax Identification Number Process Dependent Eligibility - Visa Process 19 Disabled Dependent legible when received, the sender will be contacted to resubmit the information. The following documentation is required within 60 days of the QSC event and must be received prior to any changes being made. Divorce Divorce Decree Medicare Card Medicare Card due to Disability or when a retiree turns age 65 Court Orders Court Orders signed by a judge to add/drop dependents Placement in the home for the purpose of adoption - Letter must be on letterhead and signed by the caseworker. Letter must indicate the intent to adopt IRS Guidelines govern the types of changes that can be made to pre-tax benefit plans. Eligible plan members can only add / drop dependent (s) when the following occurs: Open Enrollment (OE) Qualified Status Change (QSC) Dependents must meet eligibility requirements as indicated below. A valid Social Security Number (SSN) is requested (to avoid tax penalty) before adding any eligible dependents to plans. Member must certify dependent eligibility prior to adding dependent(s) to any plan(s). If adding a dependent due to an Adoption/Court Order/ Qualified Medical Child Support Orders (QMCSO), documentation must be received before processing the QSC. Any documentation received that requires further clarification should be sent to DSGI for review. Individual Taxpayer Identification Numbers (ITIN) is acceptable for dependents in lieu of a SSN since they are a government-issued type of identification. This process is followed when there is a Foreign National dependent that needs to be added to the benefits. Note: This process is not to be used for Adoptions. Agency/University HR office will send an to People First Client Services (PFCS) mailbox requesting a Visa enrollment for dependent(s). The should contain the employee s name, People First ID and dependent(s) name. The Visa document will remain with the HR office and does not need to be sent to the PFSC. PFCS agent opens a case to request a callback to HR to process the enrollment. PFSC case team calls the HR office back to process the request. A Disabled Dependent is a dependent who is mentally or physically disabled and who is incapable of selfsustaining employment because of mental or physical disability. Disabled Dependent Enrollment Timeframe: New hire Children with a disability are eligible ITN No.: DMS-14/ Page 6 of 40

7 20 Divorce 21 Document Processing 22 Duplicate Warrant Request Process regardless of the dependent s age Loss of other group coverage (Dependent under age 26) Children with a disability under the age of 26 may be eligible for coverage during OE or with an appropriate QSC Loss of other group coverage (Dependent over age 26) - Children with a disability over age 26 may be eligible for coverage during OE or with an appropriate QSC as long as the member has not previously been enrolled in state coverage. If previously enrolled in state coverage, once the disabled dependent loses the coverage, they cannot re-enroll except as an Over-aged Dependent (OAD) coverage that will end at the end of the calendar year the dependent child turns age 30. No changes can be made until the divorce decree is received. The divorce decree can be received by mail or fax. The divorce decree should indicate who is responsible to cover the dependents. If not indicated, the member must be contacted. Regardless of whether the divorce decree is received inside or outside the QSC window, coverage still ends at the end of the month of the divorce for dependents no longer eligible and the coverage level must be changed prospectively. Stepchildren are no longer eligible dependents due to a divorce. COBRA requirements will be mailed within 10 days for any eligible dependents removed due to the divorce if processed within the QSC timeframe. If the QSC is processed outside the 60 day window, the ineligible dependents will lose COBRA eligibility. If a premium refund is due once a divorce QSC is processed, the member should be contacted by the PFSC HR Specialist and redirected to their State agency Human Resource (HR) office. Refunds for active employees are only accepted from the HR office. All forms and correspondence mailed or faxed to the PFSC are entered into the ecase system. Agents can view them by looking under the corresponding systemgenerated case. The following information was provided to aid all HR Offices in requesting duplicate warrants. These instructions are specific to warrants originally requested through the Division of State Group Insurance. It is the responsibility of the HR Office to obtain and complete the information on the Affidavit for Duplicate Warrant form (Form DBF-AA-408), and to have the form notarized to validate the claimant's signature. All warrants that are reissued must be outstanding and they will be cancelled prior to reissue of the duplicate ITN No.: DMS-14/ Page 7 of 40

8 23 24 Employment and Child Support Verifications Enroll in Health Insurance 25 Escalation Process Fiscal Reconciliation Flex Spending Account Claims Pay Process Health Insurance Subsidy (HIS) warrant. Note: If a duplicate warrant is requested and the payee cashes the original warrant, the payee's banking institution may briefly honor the check but then deduct the money from the account once the cancellation is realized. Employment Verifications can be requested through the People First IVR. If employees need to submit employment verification for manual processing, it can be mailed or faxed to the PFSC. In order to participate in the State-sponsored benefits program, an Employee must first elect benefits. In addition, when a life or work event occurs, the Employee may need to make modifications to benefits by processing a QSC. The purpose of this process is to outline the steps that are taken to receive, research and resolve escalations through the PFSC. The PFSC manager uses this report to determine which checks to post and which checks to review on any given day. This report shows the following information: All checks entered and distributed All checks entered from the previous day and distributed All checks entered, but not distributed All returned checks The report can be run at any time during the day. The report is also set up to allow a PFSC manager to pull specific information for a report. The PFSC will administer the Flexible Spending Account (FSA) Balance process for all eligible plan members (EPP). This process includes: Reconciling FSA balances Updating EPP benefits data Providing the State with FSA claim reconciliation information Providing EPP with FSA balance information Submitting notification to eligible plan members Tracking FSA account balances Division of Retirement is also known as FRS (Florida Retirement System). Eligible retirees (or surviving beneficiary receiving monthly benefits) are eligible for $5.00 for each year of credible service with a maximum of $ per month. The subsidy is included in the monthly pension. The application for the Health Insurance Subsidy Form (HIS Form) comes from the Division of Retirement which subsidizes their Health Insurance Premiums. The PFSC will complete the necessary section of the application and fax it back to the Division of Retirement. Investment retirees are eligible for the HIS. Tier 0/ Tier 0/ ITN No.: DMS-14/ Page 8 of 40

9 29 HIPAA Request Processing 30 HMO Retro Changes Health Savings Account (HSA) and Limited Purpose Medical Reimbursement Account (LPMRA) Internal Move Premium Process Layoff - Extended Coverage The HIPAA Certificate provides evidence of the Member s prior health coverage. The Member may need to provide this certificate if they become eligible under another group health plan. Anytime a Member separates employment or coverage with the state the HIPAA Certificate is systematically generated and mailed to the primary Member. The HIPAA Certificate provides information concerning health plan information only. When a member is enrolled in an HMO and needs to move from individual coverage to family coverage, and individual premiums have already been sent to the lockbox, the PFSC must manually post premiums to the participant s record. The HMO Retro Changes is used to identify and manually submit premiums for those HMO participants. The report is created manually by the service center and contains SSN, name, coverage information payment amount and reason for retro action. A Health Savings Account (HSA) is a tax-deferred account that can be used to pay health care expenses. Unlike money in a Medical Reimbursement Account (MRA), the funds do not have to be spent in the plan year they are deposited. Money in the account, including interest or investment earnings, accumulates tax-free, so the funds can be used to pay qualified medical expenses in the future. An important advantage of an HSA is that it is owned by the employee. If they leave their job, they can take the account with them and continue to use it for qualified medical expenses. Employees must enroll in the Health Investor HMO or PPO, with a choice of enrolling in the Health Savings Account (HSA). These options enable individuals who are willing to take greater responsibility for their medical care the opportunity to reduce their insurance premiums and save money for future health expenses. Employees cannot enroll in a HSA and an MRA. However, an employee can have a HSA and a Limited Purpose Medical Reimbursement Account (LPMRA). This process describes the internal steps when receiving a request from a retiree or COBRA member to move a premium payment from one month to a different month. PFSC HR Specialist answers questions in the event that Career Service employment ends due to layoff. The employee has several options to consider if they choose to continue insurance benefits. Note: SES / SMS and Other Personal Service (OPS) positions do not qualify for Layoff. Tier 0/ Tier 1 34 Layoff Process The purpose of this process is to outline the steps that ITN No.: DMS-14/ Page 9 of 40

10 35 36 Log Receipt of EFT/JT Payments Loss of Entitlement to Medicare 37 Mail Room are taken to process employee layoffs through the PFSC. PFSC HR Specialist is responsible for logging receipt of the EFT / JT payments onto the FA1 Check Log Sheet. This point in the process is referred to daily work received. This is the process where either the member or dependent has lost entitlement to Medicare. This would only apply if under 65 years of age. SAP will only allow processing of changes that are under the Medicare guidelines. Start date reflects the day of enrollment processing. Add dependents to the member s selected benefits when dependents lose eligibility for Medicare. Only applies to Health Benefits. Incoming Mail: Courier delivers mail to the PFSC security desk daily Mail is picked up daily and brought to the mailroom Mail addressed to a PFSC manager is logged and delivered to the PFSC manager Misdirected mail is forwarded to the appropriate party or returned to the sender Update daily mail log with the number of documents received Outgoing Mail: Mailroom team collects mail during the day from the teams FSA payments received by DSGI are prepared for mailing Outgoing mail is counted and logged (including postage usage) Postage is applied accordingly Returned Mail: Returned Mail with no forwarding address and no better address in the system of record, is noted in ecase and held for 60 days Returned Mail with a forwarding address is r ed and noted in ecase All mail that is resent out should be accompanied with the Returned Mail Letter 38 Manager Balance The following are guidelines for running the Manager Balance : Payments cannot be distributed until the Manager Balance has been processed The Balance will show those payments that have been balanced by the various PFSC Specialists The Balance can be run at any time ITN No.: DMS-14/ Page 10 of 40

11 Manual Pension Payroll Request Manual Premium Payment Coupons Marketplace Employer Coverage Tool Application The PFSC manager will need to do a manual count of the number of checks for all processed batches and total the payment amounts via a calculator prior to running the Balance Pension payroll is a process that allows a retiree s retirement check to be deducted on a monthly basis to cover health and life insurance. Check the current date when this type of call is received. If the date is later than the 12th of the month, determine if the deduction will be deducted at the end of the current month. If the current date is after the Files to FRS column date, the retiree will have to send in a premium payment via check or money order for the next month. The deduction will not be effective the next month but the following month. For example, a retiree calls on the 23rd of June for Pension Payroll deduction to cover July. The retiree will have to send in a premium payment for July coverage. The Pension Payroll deduction will begin in July for August coverage. The FRS Kick-Out is used in this process. This report provides verification of payroll deductions for the health (004) and life (005) premium contributions for the State Group Insurance program retiree plan participants. In addition, the retiree team reconciles the report with the method of payment information maintained in the People First system). The report comes from FRS. The PFSC goes into the FRS system and pulls the 004 and 005 reports each month. The purpose of the report is to place participants on Direct Bill if their pension is not large enough to cover their life and health insurance premiums or if they are not receiving a pension at all. We also verify if the pension should be restarted. Once all the information is researched we send it back to FRS via ecase. Premium payment coupons are payment slips for former members on COBRA or retirees that are on direct billing to submit payment for coverage each month. Premium payment coupons are systematically generated on a semi-annual basis. A participant can fax or mail the Employer Coverage Tool application to the PFSC to complete the Employer Section. This application is used when the Marketplace requires additional information on an employee s and/or dependent's eligibility through their employer. Once the Employer Section is completed by the PFSC, the application is mailed or faxed back to the participant with the Marketplace cover letter. The participant sends the completed form back to the Health Insurance Marketplace. Participants can obtain additional information by contacting the Marketplace Call Center. 42 Medicare Program The program provides coverage for individuals: ITN No.: DMS-14/ Page 11 of 40

12 Retiree age 65 and over. Retiree whose spouse is age 65 and over Certain disabled (as defined by the federal government) people under 65 The self-insured Health Plans will coordinate with Medicare as secondary payer of claims Fully-insured Medicare Advantage Plans require enrollment into their Medicare program to coordinate accordingly. Depending on an Eligible Plan Participant s and their family s Medicare status, coverage level options will be displayed in the Health Plan options For an active employee that becomes Medicare eligible, the State Plan will remain primary until they retire. When a dependent covered under an active employee becomes Medicare eligible, they may defer the Medicare coverage and continue their coverage as primary under the active employee's State Plan 43 Medical Underwriting 44 New Hire When a member makes a new election or change to a current election that requires medical underwriting, they must obtain the Enrollment form or application from the MyBenefits website or from the provider company representative. Once the member selects an election that requires medical underwriting via the IVR or the ESS website, an indicator will be set on that account that will put the record in a pending status until approval received from the carrier. Status codes include: EORIG set indicator for enrollment completed but not approved EOIPR set indicator for enrollment completed and approved Minnesota Life requires the Short Form Health Questionnaire to be completed for medical underwriting processing. It is necessary for existing Optional Life Insurance coverage to be increased by 2 or more levels, enrolling for the first time during an Open Enrollment, choosing coverage of more than $500,000 or choosing 6 or 7 levels. AFLAC requires their application to be completed for medical underwriting processing. It is required for new enrollments or increases to the Cancer plans or new enrollment in the Intensive Care Insurance plan. New employees have 60 days in which to choose or waive benefit coverage. Two married State employees are eligible to participate in the Spouse Program for health coverage. New employees can choose benefit coverage on their first day of employment to be effective the first of the following month. If the 60th day falls on a Tier 0/ ITN No.: DMS-14/ Page 12 of 40

13 45 Non-Sufficient Funds Process 46 Open Enrollment Payment Distribution Hierarchy Post-Tax Refund Request Process Power of Attorney (POA) weekend or holiday, the employee has until the next business day to make elections. Once employees make an election within their 60 days, they can only change it during Open Enrollment or if they have an appropriate QSC Event. For example, if they make an election for health insurance on day five of employment, they cannot cancel or change to another health insurance company or plan type during their 60 days; however, they can make a new election for another type of plan, such as dental, at a later time within the 60 days. Effective dates are assigned based on the initial date of contact made by the employee. The system assigns an effective date based on the payroll schedule. If an employee wants an earlier effective date, the employee must enroll prior to the effective date requested. If enrollment is processed after the payroll cutoff, the employee must pay the premium by personal check or money order which is post-tax. Make check or money order payable to DSGI. As a New Hire, employees have the option to waive pre-tax participation for Health and Life. This request must be submitted via paper form within 60 days of employment. Supplemental plans and the Flexible Spending Accounts are only available on a pre-tax basis. All employees (including OPS) can waive all benefits. A Non-Sufficient Funds (NSF) process is used when a member s premium payment is not processed due to insufficient funds in the member s bank account. The NSF fee is added to the member s record. The payment must go through the nightly posting process before an NSF can be processed. Only PFSC Fiscal Managers have the proper security level to process an NSF. Process enrollment or modify for State of Florida (SOF) employees, COBRA members or retirees into benefit plans. Provide guidance on eligibility for benefit plans offered by SOF and give updates to employees/retirees as plan changes occur. If a member submits a check and it does not autodistribute and post, review the check submitted. If the check submitted indicates the check should be posted to a certain plan, post that check to that plan as long as there is no NSF due. (Note: Post it to oldest due for that plan before posting it to current.) The Refund of Benefit Payments process is a step-bystep process to refund any overpayment submitted by a member for any type of Benefit Premium. Validation of submitted form and request must be completed prior to creating action to refund overpayment. A Power of Attorney (POA) is a legal document authorizing another person to act as one's agent or Tier 0/ ITN No.: DMS-14/ Page 13 of 40

14 50 Pre-Tax Waiver Process Process Electronic Funds Transfer Process Manual Adjustment Process Premium Payments - JT or Mass Check Process Premium Payments - Lockbox Protected Health Information Process (PHI) Qualified Medical Child Support Orders attorney in fact, and indicates the transactions the person has authority to act upon. A person authorized by the POA has the right to transact business on the member s behalf. The POA is required to have a certified copy of the documentation on file with PFSC. PFSC will not provide information and/or process requests for POAs until the certified copy of the document has been received and validated. The system will be updated to reflect POA on the member s record once validated. The POA s information (i.e., name and contact information) will also be listed in the system. This process is linked to New Hire Processing or during Open Enrollment. As a new hire, employees have the option to waive pre-tax participation for Health Insurance premiums. Optional Life Insurance premiums are post-tax. The pre-tax waiver form must be completed within 60 days of employment. Supplemental plans and the Flexible Spending Accounts are only available in pre-tax basis. The PFSC will : Receive, verify and post all Electronic Funds Transfers (EFT) into the People First Benefits System Reconcile detail file and Collection Summary Verify and input all premium payment data into the People First Benefits System Generate report of updates and send to DSGI The manual adjustment process is used to remove the distribution of a payment from one plan / month to another. Manual adjustments can be requested by the State or internally. The PFSC Fiscal Administration Team processes premium payments received from agencies and Universities. This occurs when PFSC receives a Journal Transfer (JT) or Mass Check process. The PFSC will receive and process direct payments to continue benefits coverage. The payments are received from: Retirees / Surviving Spouses, Vested Legislators, COBRA, Layoff, Leaves of Absence, Active employee underpayments initiated by Agency HR Office / New Hire Payments, and State University System / Non- State Personnel System Entities. Processes related to disclosing federally protected health information. Explains the requirements and validation of the Authorization to Use and/or Disclose Protected Health Information Form (a.k.a. Authorization Form). A court order requiring the addition of a dependent child (ren) to the employee s coverage(s). QMCSO does ITN No.: DMS-14/ Page 14 of 40

15 57 (QMCSOs) Refund Benefits Payment 58 Reinstatements 59 Re-Routed Check Process allow employee to add other eligible dependents. Employee will be changed to the State PPO Plan under these circumstances: Employee is not enrolled in Health Coverage Employee is currently enrolled in an HMO that dependent child(ren) is not eligible for These orders will come from various states; however, the majority will come from Department of Revenue- State of Florida, and will require manual completion. QMCSOs will indicate coverage required such as medical, vision and dental. State of Florida Eligibility requirements state that eligible employee s insurance premiums may not exceed 50% of the gross salary (biweekly, monthly, or annually). Premium Withholdings Limitation Worksheet included in QMCSO packet will need to be completed by employee and PFSC in order to determine if premiums exceed 50% of gross salary. The original packet is completed by PFSC and returned to the sender who sent the order and a Child Support Verification Letter is enclosed. A Qualified Medical Child Support Order letter is mailed to the member informing the member of the change to the benefit with a cc to the agency. Refund any overpayment submitted by an Employee/Retiree/COBRA member or employer for any type of Benefit Premium. Validation of submitted form and request must be completed prior to creating action to refund overpayment. The PFSC will determine if a reinstatement of benefits (health, prescriptions, dental, vision) is needed and open a reinstatement case. There are two types of reinstatement cases: 1) Emergency, where services are needed within 24 hours and, 2) Non-Emergency, where services are needed after 24 hours but prior to the next carrier file update). Carrier files are sent to each health provider the first three Saturdays of each month plus sometimes the fourth Saturday depending on when the next month s coverage file is sent and the carrier is expected to have the records updated by start of business Tuesday morning. Dental and Vision files are still sent out on a monthly basis according to the Vendor file schedule. A reinstatement can be completed even if the Employer premiums are showing as underpaid. Checks, money orders, and cash that are sent to the PFSC Benefits Administration P.O. Box will be processed through the Re-routed Check Process and re-routed to the premium payment address. DSGI should be informed when checks are received in the wrong lockbox. 60 Retirement Process An eligible retiree must choose to continue coverage Tier 0/ ITN No.: DMS-14/ Page 15 of 40

16 61 Returned Checks 62 Reverse Check Process Under/Over Payment SAP - Premium History Process Special Determinations Team Disability Income Plan (DIP) 66 Spouse Program within 31 days of their termination date. At retirement, if the member enrolls in their spouse s SOF health coverage, they will still have the option to enroll in retirement coverage once that active coverage ends. An eligible retiree can continue their health coverage and has the option to choose the retiree life insurance of $2,500 or $10,000. For Pension Plan retirees, the system automatically continues the health plan and defaults the life insurance coverage to $2,500. The retiree would need to request the $10,000 coverage level within the QSC timeframe. The PFSC will administer the processing of Dishonored Checks for plan members. The sub-process of administering the dishonored checks includes notifying plan members and updating the People First Benefits System. The PFSC will administer the day-to-day functions of updating and revising the system regarding dishonored checks and processing any documentation required for the dishonored checks. The PFSC will reverse a check when it has been posted incorrectly to an employee s account. The check will also be reversed when it has been placed under the wrong employee ID number. The Under/Over is a detailed history of a member s payment history. It is used by the PFSC Fiscal Administration Specialist to verify payment information. This process is used to view a member s current and past premium history in SAP. Premiums can be viewed by PFSC HR Specialists back to 9/10/2004. Process for providing income while disabled. Basic Plan Highlights: Payout calculation is the annualized salary divided by 364 days X 65%. The employee must submit the completed claim form every 60 days to PFSC. The PFSC sends part B of the claim form to DSGI clinical staff for review. If disability is verified, payments begin/continue. The DIP Overpayment is sent on the 10th of each month that shows any overpayments of DIP paid out to a participant (history report) and when the money is paid back). This is a manual report produced by the service center that entails DIP overpayments. Enrollment into the spouse program (family health coverage) is permissible through certain QSCs such as marriage, new hire, change of employment status, and during Open Enrollment. All active employees are eligible to enroll in the spouse program, including eligible OPS. Legislature employees do not participate in the Spouse Program. A spouse program enrollment form must be received in order to enroll two married ITN No.: DMS-14/ Page 16 of 40

17 67 68 Surviving Spouse Process Vested Legislator Process state employees in the spouse program. A spouse program form is available in the fulfillment section on the website. Spouse Program enrollments must be requested within the QSC or OE window. One spouse will need to be the primary and the other spouse will need to be the secondary. This information is captured on the form. The primary spouse is the policy holder and is the record that is sent to the health plan carrier. Even though the dependents are listed under both records under family coverage, the dependents are only checked as enrolled under the primary. Both employees must be enrolled in the same heath plan. Changing health plan is not allowed unless the newly eligible employee becomes the primary. In this case, change the current primary to secondary, uncheck all the dependents and change the health plan to match the primary record. The premium is split between the two members as long as they are full time. Part time rates are prorated accordingly. Confirmation will be mailed to both members. The surviving spouse of an active, retired, or law enforcement state employee is eligible to continue medical coverage upon learning of the death of an insured employee or retiree with family coverage. A spouse or dependent of a law enforcement state employee, who was killed in the line of duty, is eligible for survivor benefits paid by the agency. The death PAR for an active employee or death certificate for a retiree must be entered or received prior to the creation of a surviving spouse record. The PFSC will notify the surviving spouse and any other covered eligible dependents of their right to continue coverage. This notice will be sent via certified mail and will direct the surviving spouse of the timeframes, monthly premium amount and requirements to enroll. Surviving Spouse and dependents will be able to continue health plan at retiree cost. Enrollments can be done via paper enrollment form, letter or by phone. A PFSC HR Specialist will open an internal forms case for enrollment requests by phone. Dependents on employee's health plan without a surviving spouse can continue coverage under COBRA. Dental and vision for dependents can be continue under COBRA. QSC timeframe Enrollment within 31 days of receipt of notification of benefits (surviving spouse package). Coverage will begin the first of the month after the participant s coverage ends. There cannot be a gap in coverage. The process for changing Legislators to Vested Legislator, retiree or active employee status and for enrolling them in Vested Legislator Health and Life ITN No.: DMS-14/ Page 17 of 40

18 69 View Benefits Materials View Premium History - People First View or Update Address or Phone Number Insurance. The HR action and benefits enrollment process should be completed within 48 hours of receipt by the PFSC. The premium distribution will be completed within 24 hours of receipt of payment or completion of the benefits enrollment. The My Benefits Website allows State of Florida employees and retirees to view booklets and certain enrollment forms online. This function also allows employees or retirees to print, or view fulfillment items. This process is used to view an employee s current and past premium history. Premiums can be viewed by PFSC agents back to 9/10/2004. Active employees can change their phone number, home address and/or mailing address through the People First website by going to the tab> Employee Information>Personal Information>Contact Information. PFSC should provide navigational assistance to help employees update their information. If an employee does not have access to a computer, PFSC should update the information. A confirmation letter is automatically generated once an address is updated. PFSC can assist the member with the change in health plans, if applicable. Tier 0/ Tier 1 Tier 0/ Tier 0/ ITN No.: DMS-14/ Page 18 of 40

19 C. Carrier Discrepancy Listing and Instructions Vendor Aetna Aflac Ameritas Assurant Avmed Capital Health Plan (CHP) Colonial Florida Health Care Plan Florida Blue Frequency Weekly Monthly Monthly Monthly Weekly Weekly/ Monthly Monthly Quarterly Weekly Name Discrepancy Discrepancy Discrepancy Discrepancy Discrepancy Medicare/ Medicare Advantage/ Eligibility Discrepancy State of Florida Discrepancy Sheet Reject Records Process Description Review entries on report. Correct in People First system. Review entries on report. Correct in People First system. Review entries on report. Correct in People First system. Review entries on report. Correct in People First system. Review entries on report. Correct in People First system. Review entries on the report for the following: Medicare- Verify status of participant Medicare Advantageunable to convert to the Advantage Plan. Eligibility-FYI report to reconciliation. Review entries on report. Correct in People First system. Research identifies payment discrepancies. Records are rejected for various reasons such as invalid coverage code, out of country address, a dependent of a dependent over age 18 months. The Reject Records should be reviewed and errors corrected immediately Comments / Definitions Description Discrepancy - Effective Date questions, etc. Discrepancy - Effective Date questions, etc. Discrepancy - Effective Date questions, etc. Discrepancy - Effective Date questions, etc. Employee name, SSN#, the discrepancy and file date. Medicare - Confirm the member requested cancellation or not. Medicare Adv - Free-text field that CHP populates with what CHP needs to enroll a member in Advantage Pan or provide missing information such as proof of Part A & B. Discrepancy - Effective Date questions, etc. Findings/questions specific to each case that describes the need for NGA research. Invalid Benefit Determination Data: The file contains specific information in the State Product Selection ( ); State Location Dept ( ); State Cov Code ( ) and State Sub Emp Status ( ). If any of these positions are blank or have invalid data it could cause the record to fail. This could create the above error. ITN No.: DMS-14/ Page 19 of 40

20 Vendor Florida Blue Florida Blue Florida Blue Frequency Weekly Weekly Weekly Name Duplicate Records Address Error System Process Description in People First System. Review entries on report. Correct in People First system. Entries indicate duplicate records pulled off weekly enrollment file. Review entries on report. Correct in People First system. Entries indicate Florida Blue has a different address on file. Review entries on the report. Correct in People First system. Entries indicate that the member is active in the Florida Blue system but is not on the People First weekly enrollment file. Comments / Definitions Description Dependent Rejected Due To No Subscriber: The record sent on the file contains a dependent and no employee record. Invalid Contract Number: The record sent contains an invalid contract number (only numeric allowed). Invalid Package Code: The record was sent with an invalid package code. Invalid Coverage Code: The data sent in the State Cov Code field is blank or contains an invalid code (01, 02, 22, 09, 10, 11, 12 etc.). Invalid Characters in Name: The record contains an invalid character in the name (the data must be alpha or hyphen or apostrophe). Invalid Relationship in Code: If the value in the Dependent Relationship field (47) is not one of the allowed this will cause the record to fail. (allowed values: 1 = Spouse, 2 = Child, 3 = Legal Guardianship, 4 = Grandchild, 5 = Child, 6 = Foster Child, 7 = Step Child, 8 = Unborn Child, 9 = Over-age dependent Child). Florida Blue Weekly Automated Enrollment Default Review information and correct enrollment files in People First system. Dependent Of Dependent Over 18 Months: This is for a dependent of a dependent (grandchild) and over 18 months of age. Invalid Address: Address is invalid; need file to be corrected. Dependent Name Missing: The record is missing a name. Missing Address: The record was missing the address. Invalid Zip Code: The record has an invalid zip code. Humana Weekly Discrepancy Review information and correct enrollment Invalid Birth Date: The record has an invalid birth date. Discrepancy - Effective Date questions, etc. ITN No.: DMS-14/ Page 20 of 40

21 Vendor United Health Care United Health Care Dental CVS/ Caremark Frequency Weekly Weekly Name Eligibility Eligibility Process Description files in People First system. Review entries on report. Correct in People First system when necessary. Review entries on report. Correct in People First system when necessary. Comments / Definitions Description Provides description of the field in which the error is causing the member to be rejected. There is a list of common errors and tips available on the eservices in the tutorial section. is sent to PFSC via eservices (UHC secured site). Each error has a description of the fields that are causing the member to reject. A list of common errors and tips are available on the eservices site in the tutorial section. United HealthCare Dental is inquiring to start using this process. CVS/Caremark is currently sending their report to DSGI and the DSGI Product Manager is handling the discrepancies with People First. ITN No.: DMS-14/ Page 21 of 40

22 II. Payroll Processes Listing 1 Employee Time Entry Un-Submit/Cancel Timesheets Recurring or One Time Pay Deductions Leave Balance Adjustments Create Flexible Work Schedule If an employee or HR manager is unable to enter time into the People First system, they can request assistance from the PFSC. The PFSC HR Specialists can process up to three employee's timesheets per call. If there are more than three employee timesheets, PFSC HR Specialists will open a case and assign to team to process the request. HR Officers and HR Managers have the ability to unsubmit / cancel timesheets in the People First system, but can request assistance from the PFSC. The PFSC will only process requests from an agency manager role from Department of Revenue, Department of Corrections and Department of Children & Families. All other agency manager roles will be referred back to their Agency HR for assistance. All agency HR Managers can request a Unsubmit / cancel request to be processed by the PFSC. The Tier 1 PFSC HR Specialists can un-submit/cancel up to three employee's timesheets per call. If there are more than three employees timesheets, Tier 1 PFSC HR Specialist will open a case and assign to PFSC team to process the request. HR Managers can request assistance from the PFSC to add or delete a Recurring Pay or One Time Pay Deduction for an employee. The Tier 1 PFSC HR Specialists will open a case and assign to team to process the request. Leave balances may be adjusted in compliance with Rule 60L-34, Florida Administrative Code, Attendance and Leave. HR Managers have the ability to make Leave Balance adjustments in the People First system, but can request assistance from the PFSC. Personal Holiday adjustments cannot be done by the agency and must be completed by the PFSC. The Tier 1 PFSC HR Specialists will open a case and assign to team to process the request. A flexible work schedule can be created for / by an employee when moving from one Fair Labor Standard Act (FLSA) period to another in the middle of the period based on the FLSA, if there is no time entered on the timesheet. This applies anytime a FLSA period is changed, including multiple changes in the same period. Human Resource Officers and HR Managers can request assistance from the PFSC for creating flexible work schedules for their direct reports. Flexible work schedules are entered in SAP for past pay periods. The Tier 1 team can process up to three employee's flexible work schedules per call. If there are more than three employee flexible work schedules, Tier 1 PFSC HR Specialists will open a case ITN No.: DMS-14/ Page 22 of 40

23 Delete Flexible Work Schedule Delete Time After Termination Cancel Supplemental Pay Process Leave Transactions Navigational Assistance and assign to team to process the request. HR Officers and HR Managers can request assistance from the PFSC to delete a flexible work schedule. The Tier 1 PFSC HR Specialists can process up to three employees flexible work schedules per call. If there are more than three employee flexible work schedules per call, Tier 1 PFSC HR Specialists will open a case and assign to team to process the request. An HR Officer or HR Manager must call the PFSC for assistance if a deletion of hours worked or leave recorded on a timesheet is needed after an employee termination. This process does not delete that time entry, but prevents payment. The Tier 1 PFSC HR Specialists will open a case and assign to team to process the request. HR Managers can request assistance from the PFSC to cancel Supplemental Pay for an employee. This may occur when an HR Manager creates the entry in the supplemental pay screen and later needs to have it deleted. The Tier 1 PFSC HR Specialists will open a case and assign to team to process the request. HR Managers can process leave with or without pay transactions utilizing the PAR process. The team will assist with removing any time or pay additive/pay deduction. Tier 1 PFSC HR Specialists will open a case and assign to team to process the request. Leave actions include: Leave of Absence (LOA) with Pay LOA without Pay Return from Leave with Pay Return from Leave without Pay Suspension Return from Suspension The PFSC answers general questions and provides navigational assistance to employees and managers for the following items: View / Create/ Edit Employee Time Entry View /Create / Edit Approval/Rejection of Time Entry Create / Edit Time Entry Template Create Time Keeper Group View Work Schedule View / Create W4 View / Create Direct Deposit Process Time and Payroll s Process Leave Audit View Timesheet Summary Create / Add Change Charge Objects Verify Salary Payment View Gross Pay Information Tier 1 ITN No.: DMS-14/ Page 23 of 40