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Insured by American Medical Life Insurance (AMLI). A gent T raining P resentation. IBN Agent Training - May 2010. Insurance Brokers Network. National Program Manager Sales and Marketing Agent Contracting and Commission Disbursements Website Technology On line enrollment and services
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Insured by American Medical Life Insurance (AMLI) Agent Training Presentation IBN Agent Training - May 2010
Insurance Brokers Network • National Program Manager • Sales and Marketing • Agent Contracting and Commission Disbursements • Website Technology • On line enrollment and services • Eligibility, Premium Collection, Claims and Customer Service • Excellent support and training programs
Insurance Carrier • American Medical and Life Insurance Company • Incorporated in 1964 in New York (Home Office NYC) • Rated B- by AM Best • www.usamli.com
Sponsored by NCE • National Congress of Employers • A national association • Offers a benefit package of consumer discount products, including Rx Discount Card, Dental and Vision programs! • Learn more about NCE on CoreValue site
Administrative Partner • GettHealth Administrators, Inc. • GettHealth and it’s affiliated companies are a licensed TPA’s in 49 states • Founded in 1979 (30 years in business) • Eligibility and enrollment, billing and collecting, commission accounting, and management information systems from offices in Gettysburg, PA and Ft. Washington
Product Overview • The CoreValue plans offer valuable association and insurance benefits for consumers who: • May not qualify for full comprehensive major medical • Can not afford full comprehensive major medical • Looking to reduce the cost of current medical premium • A reasonable alternative (not replacement) for more costly Major Medical programs • GUARANTEED ISSUE – NO UNDERWRITING REVIEW
Provider Access • CoreValue Medical utilizes the MultiPlan Network • maximize the client’s savings • reduce out-of-pocket expenses • All plans pay the same dollar amounts whether or not the network is utilized, and there is no reduction in benefits • If a network provider is used, the claim is electronically re-priced and a significant discount is realized by the insured • 550,000 practitioners in all 50 states! • The link to find a provider 24/7 on line is available on the CoreValue Medical website
Eligibility • Dues paying members between ages 18 and 64 • Dependent children under the age of 19 • No child only applications. A 19 year old cannot add a sibling as a dependent • Member’s unmarried dependent children with proof of full time student status between the ages of 19 and 26 • Members not in full-time service of the Armed Forces (military) • Members not eligible for Medicare • Members that are residents of United States (no SS# needed) • Members not receiving disability benefits or Worker’s Compensation
Alabama Arkansas Arizona Delaware DC Florida Georgia Hawaii Illinois Kentucky Louisiana Michigan Mississippi Missouri Nebraska Nevada Ohio Oklahoma Pennsylvania Rhode Island South Carolina Tennessee Texas West Virginia Wisconsin Wyoming States Available
Plan Highlights • Guaranteed Issue – No declines • No Deductibles to Satisfy • First Dollar Coverage – No Co-pays • HIPAA Compliant • Credible Coverage Satisfaction for Pre-X • No GAP in coverage for 63 days or less • No Lifetime Maximum Benefit Amount • 30-Day Free Look Period • On Line Enrollment
Benefit Highlights • Doctor’s office visits including chiropractors (any doctor or in the Multiplan discount provider network) • Preventive Care (Wellness) • Lab and X-Ray • Inpatient Hospital Confinement • ICU/CCU (on most plans) • Surgery Charges up to 100% of Medicare Reimbursement • Anesthesia • Maternity (covered under surgery benefit) • Accidents • Inpatient and Outpatient Mental Health • Inpatient and Outpatient Substance Abuse • Associated with MultiPlan Discount Provider Network
Doctor Office Visits • Covers charges for and require a doctor’s office visit due to injuries received in a covered accident OR sickness • Includes Chiropractors (office visit only – manipulations are not covered under this benefit) • A Doctor or Physician means a legally qualified practitioner of the healing arts acting within the scope of his or her license and is not an Immediate Family Member
Preventive Care (Wellness) • Policy will pay the preventive care test benefit, shown on the certificate schedule, if any covered person incurs charges for and has one of only the following preventive care tests listed below performed per year: • Blood test for triglycerides • Bone marrow testing • Breast ultrasound • CA 15-3 (blood test for breast cancer) • CA 125 (blood test for ovarian cancer) • CEA (blood test for colon cancer) • Chest X-ray • Colonoscopy or virtual colonoscopy • Eye exam performed by a licensed optometrist or ophthalmologist • Fasting blood glucose test • Flexible sigmoidoscopy • Hemoccult stool analysis • Mammography (baseline and annual screenings) • PSA (blood test for prostate cancer) • Pap smear or Thin Prep Pap Test • Serum Protein Electrophoresis (blood test for myeloma) • Stress test on a bicycle or treadmill • Child Screening Services from birth to age 21 (if covered under the plan). Schedule set by the American Academy of Pediatrics
Diagnostic Lab and X-ray • Medically necessary diagnostic tests and x-rays performed in a doctor's office, hospital or outpatient facility. E.g. MRI, CAT Scan, EKG.
Inpatient Hospital Confinement • Charges for a confinement in the hospital due to injuries received in a covered accident or sickness • Unlimited re-admission
ICU/CCU • Charges for a confinement in a hospital ICU/CCU due to injuries received in a covered accident OR sickness • A Hospital Intensive Care Unit that meets the definition above may include Hospital units with the following names: • Intensive Care Unit • Coronary Care Unit • Neonatal Intensive Care Unit • Pulmonary Care Unit • Burn Unit • Transplant Unit • Unlimited re-admission
Surgery (Surgeon) • If insured has a surgical procedure do to a covered accident OR sickness • Covers cost of “surgeon charges” only • The procedure must be performed by a Physician and require anesthesia administered by a licensed anesthesiologist or certified registered nurse anesthetist • Outpatient is covered, but must require an anesthesia that meets the definition above • Reimbursements are based on the Medicare/RBRVS benefits schedule • Maternity (vaginal delivery) is considered a surgery and is covered under this benefit.
Maternity • Paid under the surgery benefit • The maternity benefit would work the same as any other illness. The provider bills would be processed under any benefit that qualifies. (surgery, x-ray, lab, as shown on the physician billing). The hospital stay would fall under the hospital benefits and paid according to the hospital benefit schedule. • There is a surgical RBRVS schedule • Not subject to pre-x • Newborn is covered for 31 days • Insured must add newborn as a dependent within 31 days if they want coverage COVERED BY PREVENTIVE CARE BENEFIT • Child Screening Services from birth to age 21 (if covered under the plan). Schedule set by the American Academy of Pediatrics
Anesthesia • Anesthesia administered by a licensed anesthesiologist or certified registered nurse anesthetist • Does not cover basic anesthesia administered by a doctor (mole removal, etc.) • Payable as a percentage (20%) of the surgery benefit • Example: If surgery is $5,000, then the anesthesia benefit is $1,000
Accident • Benefit pays after the other policy benefits have been exhausted • If a Covered Person is injured in a Covered Accident, this Accident Medical Benefit will cover any remaining expenses, not covered by the policy according to the Schedule of Benefits and Policy Provisions • Costs must be incurred within 90 days of accident or injury • Benefits paid for: • Hospital Room and Board (General Nursing) • Hospital Services and Supplies • Operating and Recovery Room • Physician Charges, Private Duty Nurse • Diagnostic tests, x-rays, lab • Anesthetic and Prescription Drugs • Rental of Durable Medical Equipment • Artificial limbs, eyes and other prosthetic devices • Casts, splints, trusses, crutches and braces • Oxygen and rental of equipment for oxygen • Physiotherapy given by a licensed physical therapist
Inpatient Mental Health and Substance Abuse • Each day of confinement if confined to a hospital or licensed institution to provide treatment for mental illness or substance abuse • There are mental and substance abuse providers in the MultiPlan network
Outpatient Mental Health and Substance Abuse • Treatment received as an outpatient in an outpatient facility as a result of mental illness or substance abuse • There are mental and substance abuse providers in the MultiPlan network
NCE Membership Benefits The Discount Medical Plans, (Dental, Vision and RX), are not available in the following states: AK, MT, ND, OK, SD, and VT (Dental and Vision) are not available in FL
Discount Prescription Drugs • This plan is accepted at over 50,000 participating pharmacies nationwide • Simply visit a participating pharmacy, present your membership card and pay the pharmacy directly • Drug and pharmacy lookup (links) on CoreValue site • Tier 1: Drugs at up to a $10.00 maximum cost • Tier 2: Drugs at up to a $20.00 maximum cost • Tier 3: Drugs at up to a $50.00 maximum cost • Tier 4: All other drugs are available for your benefit at negotiated rates. (Up to 35% discount)
Dental Directory Services • Multi-tiered dental fee-for-service program Tier 1 • At select participating schedule (A) Tier 1 general practitioners across the country, you will receive: • a no-charge exam and x-rays in conjunction with a paid annual cleaning • Provider link on CoreValue site • Participating providers abide by a fee schedule of fixed payments for most procedures • Fixed schedule procedure rate savings are 25%-60% on dental care as compared to the American Dental Association
Dental Directory Services • Tier 2 • In the event a schedule (A) Tier 1 provider is not available in a given area, a secondary provider is given to member that still provides 20%-60% discounts but does not provide a free exam • Tier 3 • In the event a Tier 1 or Tier 2 provider is not available in your area, member will call customer service for assistance in accessing a Tier 3 provider which will provide them a discount
Quality Vision Network (QVN) • Tier 1 • At select participating vision outlets, a no-charge eyeglass vision exam is available once annually for every family member • Prescription must be Filled by the provider performing the no-charge exam if glasses are required • You will also receive discounted rates of 10%-50% on eyeglasses, non-prescription sunglasses and contact lenses (excluding disposables) at participating independent and retail optical locations nationwide. Most frames, lenses and specialty items are available.
Quality Vision Network (QVN) • Tier 2 • At participating independent and retail optical locations nationwide, you will receive a 10%-50% discount on eyeglasses, non-prescription sunglasses and contact lenses (excluding disposables). Most frames, lenses and specialty items are available. • Ophthalmology & LASIK Features • Save 20%-60% on medical eye exams and surgical procedures including LASIK at participating ophthalmology locations.
Medical Benefit Provisions • Pre-Existing Conditions • Policies have preexisting conditions limitations. Preexisting conditions are not covered until the policy has been in effect for more than twelve (12) months. A preexisting condition is a condition, physical or mental, regardless of cause or condition, for which medical advice, diagnosis, care or treatment was recommended, or received from a physician within a six month period preceding the effective date of coverage of a covered person.The plans are HIPAA compliant. Any persons who leave the plan will receive a HIPAA Compliant for Creditable Coverage Certificate. • Those who enter the plan presenting a Certificate of Creditable Coverage will receive credit towards this Plan's preexisting conditions limitations. • Information of where to send Certificate of Credible Coverage is provided on the CoreValue web site.
Limitations and Exclusions • Benefits will not be paid for: • Treatment, services or supplies which: • Are not Medically Necessary • Are not prescribed by a Doctor as necessary to treat Sickness or injury • Are experimental/investigational in nature, except as required by law • Are received without charge or legal obligation to pay • Is provided by an immediate family member
Additional Limitations and Exclusions • Benefits will not be paid for by sickness or injuries caused by (except as specifically provided for in the policy) • Dental Procedures • Alcoholism or Drug Addiction • Mental Illness • Elective Procedures and Cosmetic Surgery • Felony or Illegal Occupation • Manipulations of the Musculoskeletal System • Suicide, Attempted Suicide or Self-Inflicted Injuries • War or Act of War • Worker’s Compensation
Effective Date and Billing • Effective dates are the 1st and 15th of each month • On line enrollment must be submitted by the 20th of the prior month to obtain a first of the month effective date and the 5th of the same month for a 15th effective date • Payments can be made via credit card or EFT • Future drafts will occur 10 days prior to effective date month.
Fulfillment Materials • Fulfillment materials will be mailed direct to the insured • Insured will receive an email when fulfillment is processed with access to materials on line 24/7! • Kits will contain a welcome letter, ID cards for limited medical and association, certificate of coverage, claims information and customer service contact information
Sales Tips • DO NOT Represent Limited Medical as: • “Same as your employer plan” • Just like “Major Medical” • “Full Benefits” • A “PPO”
Sales Tips • Clearly explain the limited nature of the plan – it is financial assistance, not complete coverage • Explain the key elements of: • Guarantee Issue • HIPAA creditable coverage • Pre existing condition limitation • Go through the plan of benefits in detail with the consumer, including the affiliation with the Association • Explain how the discount network works • Explain the claims submission process, billing, and customer service • Explain the 30 day free look provision
Web Site Featureswww.corevaluemedical.com • Access to Consumers: • Overview of Limited Medical Plan • Plan and Benefit Comparison Chart with rates • Brochure • Association Benefits • MultiPlan Discount Network Link • Links to Discount Rx, Dental and Vision Providers • Enroll on line • Customer Service Contacts • Claim and Plan Change Forms
Web Site Featureswww.corevaluemedical.com • Available to Agents: • Plan and Benefit Comparison Chart with Rates • Brochure • Appointment Forms (PDF) • Webinar Information • FAQ’s • PPO and Association Provider Links • IBN Contacts and Information • Enroll On Line for your Customer • Agent Back Office • Track and manage business • 24/7 access to client’s policy information