PROGRAM GUIDE. For Plan Participants of Data Partnership Group, LP. *Ask About Our Vanishing Deductible Benefit

Transcription

1 PROGRAM GUIDE For Plan Participants of Data Partnership Group, LP *Ask About Our Vanishing Deductible Benefit

2 Table of Contents Access Your Medical Benefits Online 24/7...1 Find a Network Provider...2 Schedule of Benefits & Plan Design Exclusions...4 Cancellation / Refund Policy...6 in the schedule of benefits which include information on copays, deductibles, and limitations. Please review carefully. This is not a Major Medical or Comprehensive Medical Insurance Coverage, and is neither a minimum Essential Health Benefit Plan under Affordable Care Act nor a policy of Worker s Compensation Insurance under state law. This group health plan is sponsored by Data Partnership Group, LP Calabasas Road, Ste 206E Calabasas, CA, USA Not

3 Access Your Medical Benefits Online 24/7 For your complete Plan Document and Summary Plan Description, please access your Member Portal at: Your Member ID, Username and Password has been ed to the address on your account profile. If you have any questions, please contact your dedicated customer service professionals at (M-F 8:00 am to 6:00 pm) for assistance. We have partnered with Hawaii-Mainland Administrators, LLC (HMA) to administer claims payment for your medical and WellDyneRx pharmacy coverage. Your Membership Portal To create an account, go to: To create an account on the member portal: 1. Click Create Account 2. Enter Your Name, Address, Last 4 digits of your SSN, Date of Birth and Member ID 3. Accept Terms of Use Policy Some Features of the Member Portal allow you to view the following: Member Information Benefit Details Provider Search Plan Documents and Forms Claims Prior Authorization Expense Limits 1

4 Find a Network Provider Your plan allows you to enjoy great savings through First Health Network and First Access Wrap Networks, which can significantly reduce your out-of-pocket expenses. First Health is a brand name of First Health Group Corp., an indirect wholly-owned subsidiary of Aetna, Inc. As a reminder, out-of-network services are not covered by your plan. Therefore, it is important to choose an in-network provider. To locate an in-network provider, visit: and follow the easy step-by-step instructions on how to access a participating provider. 2

5 Schedule of Benefits & Plan Design Limited Inpatient Hospital Benefit Plan The CAT 50 Plan covers limited inpatient hospital care in accredited hospitals for each enrolled participant. Coverage includes inpatient surgery, but not outpatient or elective surgeries. This Plan does not cover out-of-network services. This Plan is not subject to the Patient Protection and Affordable Care Act. Plan Year for Benefits is October 1 to October 31. Annual Plan Year Deductible $5,000 Out of Pocket Maximum n/a Annual Plan Year Limit $50,000 Member Coinsurance 0% TPA Networks HMA, LLC First Health Network and First Access Wrap Networks What You Will Pay Medical Service Network Provider (You will pay less) Out of Network Provider (You will pay more) Limitations & Exceptions Inpatient Hospital Benefits including MHSA (Mental Health and Substance Abuse) $5,000 deductible, then 0% coinsurance Not Covered Outpatient or elective surgery not covered. Pre-existing conditions within past twelve months excluded. 3

6 Exclusions Preexisting Conditions Pre-existing conditions The preexisting condition limitation will apply for as long as the policy is in force. For example, if a person was treated for colon cancer in the 12 months prior to purchasing the policy, that would be a preexisting condition. The policy would not pay benefits for any services or treatments related to that person s colon cancer for as long as the person has the policy. Preexisting condition means an illness, injury, or condition: 1. For which medical advice, diagnosis, care, or treatment was recommended to or received by a covered person within 12 months immediately preceding the effective date the covered person became insured under the policy; or 2. That manifested symptoms which would cause an ordinarily prudent person to seek diagnosis or treatment within the 12 months immediately preceding the applicable effective date the covered person became insured under the policy. Other Exclusions and Limitations No benefits are payable for or relating to any of the following: 1. Any care or treatment which is not specifically provided for in the policy 2. An illness or injury occurring before the policy effective date, after termination of the policy, or during any time that coverage is not in force 3. Intentionally self-inflicted bodily harm (whether the covered person is sane or insane). 4. Any act of declared or undeclared war 5. Active service in the armed forces of any country, or related auxiliaries including the National Guard or military reserve 6. The covered person taking part in a riot 7. The covered person s commission or attempt to commit a felony, whether or not charged 8. The covered person being intoxicated, as defined by applicable state law in the state in which the loss occurred, or under the influence of illegal narcotics or controlled substance unless administered or prescribed by a doctor or voluntary taking of any over the counter drug unless taken in accordance with the manufacturers recommended dosage. 4

7 9. Cosmetic treatment 10. Abortions (including complications of abortions). 11. Hospital confinement primarily to receive rehabilitation, custodial care, educational care, or nursing services (unless expressly provided for by the policy) 12. Elective surgery that is not medically necessary 13. Donating an organ 14. Operating a taxi or any other livery (passenger transportation) services for wage, compensation, or profit 15. Any injury sustained while paid to participate or instruct in: horseback riding, racing, speed testing any non-motorized vehicle/conveyance, skiing, rock or mountain climbing 16. Any injury sustained while participating, demonstrating, instructing, guiding, or accompanying others in: sports (semi- or professional or intercollegiate not including intramural sports), parachute jumping, hang gliding, skydiving, bungee jumping, parakiting, racing or speed testing any motorized vehicle/ conveyance, rodeo sports, or scuba/skin diving (60 or more feet in depth). 17. Any injury sustained while performing the duties of any type of noncommercial aircraft crew member, including giving or receiving training on any aircraft. 18. Care or treatment which would be provided without cost to you or your covered dependent in the absence of insurance covering the charge 19. Care or treatment not administered or ordered by a doctor or are not medically necessary to the diagnosis or treatment of an illness or injury 20. Routine well-baby care of a newborn infant while inpatient 21. An illness or injury sustained while the covered person is incarcerated in a state or federal prison or other detention facility 22. Court ordered treatment programs for substance abuse or other conditions 23. Care or treatment rendered outside the U.S. states or territories 24. Dental expenses 25. Facilities, and all treatments in said facilities, which specialize in inpatient substance abuse and mental health rehabilitation 26. Skilled nursing services or skilled nursing facilities 27. Any care or treatments not provided on an inpatient basis at an accredited hospital 28. Intensive care unit ( ICU ), critical care unit ( CCU ) and neonatal intensive care ( NICU ) are covered at standard hospital room rates. 5

8 Cancellation / Refund policy: This plan has a 30 day right-to-review for cancellation. Period begins on the effective date of the plan. If no claims, including usage of prescription programs, have been utilized, then the plan may be eligible for refund and all medical claims will be denied retroactive to the effective date. 6

9 Contact us Today! (844) Spring Valley Road, Suite 1500 Dallas, Texas CAT50 9/18