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Benefit Coordinator Briefing

Below are updates and information about managing member benefits. You can subscribe to the Benefit Coordinator Briefing by clicking the RSS Feed button. RSS Feed

PEIA will hold Benefit Coordinator Quartly Workshop in Flatwoods on Wednesday, October 4, 2023.

The Benefit Coordinator Policy, Spousal Surcharge Process and other updates will be reviewed.

BC QW Fall 2023 

New Auditing Contractor

Myers & Stauffer LC is the new Auditing Contractor for PEIA.  T​hey are currently conducting reviews of policyholder eligibility.

September 28, 2022 Benefit Coordinator Quarterly Workshop

PEIA Benefit Coordinator Workshop Presentation​​

MetLife Benefit Coordinator Zoom Meetings

July 2022 MetLife Presentation 

MetLife fax number is 866-545-7517

MetLife telephone number is 888-466-8640​

​Premium Rate and IDX Changes for Plan Year 2023

Plan Year 2023 rates for Life Insurance and new IDXs for Health Insurance can be found here​.

Benefit Coordinator Updates Regarding Beneficiaries

Benefit Coordinators are now unable to change a beneficiary for a member after the original enrollment.

You will notice that the button to change beneficiaries is removed for Benefit Coordinators.

Going forward:

Only the member should be changing the beneficiaries on their account through either: (a) a written CIB form, or; (b) by creating an MMB account themselves (not created by a spouse or other 3rd party) and changing their beneficiaries there.

​​New Premium Rates for ​2/1/22

New Premium Rates were approved by the PEIA Board and can be found here.  The new rates will begin 2/1/22.

 CCP Letters

Letters will go out this week to 300 members regarding being enrolled in the Comprehensive Care Program.  Please let your members know that the letters are legitimate and that if they want to opt out of the program, they need to call PEIA customer service at 877-233-4295.

BC Quarterly Workshop 10/17/19


Below is clarification on the paper EOB issue we discussed at the BC Quarterly Workshop.. 
If a member has not registered on the Portal, they are NOT paperless and would get paper EOBs. However, they would not get EOBs if there is no patient balance or a flat copay amount.
Once a member registers on the portal then they default to paperless. But then they have the option to go into their account settings to update.

 UMR Transition 

Beginning July 18, 2019 at 7am, the 888-440-7342 telephone number will go directly to UMR.  If it needs to be redirected to HealthSmart, they will do so.

PEIA and UMR are hosting a Webinar Town Hall meeting for Benefit Coordinators on Monday, June 17th, 2019 at 1:30.  All Benefit Coordinators are encouraged to attend.  The first Webinar had some glitches, and our hope is that those unable to log into the first one will attend this second one.  Below is the link to get registered and also a list of the questions posed during the first Webinar.

PEIA/UMR Town Hall PowerPoint 

Questions and Answers from the Town Hall Webinars

Plan Year 2020 Finalized

The PEIA Finance Board met on December 20, 2018, and adopted the Governor’s recommendations to the PEIA Task Force for Plan Year 2020, which begins on July 1, 2019.  The plan includes the following changes:
For active employees, non-Medicare retirees and non-state agencies in the PEIA PPB Plans:
• Plan A back to 80/20 coinsurance for approved services in WV external bordering counties only
• Plan B back to 70/30 coinsurance for approved services in WV external bordering counties only
• Remove facility fee limits
• Remove $25 copay for out-of-state services
• Add an appeal process for people requiring a third-tier non-preferred drug to allow for reduced cost
• Discontinue the Healthy Tomorrows Program
          *There will no longer be an annual requirement for blood work in FY 2020, so nothing to do between now and May 15 
          * We are continuing to evaluate the program for future years and exploring new wellness options for the future
          * New programs
           - Pilot project – Naturally Slim (weight loss and health)
           - Diabetes Prevention Project – evaluating services
          -  Other programs are being explored
For Medicare retirees:
• Received 2-year rate guarantee from Humana
• No benefit changes for Plan Years 2019 or 2020
• Probably will see formulary changes for 2020, since those changes happen regularly

Benefit Coordinator Quarterly Workshop Set for September 27, 2018

Benefit Coordinator Quarterly Workshop at the Days Inn, Flatwoods was a success. To review the training, please click here.

Open Enrollment Training

Open Enrollment training presented by Jill Beaty from PEIA, Jake Lewellen with Go365, Emily Hoffman from FBMC, Jennifer Brown from Securian, and Bob Schappat from The Health Plan,   

January 2018 BC Quarterly Workshop

Thank you to the Benefit Coordinators who were able to make it to the BC QW in January.  The meetings were productive and we had a lot of good questions and feedback.  If you missed the meeting, please view the information you missed here.  I also would encourage you to sign onto one of the Open Enrollment Meeting in March because even more information will be presented there.  You can sign up here.


Benefit Coordinator Quarterly Workshop October 2017

Thank you to all who participated in the workshop.  For those unable to attend, click here to view the PowerPoint. 


COBRA Packets 

Due to a programming error, HealthSmart mailed COBRA packets to any policyholder who made a change during open enrollment. You can ignore any COBRA package your receive, unless you dropped your coverage. PEIA is sorry for any inconvenience this may cause.

Update for April 2017

The 2018 Plan Year Shopper's guide is available online here.  They are shipping and should be available to the employees by April 11, 2017.  Open enrollment has begun so please be sure to encourage your employees to check on the status of their Healthy Tomorrows status with these instructions.

Benefit Coordinator Quarterly Workshop has been scheduled for July 20, 2017.

It will be held in Morgantown at the Ramada Inn on Scott Avenue from 1pm to 4pm.  Please sign up here to attend. 

January 2017 Benefit Coordinator Quarterly Workshop

In an effort to keep costs down at PEIA while trying to help Benefit Coordinators do their jobs well, the January BC Quarterly Workshop will be held as Webinars.  Webinars are something that BCs have expressed an interest in that allows them to not lose time at work as well as not spend their agency's funds on travel.  We will have 2 Webinars that Benefit Coordinators may sign up for at  They will be on Thursday, January 12, 2017 at 10am and on Thursday, January 19, 2017 at 2pm. 

Healthy Tomorrows

In an effort to help policyholders, MyPathways is offering FREE lifestyle coaching, fitness assessments, nutrition and exercise videos, prevention programs and health challenges to meet the Healthy Tomorrow’s biometric ranges.   Please help your employees by posting the flyer below in places your employees will see it or email it to get the word out.



Data Match Questionnaire

The below information is what Benefit Coordinators will need to fill out a Medicare Data Match Questionnaire .
For the Health Plan:
GHP ID Numbers: 01022000, 01022000P, 01022001, 01022001P, 01242497 & 01242498
TIN: 550585592  
RxBIN: 610014
Rx PCN: This field is left blank
Rx Group: 3602
GHP= Group Health Plan number: 7700000
PEIA FEIN: 55-0526580
RxBIN        004336
RxPCN       ADV
RxGRP       RX0240

Guardianship Guidelines

There have been questions about Guardianships of children being “TEMPORARY” and/or “PERMANENT” and how that determination is made.   With the substance abuse situation in the State of West Virginia, PEIA is seeing an increase in the number of Guardianships of minors.
If the last paragraphs of the Guardianship Order contain language and/or state, “This Guardianship shall remain in effect until provisions of §44-10-3…” or similar language, then the Guardianship is considered “TEMPORARY” as the parents or others may petition the Court at any time to terminate the Guardianship and/or CPS may change the Guardianship and/or other factors may change or affect the Guardianship.  As PEIA does not have the ability to monitor the Family Courts and/or Circuit Courts, it is the responsibility of the member to provide us documentation and/or proof that the Guardianship remains in effect every year.  Further, if the Order states that there will be a subsequent hearing in the matter, e.g. language akin to, “This matter will be reviewed/reheard on…” then the Guardianship will be considered “TEMPORARY” and may term at a period of less than one (1) year.
The “TEMPORARY” Guardianships are set to term at the maximum of one (1) year from the date eligibility is established – sooner if there are terms in the Order that establish an expiration date.  To continue coverage(s), the member must provide an update to PEIA.  This update can be one of the following:
a.      A letter from the Circuit Clerk attesting that the Order on file with PEIA is the most recent action in the case/matter
b.      A new Order from the Court of record having jurisdiction stating that the Guardianship Order is “PERMANENT”
c.       A letter from Child Protective Services or an Authority Having Jurisdiction that states that the Guardianship remains in effect
If the Guardianship Order states that the Guardianship is “PERMANENT” and/or that the matter is “closed”, “stricken from the record”, “finalized” or otherwise interpreted as the last action in the matter, then PEIA views the Guardianship as “PERMANENT” and will remain in effect until the child(ren) reach the age of eighteen (18).  Remember, the “Guardianship of a Minor” is only in effect when the child(ren) is/are a minor and all rights cease once the child(ren) reach(es) adult status.
It is important to note that Guardianship is a legal status and not a matter of convenience.  Parents cannot “sign over” their children to others nor can they assign responsibilities such as insurance to others.  A notarized document does not make a “Guardianship” “legal” - only a Court of competent jurisdiction can change the custodial status of a child.  Just because notarized documents work for schools and/or others does not mean that they meet PEIA’s standards for adding a dependent.  Further, “Emergency Placements” by Child Protective Services are not Guardianships as the State retains custody of the child during the matter and is responsible for providing insurance(s) and/or health care.

Updated Termination Form  and Policy

 PEIA prefers Benefit Coordinators to Terminate Policyholders online but due to issues where members have had coverage termed, allegedly without their knowledge or consent, resulting in appeals for both Health and Life Insurance, PEIA is now requiring that there be two (2) signatures on all Termination forms if forms are used.
a)      If the member is not available to sign – write “Member Not Available” on the form and have the form signed by two staff, one of which must be the Benefit Coordinator and the other a staff member or an agent of the participating agency.  The second staff member must provide their title.
b)      If the member refuses to sign the form, write “Member Refused to Sign” on the form and have the form signed by two staff, one of which must be the Benefit Coordinator and the other a staff member or an agent of the participating agency.  The second staff member must provide their title.
c)      If the member is not available to sign and/or refuses to sign, and the member would be eligible to receive the three (3) months of continued coverage, that issue must be addressed in writing – either by marking the box asking for the three months of continued coverage, OR, marking that the member declined the continued coverage.  If marking that the member declined the continued coverage, that mark should be initialed and dated.
These requirements are necessary to ensure that participating agencies are complying with applicable State and federal laws relating to insurance and following the PEIA policies and procedures related to Terminations, including offering the three months of continued coverage, where applicable.  PEIA has been somewhat flexible in the past on this issue in an effort to accommodate participating agencies.  The changes outlined above have become necessary because of appeal issues raised, and are done in an effort to be consistent in the administration of the Plans.  Should appeals issues be raised in the future, PEIA will use the form to assess the responsible parties with regard to claims to be paid or premium(s) to be adjusted.  Improperly completed forms will assign the appeal relief responsibility to the participating agency.  Again, PEIA's preferred method of termination is online through the Web portal. 

Quarterly Benefit Coordinator Workshop PowerPoint Presentation

Benefit Coordinators are invited to attend  a workshop held on Tuesday, September 27. 2016 from 12pm-3pm.  It will be held at the Flatwoods Days Inn Conference Center.  We will cover a variety of material and questions that Benefit Coordinators often encounter.  Please click here to view the presentation.

Special Open Enrollment 
For those Benefit Coordinators that still have forms, we need them immediately. They must be postmarked by Friday, July 22, 2016 to be processed.
PEIA will not be mailing a supply of Shoppers Guides to agencies. Due to the unusual circumstances surrounding this Open Enrollment, PEIA has sent out 3 different Shopper's Guides and will have to put together yet another complete book to be available electronically for new hires throughout the plan year. The complete Shopper's Guide will be available on our website at . Benefit Coordinators may direct employees to the website link or may print out a copy to give new hires. We are sorry for the inconvenience, but want to be good stewards of the premiums paid by our policyholders.  An email will be sent to all BCs when the completed Shopper's Guide is available online.

News and Updates May 2016

PEIA has decided to extend a grace period for those who have not turned in the Healthy Tomorrows forms. We will now accept HTOM forms until  May 31, 2016.  

You  will not be receiving your shipments of Plan Year 2017 Shopper Guides or Summary Plan Description Guides as you normally do. PEIA has determined that in light of the status of the budget of West Virginia, it is not financially responsible to print additional guides that are not a true reflection of what the Plan may be.  I will be sending out an email to BCs to let you know when they are available.  Thank you for your patience.


Open Enrollment PowerPoint Available for Plan Year 2017

Thank you to all of the Benefit Coordinators who participated in the Open Enrollment trainings and Webinars.  Below you will find the PowerPoint that was presented. 

Open Enrollment 2017 PowerPoint


Benefit Coordinators for State Agencies

The below guidance that has been issued from the West Virginia Division of Personnel with regard to premium reimbursements related to the divorce audit currently underway at PEIA.  Please note that the opinion and guidance allows for disciplinary action(s) against employees identified in the audit(s).

State of WV PEIA Premium Reimbursement Policy from the DOA
PEIA Premium Reimbursement audit TM.pdf 


2017 January Benefit Coordinator Quarterly Workshops- UPDATE

Thank you to all who attended the BC Quarterly Workshops in January.  If you were unable to attend or did not get a handout, you can preview or print what was covered  by clicking here. BC Quarterly Workshop 1 16