CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Health Reimbursement Arrangement (HRA) Plan of Benefits

This document governs the establishment, definitions, eligibility, account mechanics, reimbursement, claims and appeals, and general administration of an employer-sponsored Health Reimbursement Arrangement (HRA) and applies to eligible employees and their dependents covered by the Employer's Adoption Agreement.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyHealth Reimbursement Arrangement (HRA) Plan of Benefits

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionParticipants must substantiate enrollment in individual coverage or Medicare before premium reimbursements will be made.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Account-basedAccounts are recordkeeping only; no separate fund is segregated

First-come-first-servedClaims disbursed in filing order and contingent on available account funds

Carryover optionalUnused balances may be carried over only if Employer elected in Adoption Agreement

Substantiation requiredParticipants must substantiate enrollment in individual coverage or Medicare to receive premium reimbursements

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Time to file an internal appeal after adverse determination

Employer-fundedSource of all HRA payments; no employee contributions permitted

Eligibility, Account Mechanics, Reimbursements, and Administration

Eligibility, Substantiation, and Termination Criteria

Eligibility and participation rules, including substantiation and termination conditions.

Eligible Employees and Dependents may participate only as provided in the Adoption Agreement and when they meet the HRA Plan's eligibility rules.

Election opportunity: Each Eligible Employee has one opportunity per Period of Coverage, in advance of the Period of Coverage, to elect participation or to opt out and waive future reimbursements.

Employer classification: The Employer has sole discretion to determine which individuals are Eligible Employees and Dependents; any erroneous or retroactive exclusion remains excluded for prior periods unless the Employer determines otherwise.

Initial substantiation: To become a Participant and receive premium reimbursements for Individual Health Insurance Coverage or Medicare for a Period of Coverage, the Eligible Employee must substantiate, in advance of that Period, that the Employee and each Dependent are or will be enrolled in Individual Health Insurance Coverage or Medicare. Substantiation may be either (a) documentation from the carrier, Exchange, or CMS (for example an ID card, EOB, or Exchange application/plan selection), or (b) employee attestation specifying coverage, effective date, and carrier.

Timing for new Dependents: Substantiation for a new Dependent must be provided before the new Dependent's coverage under the HRA Plan begins; if the HRA coverage is effective retroactively, substantiation may be provided within 30 days after election, but no reimbursements for the new Dependent will be made until substantiation is provided.

Ongoing substantiation: After initial substantiation for a Period of Coverage, no further reimbursements for that same Period of Coverage will be paid unless the Participant first substantiates continued enrollment in Individual Health Insurance Coverage or Medicare in the form and manner designated by the Administrator.

Cessation of membership: A Participant or Dependent ceases to be a Member upon the earlier of (a) termination or amendment of the HRA Plan removing eligibility, or (b) the date the Participant ceases to be an Eligible Employee (e.g., retirement, termination, layoff, reduction in hours, death). Reimbursements after termination follow Article V (COBRA and Claims Run-Out provisions).

Leave protections: If a Participant goes on qualifying unpaid FMLA or USERRA leave, the Employer will maintain the Participant's existing HRA coverage on the same terms to the extent required by law.

Account Funding and Reimbursement Mechanics

Account mechanics, funding, and reimbursements.

Account establishment: The Employer will establish and maintain a recordkeeping Account for each Participant but will not segregate assets or create a separate fund; the Account is for tracking credits, debits, and available reimbursement amounts.

Maximum Annual Amount (crediting): The Employer, in its sole discretion, will determine the Maximum Annual Amount credited to each Participant's Account and may change it at any time; timing of credits is specified in the Adoption Agreement and any elected carryover increases the credited amount as described in the Adoption Agreement.

Debiting of Account: A Participant's Account will be debited during each Period of Coverage, or the Claims Run-Out Period if applicable, for any approved claims for Qualified Medical Expenses incurred during the Period of Coverage.

Funding availability and ordering: The amount available for reimbursement equals the credited amount less prior reimbursements; claims are processed first-come-first-served and are contingent on the availability of funds in the Participant's Account.

Reimbursement and continuity criteria

Rules governing what expenses are reimbursable, limits, carryovers, forfeitures, COBRA continuation, and plan termination effects.

Reimbursable expenses: Reimbursements are limited to Qualified Medical Expenses incurred during the Member's Period of Coverage; for premiums, a month of coverage is the unit for determining when a premium expense is incurred.

Maximum reimbursement limit: The maximum amount a Member may receive is the balance currently available in the Participant's Account; duplicate reimbursements from other sources are not eligible and must be refunded or recovered by the Employer.

Carryovers and forfeitures: If the Employer elects carryover in the Adoption Agreement, unused Account balances may be carried over to the next Period of Coverage as specified; any additional unused balance will be forfeited permanently to the Employer. Unclaimed reimbursement payments by the close of the HRA Plan Year following the Period of Coverage are forfeited to the Employer.

Post-termination reimbursements and Claims Run-Out: Except as provided in Article V, a Member's ability to receive Benefits ends when membership ceases; a former Member (or estate) may obtain reimbursement for Qualified Medical Expenses incurred prior to termination if a claim is submitted before the end of the applicable Claims Run-Out Period; if the Employer terminates the HRA Plan, no reimbursements remain payable and there is no Claims Run-Out Period.

Operational and administrative criteria

Operational rules and criteria that govern adjudication, appeals, external review, privacy, funding, and plan changes:

Administrator authority: Benefits are payable only if the Administrator, in its sole discretion, determines the Participant is entitled to them; the Administrator has exclusive discretionary authority to interpret the Plan, decide eligibility, prescribe procedures, request information, delegate responsibilities, and override Claims Administrator decisions.

Claims processing and impartiality: All claims and appeals will be adjudicated to ensure independence and impartiality; appeals will not be conducted by the initial reviewer or a subordinate and will consider new information; the Claims Administrator must decide internal appeals within 30 days and may obtain independent experts whose identity and new evidence must be provided to the Participant.

Internal appeals and timing: A Participant must file a written appeal within 180 days of an initial Adverse Benefit Determination to preserve appeal and litigation rights; internal appeals must be exhausted before external review or litigation and failure to raise issues at each level waives them.

External review availability and timing: If a Final Internal Adverse Benefit Determination is upheld, a Participant may request external review within four months; preliminary eligibility check occurs promptly (within 5 business days), the IRO must issue a standard decision within 45 calendar days and an expedited decision within 72 hours of receiving the request; the IRO's decision must include specified content (reasoning, evidence, references, binding statement, judicial review notice, consumer assistance contact), and upon a reversing external decision the Plan must immediately pay the claim.

Administrative payment and correction criteria

Administrative rules governing payments and corrections:

Unlocated payee forfeiture: If the Administrator cannot ascertain the identity or whereabouts of a payee despite reasonable efforts, the payment and all subsequent payments due to that payee shall be forfeited permanently to the Employer after a reasonable time as determined in the Administrator's sole discretion.

Mistake correction authority: If a mistake occurs regarding a Member's eligibility, participation, allocations, or amounts paid or reimbursed, the Administrator may, to the extent administratively feasible and permissible under applicable law, allocate, withhold, accelerate, or otherwise adjust amounts (including withholding from Employee compensation) to accord the Member the correct credits or distributions under the HRA Plan.

Interpretation note: Captions and gender/number usage in the Plan are for convenience and do not affect construction or scope of the Plan provisions.

Qualified Medical Expenses, Notices, and Key Numeric Limits

Medicaremixed

MEDICARE_DEF

For Qualified Medical Expense purposes, Medicare includes Parts A, B, C, D and Medicare supplemental (Medigap) insurance under 42 U.S.C. § 1395ss(g)(1).

Denial Reason Codesmixed

ADM001	Administrative: incomplete or missing information needed to process the claim.
PLAN002	Plan Exclusion: service or item not a Qualified Medical Expense under the HRA Plan provisions.
MED003	Medical Necessity: determined not medically necessary or considered experimental/investigational.
ELG004	Eligibility: Participant or Dependent not eligible for reimbursement for this claim period.
TIM005	Timely Filing: claim submitted after applicable filing deadline.

Minimum Reimbursement Amount

Minimum Reimbursement AmountAs specified in the Adoption Agreement.

Maximum Annual Amount

Maximum Annual AmountAmount credited per Participant and Period of Coverage as set by the Employer in the Adoption Agreement; Employer may change amount and may limit or treat as taxable for Highly Compensated Individuals per Code section 105(h).

Minimum Reimbursement Amount (threshold hold)

Minimum Reimbursement Amount (threshold hold)If indicated in the Adoption Agreement, reimbursements below the Minimum Reimbursement Amount will be held until total requested reimbursements meet or exceed the threshold, except when reimbursing all remaining funds in the Participant's Account or final claim after termination/COBRA/Claims Run-Out.

What Participants and Employers Must Do — Claims, Appeals, and Administrator Powers

Documentation Required

Substantiation Requirement

Eligible Employees must substantiate enrollment in Individual Health Insurance Coverage or Medicare before premium reimbursements will be made. Initial substantiation must be provided in advance of the Period of Coverage (or within 30 days for retroactive new Dependents), and may be demonstrated by: (a) documentation from the carrier, Exchange, or CMS (for example, insurance/Medicare ID card, EOB, or Exchange plan selection confirmation); or (b) the Participant's attestation with coverage dates and insurer name. After initial substantiation, Participants must provide ongoing substantiation, in the form and manner the Administrator prescribes, that the Member remains enrolled in Individual Health Insurance Coverage or Medicare for the period in which Qualified Medical Expenses were incurred before any subsequent reimbursements will be paid.

Billing Rule

Claims Processing and Funding Availability

Claims are processed in the order filed and reimbursements are limited to the funds credited to the Participant's Account. A Participant's Account will be debited for any approved reimbursements for Qualified Medical Expenses incurred during the Period of Coverage or during the Claims Run-Out Period, if applicable. Payment of approved claims is always contingent upon availability of funds in the Participant's Account.

Key Terms and Legal References

inv-23: HRA Plan

HRA Plan definitionThe Employer Health Reimbursement Arrangement Plan (HRA Plan) established by the Employer to provide reimbursement benefits for Qualified Medical Expenses as described in the Plan of Benefits.

Effective dateThe HRA Plan is established as of the HRA Plan Effective Date shown in the Adoption Agreement.

PurposeDesigned to provide certain eligible individuals specified health benefits under the HRA Plan.

inv-24: Qualified Medical Expense

Qualified Medical Expense (IRC Sec. 213(d))An expense incurred by a Member for medical care as defined in Section 213(d) of the Code, including premiums for Individual Health Insurance Coverage or Medicare.

Prescription/OTC drugs and insulinDrugs or medicines qualify only if (1) prescription-only, (2) OTC but Member obtains a prescription, or (3) insulin.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyHealth Reimbursement Arrangement (HRA) Plan of Benefits

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionParticipants must substantiate enrollment in individual coverage or Medicare before premium reimbursements will be made.

SourceLink

On This Page

Debit card fees: Fees may be charged for any additional debit cards issued to a Member as established by the plan or Administrator.

COBRA continuation: To the extent required by federal law, Members with a COBRA qualifying event may elect to continue HRA coverage on a self-pay basis for the COBRA period; the Employer will maintain an Account for COBRA Members, reimbursements under COBRA cannot exceed the COBRA Member's Account balance, and COBRA premiums and payment timing are established by the Administrator.

Coordination with Health FSA: If an expense is covered by both the HRA and an Employer-sponsored Health FSA, reimbursement order between the HRA and the Health FSA is as specified in the Adoption Agreement; the HRA will comply with Medicare Secondary Payer rules where applicable.

Minimum reimbursement thresholds: If a Minimum Reimbursement Amount is indicated in the Adoption Agreement, reimbursements below that threshold will be held until the threshold is met, except for final or remaining funds or post-termination claims as described in the Adoption Agreement and Plan of Benefits.

Payment method limitations: Reimbursements are not provided as cash or other benefit types except as described; the Plan may pay premiums directly to an insurance carrier for premiums if the Adoption Agreement so provides.

Exhaustion and litigation limitation: No lawsuit may be brought until all administrative procedures, including external review where applicable, have been exhausted; no suit may be brought more than 180 days after the Final Internal Adverse Benefit Determination.

HIPAA and PHI handling: The HRA Plan may use or disclose PHI only as permitted by the HIPAA Privacy Rule; PHI disclosure to the Employer requires Employer certification that HIPAA provisions are incorporated into plan documents and the Employer's agreement to comply; the Employer will not disclose PHI to workforce members except for plan administration functions and must report breaches and cooperate in mitigation.

Funding and nonassignment: All amounts payable under the HRA Plan are funded solely by the Employer from general assets; no Employee contributions are permitted; Accounts are recordkeeping only and are not subject to assignment, garnishment, or attachment, and Members have no property interest in any employer assets.

Amendment and termination: The Employer may amend or terminate the HRA Plan at any time; amendments or termination apply automatically to all Employees and Dependents; upon termination no amounts are reimbursable and the Employer may eliminate balances or amounts credited to Accounts.

Fiduciary roles: The Administrator is the named fiduciary of the HRA Plan; the Claims Administrator performs ministerial functions and is not a fiduciary with discretionary authority under ERISA.

Non-assignability: Rights to receive reimbursements under the HRA Plan are not assignable and Accounts are not subject to creditors or legal process except as required by law.

Administrator feasibility threshold

Administrator feasibility thresholdAdministrator will act to correct mistakes regarding eligibility, allocations, or payments to the extent administratively feasible and permissible under applicable law; actions may include reallocations, withholdings, accelerations, or recovery from compensation.

Prior Authorization

Initial claims submission and decision timing

Submit written claims for reimbursement in the form and manner prescribed by the Claims Administrator by no later than the end of the Claims Run-Out Period for the applicable Period of Coverage. A complete claim must identify the Member(s), describe the nature and date of the Qualified Medical Expenses, state the requested reimbursement amount, confirm the expenses have not been reimbursed from another source, include supporting bills/invoices or other third-party statements, and provide any additional substantiation the Claims Administrator requests (including proof of Individual Health Insurance Coverage or Medicare when premiums are sought).

Include: person(s) on whose behalf expenses were incurred; nature and date of expense; amount requested; statement that expense is not reimbursed elsewhere; supporting bills/invoices; any further substantiation requested (e.g., enrollment evidence).
File by the end of the Claims Run-Out Period for the Period of Coverage.

Denial Risk

Internal appeal filing timeframe

If an initial claim is denied in whole or in part, a Participant (or authorized representative) must file a written internal appeal within 180 days of the Claims Administrator's initial Adverse Benefit Determination to preserve appeal rights and the right to later pursue litigation.

Documentation Required

Internal appeal review process

The Claims Administrator will review an internal appeal and issue a written decision within 30 days of receipt. The review may include independent medical or other advice and may require additional evidence; any medical expert consulted on appeal will be different from any expert consulted for the initial claim and the expert's identity will be provided. The Participant will be provided, free of charge, with any new or additional evidence or rationale considered and sufficient time to respond before an adverse determination on review is issued.

Decision timeframe: within 30 days of appeal submission.
Independent experts may be used; must differ from those used initially and their identities disclosed.
Participant receives, free of charge, new evidence or rationale and opportunity to respond.

Note

External review process and timing

After exhausting internal appeals (where required), a Participant may request an external review from an accredited independent review organization (IRO) when eligible under federal law (for example, for adverse determinations involving medical judgment or rescission). A request for external review must be filed within four months after receipt of the Final Internal Adverse Benefit Determination. Within five business days the Claims Administrator will do a preliminary eligibility review; the Participant will be notified within one business day after that preliminary review whether the request is complete and eligible, and given an opportunity to perfect an incomplete request (generally within 48 hours or the remainder of the four-month filing period, whichever is later). If eligible, the Claims Administrator will assign an accredited IRO, which will notify the Participant and allow submission of additional information within ten business days. The IRO will conduct a de novo review and issue a final decision within 45 calendar days of receipt of the request (or within 72 hours for an expedited request that meets the expedited review criteria).

File external review within 4 months of Final Internal Adverse Benefit Determination.
Preliminary review: 5 business days; notice within 1 business day after preliminary review.
If eligible, IRO issues decision: standard — within 45 calendar days; expedited — within 72 hours (written confirmation within 48 hours if initial notice not in writing).

Denial Risk

External review and appeals exhaustion

Participants must exhaust all applicable internal claims and appeals processes before pursuing external review or bringing suit; issues not raised at each level are waived. No lawsuit may be filed until administrative remedies are exhausted, and no lawsuit may be brought more than 180 days after issuance of the Final Internal Adverse Benefit Determination. If an external review reverses the prior adverse determination, the HRA Plan will promptly provide payment for the claim once the IRO decision is received.

Must exhaust internal appeals before requesting external review (unless law provides otherwise).
All issues must be raised at each level or they are waived.
Suit barred until administrative remedies exhausted; 180-day filing limit after Final Internal Adverse Benefit Determination.
If external review reverses decision, plan pays immediately.

Note

Administrator corrective authority

The Administrator has authority to correct administrative mistakes. Where a mistake occurs regarding eligibility, account allocations, or amounts paid or payable, the Administrator may reallocate, withhold, accelerate, or otherwise adjust amounts as administratively feasible and lawful. Such corrective actions may include withholding amounts from an Employee's compensation or recovering amounts owed to the HRA Plan or Employer. If the Administrator cannot locate a payee despite reasonable efforts, payments may be forfeited permanently to the Employer after a reasonable time determined by the Administrator.

Administrator may adjust allocations, withhold or accelerate amounts, and recover overpayments.
Administrator may withhold from Employee compensation to recover amounts owed.
If payee cannot be located after reasonable efforts, payments may be forfeited to the Employer after a reasonable time.

Medicare includedFor Qualified Medical Expense purposes, 'Medicare' includes Parts A, B, C, D and Medicare supplemental (Medigap) insurance under Section 1882(g)(1).

inv-25: Participant / Eligible Employee

Eligible EmployeeAn employee not offered a Traditional Group Health Plan who meets the requirements specified in the Adoption Agreement and is therefore eligible to participate.

ParticipantAn Eligible Employee who elects to participate in the HRA Plan in accordance with Article III (participation/election rules).

Entry Date and participationEntry Date is the first day of the first Period of Coverage for which an Eligible Employee is eligible and elects to participate; Adoption Agreement governs elections and timing.

inv-26: Legal Status

Compliance with IRC Sections 105 and 106The HRA Plan is intended to qualify under Sections 105 and 106 of the Internal Revenue Code and related guidance (e.g., IRS Notice 2002-45).

Integration rulesPlan is maintained consistent with federal regulations addressing HRAs and their integration with Individual Health Insurance Coverage and Medicare (29 C.F.R. § 2590.702-2).

Regulatory intentReferences to the Code include applicable regulations and sub-regulatory guidance and comparable future provisions.

inv-27: Adverse Benefit Determination

Adverse Benefit DeterminationA denial of reimbursement under the HRA Plan, in whole or in part, and any retroactive termination of participation that constitutes a rescission of coverage under 29 C.F.R. § 2590.715-2712.

ScopeIncludes denials and retroactive terminations treated as rescissions of coverage.

Appeal implicationTriggers internal appeal rights and potential external review procedures as described in the claims and appeal provisions.

inv-28: Final Internal Adverse Benefit Determination

Final Internal Adverse Benefit DeterminationAn Adverse Benefit Determination that has been upheld by the Claims Administrator at the completion of the internal appeals process.

EffectPermits the Participant to request external review where applicable and starts timeframes for external review requests.

DocumentationNotices regarding such determinations must follow the Plan's claims and appeals content requirements.

inv-29: HIPAA Rules

HIPAA term adoptionCapitalized terms used but not otherwise defined in this section have the same meaning as in the HIPAA Privacy and Security Rules (45 C.F.R. Parts 160, 162, and 164).

Rule referencesReferences to specific regulatory sections refer to the applicable sections of the HIPAA Rules and any successor provisions.

PHI use/disclosureThe HRA Plan may use or disclose PHI only as required or permitted under the HIPAA Privacy Rule (per HIPAA compliance provisions).

inv-30: Administrator

Administrator (named fiduciary)The Administrator is the named fiduciary of the HRA Plan; the Claims Administrator performs ministerial functions only and is not a fiduciary.

DesignationThe Employer is the Administrator unless another person is designated in writing and accepts the designation.

ResponsibilityAdministrator has authority and responsibility for plan administration and discretionary decisions as described in the Plan.

inv-31: Captions and Construction

Captions are non-definitionalCaptions are included solely for convenience and do not define, limit, enlarge, or describe the scope or intent of the HRA Plan.

Gender and number constructionWords in masculine/feminine or singular/plural shall be construed interchangeably where appropriate.

No effect on interpretationCaptions and construction rules do not affect Plan provisions or their construction.

inv-32: Inability to Locate Payee

Inability to Locate Payee consequenceIf the Administrator cannot ascertain the identity or whereabouts of a payee despite reasonable efforts, the payment and all subsequent payments shall be permanently forfeited to the Employer after a reasonable time determined by the Administrator's sole discretion.

Reasonable efforts standardForfeiture applies only after reasonable efforts to locate the payee have failed and after a reasonable time as determined by the Administrator.

Administrator discretionThe timing of forfeiture is determined in the Administrator's sole discretion following the date the payment first became due.

inv-33: Mistake correction

Mistake correction authorityIf a mistake occurs regarding eligibility, allocations, or amounts paid/reimbursed, the Administrator shall, to the extent administratively feasible and permissible under law, make allocations, withhold, accelerate, or otherwise adjust amounts to accord Members the proper credits or distributions.

Possible recovery actionsSuch actions may include withholding amounts from Employee compensation to recover amounts owed to the HRA Plan or Employer.

Feasibility and legality constraintsCorrections are limited to what the Administrator deems administratively feasible and otherwise permissible under applicable law.