Open Enrollment Period Open Enrollment is a period of time each year when you and your eligible dependents, if family coverage is offered, may enroll for healthcare coverage or make changes to your existing healthcare coverage. The effective date will be on the first day of your employer’s plan year. A Special Enrollment Period is a time outside the yearly Open Enrollment Period when you can sign up for health coverage. You and your eligible dependents may enroll for coverage through a Special Enrollment Period by providing required enrollment information within thirty (30) days of the following events: • you get married, the coverage effective is the first day of the month following your marriage. • you have a child born to the family, the coverage effective date is the date of birth. • you have a child placed for adoption with your family, the coverage effective date is the date of placement. Special note about enrolling your newborn child: You must notify your employer of the birth of a newborn child and pay the required premium within thirty -one (31) days of the date of birth. Otherwise, the newborn will not be covered beyond the thirty -one (31) day period. This plan does not cover services for a newborn child who remains hospitalized after thirty-one (31) days and has not been enrolled in this plan. If you are enrolled in an Individual Plan when your child is born, the coverage for thirty- one (31) days described above means your plan becomes a Family Plan for as long as your child is covered. Applicable Family Plan deductibles and maximum out-of-pocket expenses may apply. In addition, if you lose coverage from another plan, you may enroll or add your eligible dependents for coverage through a Special Enrollment Period by providing required enrollment information within thirty (30) days following the date you lost coverage. Coverage will begin on the first day of the month following the date your coverage under the other plan ended. In order to be eligible, the loss of coverage must be the result of: • legal separation or divorce; • death of the covered policy holder; • termination of employment or reduction in the number of hours of employment; • the covered policy holder becomes entitled to Medicare; • loss of dependent child status under the plan; • employer contributions to such coverage are being terminated; • COBRA benefits are exhausted; or • your employer is undergoing Chapter 11 proceedings. You are also eligible for a Special Enrollment Period if you and/or your eligible dependent lose eligibility for Medicaid or a Children’s Health Insurance Program (CHIP), or if you and/or your eligible dependent become eligible for premium assistance for Medicaid or a (CHIP). In order to enroll, you must provide required information within sixty (60) days following the change in eligibility. Coverage will begin on the first day of the month following our receipt of your application. In addition, you may be eligible for a Special Enrollment Period if you provide required information within thirty (30) days of one of the following events: • you or your dependent lose minimum essential coverage (unless that loss of coverage is due to non-payment of premium or your voluntary termination of coverage); • you adequately demonstrate to us that another health plan substantially violated a material provision of its contract with you; • you make a permanent move to Rhode Island: or • your enrollment or non-enrollment in a qualified health plan is unintentional, inadvertent, or erroneous and is the result of error, misrepresentation, or inaction by us or an agent of HSRI or the U.S. Department of Health and Human Services (HHS).
Claims Review Methodology
a. C laims Review Population. A description of the Population subject to the Quarterly Claims Review.
Contract Quarterly Sales Reports The Contractor shall submit complete Quarterly Sales Reports to the Department’s Contract Manager within 30 calendar days after the close of each State fiscal quarter (the State’s fiscal quarters close on September 30, December 31, March 31, and June 30). Reports must be submitted in MS Excel using the DMS Quarterly Sales Report Format, which can be accessed at xxxxx://xxx.xxx.xxxxxxxxx.xxx/business_operations/ state_purchasing/vendor_resources/quarterly_sales_report_format. Initiation and submission of the most recent version of the Quarterly Sales Report posted on the DMS website is the responsibility of the Contractor without prompting or notification from the Department’s Contract Manager. If no orders are received during the quarter, the Contractor must email the DMS Contract Manager confirming there was no activity.
Open Enrollment KFHPWA will allow enrollment of Subscribers and Dependents who did not enroll when newly eligible as described above during a limited period of time specified by the Group and KFHPWA.
Claims Review Population A description of the Population subject to the Claims Review.
Performance Assessment 6.1 The Performance Plan (Annexure A) to this Agreement sets out key performance indicators and competencies that needs to be evaluated in terms of –
6.1.1 The standards and procedures for evaluating the Employee’s performance; and
6.1.2 During the intervals for the evaluation of the Employee’s performance.
6.2 Despite the establishment of agreed intervals for evaluation, the Employer may in addition review the Employee’s performance at any stage while the contract of employment remains in force;
6.3 Personal growth and development needs identified during any performance review discussion must be documented in a Personal Development Plan as well as the actions agreed to and implementation must take place within set time frames;
6.4 The Employee’s performance will also be measured in terms of contributions to the goals and strategies set out in the Employer’s Integrated Development Plan (IDP) as described in 6.6 – 6.13 below;
6.5 The Employee will submit quarterly performance reports (SDBIP) and a comprehensive annual performance report at least one week prior to the performance assessment meetings to the Evaluation Panel Chairperson for distribution to the panel members for preparation purposes;
6.6 Assessment of the achievement of results as outlined in the performance plan:
6.6.1 Each KPI or group of KPIs shall be assessed according to the extent to which the specified standards or performance targets have been met (qualitative and quantitative) and with due regard to ad-hoc tasks that had to be performed under the KPI;
6.6.2 A rating on the five-point scale described in 6.9 below shall be provided for each KPI or group of KPIs which will then be multiplied by the weighting to calculate the final score;
6.6.3 The Employee will submit his self-evaluation to the Employer prior to the formal assessment;
6.6.4 In the instance where the employee could not perform due to reasons outside the control of the employer and employee, the KPI will not be considered during the evaluation. The employee should provide sufficient evidence in such instances; and
6.6.5 An overall score will be calculated based on the total of the individual scores calculated above.
