Frequently Asked Questions
- EMPLOYEES
• For Employers
• For Employees •
Glossary
This guide will help you maximize the benefits
you receive through your medical plan. Please read your certificate
for complete information on your plan. You must present your ID card
to your doctor, hospital, or other health care provider before you
receive care to show that you have coverage through your plan. Your
PPO Copay Plan offers health care coverage and the services of a network
of doctors, hospitals, and other health care providers. A directory
of network providers is included with your plan or you may access
your approved providers by going to our Provider
Lookup Page.
How can I get the most out of my plan?
When you need medical care, select a physician from your provider
directory and call to make an appointment. Be sure to ask for confirmation
that the doctor is currently participating in your network. At the
doctor’s office, simply show your ID card before you receive
care. Your ID card identifies you as a member of your employers’
medical plan.
If your plan includes copays, then specified services are subject
to a copay you pay to your network provider at the time of service.
You will know if copays are included in your plan by reading your
certificate. Your ID card also shows the amounts of most copays.
If your plan does not include copays, your plan will pay for covered
services from network providers at the network benefit percentage,
after you have satisfied your network deductible.
What is a copay?
A copay is a fee that you pay directly to your network provider if
you have a PPO Copay Plan. After you pay the copay, your plan pays
the rest of the charges covered under the copay at 100%, unless your
certificate specifies otherwise. Copays apply only with network providers.
Please see your certificate for information on the services your plan
covers with copays, and for the copay amounts. Different copay amounts
may apply for different services, such as the services of a specialist.
In regard to benefits, the following types of providers are not considered
specialists: general or family practitioners, internists, pediatricians,
obstetricians and gynecologists. Copays do not apply toward meeting
your deductible or out-of-pocket limits.
I originally did not sign up for our company’s
medical plan (when I was first eligible), however, I decided I want
to apply now. Can I apply and become a participant?
It depends on why you originally declined participation. If you refused
coverage because you had coverage elsewhere, such as your spouses’
plan and you are loosing coverage, you may be able to enroll as a
special enrollee and become insured/covered immediately. On the other
hand, if you declined to participate because you simply did not want
coverage or did not want to pay at that particular time, you may have
to wait until "open enrollment" (usually the 30 days prior
to your employers medical plan anniversary). Your effective date would
be the plan anniversary.
Do I have to receive care from only network
providers?
The decision is yours. Each time you need health care, you can decide
whether to see a network or a non-network provider. However, if you
receive care from non-network providers, your benefits will be paid
at the non-network level.
I went to the Doctor and asked the staff
if they took my insurance company. They told me no problem and assured
me they would accept my insurance. Later, when my claim was paid I
found out they were not in the approved network of providers used
by my medical plan. What’ s the deal?
This situation does happen from time to time. It is a problem of communication.
Your doctor told you they accept your insurance plan, but did not
tell you they are members of your plans approved network. Always ask
your provider if they are a member of your network.
What should I do if I find out my current
doctor is not in our medical plans network?
You can go through a lengthy process of trying to get your Doctor
to join your insurance company’s network. This is not easy
and at best lengthy. You also have the opportunities to change
providers.
Call the perspective providers and ask if they are members and are
they taking new patients. Once this is accomplished go and select
a new doctor. Many insureds are pleasantly surprised at the results
of this effort.
What are my benefits when I receive care from non-network providers?
When you receive care from non-network providers, you will usually
pay more for your care. Copays usually do not apply for non-network
providers. Your plan will pay covered charges at the non-network benefit
percentage, as stated in your certificate. Your certificate may also
show that a higher deductible and out-of-pocket limit may apply for
non-network charges.
In addition, you will be responsible for all charges made by non-network
providers in excess of the usual, customary and reasonable rates
for
the service. Your payment of these excess charges do not apply toward
meeting your deductible or out-of-pocket limit.
What if my network doctor refers me to a non-network
provider?
Network doctors normally refer patients to other network providers.
If yours does not, show him or her the list of network providers and
ask if you may referred to one of them. If you receive care from a
non-network provider, benefits will be paid at the non-network level.
What if I need a specialized medical service
that is not available within my network?
Your plan continually works to contract with more providers to reduce
the chance that this might happen. Call the number on your ID card,
and they will make every effort to find a contracted provider who
will be able to offer the services you need.
What are my benefits if I need medical
care when I am away from home?
If you need medical attention while traveling, call the number on
your ID card. Whenever possible, they will refer you to nearby contracted
providers so that you may preserve network benefits. If there are
no contracted providers available, benefits will be paid at the non-network
level.
What happens if I have an emergency and
I cannot get to a network provider?
If you have and emergency, GET CARE IMMEDIATELY! Covered charges for
emergency care received 48 hours after the sudden onset of symptoms
are paid at the network benefit level.
Does our medical plan have a pre-existing
condition clause?
Yes, most all health plans address the issue of conditions that existed
prior to the effective date of coverage. This question comes up most
frequently in regard to medical. A common definition of pre-existing
is treatment, which includes prescribed drugs, within 6 months prior
to the effective date. If you have a pre-existing condition, your
medical benefits, for that condition only may be deferred for 12 months
(possibly longer in certain situations). New laws do allow you to
receive credit for time spent under another health plan. This credit
(credible coverage) can be used to off set the 12 months of excluded
benefits. This is a general discussion or pre-existing and credits.
Call Clark Benefit Group to receive a more complete explanation of
the laws and rules pertaining to this subject.
Specifically, how does utilization review
(UR) affect my coverage?
UR is automatically included in your plan. UR can help you and your
doctor determine the most cost-effective way to give you the care
you need. A trained medical staff of UR physicians and specialists
review and certify in advance, the medical necessity of certain kinds
of care and treatment.
UR affects your coverage only for those items on your certificate’s
list of treatments and services requiring certification. If you fail
to obtain certification for those the amount that is covered could
be reduced. Your plan may require your call ahead of time for and
request certification for certain procedures. Please review your certificate
to determine whether or not certification is required.
Examples:
Is it absolutely necessary to obtain certification?
The decision is yours. However, if certification is not obtained when
required, there may be penalties imposed. Read your certificate.
What about emergency situations, when there may not be enough time
to contact the UR office before hospitalization or surgery?
If you have an emergency, GET CARE IMMEDIATELY! Your plan makes special
allowances for emergency situations, allowing you or your physician
to contact the office for certification within two business days after
an emergency admission. In any event, the utilization review office
must be contacted before discharge.
What if conditions change that require
additional days in the hospital?
Contact the utilization review office again to obtain certification
for any additional days. For maximum benefits, certification must
be obtained before any additional days of hospitalization.
Do I need to call the utilization review
office for certification if a claim is filed first under my spouse’s
insurance plan?
Yes. In order to ensure the maximum benefit under a managed care plan,
you must call if a claim may involve coordination of benefits with
another health plan.
How will I know if my hospital admission
or other treatment has been certified?
You, your physician, or other provider will be notified. If you do
not receive notice before the scheduled admission, surgeries, or treatment,
please call the utilization review office at the phone number on your
ID card.
What if my physician or I disagree with
a decision made by the utilization office?
If you or your physician disagree with the initial decision, your
case will automatically be reviewed at a higher level. This review
will be done by a physician who is an advisor to the utilization review
office. Then, if you or your physician wish to contest the result
of this review, you may submit a formal appeal in writing to the UR
office. This appeal usually needs to be submitted within 30 days after
the initial certification determination.
