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Short Term Medical and CoreMed SM Individual Medical ACA Plans Clay Peek www.peekperformanceinsurance.com 864 228 2635 office Lynette Helgeson – DSC and.

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Presentation on theme: "Short Term Medical and CoreMed SM Individual Medical ACA Plans Clay Peek www.peekperformanceinsurance.com 864 228 2635 office Lynette Helgeson – DSC and."— Presentation transcript:

1 Short Term Medical and CoreMed SM Individual Medical ACA Plans Clay Peek office Lynette Helgeson – DSC and Field Sales Trainer Updated 11/11/2013, rev

2 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) 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

3 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

4 We have opportunities to keep you selling between open enrollment periods Short Term Medical Individual Major Medical* Assurant Supplemental Coverage A Agents must be licensed and appointed by each state in which a plan is sold. You can still sell individual major medical plans to customers after open enrollment ends if a qualified life event occurs.

5 5 Changes in how they buy Assurant Health - Short Term Medical

6 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. An affordable major medical option for unforeseen illnesses and injuries. Need Short Term Medical plans; For price-sensitive customers looking for a different major medical option.

7 People who are: —Between jobs* — affordable alternative to COBRA —Waiting for employer benefits — fills the gap in coverage —Seasonal employees — flexible options A temporary health plan. Need Short Term Medical plans; for customers who are in between plans. *Penalty is not incurred until 90+ days without Minimum Essential Coverage

8 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

9 A new look at Short Term Medical Unexpected illnesses and accidents happen every day, and the resulting medical bills can be disastrous. 9  Variety of deductibles and co- insurance 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.

10 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 10 1 Network not available in RI

11 Plan details: 11 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 % coinsurance not available with $1,000 deductible.

12 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 full- time students, 1 are eligible for coverage as dependents under your policy 2 —Non U.S. citizens may qualify if they have U.S. resident address 12 1 Varies by state 2 Family coverage is not available in LA. Each family member must submit an application per person.

13 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

14 14 STM product brochure A comprehensive overview of our STM product

15 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

16 Add protection and increase persistency Easy, online quote and submission. Just a few additional health questions when adding cancer and heart/stroke or Term Life/Critical Illness Easy, online quote and submission. Just a few additional health questions when adding cancer and heart/stroke or Term Life/Critical Illness 16 Assurant Supplemental Coverage: Dental, Accident and Critical Illness with

17 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.

18 Get the materials you need Product references available for download and print Find A Form on assuranthealthsales.com State-specific versions 18

19 CoreMed SM Individual Medical 2014 Plans

20 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 –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.

21 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.

22 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)

23 Plan Characteristics Deductible Coinsurance Out of Pocket Max Office Visit Co-Pays Prescription Drug Co-Pay

24 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

25 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

26 Bronze *Plan Design and Availability may differ by State

27 Silver *Plan Design and Availability may differ by State

28 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)

29 Gold *Plan Design and Availability may differ by State

30 Platinum *Plan Design and Availability may differ by State

31 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

32 Catastrophic *Plan Design and Availability may differ by State **Not available for child only, available for ages

33 Who might be a Catastrophic customer … Someone age 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.

34 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

35 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) Who is Eligible –Eligible for dependents to age 19 (21 in KY)

36 Pediatric Dental Benefits - (In Network) – See Plan Details in EASE for more information and state specifics Pediatric DentalCHECKUPSBASIC 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‡ ‡ We pay 100% once the OOP max is met

37 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) ANNUAL EYE EXAM GLASSES/CONT ACTS FROM DESIGNATED PROVIDERS All plans We pay 100%; not subject to deductible Subject to deductible and coinsurance

38 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

39 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.

40 Billing / Submission Monthly from Checking/Savings Account (COM). Effective Date - the 1 st and 15 th of the month Quarterly with Credit Card (Visa or MasterCard). (Monthly CC in AZ, CT, KS, NC & OH). Draft Date (1 st through 28 th ) First Draft, Upon Approval. (10-15 day warehousing) No Application Fee Quote and submit through EASE (paper app submission in UT)

41 QUESTIONS? Thank you!

42 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 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


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