Clearwater Internal Company Training PDF

Internal Company Training Part 1 of 3 Link to recording Thanks for joining! Please hold all questions until the end! Write them down as we go so you don’t forget. There will be a test! ● Releasing October 30 ● Open Note ● Meant to be a knowledge check Contents Part 1: ● ● ● ● ● ● ● Company O...

Internal Company Training Part 1 of 3 Link to recording Thanks for joining! Please hold all questions until the end! Write them down as we go so you don’t forget. There will be a test! ● Releasing October 30 ● Open Note ● Meant to be a knowledge check Contents Part 1: ● ● ● ● ● ● ● Company Overview Healthshare 101 ClearShare-Only Memberships & Member Guidelines ClearShare Merge Memberships Care Coordination for ClearShare Virtual Services Questions Part 2: ● MEC Plans ● Major Medical Plans ● Care Coordination for Major Medical ● Health Savings Account 101 ● Supplemental Plans ● Questions Part 3: ● Plans Recap ● Business Rules ● Third Party Services ● GDrive Review ● Post Enrollment Review ● Questions Company Overview Who’s who in the ecosystem Clearwater Benefits Holdings, LLC This entity owns the agency and TPA. It houses shared services, such as finance, technology, and marketing. A company that provides virtual assistant services. Trident sponsors several insurance plans for Limited Partners. www.tridentbpo.com The agency or healthcare brokerage that does the selling. Sells Major Medical and supplemental insurance plans and healthshare memberships. The third-party administrator (TPA) that does the administrating (customer service, plan design, claims, billing, etc.) for health plans and employers. Previously known as Boomy Health. A nonprofit healthcare sharing organization. clearsharehealth.org Plans Major Medical Plans ● Copay 3500 ● Copay 4500 ● Copay 8000 ● HSA 5000 ● MVP Minimum Essential Coverage (MEC) Plans ● Advanced ● Basic ● HSA Supplementals ● Dental, vision ● Accident, critical illness, hospital indemnity ● Life ClearShare Memberships ● Advanced ClearShare 1000 ● Advanced ClearShare 2500 ● Advanced ClearShare 5000 ● Basic ClearShare 1000 ● Basic ClearShare 2500 ● Basic ClearShare 5000 ● ClearShare 1000 ● ClearShare 2500 ● ClearShare 5000 **ClearShare-only is often paired with a Trident MEC plan. Plans Major Medical Plans ● Copay 3500 ● Copay 4500 ● Copay 8000 ● HSA 5000 ● MVP Minimum Essential Coverage (MEC) Plans ● Advanced ● Basic ● HSA Merge Plans ClearShare -Only Supplementals ● Dental, vision ● Accident, critical illness, hospital indemnity ● Life ClearShare Memberships ● Advanced ClearShare 1000 ● Advanced ClearShare 2500 ● Advanced ClearShare 5000 ● Basic ClearShare 1000 ● Basic ClearShare 2500 ● Basic ClearShare 5000 ● ClearShare 1000 ● ClearShare 2500 ● ClearShare 5000 **ClearShare-only is often paired with a Trident MEC plan. Plans Major Medical Plans ● Copay 3500 ● Copay 4500 ● Copay 8000 ● HSA 5000 ● MVP Minimum Essential Coverage (MEC) Plans ● Advanced ● Basic ● HSA Merge Plans ClearShare -Only Supplementals ● Dental, vision ● Accident, critical illness, hospital indemnity ● Life ClearShare Memberships ● Advanced ClearShare 1000 ● Advanced ClearShare 2500 ● Advanced ClearShare 5000 ● Basic ClearShare 1000 ● Basic ClearShare 2500 ● Basic ClearShare 5000 ● ClearShare 1000 ● ClearShare 2500 ● ClearShare 5000 **ClearShare-only is often paired with a Trident MEC plan. Plan Major Medical Plans ● Copay 3500 ● Copay 4500 ● Copay 8000 ● HSA 5000 ● MVP Minimum Essential Coverage (MEC) Plans ● Advanced ● Basic ● HSA ClearShare Memberships ● Advanced ClearShare ● Basic ClearShare ● ClearShare-only ● $1000, $2500, $5000 annual max Dental and Vision Accident, Critical Illness, Hospital Indemnity, Life Clearwater (Agency) Role Clearwater Benefits Administrators (TPA) Role Trident Role ClearShare Role Broker that sells the plans. Plan administration: customer service, billing, plan design, claims, etc. Note: HMA also assists Employer of these self-funded plans. To enroll, members first become Limited Partners. NONE Broker that sells the plans. Plan administration: customer service, billing, plan design, claims, etc. Note: HMA also assists Employer of these self-funded NONE - but these plans are plans. To enroll, members first often paired with a ClearShare become Limited Partners. membership. Broker that sells the plans. Membership administration: customer service, billing, needs, etc. Broker that sells the plans. Plan administration: customer service, billing, plan design, claims, etc. Note: HMA also assists Employer of these self-funded plans. To enroll, members first become Limited Partners. NONE Broker that sells the plans. Clearwater handles billing, and a Employer of these self-funded third party (Breckpoint, Manhattan plans. To enroll, members first Life) handles claims, plan design, become Limited Partners. etc. NONE NONE Offering these healthshare membership is ClearShare’s purpose. ClearShare funds the organization. Additional Resources ● ● VIDEO: Two Paths - Major Medical and ClearShare BROCHURE: Clearwater Overview ● Websites: ○ ClearwaterHealth.com - Main/corporate website ○ ClearwaterBenefitsAdmin.com - TPA site ○ ClearShareHealth.org - ClearShare site ○ TridentBPO.com - Trident site ○ Multiple white-labeled affiliate sites where members can enroll Healthshare 101 What’s a healthshare and how is it different from insurance? What is a healthshare? A healthshare (also called medical cost sharing or a healthcare sharing ministry), provides an organized structure for a community of like-minded members to contribute toward each other’s medical costs. They are not-for-profit organizations in which members agree to abide by a commonly-shared code of conduct to help keep the overall care costs for the community down. Healthshares are not insurance. Healthshares are not bound by state or federal government laws and regulations around insurance. Additional Resources: ● ● Healthshare 101 Flyer How Healthshares work blog Healthshare vs insurance Apples: ● High in fiber, vitamins and minerals ● Can prevent many diseases ● Higher foliage Oranges: ● High in fiber, vitamins and minerals ● Can prevent many diseases ● Higher vitamin C Healthshare vs insurance Healthshare Healthshare: ● Used to pay medical expenses ● Not bound by laws & regulations ● Members submit needs Insurance Insurance: ● Used to pay medical expenses ● Bound by laws & regulations ● Providers submit claims Healthshare Terminology Healthshare Term Use this… Insurance Term Not this Need Claim “We share in needs” “We arrange cost sharing among members” “We pay claims” Monthly cost / Monthly contribution Premium Annual Max Deductible Visit fee / Member cost / Patient responsibility Copay Contents Part 1: ● ● ● ● ● ● ● Company Overview Healthshare 101 ClearShare-Only Memberships & Member Guidelines ClearShare Merge Memberships Care Coordination for ClearShare Virtual Services Questions Part 2: ● MEC Plans ● Major Medical Plans ● Care Coordination for Major Medical ● Health Savings Account 101 ● Supplemental Plans ● Questions Part 3: ● Plans Recap ● Business Rules ● Third Party Services ● GDrive Review ● Post Enrollment Review ● Questions ClearShare Memberships Clearwater is a broker and administrator for ClearShare memberships. ClearShare Membership Options We offer four ClearShare Membership types to match your healthcare needs & preferences: ClearShare-only, Advanced, Basic, and HSA. Day-to-day Coverage? Major incidents? ❍ Advanced -More comprehensive plan -Set amounts for everyday care like doctor visits, prescriptions, & diagnostics including out-of-network ❍ ❍ Basic -Set amounts for doctor visits and prescriptions in network Pick your Annual Max HSA -HSA - Health Savings Account -Rarely visit the doctor -Pay for day-to-day needs with a tax deductible HSA Supplemental Insurance? How much do you want to pay in the event of a major health incident: ❍ Dental ❍ $1,000 ❍ $2,500 ❍ $5,000 ❍ Accident ❍ Vision ❍ Critical Illness ClearShare Membership Options We offer four ClearShare Membership types to match your healthcare needs & preferences: ClearShare-only, Advanced, Basic, and HSA. Day-to-day Coverage? Major incidents? ❍ Advanced -More comprehensive plan -Set amounts for everyday care like doctor visits, prescriptions, & diagnostics including out-of-network ❍ ❍ Basic -Set amounts for doctor visits and prescriptions in network Pick your Annual Max HSA -HSA - Health Savings Account -Rarely visit the doctor -Pay for day-to-day needs with a tax deductible HSA Supplemental Insurance? How much do you want to pay in the event of a major health incident: ❍ Dental ❍ $1,000 ❍ $2,500 ❍ $5,000 ❍ Accident ❍ Vision ❍ Critical Illness Plans Major Medical Plans ● Copay 3500 ● Copay 4500 ● Copay 8000 ● HSA 5000 ● MVP Minimum Essential Coverage (MEC) Plans ● Advanced ● Basic ● HSA Merge Plans ClearShare -Only Supplementals ● Dental, vision ● Accident, critical illness, hospital indemnity ● Life ClearShare Memberships ● Advanced ClearShare 1000 ● Advanced ClearShare 2500 ● Advanced ClearShare 5000 ● Basic ClearShare 1000 ● Basic ClearShare 2500 ● Basic ClearShare 5000 ● ClearShare 1000 ● ClearShare 2500 ● ClearShare 5000 **ClearShare-only is often paired with a Trident MEC plan. ClearShare-Only Membership Where are the member guidelines? ● ClearShareHealth.org/member-guidelines/ Additional resources: ● ● ● ● ● ClearShare 1000 plan page ClearShare 2500 plan page ClearShare 5000 plan page VIDEO: ClearShare General How to Submit a ClearShare Medical Need Request Statement of Beliefs and Membership Eligibility Membership eligibility in ClearShare is primarily based on two factors: 1. 2. Adherence to the ClearSare Statement of Beliefs Participation in the community by submitting monthly contributions Enrollment Requirements Age caps: ● Primary members must be at least 18 years old. ● All members must be under 65 years old. ● Dependents can be on a parent’s plan until age 26. Membership Tiers: ● Member Only: An individual member of ClearShare ● Member + Spouse: A member and their spouse ● Member + Children: A member and their dependent child or children ● Member + Family: A member, spouse, and any dependent children Tobacco Surcharge ● Monthly tobacco surcharge is $50 per household. How Needs Are Shared Need: Expenses related to the same medical condition, whether expenses for a single incident or separate incidents, will be shared as one need. The related expenses will accumulate toward the total need amount. Annual Maximum: The annual maximum is the amount that a member will pay before the ClearShare community shares in medical expenses. The Annual Maximum is also known as your personal responsibility. ClearShare has three primary levels of personal responsibility: $1000, $2500, and $5000. Service copays or service costs that apply to a member’s deductible are not included in the annual maximum. How Needs Are Shared Family Annual Maximum: If you have family members on the plan, they have to meet their own Annual Max until the overall Family Annual Max has been met. Once the household has paid up to its Family Annual Max, the ClearShare community will share in eligible medical expenses at 100%. Family Annual Max - Example ● ● ● ● Family of four ClearShare 1000 Annual Max: $1,000 Family Annual Max: $3,000 Primary: Pays $1,000 Household: Paid $1,000 Jan 2023 Feb 2023 Mar 2023 Apr 2023 May 2023 June 2023 July 2023 Aug 2023 Sept 2023 Oct 2023 Nov 2023 Dec 2023 Family Annual Max - Example ● ● ● ● Primary: Pays $1,000 Child 1: Pays $1,000 Household: Paid $1,000 Household: Paid $2,000 Jan 2023 Feb 2023 Mar 2023 Apr 2023 Family of four ClearShare 1000 Annual Max: $1,000 Family Annual Max: $3,000 May 2023 June 2023 July 2023 Aug 2023 Sept 2023 Oct 2023 Nov 2023 Dec 2023 Family Annual Max - Example ● ● ● ● Family of four ClearShare 1000 Annual Max: $1,000 Family Annual Max: $3,000 Primary: Pays $1,000 Child 1: Pays $1,000 Primary Pays $0! Household: Paid $1,000 Household: Paid $2,000 Household: Paid $2,000 Jan 2023 Feb 2023 Mar 2023 Apr 2023 May 2023 June 2023 July 2023 Aug 2023 Sept 2023 Oct 2023 Nov 2023 Dec 2023 Family Annual Max - Example ● ● ● ● Primary: Pays $1,000 Child 1: Pays $1,000 Household: Paid $1,000 Household: Paid $2,000 Jan 2023 Feb 2023 Mar 2023 Family of four ClearShare 1000 Annual Max: $1,000 Family Annual Max: $3,000 Primary Pays $0! Child 2: Pays $700 Household: Household: Paid $2,000 Paid $2,700 Apr 2023 May 2023 June 2023 July 2023 Aug 2023 Sept 2023 Oct 2023 Nov 2023 Dec 2023 Family Annual Max - Example ● ● ● ● Family of four ClearShare 1000 Annual Max: $1,000 Family Annual Max: $3,000 Family Annual Max met! Primary: Pays $1,000 Child 1: Pays $1,000 Household: Paid $1,000 Household: Paid $2,000 Jan 2023 Feb 2023 Mar 2023 Primary Pays $0! Child 2: Pays $700 Spouse: Pays $300 Household: Household: Paid $2,000 Paid $2,700 Apr 2023 May 2023 June 2023 July 2023 Household: Paid $3,000 Aug 2023 Sept 2023 Oct 2023 Nov 2023 Dec 2023 Family Annual Max - Example ● ● ● ● Family of four ClearShare 1000 Annual Max: $1,000 Family Annual Max: $3,000 Family Annual Max met! Primary: Pays $1,000 Child 1: Pays $1,000 Household: Paid $1,000 Household: Paid $2,000 Jan 2023 Feb 2023 Mar 2023 Primary Pays $0! Child 2: Pays $700 Household: Household: Paid $2,000 Paid $2,700 Apr 2023 May 2023 June 2023 July 2023 Aug 2023 Spouse: Pays $300 Child 2: Pays $0 Household: Paid $3,000 Household: Paid $3,000 Sept 2023 Oct 2023 Nov 2023 Dec 2023 How Needs are Shared ● Members submit their need request online: ClearShareHealth.org/need-request ● Need request should include the Superbill (the itemized bill with CPT codes on it), and medical records ● Membership must be in good standing (paid) ● Membership must be active during dates of service and when determination is made. ● Six months to submit need from date of service. ● Read more: How to Submit a ClearShare Medical Need Request Pre-membership medical conditions 12 Month Treatment Free: Needs that arise from conditions that existed prior to membership are only shareable if the condition was regarded as cured and did not require treatment for 12 months prior to the effective date of membership. Any illness or injury for which a person has been: ● Examined ● Taken medication ● Had a diagnostic test performed or ordered by a physician ● Or received medical treatment Exceptions for High Blood Pressure, High Cholesterol, Diabetes High blood pressure, high cholesterol, and diabetes (types 1 and 2) will not be considered pre-membership medical conditions as long as the member has not been hospitalized for the condition in the 12 months prior to effective date and is able to control it through medication and/or diet. Exceptions for Cancer, Heart Disease, Stroke, COPD: Cancer, Heart Disease, Stroke, and COPD are only shareable if the condition was regarded as cured and did not require treatment for 5 years prior to the effective date of membership. Pre-membership medical conditions Pre-Membership Medical Condition Phase-In Period Shareable amounts for pre-membership medical conditions: ● Year One: $0 (waiting period) ● Year Two: $25,000 maximum benefit per pre-membership medical condition ● Year Three: $50,000 maximum benefit per pre-membership medical condition ● Year Four: $125,000 maximum benefit per pre-membership medical condition After year four of membership, expenses related to pre-membership medical conditions will remain shareable at a maximum of $125,000 in a 12-month rolling period and resetting each membership year based on effective date. Specific Sharing Qualifications / Medical Expenses Ineligible for Sharing Member needs not associated with a pre-membership medical condition are generally shareable. ● Specific Sharing Qualifications: 38 conditions with special rules or limitations ● Medical Expenses Ineligible for Sharing: 16 conditions that are not shareable. Use CTRL + F to quickly search the member guidelines. ClearShareHealth.org/member-guidelines Maternity As a general rule, maternity needs are shareable and are treated like any other medical need. ● ● Annual max applies Baby’s needs are separate Pregnancy Prior to Membership Conception that occurs prior to membership or within the first 60 days of membership is eligible for sharing, but with a $50,000 limit. In this event, medical expenses for all newborns are also eligible for sharing, but with another $50,000 limit. Additional Resources: ● ClearShare Maternity Guidelines ClearShare-Only Network ClearShare-only has NO restrictions on providers members can access. They can go anywhere for care! Member Guidelines ClearShareHealth.org/ member-guidelines ClearShare Memberships Merge Plans - Advanced & Basic Plans Major Medical Plans ● Copay 3500 ● Copay 4500 ● Copay 8000 ● HSA 5000 ● MVP Minimum Essential Coverage (MEC) Plans ● Advanced ● Basic ● HSA Merge Plans ClearShare -Only Supplementals ● Dental, vision ● Accident, critical illness, hospital indemnity ● Life ClearShare Memberships ● Advanced ClearShare 1000 ● Advanced ClearShare 2500 ● Advanced ClearShare 5000 ● Basic ClearShare 1000 ● Basic ClearShare 2500 ● Basic ClearShare 5000 ● ClearShare 1000 ● ClearShare 2500 ● ClearShare 5000 **ClearShare-only is often paired with a Trident MEC plan. ClearShare Membership Options We offer four ClearShare Membership types to match your healthcare needs & preferences: ClearShare-only, Advanced, Basic, and HSA. Day-to-day Coverage? Major incidents? ❍ Advanced -More comprehensive plan -Set amounts for everyday care like doctor visits, prescriptions, & diagnostics including out-of-network ❍ ❍ Basic -Set amounts for doctor visits and prescriptions in network Pick your Annual Max HSA -HSA - Health Savings Account -Rarely visit the doctor -Pay for day-to-day needs with a tax deductible HSA Supplemental Insurance? How much do you want to pay in the event of a major health incident: ❍ Dental ❍ $1,000 ❍ $2,500 ❍ $5,000 ❍ Accident ❍ Vision ❍ Critical Illness Advanced ClearShare Advanced ClearShare Healthshare Term Use this… Insurance Term Not this Need Claim “We share in needs” “We arrange cost sharing among members” “We pay claims” Monthly cost / Monthly contribution Premium Annual Max Deductible Visit fee / Member cost / Patient responsibility Copay Advanced ClearShare ● Annual Max does not apply ● Pre-membership conditions do not apply Advanced ClearShare These Services are on a Network To find a list of providers, go to the PHCS Network website: 1. 2. 3. 4. Click on "Change Network" Click on "PHCS" Click on "Specific Services" Search for a provider If you need to find a provider outside of the PHCS Specific Services network, go to the PNOAe network website. Select the "PNOAe (Exclusive) Network" option. For expensive and emergency services, members have no network restrictions and can receive care anywhere. This includes major procedures, accidents, surgeries, ER, and hospital visits. Advanced ClearShare Network Applies Services part of the “Advanced” portion of the plan = Part of PHCS or PNOA No Network Services part of ClearShare-only Advanced ClearShare: Additional Resources Watch: Advanced ClearShare ● ● ClearShare Advanced Membership Add-On Guidelines Sample plan page: Advanced + ClearShare 1000 ClearShare Membership Options We offer four ClearShare Membership types to match your healthcare needs & preferences: ClearShare-only, Advanced, Basic, and HSA. Day-to-day Coverage? Major incidents? ❍ Advanced -More comprehensive plan -Set amounts for everyday care like doctor visits, prescriptions, & diagnostics including out-of-network ❍ ❍ Basic -Set amounts for doctor visits and prescriptions in network Pick your Annual Max HSA -HSA - Health Savings Account -Rarely visit the doctor -Pay for day-to-day needs with a tax deductible HSA Supplemental Insurance? How much do you want to pay in the event of a major health incident: ❍ Dental ❍ $1,000 ❍ $2,500 ❍ $5,000 ❍ Accident ❍ Vision ❍ Critical Illness Basic ClearShare Basic ClearShare Healthshare Term Use this… Insurance Term Not this Need Claim “We share in needs” “We arrange cost sharing among members” “We pay claims” Monthly cost / Monthly contribution Premium Annual Max Deductible Visit fee / Member cost / Patient responsibility Copay Basic ClearShare ● Annual Max does not apply ● Pre-membership conditions do not apply Basic ClearShare These Services are on a Network To find a list of providers, go to the PHCS Network website: 1. 2. 3. 4. Click on "Change Network" Click on "PHCS" Click on "Specific Services" Search for a provider If you need to find a provider outside of the PHCS Specific Services network, go to the PNOAe network website. Select the "PNOAe (Exclusive) Network" option. For expensive and emergency services, members have no network restrictions and can receive care anywhere. This includes major procedures, accidents, surgeries, ER, and hospital visits. Basic ClearShare Network Applies Services part of the “Basic” portion of the plan = Part of PHCS or PNOA No Provider Restrictions No Provider Restrictions No Provider Restrictions No Provider Restrictions No Provider Restrictions No Network Services part of ClearShare-only Basic ClearShare: Additional Resources Watch: Basic ClearShare ● ● ClearShare Basic Membership Add-On Guidelines Sample plan page: Basic + ClearShare 1000 Advanced vs Basic Advanced ClearShare Basic ClearShare ClearShare Membership Options We offer four ClearShare Membership types to match your healthcare needs & preferences: ClearShare-only, Advanced, Basic, and HSA. Day-to-day Coverage? Major incidents? ❍ Advanced -More comprehensive plan -Set amounts for everyday care like doctor visits, prescriptions, & diagnostics including out-of-network ❍ ❍ Basic -Set amounts for doctor visits and prescriptions in network Pick your Annual Max HSA -HSA - Health Savings Account -Rarely visit the doctor -Pay for day-to-day needs with a tax deductible HSA Supplemental Insurance? How much do you want to pay in the event of a major health incident: ❍ Dental ❍ $1,000 ❍ $2,500 ❍ $5,000 ❍ Accident ❍ Vision ❍ Critical Illness ClearShare Membership Options We offer four ClearShare Membership types to match your healthcare needs & preferences: ClearShare-only, Advanced, Basic, and HSA. Day-to-day Coverage? ❍ Advanced -More comprehensive plan -Set amounts for everyday care like doctor visits, prescriptions, & diagnostics including out-of-network ❍ ❍ Basic -Set amounts for doctor visits and prescriptions in network The HSA portion of the plan is a Trident Minimum Essential Coverage (MEC) plan! Major incidents? Pick your Annual Max HSA -HSA - Health Savings Account -Rarely visit the doctor -Pay for day-to-day needs with a tax deductible HSA Supplemental Insurance? How much do you want to pay in the event of a major health incident: ❍ Dental ❍ $1,000 ❍ $2,500 ❍ $5,000 ❍ Accident ❍ Vision ❍ Critical Illness Contents Part 1: ● ● ● ● ● ● ● Company Overview Healthshare 101 ClearShare-Only Memberships & Member Guidelines ClearShare Merge Memberships Care Coordination for ClearShare Virtual Services Questions Part 2: ● MEC Plans ● Major Medical Plans ● Care Coordination for Major Medical ● Health Savings Account 101 ● Supplemental Plans ● Questions Part 3: ● Plans Recap ● Business Rules ● Third Party Services ● GDrive Review ● Post Enrollment Review ● Questions Care Coordination For ClearShare Care Coordination for ClearShare Care Coordination is here to help you lower your healthcare costs. We connect you with lower cost , high quality providers for your labs, imaging and major procedures. Care Coordination Example A member needed knee-replacement surgery. There were two options for care nearby: MD Anderson Hospital ● ● Specialty is NOT ortho Charges $80,000 Orthopedic Surgery Center ● ● Specializes in ortho Charges $40,000 We recommended the Orthopedic Surgery Center because: ● ● ● Their surgeons are more specialized and experienced. Their price is much lower! We cut the cost in half, allowing us to keep monthly costs low. In return, we covered this member's out-of-pocket fees. They got a knee-replacement surgery for FREE, just for choosing an experienced and fair provider. Care Coordination for ClearShare What services qualify? Care Coordination for ClearShare What services qualify? Care Coordination can help you find local providers if the primary and secondary network doesn’t provide the coverage you need in your area. Care Coordination for ClearShare What services qualify? Can I choose the doctor I want to see? Care Coordination can help you find local providers if the primary and secondary network doesn’t provide the coverage you need in your area. No, Care Coordination works to find and recommend you a fair-priced, high quality provider. If you want to choose your own provider, you an use your plan’s applicable in-network or out-of-network services. Additional Resources ● About Care Coordination ● Introduction to Care Coordination ● Care Coordination FAQ Note: Care Coordination works a little bit differently on ClearShare than on Major Medical! Contents Part 1: ● ● ● ● ● ● ● Company Overview Healthshare 101 ClearShare-Only Memberships & Member Guidelines ClearShare Merge Memberships Care Coordination for ClearShare Virtual Services Questions Part 2: ● MEC Plans ● Major Medical Plans ● Care Coordination for Major Medical ● Health Savings Account 101 ● Supplemental Plans ● Questions Part 3: ● Plans Recap ● Business Rules ● Third Party Services ● GDrive Review ● Post Enrollment Review ● Questions Virtual Services Lyric Telemedicine & Talkspace Lyric Telemedicine Access 24/7 virtual access to doctors for $0. Includes urgent care for $0 and behavioral health counseling for $0. ● ● Access Lyric Telemedicine within your Health Wallet App Or call Lyric toll free: 800-363-3725 Adding my family members ● Primary members, spouses, and dependents aged 18-26 can access their own unique Lyric accounts through their own Health Wallet accounts. ● Add child dependents within Lyric account settings. Additional Resources ● Lyric Brochures ● The Advantages of Telemedicine Talkspace Benefits ● Unlimited Messaging Therapy for members and dependents age 13+ ● Therapy: One 30-minute Live Video Session per month for individuals age 13+, $65 for additional sessions ● Psychiatry: up to 13 Live Video Sessions annually for individuals age 18+ Talkspace Access To access Talkspace, visit Talkspace.com/Clearwater and and sign up using the following information: ● Organization name: Clearwater ● Keyword for psychiatry: Clearwater Psych Therapy Additional Resources ● Talkspace FAQ ● Talkspace Comms Portal ● Video: Talkspace Member Overview Psychiatry Contents Part 1: ● ● ● ● ● ● ● Company Overview Healthshare 101 ClearShare-Only Memberships & Member Guidelines ClearShare Merge Memberships Care Coordination for ClearShare Virtual Services Questions Part 2: ● MEC Plans ● Major Medical Plans ● Care Coordination for Major Medical ● Health Savings Account 101 ● Supplemental Plans ● Questions Part 3: ● Plans Recap ● Business Rules ● Third Party Services ● GDrive Review ● Post Enrollment Review ● Questions Questions? Use the Raise Hand function on Zoom. If we run out of time or you are watching the recording, ask here: https://docs.google.com/forms/d/e/1FAIpQLSdzBRk_ jgiTEMACX2vjAgIWFA xreHtunKAWEanqF2ZQo3NL4g/viewform?usp=sf_link WEBVTT 1 00:00:05.410 --> 00:00:06.500 Amanda Sohaney: Just remember 2 00:00:07.560 --> 00:00:13.739 Amanda Sohaney: they didn't start the recording. So note that I will go back and re-record the beginning of this 3 00:00:14.740 --> 00:00:17.880 Amanda Sohaney: all right. Back to the met back to the met plans. 4 00:00:19.650 --> 00:00:28.240 Amanda Sohaney: So here's the basic Mac plan. The mech portion of the plan covers primary care visits and specialist visits only in network and prescriptions. 5 00:00:28.390 --> 00:00:44.130 Amanda Sohaney: These services are covered with a copay. Again, because the Mech plan is insurance. We can describe these costs as a copay when the basic Mac is bundled with clear share. Clearshare helps cover those additional eligible expenses, like surgeries, diagnostic tests, and imaging services. 6 00:00:44.240 --> 00:00:49.269 Amanda Sohaney: These services would count toward the annual Max as long as they are eligible for sharing. 7 00:00:52.360 --> 00:01:04.559 Amanda Sohaney: and finally, we have the Hsa Mech plan. The Hsa mech is a high, deductible plan, that is, Hsa eligible. So members of this plan can open a personal health savings account, and we will talk about that a little bit more later. 8 00:01:05.010 --> 00:01:15.549 Amanda Sohaney: The Hsa. Mac covers preventive care, primary care, specialist visits, lab work, and prescriptions. A member would pay full price for those services until they hit their mech plan deductible. 9 00:01:17.260 --> 00:01:26.329 Amanda Sohaney: So the Hsa mech plan, deductible and out-of-pocket. Max is only for the mech. It's not the same as the annual Max associated with clear share. 10 00:01:27.510 --> 00:01:32.169 Amanda Sohaney: Remember that the mech plan and the Clear share plan are 2 separate plans. 11 00:01:33.830 --> 00:01:52.610 Amanda Sohaney: so only those Hsa Mech services, doctor visits, lab work, and prescriptions are counting towards that Hsa Mac deductible because these are typically lower priced services. Most members are not going to come close to the Hsa. Deductible, deductible. If they did, then the copays listed under the Hsa Mech services would apply. 12 00:01:52.730 --> 00:02:03.390 Amanda Sohaney: And again, we're gonna talk more about Hsa's and the benefits of them. In a little bit. Any services that fall under clear share, would apply to that $1,000 annual Max, in this example. 13 00:02:05.700 --> 00:02:25.370 Amanda Sohaney: So Mech Service costs and clear share service costs all accumulate into their own separate buckets, because they're 2 separate plans bundled together. Anything that's covered under the mech will apply to the mech deductible, and Max out of pocket. And again, since the Mech plans don't include the big expenses like surgery, most numbers don't come close to these numbers. 14 00:02:25.950 --> 00:02:34.970 Amanda Sohaney: Anything that's shareable under clear share will contribute towards the annual Max. This structure enables members to pay the least possible out of their own pocket. 15 00:02:35.000 --> 00:02:50.519 Amanda Sohaney: The less expensive day to day. Stuff like doctor visits is paid for with that set copay or paid out of pocket in the case of the Hsa Mac, and then the most expensive stuff is covered after an annual max that is much lower, the most insurance plans, deductibles, and out of pocket maxes. 16 00:02:52.760 --> 00:03:02.619 Amanda Sohaney: So the Mech plans have deductibles and out-of-pocket Maxes because they are insurance plans, and those numbers are required to be stated on official planned documents. Even if that number is 0 17 00:03:02.840 --> 00:03:09.729 Amanda Sohaney: insurance insurance laws don't account for the member experience when these are paired with a health share. So we do our best to navigate around that. 18 00:03:09.910 --> 00:03:27.820 Amanda Sohaney: So we see this on our Member Id card members on a mech plus clear share plan will get a mech id card as well as the clear share id card. And I know we have a lot of challenges around that, since those mech id cards have to list those deductibles and Max out of pockets, and then the clear share id card is where that annual Max is listed. 19 00:03:31.930 --> 00:03:36.030 Amanda Sohaney: Mech services, like the merge plans, are on 2 Ppo networks. 20 00:03:36.170 --> 00:03:49.630 Amanda Sohaney: Phcs specific services is the primary network, and P. Noa exclusive is the secondary network. In this example we're looking at the basic mech doctor. Visits are included as in network services. 21 00:03:50.250 --> 00:03:57.219 Amanda Sohaney: all other services, the ones that are included in the clear share portion of the plan do not have any network restrictions 22 00:04:00.550 --> 00:04:12.090 Amanda Sohaney: so to recap here. Mac versus merge. Mac. Plans are insurance merge. Plans are all health share. The Mac portion of the plan meets Aca and individual mandate requirements, merge plans. Do not. 23 00:04:12.250 --> 00:04:17.660 Amanda Sohaney: Mac. Services are paid from the Mac bank account clear share services are paid from the clear share bank account. 24 00:04:17.690 --> 00:04:21.039 Amanda Sohaney: But the member costs and coverages look the same. 25 00:04:24.610 --> 00:04:29.450 Amanda Sohaney: I also want to note that advanced and basic mech plans have a merge plan equivalent. 26 00:04:29.640 --> 00:04:42.060 Amanda Sohaney: The Hsa plus clear share plan is always an Hsa. Mac paired with clear share. This is because to be Hsa eligible. The Hsa plan must be insurance, so there is no health share equivalent. 27 00:04:45.080 --> 00:04:53.559 Amanda Sohaney: So just a reminder to hold your questions for the end and to please write them down so that you don't forget them. and we are going to move on to major medical plans. 28 00:04:55.920 --> 00:05:03.679 Amanda Sohaney: We have 5 of them, Copay, 3,500 Copay, 4,500 Copay, 8,000 ages, say 5,000, and Mvp. 29 00:05:04.800 --> 00:05:19.909 Amanda Sohaney: Put your health share knowledge aside because major medical plans are 100% true insurance and don't have anything to do with clear share. So, like the Mech plans, members must first become limited partners with Trident, and then they have access to Trident's employer sponsored benefits 30 00:05:19.960 --> 00:05:28.319 Amanda Sohaney: similar to how you might get a job at a company. You're considered A. W. 2 or full time employee, and then you become and eligible for those employee sponsored benefits. 31 00:05:29.520 --> 00:05:35.689 Amanda Sohaney: When we sell major medical plans to another employer, group trident is replaced with whoever that employer is. 32 00:05:38.460 --> 00:05:43.659 Amanda Sohaney: her major medical plans fall into 2 buckets, Copay plans and managed care plans. 33 00:05:43.800 --> 00:05:47.610 Amanda Sohaney: And we're going to start by reviewing the 3 Copay plans. 34 00:05:50.470 --> 00:05:55.300 Amanda Sohaney: Most traditional insurance plans have just in network services and out of network services. 35 00:05:55.380 --> 00:06:06.380 Amanda Sohaney: This plan, however, has a tier one in network, preferred tier, 2 in network and tier, 3 out of network column. So we've got 3 tiers here instead of the normal 2. 36 00:06:07.690 --> 00:06:13.379 Amanda Sohaney: So tier one in network preferred is care, coordination. It's embedded directly into this plan. 37 00:06:13.690 --> 00:06:24.190 Amanda Sohaney: So in clear share plans, we advertise that out-ofpocket costs can be waived for certain services when members use care coordination. But it's not really written directly and into any of the official plan documents. 38 00:06:24.550 --> 00:06:31.630 Amanda Sohaney: and on major Medical. It is. You can see that reflected with any service that says $0. In this tier. One column. 39 00:06:31.910 --> 00:06:49.580 Amanda Sohaney: Preventive care and primary care don't qualify for care coordination mostly because the cost savings just aren't enough to justify the work involved on our end. Emergency services don't qualify because care coordination requires a lot of time, and our team has to research those providers. Emergency services usually can't wait. 40 00:06:53.420 --> 00:06:58.650 Amanda Sohaney: Always a big question with care, coordination. Can members choose the tier? One, doctor that they want to see? 41 00:06:58.700 --> 00:07:15.429 Amanda Sohaney: Answer is no care. Coordination works to find and recommend fair priced and high quality providers in the members area. This is like a custom built network for individual members. So there's no doctor lookup available for tier one. If members want to pick their own doctor, they can use tier, 2 or tier, 3 42 00:07:18.120 --> 00:07:24.239 Amanda Sohaney: tier. 2 services are in network. All major medical plans are part of the first health complementary network 43 00:07:24.710 --> 00:07:37.999 Amanda Sohaney: members can use the doctor lookup available on first health complementary.com, and they'll pay the costs. As stated in this tier. 2 column. The co co-pay plans are all named after the deductible associated with tier 2, 44 00:07:38.010 --> 00:07:48.510 Amanda Sohaney: the tier, one and tier 2 deductible, and out of pocket costs listed here accumulate together, and then the tier 3 deductible and out of pocket. Max Max accumulates into its own separate bucket 45 00:07:49.630 --> 00:08:05.959 Amanda Sohaney: when there's a copay associated with a visit. The member pays that copay out of their own pocket, and then the plan covers the rest of the visit up to the saving limits in that limits column. So for a specialist visit, the member would pay $45 at the office, and then we pay the rest. Assuming that visits under 500 bucks. 46 00:08:06.930 --> 00:08:10.460 Amanda Sohaney: When there's coinsurance, the member must first reach their deductible. 47 00:08:10.510 --> 00:08:16.329 Amanda Sohaney: then the member and the plan will share the cost. So this plan has 30 30% coinsurance. 48 00:08:16.350 --> 00:08:20.709 Amanda Sohaney: So the member pays 30%, and the plan pays the remaining 70%. 49 00:08:20.950 --> 00:08:28.060 Amanda Sohaney: This cost sharing continues until the member hits their out-of-pocket Max, and then the plan will cover everything. 100 50 00:08:34.230 --> 00:08:36.490 Amanda Sohaney: tier. 3 services are out of network. 51 00:08:36.850 --> 00:08:43.389 Amanda Sohaney: If a member sees a provider outside of the first health complimentary network. They'll pay the costs listed in this column. 52 00:08:43.799 --> 00:08:54.519 Amanda Sohaney: Members can also be responsible for balanced bills when they go out of network. This happens when the provider charges more than what the plan will pay for a service, and the member gets stuck with a bill for the difference. 53 00:08:55.170 --> 00:09:03.379 Amanda Sohaney: So, for example, if a member gets an X-ray out of network. we'll assume that the member has already hit their out of network deductible just for simplicity's sake. 54 00:09:03.580 --> 00:09:18.429 Amanda Sohaney: So it's a provider charges a thousand dollars for that. X-ray. But the plans allowable amount is $500. So for $500, the plans gonna pay 50% coinsurance, and the members gonna repay the remaining 50%, as stated in the plan. 55 00:09:18.500 --> 00:09:31.709 Amanda Sohaney: But for that $500 above that allowable map, the member stuck with the whole bill. There are laws against us for certain services like emergency emergency care. But that's generally why it's not ideal to go out of network. 56 00:09:34.780 --> 00:09:38.129 Amanda Sohaney: And the final column to note is the limons and info. 57 00:09:38.420 --> 00:09:44.149 Amanda Sohaney: Some services on this plan do require prior authorization, or else members will face a penalty. 58 00:09:44.240 --> 00:09:50.500 Amanda Sohaney: Members will call care, care, coordination to get prior authorization for the services where it is needed. 59 00:09:54.080 --> 00:10:02.270 Amanda Sohaney: Looking at the Copa 4,500 plan, it's set up in the same way we have the tier one in network preferred column for care, coordination services. 60 00:10:02.440 --> 00:10:10.249 Amanda Sohaney: the tier 2 in network column for services on the first health complementary network. and then tier 3 is this, out of network services. 61 00:10:10.900 --> 00:10:17.440 Amanda Sohaney: The copays and coinsurance on this plan are different from the Copay. 3,500 plan. But again, the structure is very similar. 62 00:10:20.090 --> 00:10:33.910 Amanda Sohaney: and the Copay 8,000 plan is the last of the 3 Copay plans. It also has a tier, one tier 2 and tier 3. It works the same as the other copay plans, but again, the exact copays and coinsurance here will vary. 63 00:10:36.280 --> 00:10:46.840 Amanda Sohaney: So here are the instructions we provide for members about accessing care on the 3 major medical copay plans. So the tier one in network preferred is care, coordination for $0 care. 64 00:10:46.910 --> 00:10:53.919 Amanda Sohaney: Our team works hard to find those tier one providers, but they're not always able to find one and tier one. Benefits are not guaranteed. 65 00:10:54.880 --> 00:11:04.879 Amanda Sohaney: Tier 2 was the traditional network search through the first health complementary network. Some services do require prior authorization, which is a call to the care coordination team. 66 00:11:08.890 --> 00:11:16.609 Amanda Sohaney: so that covers our 3 Co. K. Plans. And now let's talk about the 2 managed care plans, Hsa. 5,000 and Mvp. 67 00:11:19.050 --> 00:11:26.710 Amanda Sohaney: So, starting with the Hsa. 5,000 plan. This is not a three-tiered plan. We see that there's only in network and out of network coverage. 68 00:11:28.350 --> 00:11:38.950 Amanda Sohaney: So like the major medical copay plans, the Hsa. 5,000 is also part of the first health complementary network. Members can visit that website to find an in-network provider for services. 69 00:11:39.360 --> 00:11:52.499 Amanda Sohaney: You'll notice just about every service is 0% coinsurance after deductible. That means, after the member has paid their 5,000 deductible, the member pays 0 or nothing, and the plan covers services at a hundred. 70 00:11:52.600 --> 00:11:57.000 Amanda Sohaney: And again, this is an Hsa plan, and we're going to talk more about those in just a little bit. 71 00:11:59.790 --> 00:12:11.700 Amanda Sohaney: Most services on this plan are noted as requiring prior authorization. If members fail to get Prea for any of the required services, they will not be able to access benefits, and their claims will be denied. 72 00:12:11.880 --> 00:12:22.280 Amanda Sohaney: This is different than all. Like Major medical Copay plans on those plans. You just get hit with a penalty for not getting pre-off. But on this, Hsa. 5,000 you won't get the benefit at all. 73 00:12:23.200 --> 00:12:42.119 Amanda Sohaney: The Hsa. 5,000 plan is a managed care plan. So care coordination is embedded in this plan to ensure that members are receiving the right care and the right place for the best cost. So use of care. Coordination is required on this plan for prior authorizations, and the out of pocket costs are not waived like they are on the major medical Copay plans. 74 00:12:45.230 --> 00:12:53.980 Amanda Sohaney: The Mvp. Plan works in a similar manner, and Mvp. Stands for minimum value plan, and it meets affordable care, act minimum value standards. 75 00:12:54.200 --> 00:12:59.749 Amanda Sohaney: And, like the Hsa 5,000 plan, it also just has those in network and out of network coverage. 76 00:13:02.150 --> 00:13:12.929 Amanda Sohaney: Like the other major medical major medical plans. The Mvp plan is part of the first health complementary network members can visit that website to find an In network provider for services. 77 00:13:13.870 --> 00:13:30.520 Amanda Sohaney: This plan provides copays for many common but most are limited to 3 visits. So, for example, if you specialist for $60 3 different times, then on your fourth as the member are, gonna pay the full cost, but that full accumulate towards your deductible. services, visit a visit, you cost does 78 00:13:33.200 --> 00:13:47.610 Amanda Sohaney: like the Hsa. 5,000 plan. Most services on this plan are noted as requiring prior authorization. If members fail to get Pre on for any of these required services, they will not be able to access benefits, and their claims will be denied. 79 00:13:48.150 --> 00:14:07.019 Amanda Sohaney: This is because the Mvp plan is also a managed care plan, care, coordination is embedded into this plan to ensure members are receiving the right care in the right place for the best cost. Use of care. Coordination is required for prior authorizations, and the out of pocket costs are not waived like they are on those major medical copay plans 80 00:14:10.120 --> 00:14:15.410 Amanda Sohaney: here the instructions we provide members about accessing care on these 2 managed care plans 81 00:14:15.920 --> 00:14:24.810 Amanda Sohaney: and network providers are found for that first health complimentary network and most services require pre authorization, which is a call to the care coordination team. 82 00:14:25.060 --> 00:14:30.490 Amanda Sohaney: Care. Coordination is a requirement on these plans, and the costs are not waived like they are on other plans. 83 00:14:32.970 --> 00:14:42.260 Amanda Sohaney: All 5 major medical plans also include lyric telemedicine and talks based virtual mental health services. These are the same benefits included with the clear share plans. 84 00:14:45.490 --> 00:14:49.309 Amanda Sohaney: Let's talk a little bit more about care, coordination on the major medical plans 85 00:14:49.710 --> 00:14:58.839 Amanda Sohaney: depending on the major medical plan. The care coordination team has 2 functions, finding providers for $0 care and helping with prior authorizations. 86 00:15:00.530 --> 00:15:08.770 Amanda Sohaney: So on those Copay plans care coordination is embedded into the plan on that tier one in network preferred tier, or that 0 care. 87 00:15:09.060 --> 00:15:15.010 Amanda Sohaney: The use of care coordination on the Copa plans is not required. If members don't want to use it, they do not have to. 88 00:15:15.530 --> 00:15:25.460 Amanda Sohaney: Only some services need pre authorization to avoid a penalty which does require called a call to the care coordination team. Even if you're not using that tier. One network 89 00:15:27.640 --> 00:15:41.000 Amanda Sohaney: on the managed care plans, there is not an in network preferred tier for $0 care. Most services do require prior authorization, which requires a call to the care coordination team, even though there is no tier one network. 90 00:15:41.120 --> 00:15:46.160 Amanda Sohaney: If members fail to get pre-off on these manage care plans, their claims will be denied. 91 00:15:49.070 --> 00:15:56.110 Amanda Sohaney: So again, the care coordination team is there to ensure that members are receiving the right care and the right place for the best cost. 92 00:15:56.360 --> 00:16:05.210 Amanda Sohaney: On some plans members are rewarded with their out of pocket costs being waived on clear share plans. That is where care coordination starts and stops 93 00:16:05.580 --> 00:16:09.999 Amanda Sohaney: on major medical plans. The service also extends to prior authorizations 94 00:16:10.110 --> 00:16:21.340 Amanda Sohaney: using care. Coordination to get pre-OP doesn't usually result in your cost being waived on the copay plans. Pre-auth avoids penalty on the manage care plans. Pre-off allows access to benefits. 95 00:16:22.180 --> 00:16:27.020 Amanda Sohaney: the cost. Savings that come from pre-OP are passed down to members in the form of lower premiums. 96 00:16:27.070 --> 00:16:46.530 Amanda Sohaney: This isn't quite as enticing in the parent as at $0 care, but is part of why our premiums are often lower than the major medical plans you might find on healthcare. Gov. We do have a brochure that summarizes when pre-off is needed, and we're looking at that chart here, and the link is included in the slides which you will be able to access when I send these out. 97 00:16:48.930 --> 00:16:57.159 Amanda Sohaney: So as we've discussed care, coordination for major medical is a little bit different than care coordination for for clear share. And here are some of the differences 98 00:16:57.320 --> 00:17:03.670 Amanda Sohaney: on clear share only labs, tests, imaging and hospital procedures are eligible for $0 care 99 00:17:03.870 --> 00:17:11.829 Amanda Sohaney: on major medical copay plans. More services are eligible and care. Coordination is built into the plan. Through that tier one network 100 00:17:12.310 --> 00:17:16.969 Amanda Sohaney: on the major medical managed care plans. No services have cost waves. 101 00:17:20.230 --> 00:17:21.719 Amanda Sohaney: and here's the recap 102 00:17:22.500 --> 00:17:34.039 Amanda Sohaney: on clear to your plans. More expensive surgery or sorry, more expensive services are eligible for care. Coordination, as we just looked at members can have their out of pocket costs waived when they use a provider we recommend 103 00:17:34.300 --> 00:17:46.279 Amanda Sohaney: on major medical copay plans. Many services are eligible for care coordination. This is built into the plans on the tier. One preferred network on managed care plans, care, coordination does not waive those costs. 104 00:17:46.830 --> 00:17:54.979 Amanda Sohaney: Where's your dollar? Care is available. No provider lookup is available, and our team works hard to find providers. But the benefits are not guaranteed 105 00:17:55.710 --> 00:18:09.659 Amanda Sohaney: clear share plans don't have prior authorization requirements. Major medical Copay plans have some, and the major medical managed care plans have many use of care. Coordination is only required on the major medical. Manage care plans. 106 00:18:11.140 --> 00:18:20.299 Amanda Sohaney: There's also a great FAQ. Here for care coordination, which will soon be on our new website. But in the meantime you can access it through the link on the slide. 107 00:18:27.520 --> 00:18:30.350 Amanda Sohaney: Now we're going to talk about health savings, accounts 108 00:18:31.400 --> 00:18:32.920 Amanda Sohaney: or Hsas 109 00:18:34.590 --> 00:18:43.439 Amanda Sohaney: so high deductible health plan, or HDHP. Also commonly called an Hsa. Plan, unlocks an Hsa. Bank account for you. 110 00:18:43.740 --> 00:18:59.980 Amanda Sohaney: Hsa. Plans typically have lower monthly premiums than other plans. But the deductible is higher. The Hsa bank account is really the benefit of an Hsa. Plan. The money going in is pre-tax. It comes off the top of your income, similar to a 401 K. Contribution. 111 00:19:00.240 --> 00:19:06.820 Amanda Sohaney: all qualifying medical expenses paid for with an Hsa. With Hsa. Dollars are totally tax free. 112 00:19:07.000 --> 00:19:16.719 Amanda Sohaney: and the bank account is separate from your plan. The money is yours, even if you cancel your Hsa. Plan, and you can open your account at any bank that offers. Hsa accounts. 113 00:19:18.970 --> 00:19:25.370 Amanda Sohaney: we sell 2 Hsa. Plans, the Major, medical Hsa. 5,000 plan, and our Hsa. Mac. 114 00:19:25.580 --> 00:19:30.170 Amanda Sohaney: And again, that Hsa Mech plan is often paired with a clear share. Only plan 115 00:19:32.420 --> 00:19:40.770 Amanda Sohaney: so qualifying expenses, or the things that you can buy with your pre-tax Hsa. Money are set by the Irs. There is a very broad list. 116 00:19:41.010 --> 00:19:47.749 Amanda Sohaney: If the item is deemed Hsa eligible, you can buy it with your Hsa. Money, even if it's not covered by your health plan. 117 00:19:48.210 --> 00:20:09.870 Amanda Sohaney: So, for example, acupuncture is an Hsa eligible expense, but is not covered by any of our Hsa. Plans. That means a member of the met Major medical Hsa. 5,000 plan can go get acupuncture services and pay for them with their pre-tax Hsa. Dollars that they've been contributing to their bank account. They cannot, however, bill the expense to their insurance plan. 118 00:20:10.010 --> 00:20:14.200 Amanda Sohaney: so they get a little bit of a tax discount, even though the plan doesn't cover it. 119 00:20:17.470 --> 00:20:22.660 Amanda Sohaney: The amount of money you're allowed to contribute to your Hsa. Each year is determined by the Irs. 120 00:20:23.770 --> 00:20:30.609 Amanda Sohaney: The limit usually goes up every year less. If you're an individual a little bit more. If you have family members on your plan with you. 121 00:20:33.640 --> 00:20:37.599 Amanda Sohaney: And now let's review our major medical Hsa, 5,000 plan again. 122 00:20:38.050 --> 00:20:44.179 Amanda Sohaney: So members are paying a hundred percent of all services except for preventive care, which is always free as long as it's a network 123 00:20:44.310 --> 00:20:46.170 Amanda Sohaney: until they meet their deductible. 124 00:20:46.210 --> 00:20:52.970 Amanda Sohaney: So, for example, if you go see your primary care, doctor, for strep throat, okay for the the full cost of that doctor visit. 125 00:20:53.300 --> 00:21:04.559 Amanda Sohaney: This is different than Copay plans, where you might pay a $25, copay, and then the plan covers the rest of the visit. but you can use your pre-tax Hsa. Dollars to pay for that expense 126 00:21:05.580 --> 00:21:17.049 Amanda Sohaney: on our Hsa. 5,000 plan. The deductible equals the out of pocket, Max. So once you hit that deductible, you also hit your out of pocket, Max, and the plan is gonna pick up everything that is covered. 127 00:21:17.390 --> 00:21:30.810 Amanda Sohaney: So if you break your arm and need a $7,000 surgery, you would pay up to your $5,000 deductible, and then then the plan is covering everything else, and again you would use your Hsa. To pay for those out of pocket expenses. 128 00:21:33.530 --> 00:21:45.230 Amanda Sohaney: Now let's take another look at the Hsa Mech plan. So the member pays 100% until they meet their Hsa mech deductible. So $3,000 for an individual, and then copays will apply 129 00:21:45.450 --> 00:21:57.459 Amanda Sohaney: only covered services, count towards the deduct deductible, which is hard to meet on this mech plan. The more expensive procedures, like surgeries, are not covered on the Mac, so they do not accumulate towards the Mac deductible. 130 00:21:58.190 --> 00:22:08.210 Amanda Sohaney: So again, for example, if you go see your primary care, Doctor, for strep throat, you're paying the full cost of the doctor visit. But you use your pre-tax Hsa dollars to pay for this expense. 131 00:22:10.830 --> 00:22:16.140 Amanda Sohaney: Let's look at another example. If you paired your Hsa. Mac with a clear share, 1,000 plan. 132 00:22:16.530 --> 00:22:25.190 Amanda Sohaney: So if you break your arm and need a $7,000 surgery, you would pay up to your $1,000 annual, Max, and then clear share which air and the rest of the costs. 133 00:22:25.460 --> 00:22:29.250 Amanda Sohaney: The surgery is not covered on the Hsa Mac portion of the plan. 134 00:22:29.510 --> 00:22:40.969 Amanda Sohaney: But the hospital expense that you paid $1,000 to $1,000 towards is Hsa eligible? So you can still use your Hsa dollars to pay for that out-of-pocket expense. 135 00:22:45.250 --> 00:22:49.050 Amanda Sohaney: And last, but not least, we're going to go over our supplemental plans. 136 00:22:53.470 --> 00:22:58.199 Amanda Sohaney: We've got dental vision, accident, critical illness, and hospital indemnity 137 00:23:00.010 --> 00:23:03.660 Amanda Sohaney: and coming soon. hopefully. Life insurance. 138 00:23:03.780 --> 00:23:12.670 Amanda Sohaney: These plans are also group plans through trident. So members must first become limited partners with Trident, and then they'll have access to Trident's employer sponsored benefits. 139 00:23:15.110 --> 00:23:27.360 Amanda Sohaney: Our dental plan is pretty straightforward. The plan pays a percentage of the costs depending on the coverage tier that a service is in, you can find out which services are in which tier, by looking at the dental breakdown of codes. 140 00:23:27.940 --> 00:23:43.550 Amanda Sohaney: The plan is not part of a network, and will work with any license provider. It's pretty common for dental offices to not understand this or not want to work directly with us, and when that happens, the dental providers will usually make members pay out of pocket, and we can reimburse members. 141 00:23:44.740 --> 00:24:00.589 Amanda Sohaney: The dental plan pays up to $2,000 every year per member. There is a deductible for all coverage tiers, except for preventive care. and this plan covers some orthodontics services with no age, limits, and many other plans will only cover orthodontics for children. 142 00:24:03.990 --> 00:24:11.009 Amanda Sohaney: Our vision plan is also pretty straightforward. The plan pays a hundred percent of vision vision services up to $150. 143 00:24:11.060 --> 00:24:17.359 Amanda Sohaney: That means you can get a vision exam every year, and the plan will pay for the whole thing as long as it's a hundred $50 or less. 144 00:24:18.530 --> 00:24:29.719 Amanda Sohaney: The plan will also pay another $150 every year for frames, lenses, and or contacts. whatever glasses or lenses that you need. The plan is going to pay up to $150. 145 00:24:30.800 --> 00:24:47.170 Amanda Sohaney: The Vision plan is also not part of a network and will work with any license provider. It's extremely common for vision offices to not understand this and not want to work directly with us. And when that happens again, vision providers will usually make members pay out of pocket, and we can reimburse members. 146 00:24:53.610 --> 00:25:01.699 Amanda Sohaney: The accident supplemental benefit is from a company called Brett Point. We sell the plan and collect the premiums, but Breckpoint pays the claims. 147 00:25:03.000 --> 00:25:08.199 Amanda Sohaney: The accident plan pays a lump sum of money for medical charges resulting from a covered accident. 148 00:25:08.950 --> 00:25:24.260 Amanda Sohaney: The accident supplemental benefit pays up to the scheduled maximum app maximum amount after the deductible for medical. Oh, I just said that sorry benefits for this are paid directly to the primary member members just get the check, and they can use the money. However, they see fit. 149 00:25:24.440 --> 00:25:34.599 Amanda Sohaney: They can use it to help cover out-of-pocket medical expenses like their clear share annual Max or their major major medical plan deductible, or they can go on a shopping spree. It doesn't matter. 150 00:25:36.920 --> 00:25:49.160 Amanda Sohaney: We sell the accident plan bundled in our health plans as a pro plan or a premier plan. The pro plans will cover up to $5,000 per accident, and the premier plans cover up to $10,000. 151 00:25:49.240 --> 00:25:53.169 Amanda Sohaney: These tiers also include critical illness plans which we'll review next. 152 00:25:53.630 --> 00:26:07.090 Amanda Sohaney: We add this, it we add this pro or premier label in the plan name, and it can be bundled with any health plan. So clear share only clear share, merge, Mac, plus clear share or major medical plans. You can add the accident plan to any of them. 153 00:26:09.600 --> 00:26:15.120 Amanda Sohaney: There are quite a few services that qu