The Per4mance Health Plan

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The Per4mance Health Plan

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Major Medical Plan. Generic. Brand $10 Co-pay. Discount ... Exclusions: Surgical Supplies, Med. ... to provide medical and hospital care at discounted rates to ... – PowerPoint PPT presentation

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Title: The Per4mance Health Plan


1
The Per4mance Health Plan
  • The plan that pays to buy

2
Per4mance Health Plan Plus
  • Major Medical Insurance
  • Guarantee Issue
  • Available in all States
  • Available to all Industries
  • Takeover of Creditable Coverage
  • HIPPA Compliant
  • No One can be turned down
  • If you meet the eligibility
    requirements

3
A PACKAGED PLAN THAT WORKS
4
Guaranteed Issue Major Medical Plan
After the Annual Deductible is met, the
coinsurance for in-network benefits is 20 (30
for out-of-network) until the coinsurance
maximum of 2,000 (3,000 for out-of-network) is
reached, then the coinsurance is 0. The
Insurance Carrier will then pay 100 up to
2,000,000 lifetime maximum. NHBC is the
Network Option for The Per4mance Health Plan
5
HOW IT WORKS
  • All of the Claims received for your Medical
    Expenses will be applied to the 10,000 annual
    deductible. (Prescriptions costs will not apply
    to the deductible)
  • The Supplemental Plans have been added to
    soften the expense of the high deductible. Each
    of the following benefits will pay in addition to
    the Major Medical Plan.
  • Example1 Claim for a Heart Attack 4 days in
    Hospital with Catheterization of the Heart
    Total Charges 25,814.00
  • Network Savings of 20 - 5,162.80
  • Balance 20,651.20
  • Critical Illness Benefit -
    5,000.00
  • First Occurrence Benefit - 3,000.00
  • Daily Hospital Confinement Benefit -
    200.00
  • Total Payments Toward the Deductible
    Subtotal 8,200.00 gt
  • Insured Payment owed to meet deductible -
    1,800.00gt
  • Maximum out of pocket for 20 Co-Insurance -
    2,000.00
  • Total Owed by Insured 3,800.00
  • Insurance Company Will Pay Balance of
    8,651.20
  • Total Balance Due 0.00

10, 000 DEDUCTIBLE MET
6
SAMPLE CLAIM
  • Example 2 Claim for a first diagnosis of
    internal cancer. The insured is in the hospital
    for 7 days, surgery is required, and the hospital
    bill, including surgeons fees is 120,000.00.
  • Total Charges 120,000.00
  • Network Savings of 20 - 24,000.00
  • Balance 96,000.00
  • Critical Illness Benefit
    - 5,000.00
  • First Occurrence Benefit - 5,000.00
  • Subtotal Balance 86,000.00
  • Total Payments Toward the Deductible
    10,000.00
  • Insured Payment owed to meet deductible
    0.00gt
  • Subtotal Balance 86,000.00
  • 20 Co-Insurance (2,000 Maximum) -2000.00gt
  • Insurance Company Will Pay Balance of
    84,000.00
  • Total Balance Due 0.00

10, 000 MAX DEDUCTIBLE MET
2, 000 MAX CO-INSURANCE MET
TOTAL CLAIM CHARGES 120,000.00 TOTAL OUT OF
POCKET 1,650.00
7
SAMPLE CLAIM
Example 4 Doctor Office Visit for Sickness.
Total Charges 77.00 Network Savings
- 15.00 Balance 62.00 Doctor
Office Benefit -50.00 Subtotal
12.00 Balance Owed by the Insured
12.00 Amount applied to Deductible (62.00)

TOTAL CLAIM CHARGES 77.00 TOTAL OUT OF
POCKET 12.00
Example 5 Diagnostic MRI on lower abdomen.
Total Charges 1,115.17 Network Savings
44 - 390.31 Balance
724.86 Balance Owed by the Insured
724.86 Amount applied to Deductible
(724.86)
TOTAL CLAIM CHARGES 1,115.17 TOTAL OUT OF
POCKET 724.86
8
Supplemental Plans Accident Plan
  • Medical Expenses Benefit
  • 5,000 (100 deductible)
  • If the Insureds injuries result in expenses
    shown below, we will pay for the necessary
    medical treatment up to the usual and customary
    charge for such expense incurred within fifty-two
    weeks from the date of the accident.
  • a hospital, outpatient surgery, ambulatory
    surgical center, or clinic charges
  • physician charge
  • licensed nurse charges, who is not a member of
    the Insureds immediate family
  • ground ambulance charges within forty-eight
    hours of the covered accident
  • charges for x-ray, laboratory tests, oxygen,
    casts, splints, crutches, braces (other than
    dental braces), blood, blood plasma, drugs,
    medicines and treatment of natural teeth
  • charges for rental of durable medical equipment
    of a medical or surgical nature which can be
    utilized only for treatment of such injury.

9
Supplemental Plans First Occurrence Benefit
First Hospital Confinement Benefit Pays the
benefit amount for the Insureds First Hospital
Confinementfor a covered injury or sickness
during the Calendar Year based on the total
number of days of Hospital Confinement.
Up to 5,000 Schedule 1st day 500 2nd Day
500 3rd Day 1,000 4th day 1,000 5th day
1,000 6th day 1,000
10
Supplemental Plans Doctor Office Visit
Office Visit (Not subject to Pre-existing) Pays
the specified benefit for the treatment in an
out-of-hospital facility (including Physicians
office), due to a covered sickness. This
benefit also pays one and one half times the
benefit selected per sickness treatment in a
hospital emergency room.
Paid at 50 a visit 4 per Member/ 4 per spouse/ 4
total for ALL children
11
Supplemental Plans Daily Hospital Confinement
Hospital Confinement - Per Day Pays the daily
benefit selected for hospital confinement
(resident bed patient) due to a covered injury
or sickness beginning with the first day up to
180 days
Paid at 50 per day Up to 180 days
12
Supplemental Plans Critical Illness
  • Critical Illness 5,000 Benefit
  • This Benefit will pay 100 of the First
    Occurrence Benefit shown on the Policy Schedule
    if one of the following Specified Health Events
    occurs for the first time in the Insured Persons
    lifetime and while Benefit is in force with
    respect to the Insured
  • Heart Attack
  • Stroke
  • Life Threatening Internal Cancer
  • End Stage Renal Failure
  • Major Organ Transplant or
  • Permanent Paralysis.
  • The Company must be provided with a diagnosis by
    a Physician accompanied by documentation
    supported by clinical, radiological, histological
    and laboratory evidence satisfactory to the
    Company. The Company may, at its expense, require
    an examination or further tests by a Physician of
    its choice.
  • Once 100 of the First Occurrence Benefit has
    been paid for an Insured, Critical Care Coverage
    terminates for that Insured and no further
    benefits are payable for the Insured Person.

13
Per4mance Rx Prescription Card
  • The Per4mance Rx card allows you to buy
    GENERIC Prescriptions for 10.00. You will
    receive an ID card in the mail within a few weeks
    of enrolling. Just present the card to your
    pharmacist to receive your Generic Prescription
    for 10.00 instantly.
  • No waiting period
  • No Claim forms to fill out
  • No exclusions for pre-existing conditions
  • No age limit
  • Honored at over 57,000 pharmacies nationwide
  • DISCOUNT on Brand name Prescriptions-The discount
    varies based on the prescription. Again present
    your card and your pharmacist will apply the
    discount to your purchase right then. You will
    typically save from 15 to 30
  • MAIL ORDER program is available for Maintenance
    Prescription which will provide additional
    savings

Exclusions Surgical Supplies, Med. Devices,
Blood Components, General Anesthetics,
Injectables, OTCs, Smoking Deterrents, Multiple
Vitamins, Prenatal Vitamins, Anorexic
Medications, Growth Hormones, Bee Sting Kits,
Imitrex, MS Medications, HIV Medications,
Fertility Drugs, Contraceptives, Acne Preps,
Fluoride Preps ,ADD Drugs, Impotence Agents,
Experimental Drugs
14
Network Savings
Reduce Medical Costs by Using the NHBC Network
NHBC is one of America's largest healthcare
networks, used as part of health plans to ensure
patients have access a wide choice of doctors and
hospitals. The doctors and hospitals in our
network agree to provide medical and hospital
care at discounted rates to patients who are
members of NHBC client health plans. No matter
where you live or work in the United States there
are NHBC doctors available to care for you and
your family. NHBC facility network is comprised
of more than 15 different types of institutions
and our practitioner specialties number more than
130. The NHBC is easily accessible through the
web at www.NHBC.com which provides detailed
information about the hospitals, doctors and
other healthcare services available through the
network.
15
Patient Advocacy w/Health Plan Advocate
  • This unique service will help you and your family
    work within the Per4mance Health Plan
  • Health Plan Advocate Can
  • Help you choose a provider
  • Help you understand what your physician has told
    you
  • Help you arrange medical services
  • Answer your prescription questions
  • Help with health claim coverage issues
  • Research questions about your health concerns
  • Patient Advocacy is included in your health plan
    to help you and your family cope with a complex
    and often bewildering health care system.
  • Help in only a Phone Call Away!
  • There is no additional charge or co-pay for using
    Health Plan Advocate.
  • There will be a Toll Free number listed on the
    back of your Health Plan Card for you to call.
  • When should You Call Health Plan Advocate?
  • When you have a question about medical care or
    your health plan benefits.
  • When inpatient or outpatient hospital services
    are scheduled.
  • Health Plan Advocate will help you understand how
    to receive the maximum benefit under your plan

16
REGIONAL NETWORK COVERAGE SAVINGS
  • A regional network can save you significant out
    of pocket expenses. This program assigns you the
    best available regional network based upon your
    zip code.
  • How it worksYou will receive an ID card
    identifying the primary network you have been
    assigned.Go to the Doctor or Hospital Your claim
    will be submitted to the Network for
    processing.If your provider is in your assigned
    network it will be re-priced and sent to the
    insurance carrier for payment. These savings
    will then be passed along to you. It is that
    simple! Use a provider in your regional network
    any time available and take advantage of savings.

17
MedTestForLess HUGE savings on Laboratory Testing
and Diagnostic Procedures X-rays!
  • HOW IT WORKS
  • Order lab tests online at www.medtestforless.com.
    Diagnostic and X-ray tests must be ordered using
    our toll free number (1-866-7MEDTEST) or
    1-866-763-3837.
  • All testing is on a pre-paid basis. This is how
    you save valuable dollars on tests. You will be
    expected to pre-pay (via Automatic Checking or
    Credit Card) when ordering. Also, for diagnostic
    tests, youll need to have your doctors
    prescription ready when ordering.
  • Your doctors office may order tests for you
    (either on line for lab tests, or via toll free
    number for all tests). We provide simple
    instructions for both on line and toll free
    number ordering. Just remember to give your
    doctors office Automatic Checking or Credit Card
    information when ordering. The procedure takes
    just minutes. Its that simple.
  •  

18
Imaging Discount Plan
  • Members may save hundreds of dollars a year using
    this benefit. Members will have direct access
    for X-rays, MRIs, PET, CAT Scan, and Diagnostic
    Tests. This program provides the deepest
    discounts in the industry for many of your TESTS.
  • Benefits
  •  You have access to over 7,000 diagnostic
    facilities in the country!
  • You do have to get a Doctor to order a test
    because diagnostics require a prescription.
  • We will schedule the appointment for you, or you
    can make your own appointment arrangements at one
    of the network providers.
  • The results will be provided in an easily
    understood manner to the provider of your choice.
  • Savings range from 20-80 depending on the test.
    You can save hundreds, even thousands of dollars
    a year using our network of contracted providers.
  • The results will be provided in an easily
    understood manner to the provider of your choice.

19
Frequently Asked Questions
Are pre-existing conditions covered? Coverage is
subject to pre-existing exclusions for 12 months.
If you have been treated for an illness in the
last 12 months the plan will not cover anything
associated with it for 12 months. (Per4mance Rx
Card and Office Visits are not subject to
pre-existing condition exclusion). When can I use
my coverage? From the 1st of the month that your
coverage begins. There is no waiting period for
any of the benefits. Do I have to Use a Network
Provider? Part A benefits are payable to any
provider in or out of network. Part B benefits
are payable to any provider in or out of network,
but a differential in co-insurance applies to out
of network claims. How can I find a Multiplan
Network Provider? Visit www.multiplan.com or
call 1-866-766-9016 to find a network
provider. Is Maternity Covered? If conception
occurs after the Effective date it will be
covered as any other illness. Do my prescriptions
apply toward my deductible? No, prescription
costs do not apply to the deductible. What Proof
needs to be provided of my employment? To become
a member of AFID you must provide Proof of
employment in the form of 1099, Schedule C, W-2
or current Paystub.
20
Eligibility Requirements
  • Plan only available for member firms of AFID
  • Issue age 16 70
  • Must be employed (proof must be provided)
  • Covered age of Dependents is 18. Ages 19-23 are
    covered for full time students
  • Must complete enrollment forms and include first
    month premium and monthly draft information.
  • If other coverage is in place during the same
    time period, benefits paid are subject to
    coordination of benefits.
  • Guarantee Renew ability for medical plans except
    for the following reasons
  • Non-payment of premium
  • Fraud or Misrepresentation
  • Violation of participation or contribution
    requirements if applicable
  • Non-compliance with plan provisions
  • If carrier discontinues all coverage in that
    admitted state
  • Subject to pre-existing conditions of 12-12
    unless creditable coverage can be provided for
    the qualifying period

21
Limitations
  • When an insured Person attains age 65 or becomes
    eligible for Medicare, whichever occur first, the
    benefits of this Policy and Attachments, if any,
    are payable only to the extent that Covered
    Expenses are not paid by Medicare and would
    otherwise be payable under the Policy. The
    benefits will also be subject to any other
    exclusions set forth in the Policy.
  • It is not our intent to give advice on Medicare.
    Please consult a qualified advisor.
  • The Policy does not provide benefits for Covered
    Sickness, Covered Injury or Covered Maternity
    occurring or first Manifesting itself prior to
    the Certificate Effective date, subject to the
    Pre-Existing Conditions Limitations. Covered
    Maternity does not apply and the Policy does not
    provide benefits for anyexpense incurred prior to
    the Certificate Effective Date.

22
Enrollment and Payment Options
AFID allows our agents and members great
flexibility for enrollment and payment options.
If someone is an employee of an AFID member firm
they can take advantage of the ease in which we
automatically bill monthly.
  • Ongoing Enrollment
  • Applications received on or before the 15th of
    the month will be processed with a 1st of the
    following month effective date.
  • Online Enrollment
  • Coming Soon!
  • Payment Options
  • Automatic ACH
  • Visa/ Mastercard
  • List Billing for groups of 5 or more

23
Per4mance Health Plan
The plan that pays to buy
  • For more information Call Today!
  • 1-800-388-8342