1. Understanding Your Coverage
The Corps Network Corpsmember Healthcare Insurance Plan
July 1, 2011 – June 30, 2012 Plan Year
Hello and thank you for viewing this presentation on The Corps Network Healthcare Insurance Plan. This presentation is a tutorial designed to give you a better understanding of your benefits and how to go about using them. We’ll tackle many of the questions corpsmembers commonly have as they enter their term of service or that may arise over the course of the year.

2. CONTENTS I. Introduction II. III. What’s My Plan Called? – Who’s Who
How Does My Plan Work? – General Structure
IV.
What’s Covered? – Plan Benefits V.
Who Can I See? – Provider Network
VI.
What do I Need to Do? – At the Provider’s
VII.
How Do I File a Claim? – Medical & Rx
VIII.
What if I Still Have Questions – Key Contacts
The question we’ll start with is, what’s my plan called? There are several entities involved in putting this plan together and making it work. We’ll describe who’s who and the role each one plays.
Next, how does my plan work? We’ll go over the basic framework of the benefits then address what’s covered in a little more detail.
Who can I see? We’ll talk about the provider network and the impact of using a doctor or facility in the MultiPlan network.
Then we’ll discuss what you need to do when you’re at the provider’s office and we’ll also explain how claims are filed.
We’ll wrap up with the resources and contact information available to you should you have any further questions.

3. What’s My Plan Called?
Who’s Who – The Entities that Play a Role in Making the Plan Possible
The Corps Network
Membership Organization
Healthcare Plan Sponsor
Willis of Seattle
Manage and Market the Plan
Negotiate Renewals
Summit America
Medical/Rx Customer Service
Medical/Rx Claims Processing
Billing and Eligibility
PHCS and MultiPlan
Preferred Provider Networks (PPO)
Both networks owned by MultiPlan
Mutual of Omaha
Insurance Company/“On the Risk”
AD&D Claims
Ameritas
Dental Claims
Dental Customer Service
What’s my plan called?
MultiPlan is an independent preferred provider network. They are a group of contracted doctors and hospitals that have agreed to discount the price of their services and bill Summit America on your behalf.
Mutual of Omaha is the insurance company and risk bearing entity backing the plan financially. As a fully insured plan, if claims exceed the portion of the premium dedicated to paying benefits, Mutual of Omaha is on the hook to lose money.
Groups participating in The Corps Network Plan have the option to add dental benefits alongside the medical and prescription drug coverage. If your group has elected to add the dental benefits, they are handled by a company called Ameritas. Ameritas processes the claims and answers customer service calls.
It is referred to as ‘The Corps Network Healthcare Insurance Plan’. However, providers need to know who the PPO network is and who handles customer service and claims processing.

4. How Does My Plan Work? $100 Deductible General Plan Structure
You are responsible for the first $100 per service year
Exception: deductible is waived for preventive care
Once satisfied, the deductible will not reset until one year of continuous coverage from your initial effective date
How does my plan work?
Most of the benefits flow through the basic structure of the plan. The first $100 of medical or prescription drug services will be applied toward the deductible and will be your responsibility. The exception to this is preventive care, which is not subject to the deductible.
Once the $100 deductible is met, the benefits of the plan kick in. You will not have to meet another deductible while continuously on the plan until one year after your initial service date. Most members serve 10 or 11 months, so you won’t need to meet the deductible again unless you sign up for a second term of service.

5. How Does My Plan Work? $100 Deductible 80%/20% Coinsurance
General Plan Structure
Coinsurance
After your deductible, the plan pays 80% for most covered services
You pay 20%
Exceptions: outpatient mental health, outpatient chemical dependency after 40 visits (see benefit summary or brochure for more details)
After you’ve met your deductible, the plan pays 80% for most services and you pay the remaining 20%. Splitting the cost is called coinsurance. There are a couple exceptions that vary slightly from the 80% benefit, most notably outpatient mental health which is covered at 75% for the first 40 visits.

6. $1,000 Out- of-Pocket Maximum
How Does My Plan Work?
$100 Deductible
80%/20% Coinsurance
$1,000 Out- of-Pocket Maximum
General Plan Structure
Member Out-of-Pocket Maximum
If your 20% totals $900 in a given service year ($1,000 total out-of-pocket with the deductible), the plan pays 100%
If your 20% should add up to $900 in a given service year, you will have met the $1,000 out-of-pocket maximum (when including the $100 deductible). At that point, the plan begins paying benefits at 100%. This protects you from paying 20% indefinitely in the event of a serious illness or accident.

7. $1,000 Out- of-Pocket Maximum
How Does My Plan Work?
$100 Deductible
80%/20% Coinsurance
$1,000 Out- of-Pocket Maximum
$50,000 Per
Cause Benefit Maximum
General Plan Structure
Per Cause Maximum
Based on a condition or accident
For example, diabetes or skiing accident
After deductible and out-of-pocket maximum are satisfied, plan pays 100% up to a $50,000 maximum per cause
Plan can potentially pay more than $50,000 when multiple causes arise
The plan will keep paying at 100% for covered services until the $50,000 per cause maximum is reached. A cause is based on a condition, such as diabetes, or an accident and is determined by the diagnosis billed by the doctor or hospital. No more benefits are payable by the plan for a particular cause in which the $50,000 maximum is reached. However, it is possible to receive more than $50,000 in benefit from the plan for multiple causes.

8. What’s Covered? Covered Benefits Hospital Room & Board Intensive Care
Miscellaneous Hospital Services
Emergency Room
Professional Services
Office Visits
Surgery
Diagnostic Lab & X-ray
Preventive Care (Deductible Waived)
Routine Care - $150 maximum per year
Mammogram/Pap Smear – 100%
So what’s covered?
The plan covers a wide range of services
This includes hospital room & board, intensive care and miscellaneous hospital services and refers to both inpatient and outpatient settings. It also covers emergency room services which are typically the most expensive form of care. If your condition requires emergency room treatment, please by all means seek care immediately. However, if you’re able to avoid the emergency room, either by going to an urgent care center or making an appointment with your regular doctor, you will stretch your benefit dollars further.

9. What’s Covered? Covered Benefits Physiotherapy Inpatient
Outpatient – Limited to $500 Lifetime Maximum
Mental Health
Inpatient – 60 day maximum
Outpatient – 75% for first 40 visits; 60% thereafter
Chemical Dependency
Outpatient – 80% for first 40 visits; 60% thereafter
Injury to Teeth - $200 maximum per tooth
Ambulance

10. What’s Covered? Covered Benefits Prescription Drugs
Subject to deductible, coinsurance, out-of-pocket max and per cause maximum
No network of pharmacies – member must pay upfront
Prioritized reimbursement process
See the ‘How to File a Claim’ instructions for more detail
Pre-Existing Conditions
Covered up to $5,000 in the first twelve months of the policy
Six month “look back” period (to determine whether a condition is pre-existing) from the effective date of coverage
Diagnosed or treated, including prescriptions
Limitation period reduced by prior creditable coverage
HIPAA Cert, Certificate of Creditable Coverage
Break in coverage less than 63 days is permissible
1 year of prior creditable coverage (e.g., parent’s plan) can eliminate the entire pre-existing condition limitation period
So, if you were covered under a parent’s plan or a spouse’s plan for example and there was no break in coverage – or the break in coverage was less than 63 days – you can submit a HIPAA certificate or certificate of prior creditable coverage from the previous insurance company to reduce the 12 month limitation.
The key things to remember are that you will get a HIPAA Certificate from your previous insurance carrier if you were covered under a different plan. That should be submitted to Summit America. If you did not have other coverage before being enrolled on The Corps Network Plan, you still have up to 5000 in benefits for preexisting conditions.

11. Who Can I See? Preferred Provider Networks – PHCS and MultiPlan
You are not required to see a preferred provider, but there are two distinct advantages:
Preferred providers discount their services
Preferred providers are obligated to bill insurance
If you see a non-network provider:
They might bill you upfront
Charges above the 90th percentile of Usual, Customary and Reasonable (UCR) are your responsibility
9 out of 10 providers bill at or below this level for a given service in a given area
So now you understand the benefits and you need to use them. Who can you see?
You may see any licensed doctor. However there is a network of providers, through MultiPlan that is available to you.
It doesn’t change your benefits if you see a non-network provider
This means that 9 out of 10 doctors in a given area charge at or below that level for the specific service in question. If you doctor falls in the most expensive 10%, you will have to cover the difference in cost.

12. Who Can I See? Looking Up Preferred Providers
Website Search Engine –
Search for facilities or doctors
Search by name, specialty, city/state, zip code, etc.
Toll Free Number
Try PHCS first - In general PHCS has fewer providers but larger discounts, meaning more savings for you
If you are interested in finding a MultiPlan doctor or facility in your area or you want to look up a specific doctor, you have two options.
First, you can access the MultiPlan website at There you can search according to the parameters you choose. Second, you may call the toll free number at

13. What Do I Need to Do? At the Medical Provider’s Office
The doctor’s office wants to verify your benefits and eligibility
Show you ID card
If you don’t have your ID card, take the “How to Use Your Coverage” packet with you (available at Summit America’s website), which has the following information:
Provider Networks: MultiPlan and PHCS
Claims Processor/Administrator: Summit America
Group Number:
Member ID#: Summit America can find you by name or SSN
The doctor’s staff will call Customer Service:
You know what’s covered and you know who you are going to go see, so what do you do next?
The most important thing to remember at the doctor’s office is that they want to verify your benefits and eligibility. They need certain information in order to do that and it is all on your card. If you do not have your card, the key info you need is on this slide. It is also posted on Summit America’s website or may have been given to you as part of a packet called “How to Use Your Coverage”. Once the provider’s office has this information, they will call customer service to verify you are covered and what your benefits are.
When the provider’s office asks you “what kind of insurance do you have”, they are mostly interested in the network – MultiPlan – and the claims payor – Summit America. From their perspective, any other names will just add confusion.
Also, if the provider’s office says “we don’t take that insurance” it does not mean you cannot see that doctor. Even if the provider is not in the network, you still receive the benefits of the plan and they might still bill Summit America on your behalf.

14. How Do I File a Claim? Submitting Medical Claims
Preferred providers will bill Summit America on your behalf. Non-network providers might also bill insurance if they are able to verify the benefits and eligibility. If they do not, you can submit the claim to Summit America for reimbursement according to the plan’s benefits.
Claims Address:
The Corps Network Claims
Summit America Insurance Services
7400 College Blvd., Suite 100
Overland Park, KS

15. How Do I File a Claim? Prescription Drug Claims
No network of pharmacies, you will pay the cost upfront
Submit to Summit America for reimbursement
Prescription drug claims are prioritized
Processed within 1-2 days
Checks are run each business day of the week
Claims Address:
The Corps Network Claims
Summit America Insurance Services
7400 College Blvd., Suite 100
Overland Park, KS
Claims Fax:
Claims

16. What If I Still Have Questions?
Online Resources
Plan summary, brochure & certificate
Claim filing instructions
Online claim status lookup
Prescription claim form
ID card request form
Change of address form
Prior coverage form
MultiPlan toll free number and website link
More
Accessing Summit America’s Website
Go to
Place cursor on “Students & Participants”
Click on “Corpsmembers and Volunteers”
Click on “The Corps Network”

17. What If I Still Have Questions?
Customer Service – Summit America
(Dedicated customer service line for The Corps Network Plan)
Open 8:30 a.m. - 5:00 p.m. Central time, Monday through Friday
Check claims status
Benefit questions
Order new ID card
General plan information
On behalf of The Corps Network Corpsmember Healthcare Insurance Plan, I want to thank you for viewing this presentation. I also want to thank you for your service. We hope we’ve answered a lot of the questions you have but please don’t hesitate to use all the resources available to you should you need more information.