Blue Cross Blue Shield SC HRA Coverage Policy Update | OpenPayer
CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A
Health Reimbursement Arrangement (HRA) Plan of Benefits
Defines establishment, eligibility, account mechanics, reimbursement, claims/appeals, and administration of an employer-sponsored HRA reimbursing Qualified Medical Expenses (including individual coverage and Medicare) for eligible employees and dependents.
Policy Summary
PayerBlue Cross Blue Shield - South Carolina
PolicyHealth Reimbursement Arrangement (HRA) Plan of Benefits
Policy CodePolicy N/A
Change TypeN/A
Effective DateN/A
Next Review DateN/A
Key ActionSubmit written claims for reimbursement by the end of the Claims Run-Out Period with required substantiating documentation.
No material clinical or coverage changes in this revision.
12 monthsHRA Plan Year duration
first-come-first-servedclaims processed order
Employer discretionEmployer sets Maximum Annual Amount and eligibility
30 daysinitial claim determination timeframe
45 daysIRO external review timeframe
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180 daystime to sue after final determination
Coverage Criteria and Operational Rules
Reimbursement criteria and limitations
Reimbursement criteria and limitations
ALL of the following
Maximum reimbursement is limited to the balance available in the Participant's Account (maximum reimbursement amount).
Operational: Member cannot be reimbursed more than current Account balance.
Expenses eligible for reimbursement must be Qualified Medical Expenses incurred during the Member's Period of Coverage.
Includes services furnished during coverage and, for premiums, any full calendar month of coverage to which the premium applies.
Qualified Medical Expenses incurred before participation begins or after participation ends are not eligible.
Exceptions: COBRA continuation may apply per plan terms.
Expenses reimbursable from another source (including other health plans or insurance) are not eligible to the extent already reimbursed; remaining non-reimbursed portions may be reimbursed if plan requirements are met.
Member must refund duplicate reimbursements to the HRA Plan; Employer may recover erroneous or excess payments by offset or other means.
The HRA Plan will comply with Medicare Secondary Payer provisions under Section 1862(b) of the Social Security Act where applicable.
Medicare coordination rules apply.
If a Member's Qualified Medical Expense is covered by both the HRA Plan and an Employer-sponsored Health FSA, reimbursement ordering will follow the Adoption Agreement.
Operational: follow Adoption Agreement for coordination with Health FSA.
Reimbursement eligibility and administrative rules
Reimbursement eligibility and administrative rules
ALL of the following
Initial substantiation: Prior to receiving reimbursements for premiums for Individual Health Insurance Coverage or Medicare for a Period of Coverage, an Eligible Employee must substantiate enrollment for themselves and any Dependents for whom reimbursement is sought.
Substantiation for new Dependents must be provided before the Dependent's HRA coverage begins; if HRA coverage is retroactive, substantiation may be provided within 30 days but no reimbursements for the new Dependent will be made until substantiation is provided.
Acceptable initial substantiation includes either: (a) documentation from the carrier, Exchange, or CMS showing enrollment (e.g., ID card, EOB, Exchange documentation), or (b) an attestation by the Eligible Employee stating enrollment, effective date, and insurer name.
Provider/Member action: retain and submit documentation in the form requested by Administrator.
Ongoing substantiation: After initial substantiation, subsequent reimbursement requests for the same Period of Coverage will require the Participant to substantiate, in the form and manner designated by the Administrator, that the Member remained enrolled in Individual Health Insurance Coverage or Medicare for the period in which the expenses were incurred.
Operational and Compliance Criteria
COVERAGE CRITERIA — operational and compliance criteria drawn from the Plan of Benefits
ALL of the following
Participants and Members must exhaust all internal claims and appeals processes before pursuing external review; no lawsuit may be brought until administrative procedures, including external review where applicable, are exhausted.
Time limit: no lawsuit more than 180 days after the Final Internal Adverse Benefit Determination.
External review decisions must include a description of the request, dates, references to evidence and coverage provisions, rationale, binding statement, statement on judicial review availability, and contact information for consumer assistance, and must be provided within applicable timeframes (expedited reviews within 72 hours; written confirmation within 48 hours if not in writing).
Upon a final external review decision reversing an adverse determination, the HRA Plan will immediately provide payment for the claim.
Claims and appeals will be adjudicated to ensure independence and impartiality; appeals are conducted by individuals different from those who made the initial determination and will consider all submitted information regardless of prior consideration.
Administrative procedures and corrective actions
Administrative procedures and corrective actions
ALL of the following
Captions and construction: section captions are for convenience and do not affect interpretation; gender and number references shall be construed appropriately.
Interpretive rules for plan text.
Inability to locate payee: If Administrator cannot locate a payee after reasonable efforts, payments and subsequent payments to that individual shall be forfeited permanently to the Employer following a reasonable time as determined by the Administrator.
Operational: maintain current payee contact information; unresolved unclaimed payments will be forfeited.
Mistake corrections and recovery: In the event of a mistake regarding eligibility, Account allocations, or amounts paid/reimbursed, the Administrator may allocate, withhold, accelerate, or adjust amounts as administratively feasible and permissible under law, including withholding from Employee compensation to recover amounts owed.
Employer/Administrator may recover erroneous or excess payments; adjustments aim to accord Members the credits or distributions properly entitled under the HRA Plan.
Codes, Limits, and Key Monetary Rules
Qualified Medical Expenses referencemixed
Section 213(d)
Definition reference for Qualified Medical Expense (medical care and premiums as defined by Code Section 213(d))
Coverage limits and coordination of benefitsmixed
Reimbursements limited to Qualified Medical Expenses incurred during Period of Coverage; expenses not eligible if reimbursable from other sources; duplicate reimbursements must be refunded to the HRA Plan; maximum reimbursement equals Participant's available Account balance.
Regulatory cross-referencemixed
29 C.F.R. § 2590.702-2
Requirement for HRA integration with individual health insurance coverage and Medicare
inv-08: Minimum Reimbursement Amount / Maximum Annual Amount
Source of amountsMaximum Annual Amount and any Minimum Reimbursement Amount are the amounts specified in the Adoption Agreement; Employer determines Maximum Annual Amount credited to each Participant's Account and may change it at any time.
Maximum Annual Amount (actionable)The maximum amount available for reimbursement equals the balance currently available in the Participant's Account (Maximum Reimbursement Amount).
Minimum Reimbursement AmountIf a Minimum Reimbursement Amount is indicated in the Adoption Agreement, reimbursements less than that amount will not be issued except for (1) reimbursement of all remaining funds in the Participant's Account or (2) the final claim after termination, COBRA period, or Claims Run-Out Period.
Crediting timingA Participant's Account will be credited at the times specified in the Adoption Agreement; Employer may permit carryover as elected in the Adoption Agreement.
Member / Administrator Actions and Timelines
Documentation Required
Member / Administrator Actions and Timelines
Providers and Participants must substantiate coverage and follow timing rules to obtain reimbursements under the HRA Plan. Key requirements include enrollment substantiation (initial and ongoing), eligibility and election timing, claims submission content and deadlines, COBRA continuation and related reimbursement rules, timing and method of reimbursements (including minimums), exhaustion of internal appeals before external review, and the Administrator's corrective authority for mistakes or inability to locate a payee.
Substantiation required before reimbursement of Individual Health Insurance Coverage or Medicare premiums: documentation from carrier/Exchange/Medicare or employee attestation (name of carrier, coverage begin date). New Dependents: substantiation must be provided before dependent's coverage begins, or within 30 days if coverage is made retroactive; no reimbursements for the new Dependent until substantiation is provided.
Ongoing substantiation: for each Period of Coverage, Participants must substantiate continued enrollment in Individual Health Insurance Coverage or Medicare before additional reimbursements for that Period will be paid.
Eligibility determination & election timing: Eligible Employees and Dependents may elect participation (or opt out) once per Period of Coverage in the manner and form specified by the Administrator, in advance of the first day of the Period of Coverage. Employer has sole discretion to classify who is an Eligible Employee; retroactive reclassification does not create eligibility for prior periods unless Employer determines otherwise.
Initial claim submission and timing: claims must be submitted in writing in the form and manner prescribed by the Claims Administrator no later than the end of the Claims Run-Out Period for the Period of Coverage and must include: (a) person(s) on whose behalf expense incurred, (b) nature and date of expense, (c) amount requested, (d) statement that expense not otherwise reimbursed, (e) bills/invoices/third-party statements and any additional documentation requested, and (f) any further substantiation requested (including evidence of enrollment in Individual Health Insurance Coverage or Medicare, if requesting premium reimbursement).
Definitions and Plan Mechanics
inv-18: HRA Plan description
Plan identityHRA Plan is the Employer Health Reimbursement Arrangement Plan established by the Employer to provide reimbursement benefits for Qualified Medical Expenses as described in the Plan of Benefits.
Governing intentThe HRA Plan is intended to qualify under Sections 105 and 106 of the Internal Revenue Code and related IRS guidance (e.g., Notice 2002-45).
Effective date referenceThe HRA Plan is established as of the HRA Plan Effective Date shown in the Adoption Agreement.
inv-19: Qualified Medical Expense definition
Statutory definition'Qualified Medical Expense' means an expense for medical care as defined in Code Section 213(d), including premiums for Individual Health Insurance Coverage or Medicare (including Parts A–D and Medigap for this purpose).
Drug coverage limitation
Policy Summary
PayerBlue Cross Blue Shield - South Carolina
PolicyHealth Reimbursement Arrangement (HRA) Plan of Benefits
Policy CodePolicy N/A
Change TypeN/A
Effective DateN/A
Next Review DateN/A
Key ActionSubmit written claims for reimbursement by the end of the Claims Run-Out Period with required substantiating documentation.
Administrative: failure to provide ongoing substantiation will result in denial of reimbursement for that Period of Coverage.
Decision-makers must not consider the amount of benefits payable or financial impact on the Employer when interpreting plan provisions.
HIPAA compliance: use and disclosure of PHI by the HRA Plan, Employer, and Claims Administrator is limited to what is permitted by the HIPAA Privacy Rule; Employer must certify incorporation of HIPAA provisions before receiving PHI (other than Summary Health Information).
Employer obligations include restricting PHI access to permitted plan administration functions and reporting breaches or non-compliance.
Employer and Claims Administrator obligations under HIPAA include ensuring agents/subcontractors are subject to the same PHI restrictions, providing access to and amendment of PHI as directed by the HRA Plan, accounting for disclosures, and making records available to HHS upon request where required.
If feasible, return or destroy PHI when no longer needed; otherwise limit further use.
Employer must maintain adequate separation between Employer and the HRA Plan (per 45 C.F.R. §164.504(f)(2)(iii)) and adopt policies limiting PHI disclosures to minimum necessary for plan administration.
Employer will implement reasonable security measures and comply with HITECH Act breach notification requirements.
Funding and fiduciary rules: All amounts payable under the HRA Plan are funded solely by the Employer from general assets; no Employee contributions or cafeteria plan funding permitted, and no trust is required or created; Employer may alter Account credits per amendment process.
Claims Administrator performs ministerial functions and is not a fiduciary; the Administrator is the named fiduciary.
Plan construction and compliance: the HRA Plan will be construed and administered in accordance with the Code, ERISA, and applicable regulations; in case of conflict, Code and/or ERISA controls.
Operational: plan provisions superseded to the extent they conflict with governing law.
Amendment and termination: Employer may amend or terminate the HRA Plan at any time; upon termination no amounts will be reimbursable and the Employer makes no guarantee as to future Accounts or balances.
Amendment authority rests solely with the Employer.
Post-termination reimbursements and claims run-out: Ability to receive benefits terminates when an individual ceases to be a Member, except as provided; after termination and following the claims Run-Out Period for Qualified Medical Expenses incurred prior to termination, remaining Account amounts will be forfeited unless COBRA continuation applies. Former Members or estates may submit claims for expenses incurred during a prior Period of Coverage if submitted before the end of the applicable Claims Run-Out Period.
Operational: observe claims run-out deadlines for post-termination claims.
inv-09: Maximum and Minimum Reimbursement rules
Maximum reimbursement rule (actionable)Maximum reimbursement equals the balance currently available in the Participant's Account; reimbursements are limited to Qualified Medical Expenses incurred during the Member's Period of Coverage.
Minimum reimbursement handlingIf a Minimum Reimbursement Amount is set in the Adoption Agreement, reimbursements below that amount will be held until total requests meet the threshold, except for final account clearances as specified.
Duplicate/overpayment recoveryIf a Member receives duplicate reimbursement from the HRA Plan and another source, the Member must refund the duplicate amount; the Employer may recover erroneous or excess payments, including by offsetting other Plan payments.
COBRA continuation & reimbursement: COBRA-qualifying Members may continue HRA coverage on a self-pay basis per COBRA rules. Employer maintains an Account for COBRA Members; reimbursements cannot exceed the Account balance. COBRA Members are eligible for reimbursement of post-termination Qualified Medical Expenses only if timely COBRA premium payments are made and COBRA requirements are met. Claims Run-Out Period runs concurrently with COBRA, if applicable.
Timing and method of reimbursement: once a claim is approved, the Employer (through the Claims Administrator) will pay or reimburse as soon as administratively feasible, but no more than once per day after approval. Payments are reimbursements for Qualified Medical Expenses only — not cash or other benefits. If the Plan is permitted by the Adoption Agreement, premiums for Individual Health Insurance or Medicare may be paid directly to the carrier; if Participant already paid the expense, reimbursements will be disbursed to the Participant. If Participant has not paid the expense and receives reimbursement, Participant must use funds to pay the Qualified Medical Expense. Payments to a court-appointed guardian/conservator/legal representative will be a complete discharge of Plan liability.
Minimum Reimbursement Amount: if a Minimum Reimbursement Amount is set in the Adoption Agreement, the Plan will not issue reimbursements below that amount except for (1) reimbursement of all remaining funds in the Participant's Account or (2) the final claim after termination of participation or at end of COBRA period or Claims Run-Out Period. If a reimbursement would be less than the Minimum, the Employer will hold the reimbursement until total requested reimbursements meet or exceed the Minimum (unless an exception applies).
External review & appeals exhaustion: Participants must exhaust all internal claims and appeals processes described in the Plan before pursuing external review or litigation. No lawsuit may be brought until administrative procedures (including external review where applicable) are exhausted; lawsuits cannot be brought more than 180 days after the Final Internal Adverse Benefit Determination. Upon receipt of a final external review decision reversing an adverse determination, the Plan will immediately provide payment for the claim. Expedited external review procedures and timelines apply when life/health are jeopardized.
Administrator corrective authority & inability to locate payee: the Administrator may correct mistakes regarding eligibility, allocations, or amounts paid/reimbursed by allocating, withholding, accelerating, or otherwise adjusting amounts as administratively feasible and lawful (including withholding from Employee compensation). If the Administrator cannot ascertain the identity or whereabouts of a payee despite reasonable efforts, payments (and subsequent payments) may be forfeited permanently to the Employer after a reasonable time as determined by the Administrator.
Drugs or medicines qualify only if they are (1) prescription-only, (2) over-the-counter but obtained with a prescription, or (3) insulin.
Premium reimbursementIf the HRA Plan provides for premium reimbursement, Members may enroll in and obtain reimbursement for any Individual Health Insurance Coverage available to them in the individual market, subject to Plan terms.
inv-20: Participant / Eligible Employee
Eligible EmployeeAn Eligible Employee is an employee not offered a Traditional Group Health Plan who otherwise meets any requirements specified in the Adoption Agreement.
ParticipantA Participant is an Eligible Employee who elects to participate in the HRA Plan in accordance with Article III; Entry Date is the first day of the first Period of Coverage for which the Eligible Employee is eligible and elects to participate.
Employee exclusionsCertain workers are excluded from 'Employee' (e.g., leased employees, independent contractors reported on Form 1099, collective bargaining unit employees, self‑employed individuals, partners, and >2% S‑corp owners) consistent with Plan definitions.
inv-21: Account mechanics
Account natureEach Participant has a bookkeeping Account (not a segregated trust or fund) maintained by the Employer to track credits, debits, and available reimbursement amounts.
Crediting and Maximum Annual AmountThe Employer determines, in its sole discretion, the Maximum Annual Amount credited to each Participant's Account and the timing of credits as specified in the Adoption Agreement.
Debiting and claim timingA Participant's Account will be debited for approved reimbursements for Qualified Medical Expenses incurred during the Period of Coverage or Claims Run-Out Period, if applicable.
inv-22: Adverse Benefit Determination / Final Internal Adverse Benefit Determination
Adverse Benefit Determination'Adverse Benefit Determination' means a denial of reimbursement in whole or in part and includes any retroactive termination of participation that constitutes a rescission of coverage under applicable regulations.
Final Internal Adverse Benefit Determination'Final Internal Adverse Benefit Determination' means an adverse benefit determination that has been upheld by the Claims Administrator at the completion of the internal appeals process.
Appeals exhaustionParticipants must exhaust all internal claims and appeals processes (Article VI) before pursuing external review or litigation; failure to raise issues at each level may waive them.
inv-23: HIPAA-defined capitalized terms
Reference to HIPAA termsCapitalized terms used but not defined in the HIPAA section have the same meanings as in the HIPAA Privacy and Security Rules (45 C.F.R. Parts 160, 162, 164).
PHI use and disclosureThe HRA Plan may use or disclose PHI only to the extent required or permitted under the HIPAA Privacy Rule; Employer must certify compliance to receive PHI.
Business associate and subcontractor obligationsEmployer and Claims Administrator must ensure agents and subcontractors agree to HIPAA restrictions and report breaches and security incidents as required.
inv-24: Administrator (definition and authority)
Definition of Administrator'Administrator' is the Employer unless another person is designated and has accepted such designation in writing; the Administrator is the named fiduciary of the HRA Plan.
Administrator authority (actionable)The Administrator has sole and absolute discretionary authority to interpret the Plan, determine eligibility, payment amounts, time and manner of payments, make rules and procedures, request information, delegate duties, and override Claims Administrator decisions.
Fiduciary statusThe Administrator is the named fiduciary under ERISA; the Claims Administrator performs ministerial functions and is not a fiduciary.
inv-25: Claims Administrator (role)
Role description (actionable)Claims Administrator (Blue Cross and Blue Shield of South Carolina unless otherwise designated) performs purely ministerial functions at the Employer's and Administrator's direction and has no discretionary authority or fiduciary status under ERISA.
Operational limitsClaims Administrator administers claims and maintains files but may be reviewed or overridden by the Administrator.
DesignationClaims Administrator is Blue Cross and Blue Shield of South Carolina unless the Administrator designates another entity in writing.
inv-26: Captions and construction
Captions non‑definitionalCaptions are included solely for convenience and reference and do not define, limit, enlarge, or describe the scope or intent of the HRA Plan.
Gender and number constructionWords used in masculine or feminine gender shall be construed as the other gender where appropriate; singular and plural forms shall be construed interchangeably where appropriate.
Interpretive effectHeadings and captions will not affect construction or interpretation of any provision of the Plan.