These questions and answers are for general information purposes only. This information does not create an employment contract between the employee and the agency. This information does not create any contractual rights or entitlements. The agency reserves the right to revise the content of this information, in whole or in part. No promises or assurances, whether written or oral, which are contrary to or inconsistent with the terms of this paragraph create any contract of employment. This information does not constitute tax or legal advice.
Most Common Subscriber Questions
Q. What do I need to do if I'm going for a routine physical (wellness exam)?
A. Preventive benefits, such as routine physicals, mammograms or colonoscopies, are covered differently by each health insurance plan offered by PEBA Insurance Benefits. Regardless of the plan, you can receive many standard tests through Prevention Partners’ Workplace Screening, for only a $15 copayment.
State Health Plan Standard Plan
If you are covered by the Standard Plan, the plan pays benefits for medically necessary treatment of illness and injury. As a result, routine physical exams are not covered for subscribers older than 18. The plan does offer limited preventive benefits for certain services including mammograms, Pap tests, colonoscopies and well child care. Click on the links to read about the Standard Plan’s covered wellness benefits.
State Health Plan Savings Plan
If you are covered by the Savings Plan, you are taking greater responsibility for your health with a higher deductible. As a result, Savings Plan participants age 19 and older may receive an annual physical from a network provider. Click here to read about the services covered during an annual physical. Savings Plan participants are also eligible for additional wellness benefits, such as mammograms, colonoscopies and flu vaccinations. Click on the link to see what services are covered.
BlueChoice HealthPlan HMO
If you are covered by BlueChoice HealthPlan HMO, a routine physical exam is covered every year. BlueChoice also offers wellness benefits for women’s health, colonoscopies and children’s health. Click here for more information on the BlueChoice HealthPlan wellness benefits.
Wellness benefits are explained in detail in the Insurance Benefits Guide.
Q. Do I need a referral or preauthorization before having surgery or seeing a specialist?
A. Under the State Health Plan, subscribers do not need a referral before seeing a specialist; however, some services do require preauthorization by Medi-Call, including inpatient surgery. For services that require preauthorization, check the list in the IBG or contact Medi-Call. Your physician may call to preauthorize services for you, but it is your responsibility to ensure the call is made. Medi-Call can be reached by calling 800-925-9724.
BlueChoice subscribers only receive benefits for covered services when using a network provider. Your primary care physician must refer you to a specialist or surgeon before services are covered.
Q. I’m having a baby. Do I need to notify my health plan before receiving maternity services?
A. Regular prenatal care can help keep you and your baby healthy. All of PEBA Insurance Benefits’ health plans offer coverage for maternity care for subscribers and their spouses.
The State Health Plan requires that all expectant mothers participate in the Maternity Management Program and preauthorize maternity benefits with Medi-Call during the first trimester (three months) of the pregnancy. If you do not preauthorize, there will be a $200 penalty for failing to call, as well as a $200 penalty for each maternity-related inpatient admission and a coinsurance penalty.
BlueChoice participants do not require preauthorization for maternity benefits.
Newborns are not automatically enrolled. Once the baby is born, contact your benefits office within 31 days to add the child to your coverage.
Note: Covered children of subscribers are not eligible for maternity benefits.
Q. We’re planning a trip. Does my health plan offer coverage outside of South Carolina?
A. All of PEBA Insurance Benefits’ health plans offer limited coverage outside of South Carolina and the United States. State Health Plan and BlueChoice HealthPlan HMO subscribers have access to doctors and hospitals throughout the United States and around the world through the BlueCard Program and Blue Cross and Blue Shield provider networks. BlueChoice members have BlueCard coverage for urgent and emergency care only. Before your trip, read the BlueCard section in the IBG to find out what insurance information you’ll need on your trip and what services will be covered. Please note that BlueCard Worldwide is not available to Medicare Supplemental Plan subscribers.
Q. Can I keep my health, dental and vision insurance when I retire?
A. You may be eligible for health, dental and vision coverage in retirement if you retire from an employer that participates in the state insurance program and meet certain criteria.
Enrollment in retiree insurance is not automatic. If you are eligible for retiree insurance, you must submit a completed Retiree Notice of Election form and Employment Verification Record to PEBA Insurance Benefits within 31 days of your retirement to apply for retiree insurance.
Q. What happens to my life insurance when I retire?
A. If you are enrolled in Optional Life when you retire, you may choose to continue or convert your insurance with MetLife. A Continuation of Group Optional Life Coverage Form or Notice of Group Life Insurance Conversion Privilege Form must be completed and received by MetLife within 31 days of loss of coverage.
You may also choose to convert your Basic Life or Dependent Life for a spouse or child by completing the Notice of Group Life Insurance Conversion Privilege Form and following the instructions on the form. You must meet with a MetLife agent to complete an application. Your benefits office can assist you with completing these forms.
Q. What do I need to do if I or my spouse becomes eligible for Medicare?
A. Eligibility for Medicare is a special eligibility situation that allows you to make certain changes to your health insurance plan. The Medicare chapter of the Insurance Benefits Guide discusses what to do if you become eligible for Medicare: before age 65 if you are a disability retiree; at age 65 if you are retired and if you are an active employee at age 65 and leave employment after age 65. It also explains what to do if your spouse or child becomes eligible for Medicare.
If you are a retiree, you should enroll in Part A and Part B of Medicare when you or your spouse first becomes eligible for Medicare. Active employees and their covered family members may choose to defer Part B until they retire. To find out more about how Medicare and PEBA insurance work together, read the When You Become Eligible for Medicare handbook, which is listed under "Publications."
Q. What should I do if I’ve been called to active-duty military service?
A. Under the Uniformed Services Employment and Re-employment Rights Act (USERRA) employers are required to provide certain re-employment and benefits rights to employees who serve or have served in the uniformed services. If you are going on military leave or returning from military leave, please contact your benefits administrator for information.
Q. How do I add my newly adopted child to my insurance?
A. To add a child under 18 who is adopted or placed for adoption to your policy, you must submit an NOE with one of the following: 1) a copy of the long-form birth certificate showing the subscriber as the parent; 2) a copy of the legal adoption documentation from the court verifying the completed adoption or 3) a letter of placement from an adoption agency, attorney or the S.C. Department of Social Services verifying the adop¬tion is in progress. The effective date of health, dental and vision coverage is the child’s date of birth, if the child is placed within 31 days of birth. Otherwise, it is the date of adoption or placement. For information about international adoptions, see your benefits administrator.
Q. What changes can I make to my insurance when I get married?
A. Within 31 days of marriage, you may enroll yourself and your spouse and eligible children/stepchildren to your health, dental, vision and life insurance by submitting a completed Notice of Election form and proper documentation of dependent eligibility to your benefits office. You may also enroll in or increase your Optional Life by up to $50,000 and enroll in or change contributions to a Medical or Dependent Care Spending account.
A subscriber can enroll his spouse, without medical evidence, in $10,000 or $20,000 in Dependent Life-Spouse coverage within 31 days of the marriage. Subscribers can also enroll eligible dependent children in Dependent Life-Child coverage within 31 days of the marriage.
Q. What should I do if I’m getting divorced?
A. If you divorce, you must remove your spouse and former stepchildren from your coverage by completing an NOE and submitting a complete copy of the divorce decree within 31 days of the date stamped on the divorce decree. Coverage for your divorced spouse and former stepchildren will end the last day of the month after the divorce decree is stamped. If you fail to drop your divorced spouse or former stepchildren within 31 days of the date the court order or divorce decree is stamped by the court, the change in coverage is effective the first of the month after your signature on the NOE dropping your former dependents.
You may continue to provide health, vision and dental coverage for your former spouse and/or stepchildren only if the Family Court requires that you do so. You must provide a copy of the divorce decree ordering you to cover your former spouse and/or former stepchildren, as well as an NOE, to your benefits administrator, who will send both to PEBA Insurance Benefits. The document must list the plans under which your former spouse and/or former stepchildren must be covered. Retirees of state agencies, higher education institutions and school districts, survivors and COBRA subscribers should notify PEBA Insurance Benefits. Retirees of local subdivisions should notify their benefits administrator. The effective date is the first of the month after the divorce becomes final.
You cannot continue to cover your former spouse or former stepchildren under Dependent Life under any circumstances.
When your divorce is final, you can enroll in or increase your Optional Life coverage by $50,000 without medical evidence of good health. You may also cancel or decrease your Optional Life coverage.
You also may be able to make changes in a Medical Spending Account or a Dependent Care Spending Account.
If you remarry, you can cover your divorced spouse or your current spouse, but you cannot cover both under any PEBA Insurance Benefits plan. You can, however, cover one spouse under one plan (health, for example) and the other spouse under another plan (dental, for example). Spouses who lose coverage due to a qualifying event may be eligible to continue coverage under COBRA. For more information, you must contact your benefits administrator or PEBA Insurance Benefits as soon as possible, but within 60 days after the event or from when coverage would have been lost due to the event, whichever is later.
These rules also apply to common law marriages.
Q. What can I do to continue my insurance if I have lost my job?
A. If you are laid off or fired from your position as an active employee, you may be eligible to continue your health, dental, vision and Medical Spending Account coverage (unless the firing is due to gross misconduct).
To elect continued coverage as provided under under COBRA, you must submit a COBRA Notice of Election form within 60 days of the date coverage was terminated or the date of the COBRA notice, whichever is later. Continued coverage becomes effective when the first premium is paid and remains in effect only as long as the premiums are up to date.
Q. Who should I contact to report the death of a subscriber or his covered spouse or child?
A. If the subscriber is an active employee or a retiree of a local subdivision, you should notify his benefits office. If the subscriber was a COBRA subscriber or a retiree of a state agency, higher educational institution or school district, you should contact PEBA Insurance Benefits.
There is a checklist on page 38 of the IBG that will help you with the subscriber’s coverage, help you with any benefits payable as a result of his death, and help with enrollment in survivor coverage for his covered spouse and/or children.
Q. I have a question about a claim. Who should I contact?
A. Questions regarding claims should be directed to the appropriate claims administrator. For links to access your information online, go to the Claims Information tab on PEBA Insurance Benefits’ homepage or see the inside cover of the IBG for additional contact information.
Q. How can I get a copy of my benefits statement?
A. PEBA Insurance Benefits does not provide paper benefits statements to employees. Active employees, retirees, survivors and COBRA subscribers can access their benefits information online via MyBenefits, PEBA Insurance Benefits’ electronic enrollment system.
Q. I am being charged a fee for using tobacco. No one on my insurance uses tobacco. How can I get this charge removed?
A. If you and your covered dependents have not used tobacco for at least six months, you may complete a Certification Regarding Tobacco Use form and return it to your benefits administrator. The charge will be removed the first of the month following receipt by PEBA Insurance Benefits.
Q. I need to change my contact information (address, phone number, etc.). Can you send me a form?
A. Active employees, retirees, survivors and COBRA subscribers can update their contact information online via MyBenefits, PEBA Insurance Benefits’ electronic enrollment system.
Q. How can I get a copy of my life insurance policy?
A. There is no individual certificate available for participants in a group plan. Whether you are an active employee or a retiree who continued your life insurance policy under the state’s group plan, information about the policy is included in the IBG. For information about the value of your policy and premium information, contact MetLife at 800-638-6420, prompt 2.
Q. I need to order another insurance card. Who should I contact?
A. If you need an additional insurance card, contact the appropriate carrier.
Q. My health claims are not being paid because the carrier states it does not pay for pre-existing conditions. What does this mean and how can I correct it?
A. For an employee or dependent who enrolls when he is first eligibile, there is a 12-month waiting period before benefits will be paid for a pre-existing condition. A pre-existing condition is any illness or injury for which medical advice, diagnosis, care or treatment was recommended or received within the six months before the date the coverage became effective. Pregnancy is not considered a pre-existing condition.
This waiting period can be waived or reduced by giving your benefits office a creditable coverage letter or statement on letterhead from your former employer or insurance company that includes the date coverage began and ended, the names of those covered and the type of coverage.
If an employee or dependent is added during open enrollment, he is subject, as a late entrant, to an 18-month waiting period before benefits will be paid for a pre-existing condition.
Covered persons younger than 19 are not subject to any pre-existing condition exclusions.
Q. Is there anything I can do to better manage my healthcare costs?
A. Yes, there are a number of steps you can take, including eating a more nutritionally balanced diet, exercising, stopping smoking, losing weight, using generic rather than prescription drugs, and generally being a better-informed healthcare consumer. For a more complete list of ideas on how you can reduce your healthcare costs, click here.
Q. Why doesn't the State provide more preventive coverage such as physicals or Pap smears?
A. The State Health Plan provides coverage for a number of preventive procedures, including Pap smears. Members can receive a comprehensive blood analysis – including blood pressure and cholesterol checks – for just $15 through our Prevention Partners Workplace Screening program. Additionally, routine four-view mammograms are covered for women 35 and older, as are routine immunizations and checkups for children through age 18. Routine colonoscopies are covered once every 10 years, starting at age 50, even when no symptoms are apparent.
Generally speaking, the plan covers procedures recommended by the U.S. Preventive Services Task Force, an independent panel of experts in primary care and prevention that systematically reviews what treatments are effective. It does not recommend that individuals have an annual physical. However, BlueChoice HealthPlan HMO covers physicals and other preventive procedures that are not included in the State Health Plan.
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