HEALTHCARE, SIMPLIFIED.
Your company is offering you medical coverage through EssentialCare. Our comprehensive guide is designed to help you make the right healthcare choice for you and your family during this complex time in healthcare reform.
FIXED INDEMNITY MEDICAL PLAN
- Includes Inpatient and Outpatient services
- There are NO Deductibles and NO Co-pays on medical services
- Pays you money to cover your health needs
- Keep the difference if a covered event costs less than the amount paid to you
- Plan is supplemental coverage and is not ACA Compliant
- Plan ALLOWS you to receive a subsidy at the Exchange
- Other additional benefits, such as Dental and Vision, may be available
(check your enrollment booklet for personalized plan options)
- When to Enroll
Enroll or Add Benefits/Insured Members
- Within 30 days of your hire date
- Within 30 days of your 1st paycheck date
- During Employer's annual 30-day open enrollment period
- Within 30 days from the date of a qualifying life event
Otherwise:
- Wait until next annual open enrollment
- Wait until you have a qualifying life event
- Get Covered
Coverage for the Fixed Indemnity Medical Plan and any ancillaries selected begins the Monday following a payroll deduction and continues as long as you have a deduction from your paycheck.
Review Your Check Stub
Make direct payments to PAI if you miss a payroll deduction to avoid a break in coverage. After six consecutive weeks without a payroll deduction, coverage will be terminated and COBRA information will be sent.
- Make a Change
You may cancel or reduce coverage at any time, unless your premiums are deducted pre-tax.
To make a change, call 1-866-798-0803.
NETWORK INFORMATION
These benefit plans offer you savings for medical care through discounts negotiated with providers and facilities in the First Health Network. Although not required, choosing an in-network provider helps maximize your benefits. When you use an in-network provider, you will automatically receive the network discount and the doctor's office will file the claim for you. If you use a doctor who is not part of the network, you will not receive the discount, and you may need to file the claim yourself. To find a participating provider or to verify if your current medical provider is in-network, please call or visit the network websites listed below.
Medical
To locate a provider call:
1-800-226-5116
Or Visit: www.firsthealth.com
Prescriptions
To locate a provider call:
1-866-798-0803
Or Visit:
www.paisc.com
Do not contact the above networks for questions regarding your medical benefits.
All medical benefit questions should be directed to the EssentialCare member services line at: 1-866-798-0803
QUALIFYING LIFE EVENTS
If you experience a qualifying life event (QLE), and wish to make changes to your health coverage, you have 30 days from the date of the event to submit supporting documentation, along with a change form, to PAI at the address found on the form. In addition, you may request a special enrollment for yourself, your spouse, and/or eligible dependents either:
- Within 60 days of termination of coverage under Medicaid or a State Children's Health Insurance Program (SCHIP)
- Upon becoming eligible for SCHIP premium assistance under these medical benefits. A qualifying life event is defined as a change in your status due to one of the following events:
- Marriage or Divorce
- Termination
- Loss of Dependent Status
- Loss of Prior Coverage
- Employer Bankruptcy
- Medicare Entitlement
- Birth or Adoption of a Child(ren)
- Reduction of hours (under 30)
- Immediate Family Member Death
FREQUENTLY ASKED QUESTIONS
- After I sign up, when will my coverage go into effect?
Coverage for the Fixed Indemnity Medical Plan and ancillary plans selected will begin the Monday following a payroll deduction and continues as long as you have a deduction from your paycheck.
Please review your check stub for deductions. If you do not see a deduction for two weeks, please contact your employer or Customer Service at 1-866-798-0803.
- When should I expect my ID card?
ID cards will be mailed as soon as your enrollment form is received and processed. You should receive your ID card within 10 business days of your effective date.
If you need to receive your ID card(s) sooner you can contact Customer Service at 1-866-798-0803 and request copies to be emailed or faxed to you or your provider.
- What if I miss a payroll deduction?
If you miss a payroll deduction, to avoid a break in coverage you may make direct payments to PAI. After six consecutive weeks without a payroll deduction or six consecutive direct premium payments, coverage will be terminated, and COBRA information will be sent at that time.
If you have questions regarding a missed payroll deduction, or need information on how to make direct payments, please contact Customer Service by calling 1-866-798-0803.
- What if I want to cancel or make changes to my coverage?
Post-Tax Products: You may cancel or reduce coverage at any time. To make a change, contact Customer Service at 1-866-798-0803.
Pre-Tax Products: You will only have 30 days from your hire date to enroll, add additional benefits or add additional insured members. After this time frame, you will only be allowed to enroll, add benefits or add additional insured members during your annual open enrollment period or within 30 days of a qualifying life event.
To make changes or cancel coverage based on a qualifying life event, please contact Customer Service at 1-866-798-0803.
- What is a qualifying life event?
A qualifying life event is defined as a change in your status due to one of the following:
- Marriage, divorce, annulment (spouse, stepchildren)
- Death
- Birth, adoption, placement for adoption, legal guardianship, or legal custody
- Loss of eligibility for insurance through another plan, change of coverage on spouse's plan, or significant change in premium cost
- Employee/dependent becomes eligible for insurance through another plan, eligible for Medicare/Medicaid, or enrolls in the Healthcare Exchange
- Dependent child marries, reaches maximum age to qualify for coverage (26), or becomes eligible through employer
- Rehire (more than 6 weeks since last assignment)
- Significant reduction in hours
If you experience a qualifying life event, you must submit documentation of the event along with a change form requesting the change within 30 days of the event.
In addition, you may request a special enrollment (for yourself, your spouse, and/or eligible dependents) within 60 days of:
- Termination of coverage under Medicaid or a State Children's Health Insurance Program (SCHIP).
- Becoming eligible for SCHIP premium assistance under this Fixed Indemnity medical benefit.
- Are dependents covered?
Yes. Eligible dependents include your spouse and your children up to age 26 (this may vary by state).
- Ho do I locate a doctor?
You are encouraged to visit providers in the networks to maximize your benefit dollars. To find a participating provider or verify your current medical provider is in-network, please contact Customer Service at 1-866-798-0803.
- Do I have to go to an in-network provider
It is not required that you go to an in-network provider. If you choose a provider who participates in the PPO network, you receive two key advantages:
- PPO discount for all services
- The provider will file the claim on your behalf
- Is there a phone number my doctor can call to get a list of my benefits?
Yes. Your provider may call Customer Service at 1-866-798-0803 to receive a schedule of benefits and benefit maximums.
- Is there a pre-existing clause for this plan?
No. There are no restrictions for pre-existing conditions for the Fixed Indemnity Medical Plan and ancillary plans. Even if you were previously diagnosed with a condition, you can receive coverage for related services as soon as your coverage goes into effect.
- What if I need to have a prescription filled?
For generic and brand prescriptions, present your ID card at a participating pharmacy to receive discounts. Generic and brand prescriptions are payable based on the schedule of benefits up to the annual prescription drug maximum.
To file a claim for reimbursement, save your receipt and submit to PAI. Prescription drug coverage is not provided for drugs administered during a physician office visit or hospital stay. For more information on submitting Rx receipts for reimbursement, please contact Customer Service at 1-866-798-0803.
- Is there coverage for contraceptives on these plans?
Yes. Oral contraceptives are covered under the prescription benefit. Non-oral contraceptives are not covered.
- Are maternity benefits covered
Yes. Maternity benefits are covered the same as any other condition under this plan.
- Can I receive a subsidy on the health market exchange?
Yes. If you enroll in the Fixed Indemnity Medical Plan, you may still be eligible to receive a subsidy.
- Doe this plan satisfy the individual mandate?
No. Currently, the Federal Affordable Care Act (ACA) individual mandate does not impose a penalty. In addition to Federal Mandates, some states have implemented their own individual mandate.
Please check your state's guidelines for any individual state mandate requirements or penalties.