UnitedChoice. Limited Benefit Health Insurance Plan Overview. Copyright 2016 ABBA. All Rights Reserved

Transcription

1 UnitedChoice Limited Benefit Health Insurance Plan Overview Copyright 2016 ABBA. All Rights Reserved

2 1 Plan Overview Congratulations on becoming a ABBA Member. This handbook is an overview of your Limited Benefit Medical Plan that is underwritten by Independence American Insurance Company. a. Included is a CERTIFICATE of INSURANCE. Please review it carefully prior to seeking medical care. If any of the benefits, terms, conditions, limitations or exclusions of coverage in this overview differ from the benefits as described in the Certificate of Insurance, the Certificate of Insurance shall control and take precedence. b. Please note that this plan is NOT a major medical coverage plan. Lack of major medical coverage or other minimum essential coverage may result in an additional payment with your taxes. c. Benefits under the plan are limited to specified maximum amounts shown in your schedule of benefits and certificate for your plan. d. The information in this handbook is a brief description of important features of this insurance coverage; it is not a contract of insurance. Welcome Summary: The Certificate of Insurance shall control and takes precedence over this handbook This is a Limited Benefit Medical Plan, this is NOT a Major Medical Health Insurance Plan Underwritten by Independence American Insurance Company TABLE OF CONTENTS Plan Benefits...2 Network Plan Access...6 Plan Limitations & Exclusions...8

3 Plan Benefits COVERAGE While this plan is not a major medical plan, it does provide significant payments related to: Illness treatment Non-occupational injuries treatment Lab tests SEE ANY DOCTOR Select a Participating Preferred Provider in the MultiPlan Limited Benefit Plan Network This will save you money because pre-negotiated Network rates will reduce your medical bills before the insurance benefit is applied Select a Non-Network Provider, but do so without the negotiated network rate reduction Nominate Your Physician to be in the MultiPlan Limited Benefit Plan Network If your Physician is not in-network, you can easily nominate him or her by going to com >then Select Patient > then Nominate a Provider. You can nominate your provider through the Online Provider Referral System, or download a Provider Referral Letter to present to your provider. Your provider can then contact the network to obtain an application packet. ELIGIBLE PROVIDERS Doctors & Physicians Clinics & Specialty Centers Hospitals & Outpatient Surgical Centers Laboratories & Imaging Centers THE MULTIPLAN LIMITED PLAN NETWORK You now have access to contracted medical providers in the MultiPlan Limited Benefit Plan Network. The MultiPlan Limited Benefit Plan Network is the largest independent primary PPO in the USA. Nearly 900,000 practitioners 3,800 hospitals More than 66,000 ancillary care facilities nationwide MultiPlan Limited Benefit Plan Network has been the national leader in health care cost containment for more than 20 years, and continually strives to recruit the most respected hospitals, physicians and other healthcare professionals for you, so that you receive the quality of care you expect and deserve. The providers in the MultiPlan Limited Benefit Plan Network encompass virtually every specialty and you do not need a referral from your primary care physician to get an appointment with the specialist you may need. By negotiating fixed fee arrangements, the MultiPlan Limited Benefit Plan Network consistently achieves 40% average in-patient and physician savings. 2

4 3 Plan Benefits IHC BENEFIT MATRIX ABBA ASSOCIATION Medical Beneifts Level 1000 Level 3000 Level 6000 Provider Office Visit Benefits Benefit Per Visit $50 $70 $70 Calendar Year Maximum Visits Per Insured 2 visits 3 visits 4 visits Diagnostic Testing Advanced Studies $50 $50 X-rays & Labs $50 $50 $75 Emergency Room Visit Per Visit Benefit $125 2 per year $150 3 per year Hospital Daily Benefit Daily Hospital Benefit $200/day $500/day $1,000/day Maximum Hospital Benefit Period 10 days 10 days 10 days Intensive Care Unit N/A $200 $600

5 5 IHC BENEFIT MATRIX ABBA ASSOCIATION Medical Beneifts Level 1000 Level 3000 Level 6000 Skilled Nursing/ Hospice Facility Benefit 10 days per year $ days per year $ days per year Surgical Benefit Inpatient Surgical $500 $1,000 $1,500 Outpatient Surgical $300 $300 2 per year $500 3 per year Inpatient Anesthesia Benefit Outpatient Anesthesia Benefit 2 per year 2 per year 2 per year Outpatient Minor Surgery Ancillary Benefits Accidental Indemnity $200 $200 $200 Discount Dental & Vision N/A Careington Discount D&V Careington Discount D&V 4

6 5 Plan Benefits FILING CLAIMS / ASSIGNMENT OF BENEFITS When you need to visit a doctor or go to the hospital, there is no need for you to file a claim for in-network providers because your benefits are fully assignable and can be paid directly to your provider. Additionally, any daily hospital benefits will be paid directly to your provider and all other benefits are assignable at your discretion. In order to assign benefits, you must sign a document allowing your doctor or your hospital to collect your health insurance benefits directly from the carrier. By assigning benefits, you will not have to file a claim with the insurance carrier to be reimbursed. If you choose, you may pay your in-network provider at the time of service and submit the claim yourself for reimbursement. Contact customer service for filling a claim directly. Plan Benefits Summary: Provides fixed payments for 4 different types of events See any doctor you want Various Providers to choose from A vast network No need to file claims for in-network Providers Preferred Provider Network access is provided by: MultiPlan Limited Benefit Plan

7 Network Plan Access NETWORK ACCESS Locate a network Provider 2 ways: 1. Call Member Services at Go to > Search for a doctor or facility > Confirm & Schedule: Call your Provider of choice to confirm they are still participating in the network, and then schedule your appointment. If they are no longer a participating Provider, you may still schedule an appointment with them, but you will not receive an in-network rate reduction on your bill. Or, simply search for another in-network Provider. At the Doctor s Office Present your United Choice Membership Card upon arrival. If your doctor s office has any questions about your coverage, they can call ABBA s Member Services for assistance at: After Your Visit Your Provider (not you), will submit a claim form to your insurance company for re-pricing and payment. Confirm & Schedule: If your doctor is not a participating Provider, you may still schedule an appointment with him/her, but you will not receive an in-network rate reduction on your bill. In about 45 days, you should receive an EOB (Explanation of Benefits) in the mail. It will show you the amount of the Provider bill, the Network reduction, the amount paid by the insurance company, and, if there is a balance, the amount for which you, the patient, will be responsible. If you have chosen not to assign your benefits, you can obtain a claim form at or by calling Member Services at , Monday Friday, 9am to 5:30pm ET. 6 *

8 7 Network Plan Access This brochure provides a very brief description of the important features of United Choice. This brochure is not a certificate of insurance and only the actual certificate provisions will control. The certificate itself sets forth in detail the rights and obligations of both the certificateholder and the insurance company. It is, therefore, important that you READ THE CERTIFICATE CAREFULLY. For complete details, refer to the Group Fixed Indemnity Health Insurance certificate of insurance (IAIC MMFI CERT D610). LIMITATIONS AND EXCLUSIONS Benefits will NOT be paid for treatment, services or supplies which: Are not Medically Necessary; Are not prescribed by a Doctor as necessary to treat Sickness or injury; Are experimental/investigational in nature, except as required by law; Are received without charge or legal obligation to pay; or Is provided by an immediate family member. ADDITIONAL LIMITATIONS AND EXCLUSIONS The following is a summary of the plan s exclusions. This is not a complete listing. Consult the Certificate of Insurance for a complete list and description of the benefits not covered. Any treatment, service or supply which is provided by a government owned or operated facility, for complications of conditions that are not covered under the Policy, for breast augmentation and related to surgery, for obesity or weight reduction, for temporomandibular joint (TMJ), related to the feet by means of posting or strapping, related to paring or removal of corns, calluses, bunions or toenails, reposition the maxilla (upper jaw) mandible (lower jaw), or both,, addiction, to improve the appearance or selfperception, to restore or enhance fertility or to reverse sterilization, or Venipuncture An Illness or Injury for which treatment, services or supplies were received or purchased outside the United States, were received as a result of participation in hazardous avocations, incurred during the commission or attempted commission of a crime or felony or while engaged in an illegal act or while imprisoned, incurred due to, or contracted as a consequence of a Covered Person being intoxicated or being under the influence of any illegal drug, incurred while on active duty with the military, resulting from war, which arises out of or in the course of any employment A weekend Hospital Confinement Custodial Care, Home Health Care mpregnation techniques, penile implants and fertility and sterility studies, or Sexual reassignments or sexual dysfunctions or inadequacies Marriage or family counseling or therapy Physical therapy Meridian therapy (acupuncture) Speech and occupational therapy Physical or psychological examinations required by any third party Routine eye or hearing exams Surgery to correct refractive errors, such as radial keratotomy or radial keratectomy Intentional self-inflicted Illness or Injury Mental Illness Disorders Substance Abuse Orthotics Prescription Medications Dental care or treatment Preventive Care Telephone consultations Voluntary abortion

9 PRE-EXISTING CONDITION & PREGNANCY EXCLUSIONS Benefits shall not be payable for a Pre-Existing Condition. A pre-existing condition is a disease, accidental bodily injury, illness or physical condition for which a covered person had treatment, incurred a charge, took medication or received a diagnosis or advice from a doctor during the 12-month period immediately preceding the covered person s coverage effective date. Benefits are payable for a pre-existing condition after the person has been covered under the policy for 12 consecutive months. This does not apply to a newborn or newly adopted child placed for adoption under age 18 if such child is enrolled for coverage within 31 days from the date of birth or date of adoption or placement for adoption. FIXED INDEMNITY THIS PLAN IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR THE MINIMUM ESSENTIAL COVERAGE REQUIRED BY THE AFFORDABLE CARE ACT (ACA). LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES. ABOUT INDEPENDENCE AMERICAN INSURANCE COMPANY Independence American Insurance Company is domiciled in Delaware and licensed to write property and casualty insurance in all 50 states and the District of Columbia. Its products include shortterm medical, employer medical stop-loss, hospital indemnity, fixed indemnity limited benefit, group and individual dental, pet insurance, and non-subscriber occupational accident insurance in Texas. Independence American is rated A- (Excellent) for financial strength by A.M. Best Company, a widely recognized rating agency that rates insurance companies on their relative financial strength and ability to meet policyholder obligations (an A++ rating from A.M. Best is its highest rating). About The IHC Group Independence Holding Company (NYSE: IHC) is a holding company that is principally engaged in underwriting, administering and/or distributing group and individual disability, specialty and supplemental health, pet, and life insurance through its subsidiaries since The IHC Group (including through its 92% ownership of American Independence Corp. (NASDAQ: AMIC)) owns three insurance companies (Standard Security Life Insurance Company of New York, Madison National Life Insurance Company, Inc. and Independence American Insurance Company), a majority of Ebix Health Administration Exchange, Inc., a fully insured third party administrator, and IHC Specialty Benefits, Inc., which is a technology-driven insurance sales and marketing company that creates value for insurance producers, carriers and consumers (both individuals and small businesses) through a suite of proprietary tools and products (including ACA plans and small group medical stop-loss). All products are placed with highly rated carriers. ABBA Association America s Business Benefit Association (ABBA) is a national not-for-profit association that provides individuals, small businesses and self-employed consumers with business benefits, services and health-related options, including access to valuable association endorsed health insurance benefits. CA Association Communicating for America, Inc., (CA) is a national non-profit advocacy organization that supports affordable healthcare for all Americans. Since 1972, more than 100,000 consumers have trusted CA to help them find affordable health insurance and Gap plans to stretch their healthcare dollar while advocating on their behalf with insurance companies, regulators and lawmakers. 8

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