2017 Limited Benefit Indemnity Plan Proposal (Non HSA Qualified Plans)

Transcription

1 Connected Benefits Presented by: Bob Gaydos Date Prepared: 08/01/ Limited Benefit Indemnity Plan Proposal (Non HSA Qualified Plans)

2 Table of Contents About Us Why PanaMed Summary of Plan Benefits All products and services listed below are included with your PanaMed Plan Medical Accident Expense Discount Prescription Drug Discount Dental & Discount Vision... 9 Member Advocacy & Member Services Exclusions & Limitations Frequently Asked Questions Monthly Rates

3 About Us At Pan-American Life we provide quality benefits that offer solutions in response to the pressures of rising insurance costs in a competitive marketplace. Our products are recognized nationally for the quality of benefits, competitive pricing and the ability to customize offerings for a wide variety of industries. We strive to provide group benefit programs that are uncomplicated which means products and services that are easy to use and understand. Our benefit programs are designed to offer the coverage you need, when you need it. Since 1911, Pan-American Life has delivered reliable, flexible and quality products based on our deep knowledge and understanding of both the U.S. and Latin American markets in which we do business. Today, Pan-American Life serves and protects thousands of customers throughout the Americas. Pan-American Life Insurance Company is currently licensed in 47 states, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands. The Group has branches and affiliates in Costa Rica, Colombia, Ecuador, El Salvador, Guatemala, Honduras, Mexico, Panama, and 15 Caribbean markets, including Barbados, the Cayman Islands, Curacao and Trinidad and Tobago. A.M. Best and the Fitch Ratings Insurance Group two of the most important rating companies available in the industry- have rated Pan-American Life Insurance Company s financial strength as: A.M. Best A (Excellent) with Stable Outlook as of September 2016 Fitch Ratings A (Strong) with Stable Outlook as of October 2016 Please see the websites of the applicable rating agencies for more information on rating categories. 3

4 Why PanaMed is a customizable limited benefit indemnity plan designed to help cover the cost of employees everyday medical needs at affordable rates. PanaMed is a limited benefit indemnity plan that pays a fixed benefit amount to help cover the cost of common medical services, such as doctor visits, diagnostic tests and x-rays, hospitalization, accidents, emergency room, surgery, anesthesia, intensive care, wellness services and more. To complement the PanaMed plans we also offer Group Term Life insurance and other ancillary benefits. At Pan-American Life we provide plans that are not subject to many of the new health care reform rules. Our PanaMed fixed indemnity plans provide a healthcare solution with premiums that are reasonable to both employers and employees. Highlights No exclusions for pre-existing conditions Benefits are Guaranteed Issue for eligible participants- no medical questions, no underwriting or evidence of insurability during open enrollment First dollar coverage no deductibles, no co-pays (ancillary benefits such as medical accident, prescription drug, vision, and dental, may include a deductible or co-pay) Predetermined, fixed indemnity payment amounts for covered events based on schedule of benefits Access to a National PPO Network, resulting in discounted expenses to the insured Issued by Pan-American Life Insurance Company, rated A (Excellent) by A.M. Best, and A (Strong) by Fitch Ratings COBRA eligible (not administered by Pan-American Life) Full bilingual (English-Spanish) services Employer Advantage Proven tool for promoting employee retention and recruiting Employee benefits are made simple through payroll deductions Multiple plan choices Advocacy support for members Plans can be placed under Section 125/Cafeteria Plan Enrollment capabilities (phone, web and on-site) 4

5 Limited Benefit Indemnity Plan Pays BENEFIT DESCRIPTION Basic Value Premium Premium Plus HOSPITAL ADMISSION INDEMNITY BENEFIT Pays in addition to hospital indemnity Once per admission, once per diagnosis Benefit will not be payable for the same or related injury or illness. $1,000 first day when admitted as an inpatient into a hospital room $1,000 first day when admitted as an inpatient into a hospital room $1,000 first day when admitted as an inpatient into a hospital room $1,000 first day when admitted as an inpatient into a hospital room HOSPITAL INDEMNITY BENEFIT Must be admitted as an inpatient into a hospital room If hospital confinement falls into a category below a different maximum applies Overall calendar subject to 10 days total for any inpatient stay in a hospital Overall calendar subject to 10 days total for any inpatient stay in a hospital Overall calendar subject to 10 days total for any inpatient stay in a hospital Overall calendar subject to 10 days total for any inpatient stay in a hospital Intensive Care If the participant is confined in a hospital intensive care unit $200 per day $200 per day $200 per day $200 per day Substance Abuse Must be diagnosed and admitted as an inpatient in a substance abuse unit Mental Illness Must be diagnosed and admitted as an inpatient into a mental illness unit Up to 10 days calendar Up to 10 days calendar Up to 10 days calendar Up to 10 days calendar Skilled Nursing Facility Must be admitted in skilled nursing facility following a covered hospital stay of at least 3 days Up to 7 days calendar Up to 7 days calendar Up to 7 days calendar Up to 7 days calendar DOCTOR S OFFICE BENEFIT Benefit pays one benefit per day if the patient is seen by a doctor for an illness or injury 4 days per calendar year $60 per day 5 days per calendar year $60 per day 5 days per calendar year $75 per day 6 days per calendar year OUTPATIENT DIAGNOSTIC LABS Includes glucose test, urinalysis, CBC, and others When hospital confinement is not required and the test is ordered or performed by a doctor N/A $35 per day 3 days per calendar year $35 per day 3 days per calendar year $35 per day 3 days per calendar year OUTPATIENT DIAGNOSTIC RADIOLOGY Includes chest, broken bones, and others When hospital confinement is not required and the test is ordered or performed by a doctor N/A OUTPATIENT ADVANCED STUDIES Includes CT Scan, MRI, and others When hospital confinement is not required and the test is ordered or performed by a doctor N/A $500 per day $500 per day $500 per day 5

6 Limited Benefit Indemnity Plan Pays BENEFIT DESCRIPTION Basic Value Premium Premium Plus INPATIENT SURGICAL BENEFIT Surgery must be performed due to an illness or injury as an inpatient stay in a hospital Minor surgical procedures are excluded N/A N/A N/A $1,000 per day 1 day per calendar year OUTPATIENT SURGICAL BENEFIT Surgery must be performed due to an illness or injury at an outpatient surgical facility center or hospital outpatient surgical facility Minor surgical procedures are excluded N/A N/A N/A $500 per day 1 day per calendar year EMERGENCY ROOM SICKNESS BENEFIT Pays one benefit per day for services received in an ER as a result of an illness N/A $150 per day $150 per day $150 per day AMBULANCE SERVICES Pays one benefit per day for emergency ground, air and water ambulance transportation N/A N/A $150 per day $150 per day SPECIFIED ILLNESS PLUS Lump Sum benefit for specified major health events (first diagnosis of invasive cancer, heart attack, stroke, or major organ transplant). Waiting Period: 30 day waiting period for heart attack and stroke 90 day waiting period for invasive cancer and major organ transplants $5,000 lump sum 1 lump sum per transplant event Spouse 50% of lump sum Children 25% of lump sum $7,500 lump sum 1 lump sum per transplant event Spouse 50% of lump sum Children 25% of lump sum $10,000 lump sum 1 lump sum per transplant event Spouse 50% of lump sum Children 25% of lump sum $10,000 lump sum 1 lump sum per transplant event Spouse 50% of lump sum Children 25% of lump sum THIS POLICY DOES NOT CONSTITUTE COMPREHENSIVE HEALTH INSURANCE COVERAGE (MAJOR MEDICAL COVERAGE) AND DOES NOT SATISFY THE REQUIREMENT OF MINIMUM ESSENTIAL COVERAGE UNDER THE AFFORDABLE CARE ACT. 6

7 Group Medical Accident With Accidental Death & Dismemberment Many working Americans are not prepared to pay for expenses that may occur due to accidents. The unexpected cost of hospitalization and emergency-room care can cost more than an average family can earn in an entire month. Medical Accident insurance provides protection to families not only for accidental injury but also for the occurrence of an accidental death. Medical Accident Expense with AD&D Basic Value Premium & Premium Plus Accident Benefit* per occurrence Deductible per accident, per insured Up to $5,000 Up to $7,500 Up to $10,000 $100 deductible $100 deductible $100 deductible Accidental Death $10,000 $15,000 $20,000 Accidental Dismemberment Up to $10,000 Up to $15,000 Up to $20,000 Initial Treatment Period weeks (Initial treatment must be incurred within 12 weeks of the date of the accident) Benefit Period weeks (Expenses must be incurred within 52 weeks of the date of the accident) *Pays Off the Job Accident Medical Benefits for Covered Expenses that result directly, and from no other cause, than from a covered accident. The insured's loss must occur within one year of the date of the accident. Medical Accident insurance is issued by Pan-American Life Insurance Company on policy form number SM Medical Accident is NOT available to residents in ME, MD, and WA. Covered Charges Hospital room and board, and general nursing care, up to the semi-private room rate Hospital miscellaneous expense during Hospital Confinement such as the cost of the operating room, laboratory tests, x-ray examinations, anesthesia, drugs (excluding take-home drugs) or medicines, therapeutic services and supplies Doctor s fees for surgery and anesthesia services Doctor s visits, inpatient and outpatient Hospital Emergency care X-ray and laboratory services Prescription Drug expense Dental treatment for Injury to Sound Natural Teeth Registered nurse expense 7

8 Discount Prescription Drug Benefit Save on Discount Prescriptions Eligible medications will be available to all members at R x EDO s pharmacy s contracted rate, which can typically save members anywhere from 10% - 79% off of the pharmacy s usual and customary fee. Standard drug inclusions and exclusions apply. Diabetic Supplies: 10% to 60% Saving on Diabetic Supplies. A convenient service for members with diabetes. This program provides special member pricing on most diabetic supplies. These items include: test strips, glucose meters, lancing devices, lancets, and MORE! The R x EDO pharmacy network includes over 66,000 total participating retail pharmacy locations nationwide; all major chains are included as well as 20,000+ independent pharmacies. R x EDO provides mail order services through Walgreens Mail Service. Information and assistance can be found by visiting Walgreens Mail Service at Helpful Hints Please communicate to your pharmacist that your plan has changed to a new prescription drug processor. Show them your identification card. It includes the BIN and PCN numbers, as well as any other information they will need to process your claim through R x EDO. If your pharmacy has any questions concerning the process, please have them call the R x EDO Pharmacy Help Desk at (800) , which is printed on your new identification card. (Included with All Plans) For questions or drug look-up go to or call Sample Prescription Drugs Generic Formulary Brand ANTIBIOTIC Rimatadine Augmentin BLOOD PRESSURE Lisinopril Mavik CHOLESTEROL LOWERING Lovastatin Lipitor Pharmacy Network Some of the Pharmacy participating pharmacies Network include: Costco CVS Pharmacy K-Mart Target Walgreens Walmart And many more. Discount prescription benefits are not insurance products and are administered by RxEDO, Inc. Pan-American Life is not affiliated with RxEDO. 8

9 Discount Dental Aetna Dental Access network provides members with discounts of 15% to 50%* per visit on dental services at over 195,000** available dental practice locations nationwide in most instances. Members simply present their card bearing the Aetna Dental Access logo, along with payment in full of the discounted fee, for immediate savings at the time services are rendered. Members will want to utilize their card and enjoy the savings time and time again. Highlights In most instances, members may save 15% to 50%* per visit on services from general dentistry and cleanings to root canals, crowns and orthodontia. Over 195,000** dental practice locations. Save on routine dental services such as X-rays and fillings. Save on specialty care such as orthodontics and periodontics where available. *Actual costs and savings vary by provider, service and geographical area. ** As of May, (Included with All Plans) Dental Provider Network services are not insurance. Pan-American Life and Aetna Dental Access are not affiliated. Not available in KS, UT, VT, FL, and WA. For a full list of disclosures, visit The discount program provides access to the Aetna Dental Access network. This network is administered by Aetna Life Insurance Company (ALIC). Neither ALIC nor any of its affiliates offers or administers the discount program. Neither ALIC nor any of its affiliates is an affiliate, agent, representative or employee of the discount program. Dental providers are independent contractors and not employees or agents of ALIC or its affiliates. ALIC does not provide dental care or treatment and is not responsible for outcomes. Discount Vision (Included with All Plans) Coast to Coast Vision network is the most comprehensive in the United States and includes ophthalmologists, optometrists, independent optical centers and national chain locations such as Pearle Vision, JCPenney Optical, Sears Optical, Target Optical, LensCrafters, and QualSight LASIK. Members save 10% to 60% off provider retail prices on eyeglasses, contacts, eye exams and surgical procedures from more than 20,000 locations nationwide. Discount Vision Plan Savings Benefits Eye Exams Prescriptions Eyeglasses Frames Lenses (single, bifocal, trifocal, and non-standard) Specialty Coatings and Tints Contact Lenses Mail Order Service LASIK (refractive surgery) In-Network 10% to 30% off provider retail fees 20% to 60% off provider retail fees 10% to 40% off provider retail fees 40% to 50% off the overall national average Vision Provider services are not insurance and are provided by New Benefits, Ltd. Pan-American Life and New Benefits, Ltd. are not affiliated. Not available in KS, UT, VT, FL, and WA. For a full list of disclosures, visit 9

10 Member Advocacy What is a member advocate? A member advocate is an in-house representative that works exclusively on behalf of our members to reduce medical costs and stressful billing situations. They are able to help members find community programs, hospitals, pharmaceutical companies, and provider offices who have affordable treatment costs. Also, they serve as a single point-of-contact to help resolve on-going or challenging billing issues. They re even available to speak with members individually, as well as their physicians and medical facilities, so everyone has a full understanding of how the benefits work and can make the most informed choices with regard to planning medical treatment. Advocates can assist with: Medical bills & Prescription costs Lab work & X-rays CAT Scans / MRIs Scheduling surgical procedures Durable medical equipment Diabetic supplies Complicated claims and billing issues They help lower costs by: Negotiating balances Finding providers that offer sliding-scale treatment pricing Arranging payment plans for previously incurred bills Requesting discounted lump-sum payments to settle balances Locating community programs for specialized services or frequently recurring expenses due to chronic conditions Contacting discount pharmacies Member Services Our member service representatives are responsible for ensuring that customers receive the best assistance with their questions and concerns. Pan-American Life s customer service representatives interact with customers to provide information in response to inquiries about products and services. They communicate with administrators and members through a variety of means; by telephone, by , fax or mail. We can assist members, companies and providers with: Member Advocacy ID Cards Policy Information Member Eligibility Verification of Benefits Prescription Benefits Annual Adult Wellness Test PPO Network Information Account Management Claims And more! Monday through Friday, 7:30 AM 5:00 PM, Central Time Full bilingual (English-Spanish) services 10

11 GENERAL EXCLUSIONS AND LIMITATIONS FOR PANAMED This is a general list of exclusions and limitations and may vary by state. Benefits are not payable with respect to any charge, service or event excluded as set forth below. 1. Charges for medical or dental services of any kind, or any medical supplies or visual aids or hearing aids, or any food, supplement or vitamin, or medicine, it being understood that the Policy shall pay the Indemnity Benefits set forth in the Summary of Benefits for a hospitalization or other covered event, without regard to the actual charges made by a provider or supplier of goods or services. 2. Any claim relating to a hospitalization or other covered event where the hospitalization or other covered event was prior to the effective date of coverage under the Policy, or after coverage is terminated. 3. A claim arising out of insurrection, rebellion, participation in a riot, commission of or attempting to commit an assault, battery, felony, or act of aggression. 4. A claim arising out of declared or undeclared war or acts thereof. For life insurance: As a result of the special hazards incident to service in the military, naval or air forces of any country, combination of countries or international organization, if the cause of death occurs while the insured is serving in such forces, provided such death occurs within six (6) months after the termination of service in such forces. 5. A claim arising out of Accidental Bodily Injury occurring while serving on full time active duty in any Armed Forces of any country or international authority (any premium paid will be returned by Us pro rata for any period of active full time duty). 6. A claim related to an Injury or Illness arising out of or in the course of work for wage or profit or which is covered by any Worker's Compensation Act, Occupational Disease Law or similar law. 7. With respect to a death benefit, a claim related to bodily injuries received while the Covered Person was operating a motor vehicle under the influence of alcohol as evidenced by a blood alcohol level in excess of the state legal intoxication limit. 8. A claim arising from services in the nature of educational or vocational testing or training. 9. A claim related to Custodial Care. 10. A claim arising from medical services provided to the Covered Person for cosmetic purposes or to improve the selfperception of a person as to his or her appearance, except for: reconstructive plastic surgery following an Accident in order to restore a normal bodily function, or a surgery to improve functional impairment by anatomic alteration made necessary as a result of a birth defect, or breast reconstruction following a mastectomy. 11. Other than a claim for death benefits, any claim arising out of a surgical procedure for the treatment of obesity or the purpose of facilitating weight reduction. 12. Other than a claim for death benefits, any claim arising out of treatment of infertility. ACCIDENTAL DEATH AND DISMEMBERMENT EXCLUSIONS AND LIMITATIONS In addition to the General Exclusions and Limitation of the Policy, benefits are not provided for Loss, Injury or Illness of a Covered Employee which results directly or indirectly, wholly or partly form: A. Suicide, self-destruction, attempted self-destruction or intentional self-inflicted injury while sane or insane. B. Disease or disorder of the body or mind. C. Medical or surgical treatment or diagnosis thereof. D. Loss, Injury or Illness occurring after Termination of Coverage. E. Ptomaines or bacterial infections, except pyogenic infections at the same time and as a result of a visible wound. F. Asphyxiation from voluntarily or involuntarily inhaling gas and not the result of the Covered Person's job. G. Travel or flight in any vehicle for aerial navigation, including boarding or alighting therefrom: 1. While being used for any test or experimental purpose; or 2. While the Covered Person is operating, learning to operate or serving as a member of the crew thereof; or 3. Any such aircraft or device which is owned or leased by or on behalf of the Policyholder of any subsidiary or affiliate of the Policyholder, or by the Covered Person or any member of his household; or H. Voluntarily taking any drug or narcotic unless the drug or narcotic is prescribed by a Doctor. I. Heart attack, stroke or other circulatory disease or disorder, whether or not known or diagnosed, unless the immediate cause of Loss is external trauma. 11

12 Frequently Asked Questions 1. Is PanaMed Major Medical coverage? No. PanaMed is a limited benefit indemnity plan. This is not basic health insurance or major medical coverage and is not designed as a substitute for either coverage. PanaMed pays a fixed benefit amount to help cover the cost of common medical services. The plan is not designed to cover the costs of serious or chronic illnesses. It contains specific dollar limits that will be paid for medical services which may not be exceeded. Specific dollar limits are listed in the summary of benefits. 2. Does PanaMed have any exclusions or limitations? Benefits are subject to certain exclusions, limitations, and terms for keeping the benefits in force. For example the following services are not covered by this plan: infertility treatments, cosmetic surgery, counseling for mental illness or substance abuse, obesity, weight reduction or dietetic control, physical therapy, spinal manipulation, acupuncture. This is a partial list of services that are generally not covered. Members should refer to their certificate to determine which services are covered and to what extent. Additional information can be found in our web portal at 3. Will the PanaMed plan provide an indemnity benefit for any Physician or Hospital? Yes. The member is free to seek the services of any licensed Physician or accredited Hospital. There is no requirement that the Physician or Hospital belong to a PPO network to receive benefits. 4. Is there a pre-existing condition exclusion on the plan? No, because this is a limited benefit indemnity plan there are no pre-existing condition exclusions. 5. Can dependents be insured by PanaMed? Yes. If the member is covered by PanaMed, dependents can also be eligible for coverage. 6. Are Medicare and Medicaid recipients eligible for PanaMed? Yes. However, under Medicare and Medicaid policies, PanaMed is considered primary coverage. As a result, with PanaMed, Medicare and/or Medicaid coverage may be reduced or discontinued. 7. Can the PanaMed plan be used if the insured has separate health insurance? Yes. The specified benefits pay irrespective of any other private group coverage. 8. Is the member allowed to assign benefits to his or her healthcare provider? Yes. Benefits are automatically assigned to the member s healthcare provider. If the member would like to receive the benefit payment directly, complete the medical claim form and sign the authorization of payment section. 9. Can an employer satisfy the employer mandate under PPACA by offering this coverage? No, the coverage is not minimum essential coverage for the purposes of Internal Revenue Code 4980H. 10. Is PanaMed COBRA eligible? Yes. PanaMed is COBRA eligible for employer groups with 20 or more employees. Through Pan-American Life s partnership with Ceridian, COBRA administration is simplified for the employer and offered at competitive rates. 12

13 Monthly Rates MONTHLY RATES* Basic Value Premium Premium Plus Associate $50.62 $81.93 $ $ Associate + Spouse $85.29 $ $ $ Associate + Child(ren) $71.11 $ $ $ Family $ $ $ $ *Rates include insurance and non-insurance products. Rates assume that the employer is contributing 50% or more of the cost. 25% minimum participation of eligible employees is required. Certain benefits are not available in all states. Rates are guaranteed for 30 days from date of proposal is issued. If proposal is accepted after 30 days it must be re-rated or confirmed. Special enrollment rules apply in the states of Connecticut, Minnesota, New Hampshire, New York, Utah, Vermont and Washington. Please ask for details. Coverage is not available for employees residing in Hawaii, and Maine. Coverage for residents of Massachusetts will include certain mandated benefits. Please note, this health plan, alone, does not meet Massachusetts Minimum Creditable Coverage standards and will not satisfy the Massachusetts individual mandate that you have health insurance. Proposal is based on information provided and subject to underwriting and Home Office approval. This Group is domiciled in the state of TEXAS. 13 PanaMed is issued by Pan-American Life Insurance Company on policy form number PAN-POL-13, PAN-POL-13-FL, PAN-POL-13-LA, PAN-POL-13-NC, PAN-POL-13-T, PAN-POL-13-TX, or PAN-POL-13-WA. There are no exclusions for pre-existing conditions. The plan will not pay benefits for any care provided prior to the coverage effective date or if the insured is confined in a hospital at the time the coverage is effective. Hospital does not include a nursing home, convalescent home or extended care facility. Coverage is not available in all states. Like most group benefit programs, our products have exclusions, limitations, waiting periods and terms for keeping them in force. Rates subject to change. DMC126exp01/2014.