Group Limited Benefit Indemnity Plan

Transcription

1 Group Limited Benefit Indemnity Plan For broker use only palig.com/benefits

2 With today s escalating healthcare costs and continued economic pressures, employers are facing tough decisions about their healthcare benefits. Thanks to affordable and flexible coverage options, our limited benefit indemnity plan, PanaMed, is a smart solution for employers and employees struggling to adjust to the increasing costs of traditional major medical plans. Why PanaMed? PanaMed is a customizable plan that is well suited for a number of industries such as hospitality, transportation, construction, landscaping, cleaning services, restaurants, and more who are striving to cope with the high cost of health care. PanaMed is a limited benefit indemnity plan that offers affordable health coverage. It pays a fixed-benefit amount to help cover the cost of common services. Employees may have access to a national Preferred Provider Network, Prescription Drug Plans, Dental, Discount Vision, Telehealth Services, Member Advocates, Wellness Testing, and much more. 2

3 usdifferent What makes Offering a diverse range of rich benefits is only part of what makes PanaMed the smart, easy choice for employers. Our customer service standards are among the highest in the industry. While group administrators have their own Account Executive for all of their needs, our members have personalized attention through our Member Advocates. Our in-house team of Advocates help members make the most of their benefits. For anything else, our Advocates assist members with locating low and no-cost drug programs, negotiating treatment costs, contacting assistance programs, finding affordable medical and diabetic supplies, and anything else to help members simply focus on staying healthy. Customer Service Score Card2016 PERFORMANCE Average Speed to Answer Calls Call Quality Abandon Rate Claims processed <15 days Industry Standard* 30 Seconds 97% <3% 95% Pan-American** 28 Seconds 98% 0.67% 97% * Based on research conducted in 2010 using statistics published by the American Medical Association, data collected by our business partners, and RFPs. **Internal Statistics based on automated reports, quality control processes and internal audits. Plan Highlights First dollar coverage Access to a National PPO Network Guaranteed Issue No pre-existing conditions* Minimal administration required Voluntary or employer paid Advocacy services for members Full bilingual service (English/Spanish) * Except pregnancy in most states. 3

4 Customized Sample Plans BENEFIT DESCRIPTION PLAN 1 PLAN 2 PLAN 3 Hospital Admission Indemnity Benefit Hospital Indemnity Benefit Doctor s Office Benefit Outpatient Diagnostic Labs Outpatient Diagnostic Radiology Outpatient Advanced Studies Inpatient Surgical Benefit Inpatient Anesthesia Benefit Outpatient Surgical Benefit Outpatient Anesthesia Benefit Wellness Benefit Emergency Room Sickness Benefit $300 per admission $300 per day/ 60 days CYM $25 per day/ 3 days CYM $70 $300 $125 $62.50 $50 per day/ 3 days CYM per admission per day/ 60 days CYM $35 $70 $300 $1,000 $125 $600 per admission $600 per day/ 60 days CYM per day/ 6 days CYM $35 $70 $300 $1,000 $125 Ambulance Services Outpatient Surgical Facility Specified Illness Plus Group Term Life with AD&D N/A N/A N/A $5,000 Member Life and AD&D N/A $125 N/A $10,000 Member Life and AD&D $150 $150 $5,000 Lump Sum $10,000 Member Life and AD&D Medical Accident with AD&D Up to $2,500 per occurrence Up to $2,500 per occurrence Up to $5,000 per occurrence PPO Provider Network Prescription Drug Benefit 4 Tier Discount Card 4 Tier Discount Card Fully Insured Telehealth Services Global Repatriation Member Advocacy Monthly Premiums Employee Rates Based On Employer Paid Plans (50% or greater contributions) For Voluntary plan rates, see your sales executive. $71.67 $ $ Employee + Spouse $ $ $ Employee + Child(ren) $ $ $ Family $ $ $ 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.

5 Customized Sample Plans BENEFIT DESCRIPTION PLAN 4 PLAN 5 Hospital Admission Indemnity Benefit Hospital Indemnity Benefit Doctor s Office Benefit Outpatient Diagnostic Labs Outpatient Diagnostic Radiology Outpatient Advanced Studies Inpatient Surgical Benefit Inpatient Anesthesia Benefit Outpatient Surgical Benefit Outpatient Anesthesia Benefit Wellness Benefit Emergency Room Sickness Benefit Ambulance Services Outpatient Surgical Facility Specified Illness Plus Group Term Life with AD&D Medical Accident with AD&D PPO Provider Network Prescription Drug Benefit Telehealth Services Global Repatriation Member Advocacy $800 per admission $800 per day/ 60 days CYM per day/ 6 days CYM $60 $100 $400 $1,500 $375 0 $ per day/ 3 days CYM per day/ 1 days CYM $200 $10,000 Lump Sum $15,000 Member Life and AD&D Up to $5,000 per occurrence Fully Insured $1,000 per admission $1,000 per day/ 60 days CYM $100 per day/ 6 days CYM $85 $150 $2,000 $1,000 $100 per day/ 3 days CYM $15,000 Lump Sum $15,000 Member Life and AD&D Up to $5,000 per occurrence Fully Insured Monthly Premiums Rates Based On Employer Paid Plans (50% or greater contributions) For Voluntary plan rates, see your sales executive. Employee Employee + Spouse Employee + Child(ren) Family $ $ $ $ $ $ $ $ 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. 5

6 Additional Benefits and Services Discount Prescription Card* ( in Sample Plans 1 & 2) This plan is designed to save members money on their prescription drug costs and is recognized at all major pharmacies. Up to 80% savings on pharmacy s usual and customary fee. Up to 10% to 60% savings on diabetic supplies. Fully Insured Prescription Card** ( in Sample Plans 3, 4, & 5) Generic: $15 co-pay for a 30 day supply Formulary Brand Name: $50 co-pay or 50% (whichever is greater) for a 30 day supply Monthly maximum per insured person No Deductible Over 2, 200 preferred brand drugs included on formulary listing Member Services Members can communicate with our on-site member service representatives toll-free via telephone or for timely answers to benefit and claims questions. Full bilingual (English/Spanish) service. Member Advocacy We make healthcare work for our members. No more hassles. No more frustrations. Members in need have easy access to the Pan-American Life team of Advocacy Service Representatives. Telehealth Services* Telehealth provides members with the ability to connect with doctors for 24/7 medical consultations, with no additional cost. Members can call or U.S.- based, licensed physicians and boardcertified specialists to obtain quick and convenient medical information, advice, diagnosis, and prescriptions for common conditions when appropriate. PPO Provider Network* Members can benefit from discounted provider prices through our partnership with several leading Preferred Provider Organizations (PPO). Our Preferred Provider Organizations consist of more than 695,000 physicians, 4,600 hospitals and more than 95,000 ancillary care facilities throughout the United States. 6 *Not an insurance product. Not a Pan-American Life Product. **Not a Pan-American Life product. Discount and Fully Insured Prescription Plans provided by RxEDO, Inc. Nationwide Pharmacy Network and Mail Order Services: The Rx retail pharmacy network consists of over 62,000 national, regional, and local chains and independent pharmacies. The prescription drug plan also offers fully integrated mail order services that provide members the convenience of home delivery. The network currently manages over 2 million members located in all 50 states. Dental & Discount Vision* Employers have the choice of offering additional coverage to their employees. They may include a quality dental plan, along with a discount vision plan, within their benefit offer. Global Repatriation* Worldwide benefit designed to help the family when a member or a covered dependent suffers loss of life due to a covered accident or illness while traveling 100 miles or more away from his or her permanent residence; includes repatriation of foreign nationals to their home countries.

7 Enrollment Capabilities At Pan American Life, we believe that education must be at the core of all enrollment communication strategies. We strive to position eligible employees to make an informed decision regarding the purchase of their benefit options. Disclosure of both what a plan provides and does not provide is critical to positioning an individual to make that informed decision. Supporting our goal to present information to potential participants in a way that s easy to recognize and understand, we provide an enrollment video that helps employees understand the benefits and how the plan works. To preview the video, visit mypalic.com/videopm. We also offer options to customize enrollment communications to tailor the communication process to specific employer groups. To address the unique needs of each of our clients, Pan-American Life provides an integrated mix of enrollment solutions which include: Online Enrollment Employees can enroll in the plan 24/7 through an easy to use and secure online enrollment system that allows employees to view their benefits, select their coverage, and much more. Telephonic Enrollment Center Employees can talk with trained enrollment staff on the phone by simply calling our toll free number to enroll or to ask questions about coverage options. Benefit Counselors can also make outbound calls to eligible employees if selected by group. Group Meetings Benefit Counselors can setup employee group meetings in accordance with schedules coordinated with the employer or HR director. Benefit Counselors will assure that enrollment documents and presentation materials are distributed, and provide a question and answer session to follow. One-on-One Provides an opportunity for personal interaction with our trained enrollment staff for each employee. The one-on-one session allows for counseling and education about the coverage options being offered and helps to insure that employees have the best chance to select options that meet their individual needs. Webinars Similar to the group meetings but with the ability of having multiple locations connected and participating at the same time via web. An overview of all plan options being offered is presented with a question and answer session. Our Enrollment Center is ready to assist with all your enrollment needs! Assistance is also available in Spanish. Print Communications We offer the ability to customize enrollment materials and announcements, such as benefit guides, check stuffers, posters, postcards, text messages, and more. These communications help to create interest and enhance the probability of a successful enrollment process. 7

8 Web Portal Access Managing your account is easy online! Employers are able to: Access plan documents Print invoices Request terminations & changes Review enrollment reports Analyze cost performance Members can easily: Review claims and EOBs See their benefits Print ID cards Download forms And Much More! mypalic.com 8

9 Underwriting Guidelines Participation Requirements: The minimum participation is listed below. A minimum of 51 enrolled employees is required to form a group. All cases that are 100% employer paid (Employee only) will require 85% participation # Of Eligible Employees in the Group Minimum % of Eligible Employees Participating All Size Cases (100% Employer Paid) 85% Up to 499 Eligible Lives 25% 500 or more Eligible Lives 10% For smaller opportunities, contact your Regional Sales VP For rate determination, any case which has a 50% or greater employer contribution will be considered as nonvoluntary. Cases that have less than 50% employer contribution will be considered voluntary. Plan Benefit Requirements: The plan must include the following: - A minimum of $5,000 Employee Life and AD&D - One level of Hospital Indemnity - Groups with between 51 and 250 eligible lives may choose up to 2 benefit plans - Groups with more than 251 eligible lives may choose up to 3 plans Group Eligibility: - A group must have been in business at least one year and be in sound financial standing. - An employee must be actively at work for at least 15 hours per week and not elegible for other medical benefits - For voluntary groups only the employee must be employed a minimum of 30 days at the employer s usual place of business - California, Florida, Idaho, Kansas and Utah require at least 51 elegible lives - Employer Groups which currently offer Major Medical coverage may offer this plan to those not eligible for their major Medical plan or to all employees only if the plan has a high deductible of at least $2,000 or more - The Employer must provide documentation that all employees age 65 or older are 9

10 Underwriting Guidelines Ineligible Industries or Groups: - Groups that do not have an employer-employee relationship - Groups in Bankruptcy or Reorganization - Group of Association Members - Groups in industries susceptible to accidents that may involve multiple deaths or injuries - Groups that fall into one of the listed categories below: Bars, taverns, cocktail lounges, nightclubs, dance clubs, theaters, movie houses, barber shops, beauty parlors, bowling alleys, pool halls, sports teams, bands, orchestras, entertainers, underground mining, family farms, family ranches, explosives, fireworks, fertilizer manufacturing, chemical manufacturing and processing, race tracks, exterminators, forestry, fishing, used car dealers, junk dealers, oil or gas exploration, refining and production, and home-based groups - In addition to the above restrictions, the Short Term Disability benefit is not available to trucking firms, companies in health care, construction industry, agriculture industry, restaurants & groups consisting of 1099 employees. - Groups having 10% or more employees age 65 or older - Lodges and Fraternal Organizations Members The Following Employers Require Prior Home Office Approval: - All groups of 1,000 eligible employees must get prior home office approval prior to releasing quote - All PEO employer groups - Casinos: Please note that certain states (i.e. Nevada) will require completion of Vendor License Applications - Motels - Small restaurants - Corporate service stations or car washes - Corporate Farms and Ranches - Groups consisting of 1099 employees - Franchises & Unions - Group with Massachusetts Residents - Agents who package our program with a PPO or other medical discount program must get prior home office approval before the case is quoted. Agents must provide the PPO plan details along with the discount schedule Maximum benefits will be dictated by those discounts. Professional Employee Organizations and Franchises: All new PEO and franchise employer groups are subject to Underwriting review: - A PEO or franchiser must have been in business for minimum of two years to be eligible for consideration - Only employees working directly for the PEO are eligible for coverage. Employees who work directly for employer groups are not eligible for coverage. Quarterly wage report will be required for verification - Employer groups under the PEO must meet have been in business for a minimum of two years to be eligible - The PEO client company and franchise will be underwritten to ensure their employer makeup does not include any of the excluded industries listed above - A PEO client or franchise must comply with all PanaMed state requirements 10

11 Frequently Asked Questions 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. 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. 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 Will the PanaMed plan provide an indemnity benefit to 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. What is a PPO and the advantage for using? PPO is the abbreviation for Preferred Provider Organization. This organization of providers (referred to as a network ) has agreed to provide their services as a negotiated discount, reducing your out of pocket cost. While PanaMed may be used at any hospital or physician s office, members are encouraged to utilize the PPO network for discounted provider prices. How does a member determine which providers participate in the network? PPO participation may be verified with a simple phone call or online. The toll free number and website link can be found in your enrollment guide, ID card, and in our web portal. The insured is responsible for verifying the current PPO participation of their provider. Is there a pre-existing condition exclusion on the plan? Because this is a limited benefit indemnity plan there are no pre-existing condition exclusions. However there are certain circumstances where pregnancy is not covered if conception occurred prior to the insured s effective date of coverage. This exclusion does not apply to residents of California, Idaho, Montana, and Texas, or to North Carolina groups. Can dependents be insured by PanaMed? Yes. If the member is covered by PanaMed, dependents are also eligible for coverage. 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. 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. 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. 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 4980 H. Is PanaMed COBRA eligible? Yes. PanaMed is COBRA eligible for employer groups with 20 or more employees. 11

12 Since 1911, Pan-American Life has delivered trusted financial security to thousands of individuals, families and businesses throughout the Americas. Our affordable plans allow employers to offer quality medical benefits that can be tailored to the specific needs of the client, providing affordable and flexible plans to suit every financial need. A.M. Best and Fitch Ratings two of the most important rating companies in the industry have rated Pan-American Life Insurance Company s financial strength as: A.M. Best Ratings A (Excellent) with Stable Outlook as of June 2016 Fitch Ratings A (Solid) with Stable Outlook as of November 2015 For more information, please contact: (800) ext. 890 sales@palig.com palig.com/benefits 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 except for pregnancy in most states. 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. DMC166Rev1/2013