PLATINUM SERIES Agent Training Only

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PLATINUM SERIES Agent Training Only

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Title: PLATINUM SERIES Agent Training Only


1

PLATINUM SERIES
2
GA, LA, NC, SD, TX, WA NO Critical illness
portion CA, CO, MN, NV, NH, SD, TX, WA NO ER
benefit available
Product NOT available in the green states
3
Agenda
  • Overview
  • Administrative Partners
  • Carrier Partners
  • Limited Medical Plan Benefits
  • Association Benefits
  • Policy Information

4
Product Overview
  • GUARANTEED ISSUE NO UNDERWRITING REVIEW
  • Great for consumers that may not qualify for full
    comprehensive Major Medical
  • A reasonable alternative (not replacement) for
    consumers who cannot afford more costly Major
    Medical programs
  • The plans provide coverage for the common
    everyday expenses such as doctor office visits,
    hospital, ICU and surgical expenses

5
Sponsored by UCAA
  • United Consumer Awareness Association
    (www.unitedconsumer.org)
  • A National Association
  • Offers a benefit package of consumer discount
    products including
  • Doctor/Hospital network
  • Call MD
  • Tiered Dental and Vision
  • 3-Tier Rx
  • Chiropractic
  • 24-hour nurses hotline
  • And much more!

6
Administrative Partner Patriot Health, Inc.
  • Patriot Health is a member of the Cost
    Containment Group (CCG) of companies,
    headquartered on Long Island, New York.
  • Established in 1993, CCG services millions of
    families nationwide through various health care
    related programs and networks.
  • Patriot Health is a Managing General Underwriter
    (MGU) and Administrator for Limited Medical
    Plans.
  • They offer a single source for product
    development, networks, administration and
    customer care.
  • They combine multiple insurance carriers and
    networks to deliver the most complete and highest
    value membership plans for the consumer.

7
Health Option One
In order to provide its members with the maximum
benefit options available in their particular
state, UCAA has contracted with the following
carrier partners
8
Insurance Carrier Limited Medical Benefit
Plans
  • United States Fire Insurance Company
  • Fairmont Specialty is a registered trademark of
    United States Fire Insurance Company
  • Niche products (accident and health)
  • A member of Crum and Forster group of companies
  • Rated A Excellent by AM Best (as of 2009)

9
Medical Benefit Provisions
  • There are no coordination of benefits with other
    plans
  • There is a 30 day wait on sickness benefits
  • Pre-X definition A medical condition, injury or
    sickness, for which medical advice,
    consultations, symptoms, care or treatment was
    recommended by a doctor within 12 months prior to
    the effective date of coverage will be
    considered a pre-existing condition unless the
    loss incurred at least 12 months after the
    effective date of coverage.
  • There is a 12/12 pre-x on Hospital Confinement
    Charges, Surgery and Anesthesia
  • There is a 6/12 pre-x on the Emergency Room
    Benefit
  • There is a 12/12 pre-x on the Critical Illness
    Benefit payable only after all valid and
    collectible insurance for the same claim has been
    exhausted

10
Eligibility
  • All Members and Spouses who are 18 to 65 years
    old. At age 65 the plan ends.
  • Unmarried Children
  • Under age 19
  • Includes stepchild, foster, legally adopted,
    pending adoption proceedings and natural child
  • Up to age 24 if enrolled as fulltime student at
    accredited college or university
  • Newborn (born during coverage period) for 31 days
  • Citizens or legal residents of the United States
  • Must be a legal resident for 12 months

11
Provider Access (Beech Street)
  • Health Option One utilizes Beech Street a
    National PPO network of providers
    (www.beechstreet.com - choose the limited benefit
    plan link)
  • 564,181 respected doctors
  • 5,083 acute care hospitals
  • 87,500 ancillary network providers
  • Practitioners in all 50 states!
  • Provider lookup 24/7
  • Utilizing Beech Street Network Providers
  • Maximizes client savings
  • Reduces out-of-pocket expenses

12
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14
Members can be enrolled only once. Duplicate or
multiple memberships, including United States
Fire Insurance Company benefits, is not
allowed. Underwritten by the United States Fire
Insurance Company, rated A (Excellent) by AM
Best Company (2009 Edition). Benefits not
available to residents of AK, CT, KS, MD, NJ, NY,
and VT. Maternity is not covered, and there is a
30 day waiting period for sickness. 12/12
Pre-Existing Condition Limitations apply to
Hospital Confinement Benefit, Surgery and
Anesthesia related to Surgery, Maternity is not
covered, and there is a 30 day waiting period for
sickness.
15
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16
Doctor Visits (Fairmont Specialty)
  • Sickness or Accident -5 visits per individual per
    policy year or 10 per family.
  • Doctor Office Visit co-pay is 20 the member
    must utilize a Beech Street provider.
  • If all visits are used (5/10) the in-network
    provider discount will still apply.
  • Out-of-network Doctor Office Visit Indemnity
    Reimbursement maximum of 40 per visit.

17
Wellness Visit (Fairmont Specialty)
  • In-network Doctor Office Wellness Visit - for
    routine health examinations or immunizations of
    Covered Persons.
  • Co-pay is 20 per visit 2 visits per person per
    year.
  • The benefit does not cover any wellness testing,
    such as mammograms, PAP or PSA Testing.
  • Claims for wellness tests will be re-priced
    through Beech Street if a network provider is
    used.
  • Out-of-network Doctor Office Visit Indemnity
    Reimbursement maximum of 40 per visit.

18
Diagnostic, X-Ray Lab (Fairmont)
  • Coverage is provided when x-rays, laboratory and
    other diagnostic tests are ordered or performed
    by a Doctor.
  • Includes the services of a radiologist or
    radiology group and the services of a pathologist
    or pathology group for interpretation of
    diagnostic tests or studies that are Medically
    Necessary due to an Injury or Sickness
  • There are a maximum of 3 sittings or draws per
    Covered Person per Policy Year.
  • If the member stays in-network they can get their
    bill(s) re-priced before the benefit is applied.
  • If all sittings are used the in-network provider
    discount will still apply
  • The payment amount is up to 100 per
    sitting/draw.

19
Hospital Confinement (Fairmont)
  • Sickness is payable after a 30 day waiting
    period.
  • Injury is payable as of the effective.
  • Benefits are payable from 1-31 days, up to 250
    or 1,000 per day while confined in a hospital
    semi-private room, as a result of a covered
    injury or sickness.
  • Using a Beech Street facility will help lower
    out-of-pocket costs.

20
Hospital Confinement ICU/CCU
(Fairmont)
  • Benefits are payable for up to 31days while
    confined in a hospital ICU/CCU, as a result of a
    covered injury or sickness.
  • The benefit is up to 1,000
  • 30 day waiting period for sickness
  • Paid in lieu of hospital confinement benefit
  • Using a Beech Street facility will help lower out
    of pocket costs.

21
Ambulance (Fairmont)
  • Up to benefit amount of 100 Per Trip
  • Medical Emergency only
  • 1 Trip per person per year
  • Ground or Air
  • This benefit is available in the 1000 plan series
    only

22
Surgery In/Out Patient (Fairmont)
  • Benefits are payable up to 10,000 per surgery.
  • Based off of CPT codes on a surgery schedule.
  • 2 surgeries per covered person per policy year.
  • Sickness benefits are payable after a 30 day
    waiting period.
  • Benefit Includes but is not limited to charges
    for
  • Surgeon fees
  • Use of the operating and recovery room
  • Administration of drugs and medicines during
    surgery
  • Dressings, casts, splints
  • Diagnostic services including radiology,
    laboratory, or pathology performed during time of
    surgery.

23
Surgery Health Option One vs. RBRVS
  • Surgical Benefit
  • 10,000 Fairmont surgical schedule vs. RBRVS
    schedule
  • RBRVS will pay just the cost of the surgical
    procedure (surgeon charges only) based upon the
    RBRVS code in the covered persons county
  • Health Option One Surgical benefit is provided
    for use of the operating room and recovery room,
    including the doctors charge for performing
    surgery. Benefit also provided for medical
    services and supplies used in the performance of
    the surgery. Includes, but not limited to
  • Administration of drugs and medicines during
    surgery
  • Dressings, casts, splints
  • Diagnostic services including radiology,
    laboratory, or pathology performed during time of
    surgery

24
Sample Comparisons (Hillsborough County, Tampa,
FL)
25
Anesthesia In/Out Patient (Fairmont)
  • This benefit is payable at 25 of the surgery
    benefit
  • Using an in-network provider will lower
    out-of-pocket costs

26
Emergency Room (Presidential)
  • Availability Varies by State
  • Injury or Sickness 2 visits per year
    (individual/family)
  • Benefit is payable up to 1,000
  • Subject to a 100 deductible per visit
  • There is a 6/12 Pre-ex
  • There is a 30 day waiting period for sickness

27
ADD (GTL)
  • Availability Varies by State
  • If you are injured in a covered accident and the
    injury from such an accident causes death or
    dismemberment within 365 days from the date of
    the accident, the insurance company will pay the
    amount shown.
  • If you sustain more than one such loss as the
    result of one Accident, the insurance company
    will pay only one amount, the largest, to which
    you are entitled.
  • The benefit is 15,000 in states where available.

28
Excess Accident Medical Expense (GTL)
  • Availability Varies by State
  • If you are injured in a covered accident and
    receive treatment from a physician within 365
    days from the date of the accident, the insurance
    company will pay the amount shown for actual
    expenses, up to the maximum per accident. This
    is an excess benefit so all other benefits must
    be used first.
  • Subject to a 100 deductible per accident.
  • Benefit amount is 5,000 per accident for all
    plans.

29
Guaranteed Issue Term Life (Hartford Life)
  • Requires NO medical Exam or Tests!
  • The benefit amount shown is paid to the
    beneficiary or beneficiaries in the event of your
    death.
  • Benefit payment is subject to the definitions,
    limitations, exclusions and other provisions
    within the Certificate.
  • Covered spouse benefit is 50 of benefit amount
    shown and dependent benefit is 20 of benefit
    amount shown. Covered dependent child(ren) must
    be at least 15 days or older to be eligible for
    coverage.
  • Benefit amount is 10,000 in states where
    available.

30
Critical Illness (AIG)
  • Please see State Product Availability Chart
  • The 10,000 Critical Illness Indemnity Benefit is
    payable for Insured and covered Spouse
  • Will be paid in addition to any other benefit in
    the Certificate
  • Subject to a 12/12 Pre-Existing Condition
    Limitations
  • A benefit is payable for any one of the
    following
  • Invasive Cancer
  • Heart Attack
  • Stroke
  • Major Organ Transplant Surgery
  • Coma
  • End Stage Renal Failure

31
Plan Highlights Association Benefits
  • Doctor/Hospital Network (Beech Street)
  • 3-Tiered Rx Discount
  • Tiered Dental
  • Tiered Vision
  • Call MD
  • Chiropractic
  • Counseling
  • 24-Hour Nurses Hotline
  • Elder Care
  • Hearing
  • Diabetic Supplies
  • Fitness
  • Holistic Care
  • Much more consumer lifestyle savings benefits!

32
Beech Street Top 100 Procedures Sample Savings
33
3-Tiered Prescription Drug Discount
  • 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.
  • Tiers are based on 1 pill per day for 30 days.
  • Tier 1 Drugs at up to a 10.00 maximum cost
  • Tier 2 Drugs at up to a 20.00 maximum cost
  • Tier 3 All other drugs are available for your
    benefit at negotiated rates.
  • Please note that some participating pharmacies
    may charge beyond a particular tier.

34
Top 10 Drug Savings
35
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
  • Tier 2
  • You will also receive discounted rates of 10-50
    on eyeglasses, non-prescription sunglasses and
    contact lenses (excluding disposables) at
    participating optical locations nationwide.
  • Ophthalmology LASIK
  • Save 20-60 on medical eye exams and surgical
    procedures including LASIK at participating
    ophthalmology locations.

36
  • All members will receive 2 toll-free physician
    telephone consultations - available 24/7
  • You have access to a nationwide network of
    medical doctors and registered nurses that are
    available to discuss your medical issues.
  • You can access over-the-phone prescriptions
    (where permitted by law)
  • Additional calls available _at_ 35.00 each

37
Dental Directory Services
  • Multi-tiered dental fee-for-service program
  • Tier 1
  • At select participating schedule (A) Tier 1
    general practitioners you will receive
  • a no-charge exam and x-rays in conjunction with
    a paid annual cleaning
  • Participating providers abide by a fee schedule
    of fixed payments for most procedures savings are
    20 to 60
  • Tier 2
  • 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

38
Tiered Chiropractic Program
  • Save on testing procedures, support and orthotics
    supplement, massage and other bodywork.
  • Tier 1 save 20-50 at participating providers
    on adjustments, therapy, x-rays, exams and
    specialized procedures using a fee schedule of
    fixed payments for most procedures.
  • First visit is 35 with adjustments thereafter at
    20.
  • Tier 2 Save 5-20 at participating providers

39
24 Hour Counseling Hotline
  • You and your immediate family members have
    unlimited access to a Masters Level Therapist.
  • Toll-free number available 24/7
  • Free support and self-help group referrals and
    referrals to local licensed therapist
  • All counselors have been specially trained to
    offer prompt, confidential counseling.

40
24 Hour Nurse Hotline
  • Unlimited, Toll-Free, 24/7 Access to Registered
    Nurses.
  • Confidential service is available to help you
    become more knowledgeable about healthcare
    services and more comfortable working in
    partnership with your healthcare providers
  • You will receive information regarding, the
    treatment of common illnesses, what to expect
    during medical testing, diagnostic and surgical
    procedures, recently diagnosed medical condition,
    prescriptions, and over-the-counter medical
    information.

41
Holistic Care
  • The Holistic Care Service provides a concierge
    approach to finding a Holistic Care provider
    that will meet your specific needs.
  • A Customer Care Consultant will take your request
    for an Acupuncturist, Massage Therapist,
    Dieticians and Naturopathic providers and call
    you back with the nearest location.
  • Up to 20 savings on, all treatments and
    services. There is no limits on number of visits.

42
Hearing Care
  • Beltone Features
  • Free hearing screening and 15 discount on
    Beltone hearing aides at more than 1,300 Beltone
    locations.
  • Lifetime care program includes complimentary
    hearing aid checkup, free cleaning and inspection
    while under warranty and a 30 day refund policy.
  • HearPO Features
  • 20-50 off audiology and hearing aid services
    at more than 1,400 participating HearPO
    providers.
  • Comprehensive follow up for one year at no
    charge. 100 discount on repairs and a 60 day
    refund policy
  • Your hearing aid comes with a 12 month standard
    manufacturers warranty. Modifications will be
    made without cost during warranty should a change
    within hearing levels require different
    circuitry.

43
Elder Care
  • Save on home health and long term care services,
    available for any member for your family
    including grandparents!
  • Save 10-25 on home health aides, nursing homes,
    assisted living facilities, Alzheimers special
    care units and respite care facilities. (savings
    are available for new patients only)
  • Toll free 24/7 advice hotline

44
Diabetic Supplies
  • Save 10-60 on Diabetic supplies
  • This program provides special member pricing on
    most diabetic supplies such as
  • Test strips, glucose meters, lancing devices and
    lancets and convenient free home delivery!

45
Fitness
  • Enjoy 10-50 off membership dues at over 1,000
    locations nationwide!
  • Month to month memberships at top area fitness
    centers . (10 administrative fee may apply upon
    cancellation)
  • This program includes many franchises of Golds
    Gym, Ballys Fitness, Curves for Women and other
    chains as well as independent fitness clubs.

46
Association Consumer Discount
  • Consumer discount programs vary by plan but
    include
  • Medical records software
  • Hotel savings
  • Rental car savings
  • Mortgage and Realtor discounts
  • Financial planning
  • Tax hotline
  • Roadside assistance
  • And many more

47
Effective Dates and Billing Dates
  • If a member enrolls between the 1st and the 15th
    they will be effective on the 1st of the
    following month. Initial charge occurs on the day
    of enrollment and recurring charges occur on the
    15th of every month there after.
  • If a member enrolls between the 15th and the last
    day of the month they will be effective the 15th
    of the following month. Initial charge occurs on
    the day they enroll and recurring charges occur
    on the 1st of every month there after.
  • Future effective date options are available up to
    60 days.
  • Payments can be made using Credit Card or by
    drafting a checking/savings account NO
    individual paper bills

48
Fulfillment Materials
  • The insured will receive an email fulfillment
    with ID card, certificate, schedule and benefit
    booklet instantly after enrollment submission.
  • Fulfillment materials will be mailed direct to
    the insured within 24 hours after premium
    processing is verified.

49
Rules For Limited Medical Plan Sales
  • DO NOT Represent Limited Medical Plans as
  • Same as your employer plan
  • Just like Major Medical
  • Full Benefits
  • A PPO

50
Rules For Limited Medical Plan Sales
  • Clearly explain the limited nature of the plan
  • This limited medical benefits plan
  • Does Not Provide comprehensive medical coverage
  • Is a basic or limited benefits policy and is not
    intended to cover all medical expenses.
  • Is not designed to cover the costs of serious or
    chronic illness.
  • Contains specific dollar limits that will be paid
    for medical services which may not be exceeded.
    (if the cost of services exceeds those limits,
    the beneficiary and not the insurer is
    responsible for payment of the excess amounts)

51
Rules For Limited Medical Plan Sales
  • Explain the key elements of
  • Guarantee Issue
  • Pre-existing condition limitation
  • 30 day wait on sickness
  • Go through the plan of benefits in detail with
    the consumer, including their membership in the
    Association
  • Explain how the Beech Street Network discount
    works
  • Explain that the Rx card is a discount program
  • Explain the claims submission process, billing,
    and customer service
  • Explain the 30 day free look provision and how
    refunds work
  • All agents soliciting sales and enrolling
    consumers must hold a valid health insurance
    license in the state in which the consumer
    resides!

52
Administrative Partner Patriot Health, Inc.
  • Customer Care
  • Members are encouraged to speak directly with a
    Patriot Representative.
  • Dedicated consultants assist members with
    benefits, provider locater, and coordination
    services.
  • Members can contact Patriots toll free phone
    number Monday through Friday, 900 AM until 700
    PM (EST). 888-633-5080

53
Cancellation Refund Policy
  • A member may cancel at any time.
  • Cancellation will be required in writing
  • If an insured calls Patriot to cancel, they will
    be sent a form to sign. Once the form is
    received, agent will be notified and copied. If
    agent can conserve the case, and the consumer
    verifies in writing they wish to keep the policy,
    Patriot will reinstate the policy back to the
    original effective date, and premiums will be
    collected accordingly.
  • If a member cancels within the first 30 days, the
    membership cost will be refunded. The one time
    enrollment fee is non-refundable, except where
    specified by state law. Those states are
    AR,MD,NE,FL,SC, TN ,
  • If a member cancels within 3 days from the
    enrollment date, the member will be refunded the
    first months membership costs plus the one time
    enrollment fee.

54
Policy Changes
  • The insured or the agent can call or email
    Patriot to make changes for
  • Dependent status
  • Plan changes
  • Payment changes
  • Address changes

55
Claim Processing
  • Claims are processed by Administrative Concepts,
    Inc. (ACI) located in Wayne, PA (Toll Free
    888-293-9229)
  • ACI is an industry leader in providing superior
    services for specialty insurance products and a
    valuable resource to insurance companies and
    brokers
  • Re-pricing for PPO discounts
  • Claim payment
  • Explanation of Benefits sent
  • Providers
  • Patients
  • www.visit-aci.com

56
Web Site Features
  • Plan and Benefit Availability by State with Rates
  • Brochure and Sample Certificates
  • Training Power Point
  • FAQs
  • Association Provider and Beech Street Links
  • Enroll On Line for your Customer
  • Agent Back Office
  • Track and manage business
  • 24/7 access to clients policy information

57
Thank You and Welcome to H.O.1
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