A guide to using your Select Benefits coverage

Transcription

1 Select Benefits Fixed-Payment Medical Insurance A guide to using your Select Benefits coverage Your Select Benefits coverage is provided under a group insurance policy that pays benefits at a preselected, fixed dollar amount. Coverage is designed to help reduce your out-of-pocket health-related expenses and benefits will be paid regardless of any other coverage you may have. Contact Information Select Benefit Administrators (SBA) Customer Service Hours: Monday through Friday, 6:30 a.m. to 5 p.m., CT Toll-free phone: symsba@symetra.com Fax: (715) P.O. Box 440 Ashland, WI Scan to download and save this contact information to your smartphone. Select Benefits is not a replacement for a major medical plan or any other comprehensive coverage and does not satisfy the requirements of the Affordable Care Act (ACA). If the benefit amount provided by the policy does not cover the entire cost of the visit or procedure, you are responsible for any remaining balance. The Policy Administrator Select Benefit Administrators (SBA) handles the administration of your Select Benefits coverage. This includes verification of eligibility, billing and claims payment. SBA is available to help you understand and use your benefits. Please feel free to contact them with any questions or concerns. How Does It Work? To use the coverage, follow these steps: 1 2 Present your ID card to your provider at the time of service. If you need to use your coverage before you receive your insurance card, contact SBA before your visit and ask for the case number. Give your provider this number along with the SBA customer service phone number. Ask your provider to bill the policy administrator, SBA, and accept an assignment of benefits. If your provider will not accept the assignment, or if you wish to be paid directly, you will need to file a claim yourself. To file a claim yourself, complete a Select Benefits claim form and return it to SBA. You will need a signed Authorization for Release of Medical Information form and an itemized bill from the provider listing dates of service, procedure codes and diagnosis codes. SBA cannot process your claim without these codes. Symetra Life Insurance Company th Avenue NE, Suite 1200 Bellevue, WA Symetra is a registered service mark of Symetra Life Insurance Company. 3 Pay the provider any outstanding balance due. Any charges that remain after the claim has been paid to the provider are your responsibility. Select Benefits policies are insured by Symetra Life Insurance Company, th Avenue NE, Suite 1200, Bellevue, WA Select Benefit Administrators is an administrative division of Symetra Life Insurance Company. SBM /15

2 Using Select Benefits as supplemental insurance As an insured in your company s Select Benefits group insurance policy, you are free to use any doctor you choose. Regardless of any other insurance coverage that you may have, you are entitled to the full amount of the fixed benefit that the policy allows. Should the bill be paid in full by your other insurance, you can file the claim yourself and Select Benefit Administrators (SBA), will pay the benefit directly to you. 3 a Visit the provider and present your insurance 9card(s) prior to service. See below for instructions on how to file claim directly with SBA. 0 1 SBA If the provider has not billed SBA, then you can file the claim and the benefit will be paid directly to you. After the service, the provider could bill one or both insurance companies. If the claim is paid in full by the other insurance company, the provider may or may not bill SBA. If the provider bills SBA, your benefit will be paid to the provider according to the policy. To file a claim with SBA, follow these steps: 1. At the time of service, show your ID card(s). The provider may or may not submit a claim to SBA, but they are more likely to submit it if they have a copy of your card on file. 2. Be sure to obtain a receipt for payments made at the time of service and an itemized bill listing dates of service, procedure codes and diagnosis codes. 3. To file the claim yourself, complete a Select Benefits claim form and return it to SBA. You will need to include a signed Authorization for Release of Medical Information form as well as the documents mentioned above in step two. Mail or fax claims to: Select Benefit Administrators Attn: Claims Dept. PO Box 440 Ashland, WI Fax (715) You will receive payment in accordance with the policy and state insurance law requirements. Symetra Life Insurance Company th Avenue NE, Suite 1200 Bellevue, WA Symetra is a registered service mark of Symetra Life Insurance Company. If you have questions about using your coverage, please contact SBA at , Monday through Friday, 6:30 a.m. to 5 p.m., CT. Select Benefits policies are insured by Symetra Life Insurance Company, th Avenue NE, Suite 1200, Bellevue, WA Select Benefit Administrators is an administrative division of Symetra Life Insurance Company. SBM-5756/Sup 3/14

3 Value-Add Benefits Help is just a phone call away Your coverage includes 24/7 access to value-add benefits and programs, provided by Health Advocate, at no additional cost to you. These services can help you and your eligible family members with a wide range of health care and insurancerelated issues. EAP+Work/Life This confidential program offers unlimited, toll-free access to licensed professional counselors and work/life specialists for short-term assistance with a wide range of family- and workrelated issues. Educational materials, webinars and other resources are available through a dedicated website. Specialists can help you address: Stress, depression and anxiety Substance abuse Financial and legal problems Divorce, grief and loss Child and elder care concerns Health Advocacy Unlimited access to a Personal Health Advocate, typically a registered nurse supported by medical directors and benefits and claims specialists, who can help: Find qualified doctors, hospitals and other providers Explain conditions and treatments Resolve billing and claims issues Arrange for second opinions and the transfer of medical records Clarify health insurance benefits and answer coverage questions NurseLine You can reach a registered nurse 24 hours a day, 7 days a week for trusted advice when you need it most. Our experienced nurses are available to: Answer questions about symptoms or medications Offer self-care information for non-urgent health issues Explain health conditions and treatments Direct you to the appropriate care for immediate attention, if needed Medical Bill Saver Expert negotiators will work with providers to reduce the cost of medical and dental bills that are not covered by your insurance saving you time and money. Our skilled negotiators can: Help reduce your out-of-pocket costs on non-covered bills Handle negotiations and obtain provider signoff Provide you with an itemized summary of the outcome and payment terms Wellness Coaching Our Wellness Coaching program provides a personalized, actionoriented approach to help you and your eligible family members reach and maintain your best possible health. Features include: Unlimited confidential support from a personal Wellness Coach by telephone, or secure web messaging A comprehensive website featuring a personalized health profile to identify health risks, wellness tools and trackers, and self-guided programs on weight loss, nutrition and exercise continued > SBM /15

4 Who s eligible? Your Health Advocate benefits are available to enrolled members, their spouse, dependent children, parents and parents-in-law. The Wellness Coaching feature is available to enrolled members, their spouse and dependent children age 18+. Questions? For more information about your Health Advocate benefits or your specific group coverage, contact your company s benefits representative or contact Select Benefit Administrators at symsba@symetra.com or Symetra Life Insurance Company th Avenue NE, Suite 1200 Bellevue, WA Symetra is a registered service mark of Symetra Life Insurance Company. Value-add programs are offered by Health Advocate TM through Symetra Life Insurance Company. Health Advocate, a subsidiary of West Corporation, is not affiliated with any insurance or third party provider. Health Advocate does not replace health insurance coverage, provide medical care or recommend treatment. Select Benefit Administrators is an administrative division of Symetra Life Insurance Company.

5 Select Benefits Plan Summary for Collaborative for Educational Services - Fixed Payment Fixed-Payment Indemnity Insurance Fixed-Payment Indemnity Policy Plan 1 Plan 2 Inpatient Hospital Benefits 500 days per lifetime unless noted Hospital Stay $300 per day, 10 days pp/pcy 1 $500 per day, 10 days pp/pcy 1 Intensive Care Unit $600 per day, 10 days pp/pcy $1,000 per day, 10 days pp/pcy Substance Abuse Facility $300 per day, 10 days pp/pcy $500 per day, 10 days pp/pcy Mental Health Facility $150 per day, $250 per day, 180 days lifetime maximum 10 days pp/pcy 10 days pp/pcy Nursing Facility $150 per day $250 per day 60 consecutive days per stay maximum. This benefit is paid only if following a covered hospital stay of at least three consecutive days and the insured is under age 65. Health Advocacy Services EAP+Work/Life Program Wellness Coaching Program Survivor Benefit Bi-Weekly Premium Rates are based on 26 Pay Periods per year Employee $6.61 $11.00 Employee + Spouse $14.08 $23.46 Employee + Children $10.83 $18.05 Family $19.60 $ pp/pcy=per person, per calendar year The Policyholder will determine the minimum required hours to be eligible for coverage. The minimum weekly hours to be established must be at least 15 hours. Patient advocacy services are included at no additional cost. These services are provided by Health Advocate, Inc., 3043 Walton Road Suite 150, Plymouth Meeting, PA This is not an insured benefit. EAP+Work/Life and Wellness Coaching Programs are included at no additional cost. These programs are provided by Health Advocate, Inc., 3043 Walton Road Suite 150, Plymouth Meeting, PA This is not an insured benefit. These benefits are designed to be offered to those covered under a High-Deductible Health Plan ('HDHP') without the effect of disqualifying a participant from electing an HSA. Please consult with your Benefits Advisor to assist with determination that electing this limited benefit coverage is in fact permitted coverage under the rules applicable to an HSA. Select Benefits insurance policies are not a replacement for a major medical policy or other comprehensive coverage and do not satisfy the minimum essential coverage requirements of the Affordable Care Act. They are designed to provide benefits at a preselected, fixeddollar amount. Coverage may be subject to exclusions, limitations, reductions, and termination of benefit provisions. Select Benefits policies are insured by Symetra Life Insurance Company located at th Avenue NE, Suite 1200, Bellevue, WA 98004, and are not available in all U.S. states or any U.S. territory. Coverage is provided under generic policy form numbers SBC-00500, LGC-9095, and LGC or LGC LG _MA(15.0) 1 / 2 03/09

6 Select Benefits Description Of Benefits for Collaborative for Educational Services - Fixed Payment Fixed-Payment Indemnity Insurance Inpatient Hospital Benefit Benefits are paid on the first day of a covered stay. ICU, substance abuse, mental health and nursing facility stays are included with the hospital stay benefit. Each facility has a calendar year maximum number of days as selected, 500 days per lifetime unless otherwise noted in the policy. Please refer to your Plan Summary for details. Health Advocacy Personalized assistance with a full range of health coverage and insurance-related issues such as locating doctors and other providers, scheduling appointments, getting cost estimates and more. NurseLine Direct access to a registered nurse 24/7 for non-urgent concerns. Medical Bill Saver Help negotiating with providers for medical and dental bills that are not covered by your insurance. EAP+Work/Life Licensed professional counselors and work/life specialists provide confidential, short-term help with personal, family and work-related issues. Wellness Coaching Unlimited access to highly trained wellness coaches by telephone, or instant messaging. Includes a comprehensive, secure wellness website. Survivor Benefit If an employee dies while insured, any covered dependents will be extended benefits (except Dependent Life, Group Accident, and Critical Illness) without premium payments for up to two years after the employee's death. This is as long as the plan remains in force and the covered dependent meets the coverage requirements in the policy. Select Benefits insurance policies are not a replacement for a major medical policy or other comprehensive coverage and do not satisfy the minimum essential coverage requirements of the Affordable Care Act. They are designed to provide benefits at a preselected, fixed-dollar amount. Coverage may be subject to exclusions, limitations, reductions, and termination of benefit provisions. Select Benefits policies are insured by Symetra Life Insurance Company located at th Avenue NE, Suite 1200, Bellevue, WA 98004, and are not available in all U.S. states or any U.S. territory.

7 Group Accident Coverage Help when the unexpected happens After an accident, unexpected medical costs can make a bad situation even more stressful. Group accident coverage can help relieve some of the financial pressure. Accidents happen. When they occur, out-of-pocket costs for things such as doctor visits, X-rays and physical therapy can add up fast. Group accident coverage from Symetra Life Insurance Company can help. How it works You are being offered group accident coverage for three (3) separate accidents per year. The coverage pays benefits for eligible expenses incurred as a result of an accident (unless covered by workers compensation or similar law) up to the benefit amount selected per occurrence. This means that eligible expenses related to a specific accident occurrence even if incurred on different days or with different providers will be covered under the same per occurrence benefit. Eligible expenses related to an accident occurrence will be paid at 100% up to the preselected benefit amount. You are responsible for any remaining balances. You may receive up to three (3) benefits per year. Each per occurrence benefit is tied to a specific accident and cannot be used to cover expenses related to any other accident occurrence. Here are two examples of how benefits would be paid on a benefit amount of $2,500 per accident occurrence: Example 1 Eligible incurred expenses Emergency room $720 X-ray and lab tests $510 Diagnostic testing (MRI) $850 Physician fees $300 Physical therapy $690 Example 2 Eligible incurred expenses Urgent care $310 Lab tests $235 X-rays $280 Physician fees $120 Chiropractic services $510 Total expenses $3,070 Total expenses $1,455 Benefits paid = $2,500 Out-of-pocket costs = $570 Benefits paid = $1,455 Out-of-pocket costs = $0 SBM /15

8 Eligible benefits Benefits will be paid for eligible expenses that are incurred as a result of an accident that occurs while you are covered under the group accident policy. The combined benefits paid for medical, dental, surgical, inpatient hospital, X-ray and lab and inpatient prescription drug expenses will not exceed the maximum benefit amount shown in the Summary of Benefits. Expenses must be incurred within 52 weeks from the date of the accident and the first expense must be incurred within 60 days after the date of the accident. Medical benefits Services and supplies provided or prescribed by a licensed physician or other licensed health care provider for the following: Nursing services Physician s office visits Hospital emergency room visits Outpatient hospital visits Urgent care visits Chiropractic visits Rehabilitation services Dental benefits Dental benefits will be provided for eligible expenses incurred for procedures performed by a licensed physician or licensed dentist in connection with an accident. Procedures include: A closed or open reduction of a fracture Dislocation of the jaw Injury to natural teeth Surgical benefits Surgical benefits will be provided for eligible expenses incurred for surgical procedures performed by a licensed physician in connection with an accident. Inpatient hospital benefits Inpatient hospital benefits will be provided for eligible expenses incurred in connection with an accident while covered under this policy only if all of the following conditions are met: The insured is confined in a hospital A charge is made for room and board The entire duration of such hospital confinement is recommended and approved by a physician Confinement is the result of a non-occupational accident The services and supplies are not excluded under the exclusions and limitations provision of the policy X-ray and laboratory benefits Benefits will be provided for eligible expenses incurred in connection with an accident while covered under the policy when they are ordered or performed by a physician. Inpatient prescription drugs Benefits will be provided for eligible expenses incurred in connection with an accident if the insured is confined in a hospital and the drugs are prescribed by a physician and administered in the hospital by a licensed health care provider. Symetra Life Insurance Company th Avenue NE, Suite 1200 Bellevue, WA Symetra is a registered service mark of Symetra Life Insurance Company. Select Benefits insurance policies are designed to provide benefits at a preselected, fixed dollar amount. They are not a replacement for a major medical policy or other comprehensive coverage and may be subject to exclusions, limitations, reductions and termination of benefit provisions. Select Benefits policies are insured by Symetra Life Insurance Company, th Avenue NE, Suite 1200, Bellevue, WA Policy form number is LGC /11 in most states and is not available in all U.S. states or any U.S. territory.

9 Select Benefits Plan Summary for Collaborative for Educational Services - Fixed Payment Group Accident Policy Plan 1 Plan 2 Group Accident Benefit Coverage per occurrence up to $5,000 up to $10,000 Occurrences 3 pp/pcy 1 max. 3 pp/pcy 1 max. Health Advocacy Services EAP+Work/Life Program Wellness Coaching Program Domestic Partner Benefit Bi-Weekly Premium Bi-Weekly Rates are Based on 26 Pay Periods Per Year Employee $9.87 $11.02 Employee + Spouse $21.03 $23.48 Employee + Children $16.17 $18.06 Family $29.28 $32.70 The Policyholder will determine the minimum required hours to be eligible for coverage. The minimum weekly hours to be established must be at least 15 hours. Patient advocacy services are included at no additional cost. These services are provided by Health Advocate, Inc., 3043 Walton Road Suite 150, Plymouth Meeting, PA This is not an insured benefit. EAP+Work/Life and Wellness Coaching Programs are included at no additional cost. These programs are provided by Health Advocate, Inc., 3043 Walton Road Suite 150, Plymouth Meeting, PA This is not an insured benefit.

10 Description of Benefit Group Accident Benefit This benefit pays eligible expenses up to the benefit amount selected per accident occurrence. Expenses must be incurred within 52 weeks from the date of the accident with the first expense incurred within 60 days of the date of the accident. Health Advocacy Personalized assistance with a full range of health coverage and insurance-related issues such as locating doctors and other providers, scheduling appointments, getting cost estimates and more. NurseLine Direct access to a registered nurse 24/7 for non-urgent concerns. Medical Bill Saver Help negotiating with providers for medical and dental bills that are not covered by your insurance. EAP+Work/Life Licensed professional counselors and work/life specialists provide confidential, short-term help with personal, family and work-related issues. Wellness Coaching Unlimited access to highly trained wellness coaches by telephone, or instant messaging. Includes a comprehensive, secure wellness website. Select Benefits insurance policies are not a replacement for a major medical policy or other comprehensive coverage and do not satisfy the minimum essential coverage requirements of the Affordable Care Act. They are designed to provide benefits at a preselected, fixeddollar amount. Coverage may be subject to exclusions, limitations, reductions, and termination of benefit provisions. Select Benefits policies are insured by Symetra Life Insurance Company located at th Avenue NE, Suite 1200, Bellevue, WA 98004, and are not available in all U.S. states or any U.S. territory. Coverage is provided under generic policy form number LGC