Service Net, Inc. Health Reimbursement Arrangement Benefit Overview

Transcription

1 Service Net, Inc. Health Reimbursement Arrangement Benefit Overview Your employer is providing you with tax-free reimbursement for certain qualified medical expenses through an HRA Health Reimbursement Arrangement. Group Dynamic, Inc. reimburses you for eligible expenses upon receipt of required documentation. Effective date: July 1 Basic Facts About Your HRA Benefits: Who is eligible for What types of expenses are reimbursed? Employees and IRS-defined dependents enrolled in the Health New England Essential 2000 group health plan. Deductible as defined by the Health New England Plan. What is the coverage period? The coverage period is a plan year from July 1 to June 30. When do I submit a request for What documentation do I need to request a How do I submit a request for How much time do I have to submit my request for How can I check the status of a reimbursement request? Submit your request upon receipt of an Explanation of Benefits from Health New England. Submit the Explanation of Benefits that Health New England sent you with a signed Reimbursement Request Form to Group Dynamic (see reverse side). Submit your request to Group Dynamic, Inc. via , fax or mail. You have 90 days after June 30 to submit requests. If your coverage terminates mid-year then you have 90 days from the coverage end date to submit requests. Access the Participant Portal from GDI s website at to view all account transactions. Here is How the Plan Shares Expenses with You: Total Deductible: HRA Pays First: You Pay Last: Single: $2000 $1500 $500 Two-Person or Family: $4000* $2500* $1500 *Health Plan Deductible and HRA benefits are capped at the Single Plan level for individuals who are part of a Two Person or Family Plan. See Reverse for Important Information June 2, 2014

2 Service Net, Inc. Health Reimbursement Arrangement Reimbursement Request Form EMPLOYEE INFORMATION Employee Name (please print): ` Last 4 digits of your Social Security Number: IMPORTANT INFORMATION FOR SUBMITTING A REQUEST FOR REIMBURSEMENT 1. Receive your medical care as you normally would. Your medical care provider will file claims with Health New England. 2. Provide clear copies of the Explanation of Benefits. These statements are mailed to you after your medical services have been processed by Health New England. You may also be able to print a copy from their web site. Group Dynamic Inc. cannot reimburse you without clear documentation that you incurred eligible expenses and met any out-of-pocket requirement. 3. Enter your name, last four digits of your Social Security Number and sign this Reimbursement Request Form. 4. Submit your Request using one of the following methods: Scan & to: claims@gdynamic.com Fax to: Mail to: Group Dynamic, Inc., 411 US Route One, Falmouth, Maine GDI processes reimbursements on a weekly basis for requests and supporting documentation received by noon on Tuesday. 5. View account activity, account balance and access other information on the Participant Portal: Go to GDI s website at and click on Participant Login Temporary Username: first name/state abbreviation/last 5 digits of SSN Example: lisame12345 Temporary Password: first initial/state abbreviation/zip code Example: lme04105 You will be asked to create a new username and password after your initial login REIMBURSEMENT REQUEST I request reimbursement for my qualified medical expenses as indicated on the attached documentation. I certify that I incurred these expenses as a participant in the HRA established by the employer named above and that these expenses must qualify for reimbursement under the terms of my employer s plan and the Internal Revenue Code and cannot be claimed as credits or deductions on my personal income tax return. I understand reimbursements from this plan are paid from my employer s HRA and I acknowledge that I am responsible for paying each provider for the medical services received. I have retained copies of the documentation included with this request. I understand materials submitted will not be returned to me. EMPLOYEE SIGNATURE AND DATE Signature Date Questions? Contact GDI s Reimbursement Team at Monday to Friday, 8:00am 5:00pm ET. See Reverse for Important Information June 2, 2014

3 EXPLANATION OF BENEFIT (EOB) THIS IS NOT A BILL Questions about this statement? Visit or call HNE Member Services at 1-(800) , M-F 8:00AM to 5:00PM. Statement Date: 5/17/ ANYWHERE RD 1 Monarch Place, Suite 1500 Springfield, MA ANYWHERE, MA Section 1: Claim Payment Information Your Plan Information Plan HNE Essential 1500 Claim #: E Provider Date of Service: 4/21/2011-4/24/2011 Description of Services: HNE was billed: BAYSTATE MEDICAL CENTER HNE Allowed: Paid by HNE: Other Insurance Payments: MEMBER RESPONSIBILITY: Deductible: Copay: Coinsurance: Diagnostic Radiology $1, $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Other Pharmacy $1, $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Surgery $5, $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ER $1, $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Diagnostic Radiology $ $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Anesthesia $ $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Laboratory/Pathology $ $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Other Diagnostic Services $3, $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Inpatient Pediatrics $3, $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Inpatient Med/Surg $1, $6, $4, $0.00 $1, $0.00 $0.00 Totals: $20, $6, $4, $0.00 $1, $0.00 $0.00 : Explanation: K6 - You do not have to pay for this service. HNE and the provider have a contract agreement that covers this service. Page 1 of 3

4 Your Plan Information Plan HNE Essential 1500 Section 2: Your Payment Information This amount was applied to your deductible: Your copayment for this service(s) is: Your coinsurance for this service(s) is: The amount you are responsible to pay (Deductible + Copayment + Coinsurance)* is: $1, $0.00 $0.00 $1, *Your provider may bill you for the amounts listed above, if you have not already paid them. Section 3: Summary of Deductibles and Out-of-Pocket Maximums These totals are based on our information to date and may not reflect all outstanding claims. Deductible/OOP Plan Maximum: Amount Applied this Statement: Medical: Rx: Plan Year: Total to Date: 5/1/2011 Amount Remaining: FAMILY - Deductible HMO $4, $1, $0.00 $0.00 $2, FAMILY - Out-of-Pocket Maximum* $4, $0.00 $0.00 $0.00 $4, INDIVIDUAL - Deductible HMO $2, $1, $0.00 $0.00 $ MEMBER - Out-of-Pocket Maximum* $2, $0.00 $0.00 $0.00 $2, * Copayments that are greater than $100 are applied to the Out-of-Pocket maximum Note: A dollar amount ($X) shows a credit or deduction. Page 2 of 3

5 Your Plan Information Plan HNE Essential 1500 HNE is committed to improving the health and lives of the people in our communities. One of the ways we do this is by following sustainable business practices. We have stopped sending EOB statements for services where the claim does not affect your deductible or coinsurance. If you would like to view claims information, it is available on-line at HNEDirect. We will continue to send EOBs for claims that do affect your deductible or coinsurance. What if I want more information or I disagree with the information on this EOB? If you have any questions or would like to obtain a copy of the specific plan provisions relating to this claim, please contact the HNE Member Service Department at or Our representatives are able to help you Monday through Friday between 8:00 am and 5:00 pm. If you do not agree with how this claim was processed, you may have the right to appeal. You have 180 days from the date of this notice to request an appeal. You may have anyone of your choosing represent you in your appeal. You may submit your appeal by: telephone (413) or (800) fax (413) in person or by mail Health New England Attention: Complaints and Appeals Department 1 Monarch Place, Suite 1500 Springfield, MA Please provide your member ID number, daytime telephone number, a description of your appeal, the resolution you are requesting, and any documents that you feel are relevant to your appeal, such as copies of medical records or billing statements. In general, HNE will send you a written statement of the decision 30 business day after the receipt of your appeal request. You also may have the right to bring a civil action under Section 502(a) of ERISA if all required reviews of your claim have been completed and your claim has not been approved. Normally, you must exhaust the plan s internal review procedures before you can initiate a civil action under Section 502(a) of ERISA. More detailed information about your rights to appeal is provided in your membership material. Page 3 of 3