A Powerful Force Working For You

Transcription

1 A Powerful Force Working For You Fortis Health helps people meet their insurance needs by offering an array of individual, small group and specialty health insurance products. In business for more than 110 years, the company is an industry leader, providing health insurance coverage to more than one million people nationwide. Fortis Health markets insurance products that are underwritten and issued by Fortis Insurance Company, John Alden Life Insurance Company and Fortis Benefits Insurance Company. It is headquartered in Milwaukee, Wisconsin and has operations offices in Florida, Idaho, Minnesota and Ohio. Fortis Health is part of Fortis, Inc., a financial services company that, through its operating companies and affiliates, has built leadership positions in a number of specialty insurance markets in the U.S. Fortis, Inc. is part of Fortis, a financial services provider active in the fields of insurance, banking and investments. Fortis Health 501 West Michigan Milwaukee, WI Find Fortis Health on the Internet at Fortis is a registered service mark of Fortis (B) and Fortis (NL) N.V Fortis Insurance Company Health Plans for Individuals and Families (Form 236) is underwritten and issued by Fortis Insurance Company, a Fortis Health member company, Milwaukee, WI. Form MN (Rev. 1/2003)

2 Health Plans to Fit Your Life Preferred 2000 Health Plans Health Plans for Individuals and Families Minnesota from Fortis Insurance Company a Fortis Health member company

3 Trust the Tradition of Fortis Health Trust the Strength Fortis Insurance Company is a Fortis Health member company, and part of a long and stable company tradition. Fortis Health is the big company that helps individuals, families and small businesses with their health insurance needs. Our size gives us the clout to provide you with more choice in hospitals and networks. Trust the Experience With more than one million customers, over 110 years of experience and strong industry ratings, we have a long tradition you can depend on. Trust the Stability Fortis Health is a part of Fortis, an international banking and insurance company. We are solid and strong. Take a look at how Fortis is growing: Assets have increased over 14 times since Bigger than Microsoft, Procter & Gamble and DuPont. (1) Owns more than 200 companies and employs more than 70,000 people worldwide an entire community in itself! (1) Source: 2001 Fortune Global 500 listing, based on 2000 revenues. 1

4 Exclusions Summary Preferred 2000 Health Plans do not provide benefits for: Illness or injury caused by war, commission of crime, attempted suicide, influence of illegal substance. Routine hearing care, routine vision care, vision therapy, surgery to correct vision, routine foot care, or foot orthotics. Cosmetic services. Charges by a health care practitioner or medical provider who is an immediate family member. Immediate family members are you, your spouse, your children, brothers, sisters, parents, their spouses and anyone with whom legal guardianship has been established. Custodial care. Charges reimbursable by Medicare, Workers Compensation, automobile carriers. Growth hormone stimulation treatment. Dental care not related to a dental injury. Any treatment for correction of malocclusion, protrusion, hypoplasia or hyperplasia of the jaws. Mental illness/nervous disorders. Substance abuse, unless you have the Substance Abuse Rider. Charges for educational testing or training, vocational or work hardening programs, transitional living, or services provided through a school system. Infertility. Maternity and routine nursery charges. Genetic testing, counseling and services. Charges for sex transformation, and treatment of sexual dysfunction or inadequacy. Over-the-counter products. Contraceptive drugs or devices. Treatment of quality of life or lifestyle concerns including but not limited to smoking cessation; obesity; hair loss; sexual function, dysfunction, inadequacy or desire; or cognitive enhancement. Treatment used to improve memory or to slow the normal process of aging. Telemedicine. Additional Information Preauthorization When you need inpatient treatment or certain outpatient procedures, you must obtain preauthorization. If you do not obtain preauthorization, you can incur a penalty of 25% of the charge, up to $1,000. There is no coverage for transplants which are not authorized. Conversion Privilege A spouse or dependent who is no longer eligible for coverage under this plan may obtain a similar plan without evidence of insurability. Waiting Periods on Certain Conditions Benefits for certain conditions are payable after the waiting period listed here: tonsils/adenoids, 3 months; sterilization, 12 months; hernia (except strangulated or incarcerated), 6 months; bunionectomy, 6 months; varicose veins, 6 months; hemorrhoids, 6 months. The waiting period is waived when this plan is replacing other similar in-force coverage. Pre-existing Conditions A pre-existing condition is an illness, injury and any related complications for which, during the 12-month period immediately prior to your effective date, you received medical treatment, diagnosis, consultation or prescription drugs; or which produced symptoms or was capable of being diagnosed. The Preferred 2000 plan does not pay benefits for covered charges incurred due to a pre-existing condition, as defined in the contract, until you have been continuously insured under this plan for 12 months. After this 12-month period, benefits will be paid for a pre-existing condition on the same basis as any other condition. 8

5 Plans for Simplicity and Tax Advantages One Deductible Plan Get simplicity and affordability with the One Deductible Plan. While saving premium, you get a unique, integrated family deductible including prescriptions so you don t have to keep track of individual deductibles. It s easy. Here are the details on the One Deductible PPO and One Deductible Traditional Plans. Lifetime maximum benefit of $6 million for PPO and Traditional ALL covered services (including prescription drugs) are applied to one deductible and coinsurance Wellness services (covered subject to deductible and coinsurance) up to $500 per calendar year $1,700, $2,000 or $2,500 individual deductible options $3,400, $4,000 or $5,000 family deductible options 100%, 80%, or 50% coinsurance options (For PPO plans, non-network coinsurance is 20% less than network coinsurance, up to the out-of-pocket maximum.) Medical Savings Account (MSA) Plan Get tax-advantaged savings* by adding a Medical Savings Account to your One Deductible Plan. An MSA allows tax-deductible contributions, tax-deferred interest and tax-free withdrawals. It works like an IRA only better. You can use your MSA savings for qualified medical expenses that your health plan may not cover, like your deductible, contact lenses or certain types of alternative medicine, or simply let the funds accumulate for distribution after retirement. Check with your tax advisor to see if you qualify for an MSA. *Fortis Health and its subsidiaries are not engaged in rendering tax, investment, or legal advice. Federal and state tax regulations are subject to change. If tax, investment, or legal advice is required, seek the services of a licensed professional. Non-network deductibles do not apply to One Deductible /MSA PPO Plans. Deductibles are subject to change annually based on the Consumer Price Index. Preferred 2000 Options Doctor Office Copay (DOC) When you add the DOC option to your plan, your copay is all you pay for up to two eligible network office visits. Eligible office visit services are limited to history, examination, diagnosis, immunizations and allergy shots. The following are covered subject to deductible and coinsurance, but are not eligible for DOC option benefits: in-office surgeries, allergy testing, treatment of mental illness/nervous disorder/substance abuse conditions, as described in the contract and Value Plan wellness services. As an additional benefit, the first $100 of covered outpatient lab and x-ray per person per calendar year is paid at 100%. Physician/Hospital PPO wellness services, including covered immunizations, are subject to the Wellness Benefit limit. The DOC option varies by plan. For more information, refer to the plan features chart. Optional coverages are available for an additional cost. Not all options are available with all plans. Check software for availability. 6

6 Preferred 2000 Options continued Accident Medical Expense (AME) Get first-dollar coverage in the event of an accident! First-dollar coverage means the AME benefit of $300, $500 or $1,000 is paid before any copays or access fees are applied. For each accident occurrence, benefits are available for charges incurred within 90 days of the accident. Fortis Health Dental and Vision Card You won t pay full price on dental services and eyewear when you have the Dental and Vision Card. Just present your card to a participating dental or eyewear provider and receive: Discounts of up to 60% on dental services, including cleanings, x-rays, fillings, crowns and orthodontia. Discounts of 10% to 60% on eyewear, including eyeglasses, contact lenses and sunglasses. The discounts extend to all family members in your household. If just one person in your family requires vision correction, you could save enough on eyeglasses or contacts to cover the cost of the card for a year! And there are no limits on the number of times you use the card. Substance Abuse Rider Benefits are provided for covered charges incurred for substance abuse on the same basis as any other illness subject to the following: Inpatient treatment in a state-licensed facility up to 28 days each calendar year. Outpatient treatment from a state-licensed practitioner or facility up to 130 hours each calendar year. See the Plan Summary included with your proposal for more information on benefits and provider networks in your area. This is a discount program, not an insurance product. Optional coverages are available for an additional cost. Not all options are available with all plans. Check software for availability. 7

7 Preferred 2000 Family of Plans You expect a plan with good benefits. additional benefits you receive. Lifetime maximum benefit options up to $6 million $25 copay for doctor office visits Wellness benefits Prescription Drug Card Optional Dental and Vision Card Optional Accident Medical Expense (AME) benefit: we pay first when you have an injury before you pay deductible or coinsurance Optional Medical Savings Account (MSA) Worldwide coverage, 24 hours-a-day Take a look at some of the Your choice of doctors and hospitals from extensive networks Initial 12-month rate guarantee There s a Preferred 2000 plan to meet your needs and budget. Value Plan for Economy Optional first-dollar benefits Strong network incentives Traditional (Indemnity) Plan for Choice The freedom to choose your own providers A great choice for those who live outside a PPO network area Physician/Hospital PPO Plan for Control The most choice, with all plan options available Reduced non-network out-of-pocket costs One Deductible Plan for Simplicity All covered expenses for all covered persons apply to one deductible Premium savings for the Physician/Hospital PPO and Traditional Plans Medical Savings Account (MSA) Plan for Tax Advantages* If you are eligible, add an MSA custodial account to the One Deductible Plan and save for medical expenses tax-free* *Fortis Health and its subsidiaries are not engaged in rendering tax, investment, or legal advice. Federal and state tax regulations are subject to change. If tax, investment, or legal advice is required, seek the services of a licensed professional. 2

8 The Preferred 2000 Family of Plans Feature Lifetime Maximum Benefit Doctor Office Copay (DOC) $2 million or $6 million Value Plan $25 copay per office visit for up to two non-wellness visits per person per year, including first $100 lab and x-ray paid at 100% 1 Optional Wellness Benefit Prescription Drugs The family prescription drug deductible is two times the individual prescription drug deductible. Hospital Services Available after you have been insured by the plan for one year Subject to deductible and coinsurance $500 calendar year maximum 2 $500 deductible For generic: $10 copay For brand when generic not available: You pay the $25 copay + 50% of the remaining costs For brand when generic available: You pay the difference between the cost of brand versus generic + $25 copay + 50% of the remaining costs $500 inpatient facility access fee $250 outpatient surgical facility access fee Then subject to deductible and coinsurance Plan Deductible This is the amount you pay each calendar year before benefits are paid. Individual: $500, $1,000 or $2,000 Family: three times the individual plan deductible 3 Non-network Deductible Network Coinsurance This is the percentage of covered medical expenses we pay after the deductible is met. Non-network Coinsurance If you go out of network, this is the percentage of covered medical expenses we pay after the deductibles are met. Network Out-of-Pocket Coinsurance Maximum This is the maximum amount you pay in coinsurance each calendar year before we pay 100%. Individual: $1,000 + plan deductible Family: three times the individual non-network deductible 3 50% 30% Individual: $1,250 Family: $2,500 Non-network Out-of-Pocket Coinsurance Maximum If you go out of network, this is the maximum amount you pay in coinsurance each calendar year before we pay 100%. Individual: $10,000 Family: $20,000 1 Additional lab and x-ray charges and office visits beyond the two-visit limit are covered subject to deductible and coinsurance. 2 The $500 maximum does not apply to routine Pap smears, mammograms and PSA tests. Neither the $500 maximum, nor the deductible and coinsurance apply to child health supervision visits. 3 Family deductibles can be met collectively by three or more family members. Copays and access fees do not apply toward your deductible or out-of-pocket maximums. 3

9 The One Deductible Plan available with or without an MSA. Learn more on page 6. Feature Physician/Hospital PPO Traditional Lifetime Maximum Benefit $6 million $6 million Doctor Office Copay (DOC) $25 copay per office visit for up to two visits per person per year, including first $100 lab and x-ray paid at 100% 1 Optional Not available Wellness Benefit Prescription Drugs The family prescription drug deductible is two times the individual prescription drug deductible. DOC Option benefits apply if selected, otherwise deductible + coinsurance $500 calendar year maximum 2 $250 or $500 deductible For generic: $10 copay For brand when generic not available: You pay the $25 copay + 20% of the remaining costs For brand when generic available: You pay the difference between the cost of brand versus generic + $25 copay + 20% of the remaining costs Subject to deductible and coinsurance $500 calendar year maximum 2 $250 or $500 deductible For generic: $10 copay For brand when generic not available: You pay the $25 copay + 20% of the remaining costs For brand when generic available: You pay the difference between the cost of brand versus generic + $25 copay + 20% of the remaining costs Hospital Services Subject to deductible and coinsurance Subject to deductible and coinsurance Plan Deductible This is the amount you pay each calendar year before benefits are paid. Non-network Deductible Network Coinsurance This is the percentage of covered medical expenses we pay after the deductible is met. Non-network Coinsurance If you go out of network, this is the percentage of covered medical expenses we pay after the deductibles are met. Network Out-of-Pocket Coinsurance Maximum This is the maximum amount you pay in coinsurance each calendar year before we pay 100%. Non-network Out-of-Pocket Coinsurance Maximum If you go out of network, this is the maximum amount you pay in coinsurance each calendar year before we pay 100%. We pay 20% less coinsurance when you go out of network. Individual: $500, $1,000, $1,500, $2,500 or $5,000 Family: two times the individual plan deductible 4 Individual: $1,000 + plan deductible Family: two times the individual non-network deductible 4 100%, 80% or 50% (100% available with no DOC option, a prescription drug deductible of $500 and a plan deductible of $1,500 or greater) Network coinsurance less 20% Individual: 100% plan = $0 80% plan = $1,000 or $2,000 50% plan = $1,250 or $2,500 Family: two times the individual out-of-pocket Individual: 100% plan - 20% = $5,000 80% plan - 20% = $2,000 or $4,000 50% plan - 20% = $1,750 or $3,500 Family: two times the individual out-of-pocket Individual: $1,000, $1,500, $2,500, $5,000 or $10,000 Family: two times the individual plan deductible 4 Not applicable 100%, 80% or 50% (100% available with deductibles of $2,500 and greater) Not applicable Individual: 100% plan = $0 80% plan = $1,000 or $2,000 50% plan = $1,250 or $2,500 Family: two times the individual out-of-pocket Not applicable 4 Family deductibles can be met collectively by two or more family members. Copays and access fees do not apply toward your deductible or out-of-pocket maximums. 4

10 What All Preferred 2000 Health Plans Cover Service Inclusions Office Services History, exam, medical diagnosis and office surgery Wellness Exams, immunizations, lab tests, Pap smears, mammograms and PSAs (benefit varies by plan) Lab and X-ray Screening for covered illness or injury Emergency Room $75 access fee (waived if you are admitted to the hospital), then deductible and coinsurance Covered emergency services are always paid at network coinsurance levels Ground/Air Ambulance Emergency transportation to the nearest hospital equipped to provide appropriate care Physician Diagnosis and treatment for covered illness or injury, including surgery and anesthesia Hospital The hospital semiprivate room rate and covered ancillary charges Intensive Care Unit services have no special limit Organ Transplants Up to the lifetime maximum benefit at a designated provider or a $100,000 lifetime maximum per transplant at a non-designated provider Kidney, cornea and skin transplants are covered the same as any other illness Complications Complications of pregnancy as defined in the contract are covered as of Pregnancy any other illness Rehabilitation Inpatient: paid at 100% with a 180-day calendar year maximum Outpatient: occupational, physical and speech therapies, and cardiac rehabilitation with a $3,000 calendar year maximum Supplies and Equipment Whole blood, prosthetic devices, crutches, basic hospital bed, nonmotorized wheelchair, braces, oxygen, apnea monitor, but not repair or replacement of equipment Outpatient Treatment Covered the same as any other illness with a $750 calendar year maximum of Back/Spine/Neck (nonsurgical) Home Health Care Paid at 100% with a 160-hour calendar year maximum Hospice Care Inpatient or home care paid at 100% with no limit Skilled Nursing Facility Paid at 100% with a 30-day calendar year maximum Dental Injury Treatment for injury to sound teeth if the treatment begins within 90 days of the injury and is completed within 180 days of the injury TMJ/CMJ Covered the same as any other illness Sterilization $500 benefit after you have been insured by the plan for one year Prenatal Care Services Risk assessment, serial surveillance, prenatal education and use of specialized skills and technology when medically necessary based on standards set by the American College of Obstetricians and Gynecologists Deductible and coinsurance do not apply Dependents are covered through age 18, or through age 24 if a full-time student. Listed benefits are per covered person and are subject to 1) a determination of medical necessity 2) reasonable and customary or negotiated rates and 3) deductible and coinsurance, unless otherwise noted. Any medical procedure may be subject to clinical audit for determination of medical necessity. For catastrophic or chronic illnesses or injuries, we provide you with the option of working with our RN Case Manager who will assist you in obtaining appropriate, cost-effective care. 5