NetCare has adopted a prepaid advanced billing program that generates your monthly billing statement one month in advance. The billing is electronically mailed to you before the 31st of each month using the Hypersend program or is available on NetCare’s web site at www.netcarelifeandhealth.com for you to download. The billing statement reflects current and prior billing information, including any changes in your group’s eligibility which is reported to NetCare since the last billing statement.

You may use the monthly billing statement to make any corrections or adjustments by writing the changes directly on the billing statements. Although, you can make the changes and adjustments directly in the billing statement, you are still required to complete the appropriate Enrollment/Change of Status Form indicating any eligibility changes and terminations.

Billing Statement
The monthly billing statement consists of four major sections:

1. Group Information
   • Date of the billing statement
   • Group Number
   • Monthly Billing Period
   • Group/Company Name and Address
2. Subscriber Listing Report
   • Subscriber’s NetCare Policy Number
   • Subscriber’s Name
   • Billing Class Type (Single, Couple, Family)
   • Premium Amount
3. Total for Location
   • Total Number of subscribers being billed
   • Total Number of subscribers enrolled for each plan (Medical, Dental)
   • Total Number of subscribers with adjusted premiums
4. Summary of Billing Statement
   • Balance forward amount from previous month
   • Payments received and posted from the previous month
   • Premium adjustment from prior month
   • Beginning Balance
   • Current Amount Due
   • Current Adjustments
   • Total Amount of Payment Currently Due NetCare

Submitting Payment
Pursuant to the terms of your Group Service Agreement with NetCare, premium payments are due and payable in advance on or by the twentieth (20th) day of the prior month. A grace period of ten (10) days is allowed for late payments. We request that you pay the “Total Amount Due” even though some recent changes you might have made are not reflected on the current billing. All changes and adjustments, which were not received on time to be reflected on the current billing statement, will be shown on next month’s billing statement.

Timely payments of the monthly premiums are critical and ensure eligibility changes submitted with your payments are processed and reflected on subsequent billing statements. We will do our part in ensuring that you receive your monthly billing statement timely and accurate as well.

When you receive your billing statement, please do the following:

1. Audit your billing statement thoroughly and write any changes directly on the bill.
2. Prepare the necessary forms for enrollment or changes and submit to NetCare by the 20th day of the month prior to the effective date.
3. Please make payments to NetCare Life & Health Insurance Company by the 20th day of the month prior but no later than the 30th day of the month prior.
4. Include with your premium payment any applicable enrollment/change of status forms and any other pertinent documentation required when reporting changes.
5. Please be advised that failure to make timely payments will result in claims being pended and not processed and paid.

Billing Timeline
Listed below is a timeline pertaining to billing and payment deadlines:

Cut-off date to submit changes	20th of the month prior
Billing Statement transmitted to groups	25th – 30th of the month prior
Payment is due and payable to NetCare	20th of the month and no later than the 30th of the month prior
Delinquent letters transmitted to groups	10th of the month
Group Termination Effective	30th of the month

Non-Payment of Premium
If your group fails to remit premium prior to the end of the applicable grace period, your coverage will be terminated. Should any group cancelled previously for non-payment of premiums or returned checks apply for coverage within 12 months of the cancellation, the group must be approved by NetCare’s Chief Financial Officer and comply with all credit and collections policies in place before re-enrolling for coverage. These may include payment of any previously unpaid grace period premiums and advance payment of multiple months of premiums.

If the group is cancelled for non-payment of premium, NetCare is not obligated to reinstate coverage in the event that past due premium is later paid. However, the group may request reinstatement to NetCare’s Chief Financial Officer in writing. If approved for reinstatement, the group will be subject to premium payment terms that may include the payment of all past due premiums and advance premiums in the form of certified funds.

Policy:
NetCare is required by Guam law to offer certain appeal and grievance procedures. These procedures are listed below. NetCare does have the option to impose time limitations on filing the appeals or grievances. These specific plan limitations, as well as any other plan specific information, are listed below.

Process:
Plan members have two (2) separate appeal routes. One takes place when the member contests a decision to deny or limit health care services "non-certification decision" or for experimental or investigational treatment. This is called an APPEAL. The other appeal route occurs when a member is unhappy with other aspects of the plan’s operations. A complaint about other operations of the plan is called a GRIEVANCE.

Members have the right to two (2) levels of review, for both appeals and grievances. The first level of review has a different name and a slightly different process depending on whether it is a first-level appeal or first-level grievance review. However, the second-level review is the same regardless of whether the dispute is a denial of services or another problem with the plan’s operation. This is referred to as a second-level grievance hearing or an external hearing.

Members who contest non-certification decisions (denials of services or procedures) have a right to ask for expedited review if the normal time limits could hurt the person’s health. Otherwise, the normal time limits apply. There is not an expedited process for first-level grievance decisions, because first-level grievance hearings do not deal with non-certification decisions (these are handled at the first level appeals).

Informal Reconsideration: NetCare has an informal process where it can resolve disputes quickly. The informal process is voluntary.

Appeal

• First Level Appeal: Members can file an appeal on their own behalf. In addition, a physician or other person acting on the member’s behalf can file an appeal. NetCare offers at least two levels of appeals. A physician who was not involved in the original decision must hear the first appeal. In this level, normally the physician has thirty (30) days for post-service claims or fifteen (15) days for pre-service claims to decide and inform the member of its decision of the appeal. All appeals from a member or physician acting on behalf of a member must be made in writing.
  
  NetCare must provide a written decision to the member and the member’s provider. The decision should contain the qualifications of the person reviewing the appeal, the reviewer’s decision including the medical rationale and evidence used as the basis for the decision, and instructions on how to file a second-level grievance hearing.
• First Level Expedited Appeal: Members can request an expedited appeal if their health would be harmed by the 30-day or 15-day delay. In an expedited appeal, the physician has up to thirty-six (36) hours to make a decision. However, members can request the decision be made immediately if there is a more immediate health care need. Members will have their health services covered until the member is notified of the expedited review decision, if the appeal involves concurrent review such as continued stay in a hospital. Members are not entitled to expedited review if the health care services have already been provided and the issue is whether the care was appropriate.
• Second Level Expedited Appeal: Members can request an expedited second-level review if their health could be harmed because of any time delays. Members may request an expedited second-level review even if the first-level appeal or grievance review was not expedited. In this level review, the Plan has thirty-six (36) hours to make a decision. If necessary, NetCare may conduct the hearing over the phone or through submission of written information.

Grievance

• First Level Grievance Hearing: The member, his representative or the provider may submit a first-level grievance. NetCare must provide the member with information on how to submit written materials, within seven (7) business days after receiving notice of the grievance. The person reviewing the grievance cannot be the same person who initially handled the grievance. If the issue is a clinical one, at least one of the reviewers must be a medical physician with appropriate expertise. NetCare must make a grievance decision within thirty (30) days after receiving the complaint. The notice of the decision must include the same information as provided in first-level appeal decisions.
• Second Level (External) Hearing: NetCare also has second-level grievance reviews for members who are dissatisfied with the decision of the non-certification appeal or first level grievance review. NetCare must notify the member of the name and telephone number of the grievance coordinator, as well as information about the second-level grievance process within five (5) business days of receiving a request for a second-level grievance. Members have more extensive due-process rights at the second-level grievance review.
  
  The member may request for an external review where NetCare will convene a hearing panel that will comprise of people who are not employees of NetCare or utilization review organization, who were not previously involved in the decision, and who do not have a financial interest in the outcome of the review. All people reviewing a second-level appeal involving a non-certification or clinical decision should be providers who have appropriate expertise in the health issue in dispute. If the review involves a grievance, the people should be members of the community who have appropriate expertise in the issue in dispute.
  
  The member can attend the second-level grievance-hearing, request and receive all information relevant to the case in order to prepare for the hearing. Members may present his or her case to the review panel, submit supporting materials before and at the review meeting, ask questions of any member of the review panel and bring another person to help in the review hearing. These could include a family member, employer representative or attorney. If the member chooses to bring an attorney, then an attorney may also represent NetCare. The review panel has up to fifteen (15) business days to hold the hearing, and up to ten (10) business days thereafter to make a decision. This decision is a recommended decision to NetCare.
  
  NetCare may provide expedited access or process of the external hearing if the member’s health or issue will be harmed by the thirty (30) day time delay. Expedited access to the External hearing level will follow the same process as the Expedited Appeal.
  
  NetCare must provide a written decision to the member and the person’s provider (if appropriate). The decision should contain the qualifications of the people reviewing the grievance, the reviewer’s decision, including the medical rationale for the decision and the evidence used as the basis for the decision. The account states that the decision is the insurer’s final determination in the matter.

Appeals and Grievances Procedures (PDF version)
Grievance Complaint Form

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NetCare’s Consumer-Driven Health Care Plans (called the SmartChoice Plan) are offered as another flexible and affordable health care solution for employers. As Consumer-Driven Health Plans continue to grow in popularity, NetCare’s strategy is to deliver a single source that educates and empowers our members about their healthcare choices.

NetCare’s SmartChoice Plans focuses on turning health care users into accountable consumers by providing education on different options available and illustrating the financial consequences of the options. By training consumers to be their own health care advocates, employees and employers can achieve long and reduction of health care costs with improved health outcomes.

NetCare offers two High Deductible Health Plans (SmartChoice 1500 and SmartChoice 2500). At the base of these plans is a Health Savings Account to help offset the high deductible impact.

Health Savings Account (HSA)
The Health Savings Account (HSA) can be funded by the employer, the employee or both. Employer contributions can be made up in a lump sum at the beginning of the plan year, or made throughout the plan year. Employee contributions are made through pre-tax payroll deduction.

HSA funds are deposited with a third party trustee. NetCare offers members and employers three trustees in which to open a Health Savings Account: HSA Bank; Bank of Guam and Administrative Services Corporation (ASC). Only funds actually in the account can be accessed for reimbursement.

In addition to covering out-of-pocket medical costs, an HSA allows employees to put aside pre-tax income, thus reducing their tax liability while also earning interest on their savings. Any money not used remains in the portable account and can be used for future health care expenses. HSA balances belong to the employee when they retire or change jobs.

Overview
The intent and purpose of the Underwriting Guidelines is to properly assess risk or the potential risk of a group or population to be enrolled in the plan and develop an appropriate premium price to cover that risk.

Some key factors generally considered by NetCare in underwriting and pricing strategies include:

• Age and Gender
• Industry and Occupation
• Likely Network Compliance
• Special Populations
• Impact of Selection
• Restrictions on Pricing
• Health Status and Medical History
• Lifestyle (smoking, drinking, drug use)

Who is Eligible?
Firms classified in most business in the following industries:

• Retailers
• Wholesalers
• Services
• Communications
• Manufacturing

Participation Requirements
The following participation requirements for medical, dental and vision are:

• Medical Plan
  • The Standard, Prime, Advantage, Access and SmartChoice Plans are offered to groups employing two or more full-time employees.
  • For firms with 2 to 10 employees, 100% participation is required of eligible employee.
  • For firms with more than 11 employees, 80% participation is required of eligible employees.
• Dental Plan
  • The SMILE Dental Plan ($1000 Max) is offered to groups with 2 to 50 full-time employees.
  • The BRITE Dental Plan B ($1500 Max) is offered to groups with 50 or more full-time employees.
  • For groups with 16 or more employees, a minimum of 50% participation is required
  • For groups with 2 to 15 employees, a minimum of 100% participation is required
• Vision Plan
  The Vision Plan requires 100% participation of all eligible employees regardless of the size of the firm.
• Orthodontic Plan
  The Orthodontic Plan is only available for firms employing 100 or more full-time employees and requires 100% participation of all eligible employees.

Employer Contribution Requirements
In order to reduce adverse selection and encourage enrollment of ‘healthy’ employees, NetCare requires the following employer contributions to the monthly premiums:

1. For groups with 2 to 10 eligible employees, NetCare requires 100% employer contribution of the single premium.
2. For groups with 11 to 50 eligible employees, NetCare requires a minimum of 70% employer contribution of the single premium.
3. For groups with 50 or more eligible employees, NetCare requires a minimum of 50% employer contribution of the single premium.

Please keep in mind that a non-contributory plan where the employer does not contribute towards the monthly premium will lead to high losses and adverse selection since only those employees that have a medical condition will enroll and will pay whatever the premium amount is due to their medical conditions. A healthy employee is less likely to enroll under the plan since he or she will have to pay the monthly premiums fully under a non-contributory plan.

Standard Requirements

1. All firms must be legitimate businesses on Guam, CNMI or Palau with a valid business license and compulsory Worker’s Compensation Coverage.
2. NetCare’s group health products are available to firms that employ a minimum of 2 or more full-time employees and can demonstrate that there is a clear employee/employer relationship.
3. For groups under 10 employees, a Wage and Hourly Report for the two preceeding quarters filed with the Department of Labor must be submitted to NetCare as proof of employment for each individual at the time of enrollment.
4. An annual audit of each employer and covered employee may be conducted by NetCare in order to determine the firm’s continuing eligibility.
5. For COBRA enrollees, a letter of election and a copy of the last payroll report of the enrollee must accompany the enrollment form.
6. A firm may add a rider benefit such as dental and vision coverage or make changes to their group policy only at the anniversary date.
7. If the firm has been terminated within the prior 12 months due to non-payment of premiums, NetCare will not issue the firm a group policy or reinstate the firm.
8. All firms employing individuals working at least 20 hours or more per week are eligible for participation and enrollment. If an employee is out of work for reasons of sickness when the policy commences, he/she will not be eligible for coverage until he/she returns to full-time work.
9. Eligible employees and their dependents who choose not to enroll when they are first offered and eligible will not be eligible to enroll with NetCare until the firm’s anniversary or enrollment period unless they meet a qualifying event under the Health Insurance Portability and Accountability Act (HIPAA).
10. Eligible Employees and their dependents who choose not to enroll when they are first offered and eligible because of other health insurance coverage will be required to sign a NOTICE OF SPECIAL ENROLLMENT RIGHTS form that allows the eligible employee to enroll in the future as a SPECIAL ENROLLEE due to a HIPAA qualifying event.
11. Eligible employees must enroll according to their marital status when married to an employee of the same group, unless one of the spouses can provide evidence acceptable to NetCare through another health plan.
12. NetCare will provide credit toward pre-existing condition limitations for prior coverage under other plans to the same extent and according to the provisions of HIPAA.
13. When determining the extent of the pre-existing condition limitation, full month for month credit will be given for Medicaid/Medicare coverage and coverage under other private plans, provided there exists no more than a 63 –day lapse in coverage.
14. When a firm enrolls with NetCare, the date of coverage will be effective on the first day of the month following approval of the group application.
15. All groups enrolling less than 25 employees are subject to medical underwriting review, including a completion of a Health Statement.
16. Once the application process is completed and approved, NetCare will transmit a Group Service Agreement, Administrative Manual, Member Identification Cards to the firm for distribution.
17. The group billing statement will be sent to the firm and payment must be made in advance prior to the release of any ID cards and Group Service Agreement.
18. Firms must have been in business for a minimum of two (2) years prior to enrollment.
19. Firms that do not have prior insurance coverage in the past two (2) years prior to enrollment will not be accepted or approved.

Residency Requirements
Coverage under NetCare requires that the eligible employee and his/her dependents must have been residing in the service area in which the policy is to be issued for at least three (3) consecutive months and must continue to be a resident in that jurisdiction during at least nine (9) months of each year.

Employee Eligibility
All active full-time employees working at least 30 hours or more per week, including owners or partners are eligible. If an employee is out for reasons or sickness when the policy commences, he or she will not be eligible until he or she returns to work on a full-time basis.

Employee Eligibility
All active full-time employees working at least 30 hours or more per week, including owners or partners are eligible. If an employee is out for reasons or sickness when the policy commences, he or she will not be eligible until he or she returns to work on a full-time basis.

Effective Date of Coverage
When a firm joins the plan, the insurance of its current eligible employees will be effective on the first day of the month following approval of the group application. All eligible employee enrollment applications are subject to underwriting and final approval of the insurance applied for if the firm employs less than 25 eligible employees. Firms employing more than 26 eligible employees are not subject to underwriting approval unless enrolling outside of open enrollment or is a late applicant.

Applying for Coverage
The following documents must be submitted to the Group Administration Department for processing:

1. Completed and signed Master Group Application
2. Enrollment Application for each eligible employee, including Health Statements when applicable.
3. Employee Census Data
4. One’s months advanced premium payment
5. Wage & Hourly Report (for groups under 10 eligible employees)
6. New/Renewing Group Data & Information Sheet
7. Rate Proposal Sheet with signature acceptance

The above documents should be submitted at least 15 days prior to the effective date of coverage, in order to properly underwrite the case, prepare member identification cards, Group Service Agreements and billing statement. All group policies are issued with an effective date of the first of the month only, unless exceptions are approved by the Plan Administrator.