A. Overview. B. Plan Description. C. Rates & Guarantees
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2 Table of Contents A. Overview B. Plan Description C. Rates and Guarantees D. Competitive Advantage E. Optional Benefits F. Underwriting Guidelines G. Quote Requests H. Submitting New Business I. Limitations & Exclusions J. Policy Description of Benefits K. Agent Contracting L. Marketing Guidelines M. System Access and Overview N. Claims Administration
3 A. Overview Pre-Med Defender is a Group Supplemental Medical Expense Insurance Plan designed to cover out-of-pocket expenses such as deductibles and co-insurance. It's available to employer groups of 10 employees or more in selected states and it must be offered in tandem with a comprehensive group medical policy. B. Plan Description Pre-Med Defender pays a coverage year benefit, up to the maximum benefit amount selected, for each covered person who incurs covered expenses. These benefits are paid equally for both inpatient and outpatient benefits up to the maximum benefits amount selected. The Covered Person must be under a Doctor's care and the treatment must be for covered Injury or Sickness. Covered Expenses are the unpaid portions of charges applied to the deductible, co-insurance and copays for medical care (treatment and services) that are eligible for reimbursement under and deemed allowable by the policyholder s major-medical plan and which are not excluded from coverage under the policy. We will pay the applicable benefit percentage for the Covered Expenses up to the applicable Coverage Year Maximum. Pre-Med Defender insurance coverage is underwritten by National Guardian Life Insurance Company and is not affiliated with the Guardian Life Insurance Company. C. Rates & Guarantees Coverage is Guaranteed Issue Initial Rates are Guaranteed for 12 months; Age based rates in following bands: Under Age 40, Ages and age 50+. Composite rates are available upon receipt of a census and subject to revision upon review of the final enrollment census.
4 D. Competitive Advantage Flexible Benefit Amounts Today, ACA dictates the allowable health/primary medical plan maximum out-of-pocket expenses. In 2018 the maximum individual amount is $7,350 and the family maximum is $14,700. Pre-Med Defender plans can be issued to the current maximum levels. Some states have lower maximum benefit levels until the filings can be updated in those respective states. Pre Med Defender plans can be modified to accommodate an array of coverage deductibles and maximum benefit combinations to meet the needs of most employer groups. In-Patient & Out-Patient Services Pre-Med Defender plans do not reduce the benefit percentage for outpatient services. Plan maximums cover both the inpatient and outpatient charges at 100% up to the benefit maximum selected. "Inpatient" means a Covered Person who has been formally admitted to a Hospital for purposes of receiving Inpatient Hospital services for no less than 23 hours. Outpatient" means a Covered Person who receives medical treatment without being admitted to a hospital. Outpatient Expenses Include: Emergency Room, Primary Care, Specialist, Mental Health and Substance Abuse, Imaging, Speech Therapy, Occupational & Physical Therapy, Preventive Care, Laboratory, X-rays & Skilled Nursing Facilities. E. Optional Benefits Doctor Office Visits Pre-Med Defender plans can provide a co-payment for doctor office and specialist visits when they have been removed from the primary health plan. Co-payments can be set within the filing bracket of 0 - $200 per visit. Annual maximum for Doctor Visits is $500. "Co-payment" means a specified amount that a Covered Person is responsible for paying (each time the Covered Expense is incurred) before benefits are payable under the policy.
5 Pharmacy Plans Many High Deductible Health Plan prescriptions drug benefits are subject to the out-ofpocket maximum of the health plan and can be very troublesome for employees. Our Rx programs can provide basic prescription benefits as well as provide a full "managed care pharmacy solution" to further enhance plan satisfaction and tremendous long-term health plan cost savings. By carving out the prescription component of a traditional medical plan, the cost savings can be substantial. Pharmacy carve out plans can be customized to accommodate the formulary requirements of most employer groups. "Prescription Drug" means any medical substance, remedy, vaccine, biological product, drug, pharmaceutical or chemical compound, which can only be dispensed pursuant to a prescription and which is required to bear the following statement on the label: "Caution: Federal law prohibit dispensing without a prescription." F. Underwriting Guidelines Eligibility Employee must be covered by a Major Medical Plan* Minimum size requirement for eligible groups is 10 eligible employees. (Florida requires groups of 51+) Eligibility is restricted to W-2 employees and their dependents participating in the Major Medical Plan. (1099 contract persons are not eligible, unless the "employer" is sponsoring the medical plan); The Major Medical Plan must have a common deductible for all conditions. *A Major Medical Plan is any self-funded or fully insured major medical or comprehensive medical plan. Major Medical Plan does not include any limited medical program, Medicare or Medicaid. Plan limits will apply according to the policy.
6 Employer Contribution When employer contributes 100% of the employee premium, 100% participation will be required; Minimum employer contribution is 50% of the employee premium. When employer contribution is less than 100%, there is a 75% participation requirement of those employees taking part in their current health plan. G. Quote Request The following information is needed to have a case quoted: Name of Employer Group Census of eligible employees and their dependents Health Benefit Plan design Current and Renewal rates ( if available ) Out of Pocket costs to the insured ( Deductible and Co Insurance max ) If case currently has secondary coverage, provide plan and rates Situs state of the Employer A binding proposal cannot be issued more than 90 days prior to the proposed effective date. In addition, proposals will automatically expire 60 days after the day of quotation. At each subsequent anniversary, rates may be adjusted based on the group s experience and other pertinent underwriting information as considered by the insurance company. Rate adjustments are at the sole discretion of the insurance company. Written notice of rate adjustments will be given at 60 days prior to the policy anniversary.
7 H. Submitting New Business The following information is required for sold cases: Fully completed agent licensing paperwork (unless currently appointed with NGL) New Group Cover (to be completed by the Broker) in PDF format labeled as: Group Name, Group Cover Fully completed Employer Application in PDF format, with original signatures, labeled as: Group Name, Employer App Major Medical Summary in PDF format labeled as: Group Name, MM Summary Signed copy of the proposal rate page signifying acceptance of the rates labeled as: Group Name, Sold Rates Enrollment Spreadsheet on the approved submittal Excel format labeled: Group Name, Enrollment First month s premium Census of enrolled employees as of the effective date based on the online enrollment data All information & documentation required by the underwriter All of the above listed documents must be submitted as separate documents. Typically, the selling agent will complete all documents with the exception of the New Group Cover and submit these documents to the Broker. The Broker will review and submit to Equipoint Partners, LLC. Acceptance of the group is contingent upon receipt and review of this information. The quoted rates may change after final enrollment if there has been a material change in the group since the quote was released. In addition, if a group has been given composite rates, these rates are subject to change based on the demographics of the final enrollment of the employees and their dependents.
8 I. Limitations and Exclusions No benefits will be paid for loss caused by or resulting from: Intentionally self-inflicted injuries, suicide or any attempt thereat while sane Declared or undeclared war or any act thereof The Covered Person s commission of a felony Work-related Injury or Sickness The Covered Person s voluntary participation in a riot, civil commotion or disobedience or unlawful assembly In addition, no benefits will be paid for: Co-payment amounts charged under a Major Medical Plan ( unless you ve added the Dr. Co Pay Benefit option ) Non-Prescription Drug charges Charges that are not eligible for reimbursement under a Major Medical Plan Charges for medical care, treatment and services or portions thereof, that are in excess of what is deemed allowable by a Major Medical Plan Charges for care, treatment or services that are incurred at a provider that is not included in the provider network of a Major Medical Plan (unless otherwise covered) Charges for which a Covered Person is not required to pay Cost Sharing under a Major Medical Plan J. Policy Description of Benefits We will pay the applicable benefit percentage for the Covered Expenses* up to the applicable Coverage Year maximum. Benefits will be paid, after satisfaction of any applicable Deductible or Co-payment amount and subject to any applicable benefit limitation, for Covered Expenses* that are incurred while the Covered Person's coverage is in force. The Covered Person must be under a Doctor's care and the treatment must be for covered Injury or Sickness. Deductible and Co-payment amounts, benefit percentages, maximums and limitations are shown in the SCHEDULE OF BENEFITS.
9 *Covered Expenses are the unpaid portions of charges applied to the deductible, co-insurance and copays for medical care (treatment and services) that are eligible for reimbursement under and deemed allowable by the policyholder s major-medical plan and which are not excluded from coverage under the policy. K. Agent Contracting All Agents must be appointed with National Guardian Life Insurance Company Agents must be contracted with Equipoint Partners, MGA for Pre Med Defender NGL Contracting Agreement documents will be provided by Equipoint Partners L. Marketing Guidelines All Marketing Materials for agent distribution are developed by Equipoint Partners, LLC. No unauthorized creation or manipulation of marketing materials is allowed. Marketing Materials Pre Med Defender Brochure ( PMD 1001 ) Pre Med Defender One Page Flyer ( PMD 1002 ) Pre Med Defender Sample Pricing ( PMD 1003) M. Equipoint System Overview The Equipoint System is accessible to all groups, agents and brokers, giving them editing capabilities, making it easy to keep group employees information up to date. New Hires, Terminations & Changes Once employee demographic information is uploaded into the system, making changes to existing employees (i.e. adding/editing dependents), removing a former employee or updating tier information is easily accomplished. Equipoint System Training
10 A Training Video is available. We also provide training classes on how to navigate through the system if needed. To schedule training, please contact your account manager. N. Claims Administration We have set up an electronic payer ID for your provider to file the claim electronically; let your Provider file the claim for the Major Medical plan (Primary) and your Pre-Med Defender plan (Secondary). The insured will need to provide his/her primary medical card as well as the Pre-Med Defender card to the provider. Most providers will file the claim electronically because it is easy and they get paid faster. A claim s contact phone number is printed on the ID card along with the claims payer information for the provider. If needed, our customer service staff can and will send a letter to each provider explaining how to file claims. Pre- Med Defender claims should flow as follows: The insured s claim is filed with their major medical carrier and with Pre-Med Defender electronically. The insured s major medical carrier will process the claim and the insured and provider will receive an EOB (Explanation of Benefits). This form describes the procedures covered, facility used, benefit paid and the amount applied to the insured's deductible or co-insurance. The provider will/should send and include an electronic copy of EOB as well as the standard CMS 1500 or a Hospital Claim Form (UB04). These forms describe the medical procedure codes and provide all the information needed to pay the secondary coverage claim. Claims Administration Providers: TCC Benefits Administrator Planned Adminstrators, Inc. ( PAI ) Covenant Adminstrators
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