Transcript Metal Individual Medical Plan

Short Term Medical and CoreMedSM
Individual Medical ACA Plans
Clay Peek
www.peekperformanceinsurance.com
864 228 2635 office
Lynette Helgeson – DSC and Field Sales Trainer
Updated 11/11/2013, rev 02012014
Strong and experienced company
Part of Assurant, Inc., a Fortune 500 company
Rated A- (Excellent) by A.M. Best Company
120 years of experience
Health insurance solutions for small businesses and individuals
nationwide
Source A.M. Best Ratings and Analysis of Time Insurance Company
Assurant Health is the brand name for products underwritten and issued by Time Insurance Company (est. 1892)
Value provided to agents
Financially secure and experienced
120 years of dedicated focus to agents’ needs
Business model for success
Products sold through agents from the start
Service that stands out
Administrative support with dedicated customer service
centers
Broad portfolio
Reach more customers with more product choices
We have opportunities to keep you selling
between open enrollment periods
Short Term Medical
Individual Major
Medical*
Assurant Supplemental
Coverage
You can still sell individual major medical plans to customers
after open enrollment ends if a qualified life event occurs.
A
Agents must be licensed and appointed by each state in which a plan is sold.
Assurant Health - Short
Term Medical
Changes in how they buy
5
Short Term Medical plans; For price-sensitive customers
looking for a different major medical option.
Need An affordable major medical option for
unforeseen illnesses and injuries.
For People who are:
— Willing to trade off price for a higher deductible/out-of-pocket maximum
— Willing to pay out of pocket for ongoing health conditions; they are
subject to the pre-existing condition limitation
— Willing to pay out-of-pocket for preventive care; preventive benefits are
not covered under this plan
— Not opposed to paying a tax penalty; this plan is not considered Minimum
Essential Coverage.
Short Term Medical plans;
for customers who are in between plans.
Need
A temporary health plan.
People who are:
— Between jobs* — affordable alternative to COBRA
— Waiting for employer benefits — fills the gap in
coverage
— Seasonal employees — flexible options
*Penalty is not incurred until 90+ days without Minimum Essential Coverage
The Facts: Know the risk
Short Term Medical is not renewable.
– Termination of the plan does not constitute a
qualifying life event and does not create a special
enrollment period for a metallic plan.
Pre-ex starts over with each consecutive
plan
Unexpected illnesses and accidents happen every day, and the
resulting medical bills can be disastrous.
A new look at Short Term
Medical
 Variety of deductibles and coinsurance options
 $2 million lifetime benefit
 Prescription drug coverage
 Doctor office visits for illness
 Hospitalization, inpatient and
outpatient services
 X-ray and lab services
 Ambulance to nearest hospital
equipped to treat condition
STM plans from Assurant Health
offer affordable major medical coverage.
9
Assurant Health Short Term Medical,
Providing access to exceptional
features!
 Coverage options up to 180 days
 Coverage as soon as the next day
 Keep their doctors and hospitals — if your
customer chooses to go in-network they will
save 20-35%1
 Prescription drugs are covered and accumulate
to medical deductible
 Families need to satisfy only one deductible
1Network
10
not available in RI
Plan details:
Plan duration
30—180 days
Deductible
$1,000, $2,500, $3,500 or $5,000
Coinsurance
100%1, 80%/20% or 50%/50%
Coinsurance out-of-pocket
maximum
$0—$5,000
Plan options vary by state.
1
11
100% coinsurance not available with $1,000 deductible.
Eligibility: Guidelines have
not changed
– Can answer “NO” to all health questions on
application
— Ages 30 days to 64 years, 11 months
— Unmarried dependents up to age 18 or 24 if fulltime students,1 are eligible for coverage as
dependents under your policy2
— Non U.S. citizens may qualify if they have U.S.
resident address
1
Varies by state
Family coverage is not available in LA. Each family member
must submit an application per person.
2
12
Convenient payment options
• Single pay option
— Customer saves 20% on premium
— When customers know how long they’ll need coverage (e.g., need 64
days of coverage because they are waiting for employer benefits)
• Monthly pay option
— “Pay as you go”
— If customer is unsure how long they will need coverage, they can cancel
when they wish
• Key consideration: plans are “up-to” policies
– If customers are unsure of the length of coverage needed, they may
want to purchase a 6-month plan and pay month-to-month
•
13
STM product brochure
A comprehensive
overview of our
STM product
14
Get the materials you need
• New product brochures are available for download and
print (Form 30697)
• Find a Form on assuranthealthsales.com
• Visit the landing page, then click on the STM banner in
assuranthealthsales.com
• New tip sheet and state-specific rate sheets continue to
include state specific variances
15
Add protection and increase persistency
Assurant Supplemental Coverage:
Dental, Accident and Critical Illness with
• Easy, online quote and
submission.
• Just a few additional health
questions when adding
cancer and heart/stroke or
Term Life/Critical Illness
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Customers and Minimum Essential
Coverage-What they need to know
•
•
It is critical to discuss whether the plans you recommend to customers are
considered MEC and the possible consequences of purchasing a plan that is not
MEC
Our non-MEC plans are:
Short Term Medical
Assurant Health Access
Assurant Supplemental Coverage.
•
Most Americans must now have health insurance coverage that is minimum essential coverage
(MEC). If customers do not have MEC, they may be subject to payment of a penalty.
•
The 2014 Assurant Health individual major medical CoreMed plans qualify as
Minimum Essential Coverage (MEC).
*The special enrollment period for the individual market is typically 60 days from the date of a
triggering event.
Please note that small group fully insured, self-funded, Short Term Medical, Assurant Health Access, and Assurant Supplemental
Coverage products will still be available after the open enrollment period.
Get the materials you need
• Product references available for download and print
• Find A Form on assuranthealthsales.com
• State-specific versions
18
CoreMedSM Individual Medical
2014 Plans
What are Metallic Plans?
• The CoreMed Metallic Plans are guarantee
issue health care plans that are compliant with
the Patient Protection & Affordable Care Act
law of 2010.
– PPACA, ACA, ObamaCare
• The Law requires Health Insurance Companies
offer coverage to all customers, regardless of
health conditions
• A customer can not denied coverage based on
pre-existing health conditions.
Metal Plans
• Guarantee issue
– Guaranteed Issue up to age 65
– Dependents – children to age 26
• Essential Health Benefits (EHB)
– 10 Basic Coverage categories
• Individual mandate
– All individuals must have minimum essential coverage (MEC) in order to
avoid being subject to a tax penalty (some exceptions)
• Pediatric Dental and Vision
– All plans include Dental and Vision benefits for children.
Metal Plans cont…
• Broad networks of doctors and hospitals
– Including Aetna Signature Administrators, which has more then one
million doctors nationwide.
• Personalized Assistance and support
– From specially trained Health Care Advocates that can:
– Help find Drs and hospitals in your network
– Work through any billing or claim issues after services are received.
• Child Only option
– Not available on the Catastrophic plan
• Preventive care paid at 100%
– Recommended under the Affordable Care Act (USPTF)
Plan Characteristics
• Deductible
• Coinsurance
• Out of Pocket Max
• Office Visit Co-Pays
• Prescription Drug Co-Pay
Plan Characteristics
• Revised plan designs
• Total out-of-pocket maximums decrease for
2014
– Individual = $6,350
– Family = $12,700
• Out-of-pocket amounts include deductibles,
coinsurance, copays and access fees
Overview of Metallic CoreMed
Plan Designs
• 5 Levels
– Bronze (5)
– Silver (4)
– Gold (2)
– Platinum (2)
– Catastrophic
*Plan Design and Availability may differ by State
Bronze
*Plan Design and Availability may differ by State
Silver
*Plan Design and Availability may differ by State
Who might be a Bronze or
Silver customer
• Someone seeking a lower cost or reasonably
priced plan that meets the ACA requirements
• Those that are fairly healthy, with minimal or
just basic immediate healthcare needs
• Appreciate the ease of use at providers with copays
etc
• Someone that likes the idea of a plan that meets
the ACA requirements and has options for a
Health Savings Account (HSA)
Gold
*Plan Design and Availability may differ by State
Platinum
*Plan Design and Availability may differ by State
Who might be a Gold or
Platinum customer
• Someone wanting a low or $0 deductible plan and
less out of pocket for overall medical expenses
• Those that are likely going to use their plan for
various medical needs
• Someone looking for simple plan designs that are
easy to use when receiving care
• Those looking for a richer ACA plan option
Catastrophic
**Not available for child only, available for ages 21-29.
*Plan Design and Availability may differ by State
Who might be a Catastrophic
customer …
• Someone age 21-29 at the time of application.
• Those that are younger and looking to buy a
lower cost plan that meets the requirements.
• Someone whose cost of insurance exceeds 8% of
his MAGI
• Someone comfortable with a larger deductible
and up front costs to help keep the premium
more affordable.
Essential Health Benefits (EHB)
The federal government requires EHB to cover the following ten
categories:
• Ambulatory patient services
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health and substance use disorder services, including
behavioral health treatment
• Prescription drugs
• Rehabilitative and habilitative services and devices
• Laboratory services
• Preventive and wellness services and chronic disease
management
• Pediatric services, including dental and vision care
Pediatric Dental
• Pediatric dental benefits
Pay no deductible, copay or
coinsurance for annual dental
checkups
Choose from approximately 160,000
dentists nationwide in the Careington
Dental Network
Save 5 to 40% on routine dental exams,
cleanings and major services including
orthodontics and specialists’ fees at
network providers
Good opportunity to sell ASC Dental to adults on the plan
• Provider Network
– Careington Dental Network – (800)290-0523
• Who is Eligible
– Eligible for dependents to age 19 (21 in KY)
Pediatric Dental Benefits -
(In Network) –
See Plan Details in EASE for more information and state specifics
Pediatric Dental
CHECKUPS
BASIC SERVICES
MAJOR SERVICES AND
ORTHODONTICS
Non-HSA plans
We pay 100%; not
subject to deductible
We pay 80%;‡ not
subject to deductible
We pay 50%;‡ not
subject to deductible
HSA-compatible plans
We pay 100%; not
subject to deductible
Subject to deductible
and coinsurance‡
Subject to deductible
and coinsurance‡
‡ We pay 100% once the OOP max is met
Pediatric Vision
• Pediatric vision benefits
Pay no deductible, copay or
coinsurance for one annual eye exam
Receive in-network benefits for
services from network providers and
eyewear in designated collections
See Plan Details in EASE for more info
Choose from large providers
offering eyewear and contact lenses
through retail locations and online
• Provider Networks
– VisionWorks of America
– Kids Glasses.com or
39dollarglasses.com
• Who is Eligible
– Eligible for dependents to age
19 (21 in KY)
All plans
ANNUAL EYE
EXAM
We pay 100%;
not subject to
deductible
GLASSES/CONT
ACTS FROM
DESIGNATED
PROVIDERS
Subject to
deductible and
coinsurance
When can they buy a Metal plan?
• Metal plans can only be purchased during Open
Enrollment (OE), and when a life event triggers
a special enrollment period (60 days from date
of triggering life event).
– We can not sell them to an individual outside of open enrollment unless
they have a life event. A qualifying life event (birth, death, marriage,
loss of coverage) can trigger a special enrollment period where
individuals can purchase on the Exchange outside of open
enrollment
– The special enrollment period for the
individual market is 60 days from the
date of a triggering life event
• 2015 OE is 11/15/14 to 2/15/15
Life Events that Trigger Special Enrollment
Triggering events include such events as:
• Loss of minimum essential coverage (group!)
• Individual gains a dependent or becomes a dependent
through marriage, birth, adoption or placement for
adoption
• Permanent move to a new state
• Individual gains status as a citizen, national or lawfully
present individual (who previously was not)
• Release from incarceration
• Return from Active Military duty
Additional Event specifics exist. See additional Training pieces.
Billing / Submission
• Monthly from Checking/Savings Account (COM).
• Effective Date - the 1st and 15th of the month
• Quarterly with Credit Card (Visa or MasterCard).
•
(Monthly CC in AZ, CT, KS, NC & OH).
• Draft Date (1st through 28th)
• First Draft, Upon Approval. (10-15 day warehousing)
• No Application Fee
• Quote and submit through EASE (paper app submission in UT)
QUESTIONS?
Thank you!
CoreMed Exclusions:
We want you to understand your plan and your coverage. To help you do
that, here is a summary of what is not covered by your plan. Complete
details are included in your insurance contract. No benefits are provided
for the following, except where state mandates apply.
• Treatment not listed in the Covered Medical Services provision
• Complications of an excluded service
• Charges reimbursable by Medicare, Workers’ Compensation or
automobile insurance carriers or expenses for which other coverage
is available
• Charges billed by a non-participating provider that waives the
covered person’s payment obligation of any copayment, coinsurance
and/or deductible amounts for the billed treatment, services,
supplies or drugs, except as provided for under contract or
agreement with us
• Illness or injury caused by acts of war, felony, influence of an illegal
substance or hazardous activity for which compensation is received
• Charges for routine dental or orthodontic treatment, drug, service or
supply for persons 19 years of age and older
• Routine hearing care, vision therapy, surgery to correct vision, foot
orthotics, or adult routine vision and foot care unless part of diabetic
treatment
• Except as provided in the Medical Benefits section, any correction of
malocclusion, protrusion, hypoplasia or hyperplasia of the jaws
• Treatment of “quality of life” or “lifestyle” concerns, including but
not limited to obesity; hair loss; or cognitive enhancement unless
otherwise required by law
• Cosmetic services such as chemical peels, plastic surgery and
medications
• Prophylactic treatment
• Charges for non-medical items
• Charges for custodial care, private duty nursing, telemedicine or
phone consultations
• Growth hormone stimulation treatment to promote or delay growth
• Charges for sex transformation, treatment of sexual dysfunction or
inadequacy or to restore or enhance sexual performance or desire
• Charges for umbilical cord storage; genetic testing, counseling or
services
• Charges for diagnosis and treatment of infertility or surrogate
pregnancy
• Chelation therapy
• Charges for testing and treatment related to the diagnosis of
behavioral conduct or developmental problems, educational testing
or training, vocational or work hardening programs, transitional
living or services provided through a school system
• Charges for alternative medicine, including acupuncture and
naturopathic medicine
• Drugs not approved by the FDA
• Charges by a medical provider who is an immediate family member
or who resides with a covered person
• Charges in excess of any stated benefit maximum
• Experimental or investigational services
• Drugs obtained from sources outside the United States
• Charges related to health care practitioner-assisted suicide
• Charges for over-the-counter drugs (unless recommended by the
United States Preventive Services Task Force and authorized by a
health care provider)
• Cranial orthotic devices, except following cranial surgery
• Charges for medical devices designed to be used at home, except as
otherwise covered in the Medical Benefits section of the contract
• Charges for treatment, services, supplies or drugs provided by or
through any employer of a covered person or the employer of a
covered person’s family member
• Charges for treatment, services, supplies or drugs provided by or
through any entity in which a covered person or a covered person’s
family member receives, or is entitled to receive, any direct or
indirect financial benefit
• Charges for Retin-A (tretinoin) and other drugs used in the treatment
or prevention of acne, rosacea or related conditions for anyone age
30 or older
• Charges for devices or supplies, except as described under a
prescription order
• Charges for viral culture; saliva analysis, including chemical or
biological diagnostic saliva analysis; caries testing; adjunctive prediagnostic
testing; electronic diagnostic modalities; occlusal analysis;
muscle testing
Exclusions for pediatric dental and
vision benefits
• Charges for declassification procedures; special stains, either for or
not for microorganisms; immunohistochemical stains; tissue in-situhybridization
• Charges for electron microscopy; direct immunofluorescence;
consultation on slides prepared by another provider; consultation
with slide preparation; accession transepithelial; TMJ dysfunction
arthrogram and other TMJ dysfunction films; tomographic surveys;
Cone Beam CT, Cone Beam multiple images 2 dimension, and Cone
Beam multiple images 3 dimension
• Charges for instruction on oral hygiene
• Charges for screw retained surgical replacement; surgical
replacement with or without surgical flap; TMJ disorder appliances
and therapy; sinus augmentation with bone or bone substitutes;
appliance removal; intraoral placement of a fixation device;
appliances for tooth movement or guidance; removal of fixed space
maintainer
• Charges for gold foil surfaces; provisional crown(s); post removal;
temporary crown(s); coping; endodontic implant; intentional
re-implantation; surgical isolation of tooth; canal preparation;
anatomical crown exposure; splinting, either intracoronal or
extracoronal; complete interim denture, either upper or lower;
partial interim denture, either upper or lower; precision attachment;
replacement precision attachment; fluoride gel carrier; custom
abutment; provisional pontic; interim pontic; interim retainer crown;
connector bar; stress breaker
• Charges for equilibration, periodontal splinting, full mouth
rehabilitation, restoration for misalignment of teeth, or other
orthodontic services that restore or maintain the occlusion or alter
vertical dimension
• Charges for orthodontic services and supplies that are for cosmetic
purposes or are not medically necessary; repair of damaged
orthodontic appliances; lost or missing orthodontic appliances or
replacement thereof; retention of orthodontic relationships
• Charges for visual therapy
• Charges for two pairs of glasses in lieu of bifocals; nonprescription
(plano) lenses; lost or stolen eyewear; insurance premium for contact
lenses or glasses; replacement lenses within the same calendar year