Are employers required to make a premium contribution?
No. The plan is a voluntary payroll deduction group plan. However, some level of premium contribution can increase participation and enhance an employer’s ability to attract and retain employees.
Is everyone guaranteed coverage in the plan?
Yes. Eligible employees and their eligible dependents are automatically accepted for all Foundation One Security plans.
What happens after enrollment?
An orderly enrollment enables the administrator to issue and mail the employees’ Identification Cards and Certificates of Insurance in a timely fashion. Identification cards and member packets for LifeGuard Health Options will be issued separately, but included with the Certificates of Insurance.
Can an employee cancel coverage at any time?
Yes, unless deductions are being made through a Section 125 Plan. In that event, the timing of the change must comply with Section 125 guidelines.
Can employees’ coverage continue under COBRA?
Yes. The administrator will fully administer all aspects of COBRA continuation laws, including mailing COBRA notification correspondence to the employee’s home address of record. The plan administrator will also be responsible for collecting premium for COBRA continuation coverage. A separate agreement for the COBRA services must be signed, but there is no additional charge.
Will Certificates of Creditable Coverage be provided?
Indemnity insurance is not subject to the Health Insurance Portability and Accountability Act (HIPAA) and is not considered to be "creditable coverage." Therefore, Certificates of Creditable Coverage will not be issued for coverage periods under the health indemnity plan.
Can employees go to any doctor or hospital?
Yes. There is no restriction of doctors or hospitals in the plan. However, employees will receive an added value of having the Beech Street PPO network discounts applied towards their charges, when they utilize in-network providers.
How does indemnity insurance work?
Indemnity insurance coverage is reimbursed at the stated benefit amount, regardless of the provider’s fee. When a provider’s charge exceeds the plan benefit, the employee is responsible for paying the balance. If the provider’s charge is less than the indemnity benefit, the employee will be paid for the difference – when a claim is processed, the administrator will send the employee a check with a remark code on the Explanation of Benefits indicating that the check is the payment of indemnity plan benefits that exceeded the amount charged by a provider or pharmacy.
How do employees receive plan benefits when they go to a health or dental provider?
If the provider accepts assignment of benefits, the provider will file a claim for their services and will be paid an amount equal to the plan benefits. If the provider bill is less than the plan benefits, the employee will receive payment of the difference from the plan. If the provider’s charge exceeds the plan benefit, the provider will bill the employee directly for the balance.
If a provider does not accept assignment of benefits, the employee will be responsible for paying their health care or dental costs at the time of service and for filing a claim under the plan.
Can employees go to any pharmacy?
Yes, but the best value will come from negotiated network discounts at participating pharmacies in the CVS/Caremark nationwide pharmacy network. There are over 55,000 participating pharmacies across the country.
How does the Outpatient Prescription Drug Indemnity Benefit work?
An employee’s best value will come from negotiated network discounts at participating pharmacies in the CVS/Caremark nationwide pharmacy network. There are over 55,000 participating pharmacies across the country.
The program provides benefits for both brand name and generic drugs. The employee simply presents his insurance ID card at a participating pharmacy in the CVS/Caremark network. If the plan benefit is less than the cost of the prescription, the employee must pay the difference. If the plan benefit is more than the network discount price, the employee pays nothing, and will receive a check for the difference after the pharmacy submits the claim to the administrator.
What happens if an employee’s deduction is not enough to cover the insurance premium?
Our Normal Pay Date effective date procedure was specifically developed to accommodate pay cycle business. This coverage includes a Missed Premium Provision, which offers employees the opportunity to keep their insurance coverage active during periods when a reduction in hours worked results in a paycheck that does not support the full amount of the payroll deduction premium for their insurance coverage.
Here’s how it works. In the event an employee’s paycheck is not large enough to cover the full amount of the payroll deduction premium for insurance, coverage on the employee and any covered dependents will not end immediately but will, instead, be placed in a suspended status for up to 35 days if their deductions are weekly, or 42 days if deductions are bi-weekly. The employee is not required to make up premium missed during the suspension period, but will have the option of doing so by paying their premium directly to the administrator. If an employee or one of his dependents incurs an eligible claim during the suspension period, such claim will not be considered for payment unless the missed premium is paid.
If premium deductions do not begin again by the end of the 35- or 42-day suspension period, the employee’s insurance coverage will be terminated as of the end of the last period that was paid. If this happens, the employee will be eligible to re-enroll during the employer’s next open enrollment period.
The Missed Premium Provision is available only to groups with a Normal Pay Date effective date. Our monthly coverage (First of Month effective date) requires that monthly premium be submitted without interruption to keep coverage in effect.