Presentation on theme: "Employee Orientation THE ESSENTIALS 300 A New Employee Benefit Plan."— Presentation transcript:
Employee Orientation THE ESSENTIALS 300 A New Employee Benefit Plan
Purpose The following slides illustrates the Essentials 300 Health Plan. It is important that you understand how the plan works so that you can make it best work for you and your eligible dependents. Your employer provides a contribution for the cost of the Plan
What is it? The Essentials 300 Health Plan consists of two separate components: A Limited Benefit Medical and Life insurance policy insured by Symetra Life Insurance Company; and, A PPO provider network & health resource program, the Sekure Healthcare Program, administered by Sekure Healthcare. When used together, these two components work in tandem for a better benefit plan with flexibility and value Symetra SM and the Symetra Financial logo are service marks of Symetra Life Insurance Company Sekure Healthcare SM and Sekure logo are service marks of Access Salud, Inc.
Insurance Benefits The Symetra Select Benefits Insurance Policy is a fixed indemnity/limited benefit medical plan This means that the Plan pays a preselected fixed amount with a maximum limit to the covered person based on a covered event This is different from an HMO Copay Plan The benefit is paid regardless of the provider chosen Symetra has an A Excellent (3 rd highest of 15) rating by A.M. Best and over $20B in assets and over 2 million customers (as of 12/31/2006)
Summary of Insurance Benefits Benefits are payable to the Member` BenefitCoverage Doctors Office Visit Benefit $35 per visit 1, with a max of $300 PP/CY (per person per calendar year) Preventive Care Benefit $50 per visit, up to $150 PP/CY Diagnostic X-ray & Lab $40 per visit 2, up to $300 PP/CY Hospital Indemnity Benefit Maternity covered as any other condition $300 per day for hospitalization, up to 30 days PP/CY $600 per day for intensive care, up to 30 days PP/CY $300 per day for Substance Abuse, up to 30 days PP/CY $150 per day for Mental Health, up to 30 days PP/CY $150 per day for Skilled Nursing, up to 60 days per consecutive stay PP/CY Survivors BenefitExtended benefits to surviving dependents for two years 1 Visit means: One meeting with a Doctor in a non-hospital setting. 2 One sitting for one or multiple Diagnostic X-ray Procedures: or one sitting for one or multiple Diagnostic Laboratory Procedures
Sekure Healthcare Program The Sekure Healthcare Program helps to reduce medical expenses. Sekure integrates access to important services (medical, hospital, dental, pharmacy, vision, chiropractic, acupuncture, dietetic counseling & more) in the US & in Mexico. National PPO healthcare networks offer Members significant savings with an average of 20% to 35% discount before benefits are paid. Health Advocate Unit available toll-free to assist Members in finding network providers. 24/7 toll-free nurse line (800) provides helpful medical information & assistance.
Sekure Healthcare Program Networks Medical/HospitalBeech Street PPO Network - average savings of 25% - 35% DentalFirst Dental Health - average savings of 30% - 35% PharmacyCaremark - average savings of 20% Vision CareNational Vision Administrators - average savings of 25% Chiropractic, Massage Therapy, Acupuncture American Specialty Health has wide range of complementary care - average savings of 25% - 30% Nurse-lineHealth Contact Partners – No charge Health AdvocacyHealth Contact Partners – No charge Mexico Health AccessSekure Healthcare – average savings of 25% - 35% For health care not covered by insurance or when insurance coverage limits are reached, the Sekure Healthcare Program offers substantial discounts.
Example - Scenario A Doctors Office Visit Benefit – Pre-selected fixed amount that pays $35 per visit, with a maximum of $300 per person, per calendar year. Covered Person (Member) goes to Doctor A (who is not affiliated with a network) and charges Member $150 for an office visit. C – D – B = MR $150 – $0 – $35 = $115 Provider Charges C is $150 Network Discount D is $0 Fixed Benefit B is $35 Members Responsibility MR becomes $115
Example - Scenario B Doctors Office Visit Benefit – Pre-selected fixed amount that pays $35 per visit, with a maximum of $300 per person, per calendar year. Covered Person (Member) goes to Doctor B who charges $150 for the office visit But Doctor B is in the Sekure Healthcare Network. The contracted rate is $80 using the discount pricing from the Sekure Healthcare Program which is a $70 network discount savings C – D – B = MR $150 – $70 – $35 = $45 Provider Charges C is $150 Network Discount D is $70 Fixed Benefit B is $35 Members Responsibility MR becomes $45 Regardless of the Provider Charges or the Contracted Rate, the Fixed Benefit remains the same for the covered event.
Save More With Sekure Healthcare Network! Doctor A Doctor B C $150 $150 - D $0 $70 - B $35 $35 =MR $115 $45 C - D - B = MR Provider Charges C Network Discount D Fixed Benefit B Members Responsibility MR Covered Persons (Members) have an incentive to seek out affordable health coverage – Sekure Healthcare Program has the tools to assist
Most Provider Networks in the Sekure Healthcare Program (Beech Street PPO) will accept assignment of the insurance benefit. This means Covered Persons will not have to send in a claim or copy of the itemized doctor bill for Symetra Life to pay the insurance benefit. In cases where a Provider does not accept assignment, the Covered Person will need to submit a claim to Symetra Lifes Policy Administrator, Select Benefit Administrators of America (SBAA)*. Covered Person should contact SBAA toll-free (800) for assistance in submitting claims. Assignment of Benefits * SBAA is a division of Employee Benefits Inc., a Symetra Company
Transportability Toll-free 24 hour Nurse-line and Medical Information Members have unlimited telephone access to registered nurses who can answer questions on family health and other issues A resource for Members to use at any time, especially when an issue is serious, but may not be a true emergency Toll-free Customer Service and /Health Advocacy For Members who prefer to speak with a live person, telephonic assistance is provided to find healthcare providers in our networks to help meet your specific needs For finding a specialty physician in your local area or away from home. 24/7 Nurse-line & Health Advocacy
Transportability Workers and eligible dependents can also use their insurance benefits on a reimbursement basis with Sekure Healthcare Network providers in more than 400 cities & towns in Mexico. Unlimited toll-free 24/7 patient advocacy and medical advice from trained physicians in Mexico City call center. Benefits are transportable – for example, a worker who lives in Fresno can enroll his dependents who live in Cancun. Dependents can access healthcare from providers in Mexico. Health Coverage Health Access Extends into Mexico
Club Benefits in Mexico General Practitioner Office Consultation250 Pesos* Specialist Physician Office Consultation350 Pesos* Hospital and Medical Procedures10-30% discount Laboratory, radiology & other services10-30% discount Dental Care Consultation; and major procedures 300 Pesos*; 10-20% discount Prescription Drugs10-30% discount** Vision Care – Eye Examination; Lenses, frames, contacts No Charge 15% discount 24/7 Toll-free Telephone Medical Information Service by Bilingual Doctors No Charge 24/7 Telephone Appointment (Concierge) Service & Customer Service No Charge * Contracted rate before insurance benefits are paid if applicable. ** Insurance benefits for prescription drugs can not be obtained in Mexico, discounts of 10% (generic) to 30% (brand) have been negotiated in participating pharmacies. Network Savings in Mexico
Symetra Life Insurance Select Benefits Policy & Sekure Healthcare Program are separate components that create the Essentials Plan. Symetra Life underwrites the insurance, Sekure Healthcare offers the network discounts and health advocacy services. Dont think about this health coverage in terms of Copays – this is a new model. The Fixed Benefits are more cost-effective than major medical plans, but are not comprehensive nor a substitute for major medical plans. Benefits are paid to Member based on a pre-selected fixed dollar amount and subject to exclusions and limitations. Mexico healthcare access is an added feature. Essentials Plan Summary
Follow the directions given to you by the Company Human Resources Department. Complete an enrollment form for the Symetra Insurance Plan and the Sekure Healthcare Program. Customer Service Representatives from Contractors Choice are available at (800) Let the representative know that you are enrolling. You will receive a welcome packet with ID cards from both Symetra Life and the Sekure Healthcare Program. To Enroll
Become familiar with your Essentials Plan. Review the Select Benefits Certificate of Coverage and the Sekure Healthcare Member Booklet Call Customer Services (800) for an orientation. Use this same number for the 24-hour nurse-line. If you have not seen a doctor for some time, consider scheduling a preventive care visit. If you do not have a doctor, Sekure Healthcare will help you find one. Let us know how we can better serve you. Best wishes! This concludes the orientation. How To Use the Plan Select Benefits is not a replacement for a major medical policy or other comprehensive policy. It is designed to cover benefits at preselected fixed dollar amount used on a routine basis. Coverage may be subject to exclusions, limitations, reductions and termination of benefits provisions.