J A NU AR Y 2 7 , 2 0 1 6 | I D A H O
not an Individual plan member, the AOR
will not be accepted.
IN THIS ISSUE
-
Validating the current AOR. If you are the
current agent, you will receive an alert.
-
Filtering out Your Health Idaho (YHI)
enrollees. Any AOR changes for YHI
enrollees must be submitted directly to
YHI. Broker Exchange will not allow you to
submit the AOR and you will receive an
alert message.
Submit Your Individual AOR Electronically
1095 Reporting Update
Embedded Out-Of-Pocket Maximums on
HealthSaveSM Plans
Reminder: Send PHI Securely
Submit Your Individual Agent of Record
(AOR) Electronically with Our New Link
We are pleased to announce the Phase I launch of
our new electronic AOR submission process for
Individual plans. You may have already noticed the
link under the Individual Plans Management
section of Broker Exchange:
To use this tool, simply enter the subscriber
information and upload the completed form. You
must first enter the subscriber ID or a combination
of the subscriber name, birth date, and SSN.
The tool will determine which AORs may not be
valid before allowing you to upload a completed
and signed AOR form. These validations include:
-
Determining the eligibility of the
policy. If the subscriber is ineligible, or
A newsletter for SelectHealth-appointed agents and agencies.
Users who are set up as a proxy to an agent can
also submit an AOR change on behalf of an agent.
To do so, they must proxy the appropriate agent
before submitting the form. This will ensure that
the AOR will be uploaded for the correct agent.
Please note that the AOR will not be automatically
approved. We will continue to process and
approve each form manually, and the effective
date will typically be the first day of the following
month.
If you used this tool to upload an AOR prior to
January 19, 2016, the AOR may not have been
received due to technical issues in the first few
days using the new link. Please resubmit AORs
uploaded prior to that date.
If you have questions, please contact
[email protected] or
[email protected].
1095 Reporting Update
The Affordable Care Act (ACA) requires
SelectHealth® to report insurance coverage for the
current year to the Internal Revenue Service (IRS).
BROKERLINE
As you may be aware, the IRS recently announced
that the deadline for providing employees with
1095 forms for 2015 was extended from February
1, 2016, to March 31, 2016.
1095-A – Marketplace (FFM) and Your Health
Idaho (YHI) Members
The FFM or YHI will provide the required report
(1095-A) to enrollees and to the IRS.
1095-B – Fully Insured Employer, Individual Plan
(Off-Marketplace), and Federal Employee Health
Benefits Members
We will populate the 1095 form with names,
birthdates, SSNs, and months of coverage. We will
mail copies to each member throughout February
(no later than February 29) and to the IRS by
March 31.
To read more about the ACA and IRS reporting
requirements, visit irs.gov/Affordable-CareAct/Questions-and-Answers-on-InformationReporting-by-Health-Coverage-Providers-Section6055.
Remember to Send Protected Health
Information (PHI) Securely
During this busy time of year, it’s easy to forget
that we need to follow HIPAA rules and send
personal information securely. Any message or
document that contains identifiable client
information such as names, birth dates, addresses,
and subscriber IDs should be sent one of these
secure ways:






Traditional mail
Fax
Via Broker Exchange message
Ask a SelectHealth representative to send you
a secure email to which you can reply
Use selecthealth.org/securemessage
Other encrypted email system
A newsletter for SelectHealth-appointed agents and agencies.
JANUARY 27, 2016 | IDAHO
HealthSave Embedded Out-Of-Pocket
(OOP) Maximums Explained
Due to new regulations limiting the OOP
maximums for individuals, SelectHealth
implemented changes to HealthSave family plans
(with two or more family members). This may have
caused some confusion.
We created a flyer—see the end of this
newsletter—to help you and your clients
understand this change.
© 2016 SelectHealth. All rights reserved. 4916 01/16
BrokerLine is a registered trademark of SelectHealth. The information
in this newsletter may or may not indicate whether a treatment is
subject to insurance benefits. Please refer members with questions
about benefits or coverage to Member Services at 800-538-5038.
HealthSaveSM Plans
Embedded Out-of-Pocket maximum
INDIVIDUAL AND SMALL EMPLOYER PLANS
An Out-of-Pocket (OOP) maximum is the maximum amount you pay for services covered by your
plan each year when you use a participating provider. If you are on a HealthSave family plan, your
OOP maximum is embedded. That means that a family member won’t have to pay anything beyond
the single OOP maximum amount for covered services.* If one family member reaches the single
OOP maximum, other family members will still need to pay applicable deductibles, copays, and
coinsurance for covered services until the family OOP maximum has been reached.
The Out-of-Pocket maximum is the total amount a member will pay for covered services
in a plan year.
FAMILY EXAMPLE:
FOR PARTICIPATING PROVIDERS
Deductible – Family/$9,000
Out-of-Pocket maximum - Single/$6,550 - Family/$10,000
Anne is on a plan with a spouse and two children. Her plan has an embedded OOP maximum of $6,550 (single) and
$10,000 (family). She receives services from a participating hospital totaling $8,000 of allowable charges. Because
her embedded OOP maximum is $6,550, that is the total amount she will be responsible to pay toward her services.
Later that year, her husband, Frank, has a medical procedure that costs $5,000. He will still be responsible to pay for
the first $3,450, but because he will reach the family’s total OOP maximum ($10,000), his plan will cover all covered
services above that amount.
ANNE HAS SPENT $6,550 THIS YEAR
She pays NOTHING for covered services
for the remainder of the year.
$3,450 IS THE REMAINING BALANCE
the rest of the family must pay to
meet the $10,000 annual Family OOP limit.
$6,550
$3,450
$6,550 + $3,450 = $10,000
Entire Family pays NOTHING for covered services for the remainder of the year when they use
participating providers after reaching $10,000 OOP MAXIMUM.
*For plans with out-of-network benefits, a separate out-of-network
OOP may apply. Some plans may also have a separate OOP for certain
covered services. Refer to your member materials for more information. © 2015 SelectHealth. All rights reserved. 4809 12/15