REFERENCE GUIDE HOW-TO HANDBOOK

Transcription

1 Abacus Medical Support Insurance Plan REFERENCE GUIDE HOW-TO HANDBOOK

2 TABLE OF CONTENTS I. About The Product Benefit Sheets II. Underwriting III. Claims How to File a Claim Sample of Hospital Bill Toll Free Number Forms IV. Policy Terminology V. Enrollment

3 Abacus Medical Support Insurance Plan The Abacus Medical Support Insurance Plan (AMS) has been designed exclusively for Word & Brown General Agency. The plan provides Indemnity based benefits that pay in addition to all other coverages. The unique feature of this plan is it s pricing point allows the brokers to increase their medical plan deductibles and co-pays, which frees up dollars to pay for the AMS plan. The result is more first dollar benefits at a lesser cost - a win for both the employer and the employees. BENEFITS Summary / Overview Through your employer, you are presently covered under your group medical plan, with benefits that are mandated through the PPACA Patient Protection and Affordable Care Act, which was passed into law by Congress. Based on your specific plan benefits, your coverage has deductibles and co-pays that may require you to pay out of pocket expenses for as much as $6, on an individual and $12, on the family. You can t stop medical cost from rising! You can t prevent gaps in coverage from occurring! However, you can help manage the cost you will incur through deductibles and co-pays by purchasing the Abacus Affordable Supplemental Plan. BENEFIT First Hospital Confinement Pays the benefit amount for an insured s first hospital confinement up to 3 days at $1500 per $4,500 day. Limited to the First Hospital Confinement each Calendar Year for each Insured and will not exceed: Day-1 - $1500 Day 2 - $1500 Day 3 - $1500 Critical Care Makes a one-time payment of the benefit amount if one of the following specified health events occurs for the first time in the insured person s lifetime while the Rider is in force: Heart Attack, Stroke, Life Threatening Internal Cancer, End Stage Renal Failure, Coronary Artery Bypass, Major Organ, or Permanent Paralysis. Subject to a 30-day waiting period. 12/12 Pre-Existing Condition limitation applies. - Requires diagnosis by a Doctor. Once the maximum benefit has been paid, coverage under this Rider terminates for the insured person. Accident Expense Pays the lesser of the benefit amount or actual expenses for covered charges incurred by an insured person as a result of a covered Accidental Bodily Injury which occurs while coverage is inforce under this Rider. - Initial charges must be incurred within 90 days of the covered Injury and while coverage is continuously inforce. Employee Employee & Spouse Employee & Child(ren) Employee & Family $5,000 first occurrence; lifetime max benefit of 1 day $2,500 per Injury per year WEEKLY PREMIUMS Employer Paid Voluntary $6.66 $11.11 $15.09 $25.15 $11.89 $19.81 $18.84 $31.39 Guarantee Issue Minimum Group Contribution Size Employer Paid or Voluntary Voluntary Offer Benefit Payment Telephonic Claims Initiation Highlights No Health Questions to answer 2 Enrolled with Group Contribution 0 Pre-Existing Condition Limitations on HI and Accident 12/12 Pre-ex on Critical Illness 2 Enrolled - No Percentage Participation Requirement No Physician/Hospital Restrictions Pays directly to the insured & in addition to all other plans

4 UNDERWRITING The Abacus Medical Support (AMS) Insurance Plan is designed to be written as either an Employer Contribution Plan or a Voluntary Plan. 1. Both Plans are Guarantee Issue with No pre-existing condition limitations, with the exception of the critical care rider (12/12 Pre-ex). 2. Minimum Participation: Employer Contribution Plan- Group size 2+ employees. We realize that the percentage of premium paid for by the employer may vary, however the goal of the plan is for everyone being insured under the major medical will also be insured under the AMS plan whether the employer percentage is 80/20, 70/30, or 50/50. Voluntary Plan- Group Size 2+

5 CLAIMS Claims can be filed in two ways. 1. TELEPHONIC As a result of the simplicity of the plan design and underwriting we prefer that the claims be initiated telephonically. STEPS - 1. Call A claims analyst will be assigned to the claims case and will go through a series of questions to start the process. 3. Most likely, the insured will be asked to submit a copy of the hospital bill, which should indicate admission date and discharge date on the bill. (See below). If a surgery or emergency accident benefit claim is being filed, additional data may be requested. 4. The claims analyst will contact the physician and/or hospital; however, they may need the insured s assistance or authorization for the medical information. 5. Benefits will be paid directly to the Insured unless otherwise requested. 2. A paper claim form is available at your request. SAMPLE BILL

6 POLICY TERMINOLOGY 1. HOSPITAL means admission to a Hospital and confinement as a resident bed patient due to an Injury or Confinement Sickness. The confinement must be on the advice of a Physician and be Medically Necessary. (Confinement to an emergency room, outpatient treatment room, or observation unit is not considered a hospital confinement.) 2. FIRST HOSPTIAL CONFINEMENT: The first Period of Confinement in a Calendar Year for an Insured. No other Period of Confinement during a Calendar Year will be considered a First Hospital Confinement. Day of Confinement means a day of inpatient Confinement in a Hospital for which a daily room and board charge is made for a full day of Confinement. (This includes one continuous Hospital Confinement or several Hospital Confinements for the same or a related cause, which are separated by less than 60 days from date of discharge). 2. CRITICAL CARE Makes a one-time payment of the benefit amount if one of the following specified health events occurs for the first time in the insured person s lifetime while the Rider is in force: Heart Attack, Stroke, Life Threatening Internal Cancer, End Stage Renal Failure, Coronary Artery Bypass, Major Organ, or Permanent Paralysis. Subject to a 30-day waiting period. 12/12 Pre-Existing Condition limitation applies. - Requires diagnosis by a Doctor. Once the maximum benefit has been paid, coverage under this Rider terminates for the insured person. 3. Accident Expense Pays the lesser of the benefit amount or actual expenses for covered charges incurred by an insured person as a result of a covered Accidental Bodily Injury which occurs while coverage is inforce under this Rider. - Initial charges must be incurred within 90 days of the covered Injury and while coverage is continuously inforce.

7 GROUP SET UP AND ENROLLMENT To make it easy to write a new group and enroll their employees, we have designed a Special Website which contains all of the information and steps necessary. Download a interactive employer agreement and a XL spreadsheet that already has the titles for each column needed. The employer agreement will be ed over when they hit submit and we will have a FTP site for them to upload a XL spreadsheet showing who is being enrolled. IT S JUST THAT EASY!