Members Definitions
The Members menu allows you to locate, add, and maintain member records. A Member is the person covered under an insurance plan. In COBRA & Direct Billing, there are three kinds of members; Qualified Beneficiaries (QB), Special Plan Members (SPM), and New Plan Members (NPM). Information about a member (address, plan, premium, etc.) is contained in a member record; the specific content of the record depends on the member type.
| QB - Qualified Beneficiaries |
A Qualified Beneficiary (QB) is an individual who has lost group health plan coverage due to a qualifying event such as termination or retirement. The individual must be a covered employee, spouse of a covered employee, or the dependent child of a covered employee. The person can elect to continue the group health plan coverage for a limited time on a self-pay basis. A QB may qualify for an extension of their COBRA benefits past the standard coverage period if they have a disability. The specific regulations regarding the QB's rights, election period, payment periods, and length of coverage are defined in the federal COBRA law. |
| SPM - Special Plan Members |
A Special Plan Member (SPM) is an individual who is billed on a regular schedule for one or more plans or benefits. The billing frequency and specific types of plans or benefits are not associated with any laws or regulations. Therefore, an SPM record can be used differently for specific needs and business processes. For example, an SPM can be an individual who is billed monthly for a retiree dental plan, while another SPM can be an individual who is billed quarterly for a loan repayment. |
| NPM - New Plan Members |
A New Plan Member (NPM) is an individual who is a current employee of an employer and not yet receiving COBRA benefits. |
Member Status
Status is used to indicate the current state of a member’s coverage under a plan. A status may also be called Member status, Member record status, Member plan status, and plan status. All of these terms have the same meaning.
Status is automatically changed by our system based on defined time periods, system actions, payment activity, and letter generation rules. There is a basic order for the statuses, but the order can vary depending on unique factors for a particular member plan. Also, a member plan does not have to be in each status; one or more may be skipped, and the member plan may return to a previous status because of unique factors. If a member is covered under multiple plans (e.g. medical, dental, and vision), each plan can have a different status.
| P (Pending) | The COBRA Specific Rights Notice has been sent (to the QB) and the SPM Welcome Letter has been sent (to the SPM). The member has not returned the election form (but is still in the election period), has not made any payment, and is not covered under the plan. This status applies to QBs and to SPMs (when the SPM election feature is enabled). |
| PR (Pending Received) |
The member is not covered under the plan but has sent their election form to Ameriflex without payment. This status applies to QBs and to SPMs (when the SPM election feature is enabled) |
| E1 (Enrolled and in Initial Grace Period) |
The member is currently covered under the plan and has made an initial payment within the initial grace period, but still owes an amount to satisfy the complete initial payment. This status applies only to SPMs when the SPM election feature is enabled. |
| E45 (Enrolled and in 45 Day Grace Period) |
The member is currently covered under the plan and has made an initial payment within the first 45 days of being covered, but still owes an amount to satisfy the complete initial payment. This status applies only to QBs. |
| Active | The member is currently covered under the plan and is not past due on any payments. This status applies only to SPMs when the SPM election feature is disabled. |
| E (Enrolled) | The member is currently covered under the plan and is not past due on any payments. This status applies to QBs and to SPMs (when the SPM election feature is enabled). |
| TP (Terminated Pending) |
The member did not return the election form within the election period or did not make any payment and was not covered under the plan. This status applies to QBs and to SPMs (when the SPM election feature is enabled). If you select this status type, enter a value in the ‘terminated in the last number of days’ field. The default is 30 days. In the report, the system includes all QBs with a status of terminated where the status was changed to terminated in this time period. |
| TE (Terminated Enrolled) |
The member was previously covered under the plan but did not make a payment within the required time and therefore lost their coverage under the plan. This status applies to QBs and to SPMs (when the SPM election feature is enabled). If you select this status type, enter a value in the ‘terminated in the last number of days’ field. The default is 30 days. In the report, the system includes all QBs with a status of terminated where the status was changed to terminated in this time period. |
| Terminated | The member was previously covered under the plan but did not make a payment within the required time and therefore lost their coverage under the plan. This status applies only to SPMs when the SPM election feature is disabled. |
