TEMPORARY HEALTH INSURANCE
(SMART Short Term Medical) – FREQUENTLY ASKED QUESTIONS

Click on a question below to see the answer and more information on the topic or call us at 877-267-3752 and we will do the work for you!

I don’t wear glasses and can see fine! Why do I need an eye exam?

Getting an eye exam is not just about finding out if you need glasses. It’s about your health! An eye exam can detect eye health problems like glaucoma or cataracts, but it can also help identify early signs of diseases that impact your whole body- high blood pressure, diabetes and high cholesterol – just to name a few. So, schedule an exam today and keep an eye on your health.

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When does coverage begin?

Coverage becomes effective next day (12:01 am) following the date the completed enrollment form is received and approved, or a specified date in the future (not more than 30 days in advance), provided that full premium for the coverage has been received.

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At what age should my child first visit the eye doctor?

The American Optometric Association recommends that your child should have his or her first eye exam with an optometrist or ophthalmologist between 6 months of age and 1 year. The doctor will check for nearsightedness, farsightedness, astigmatism, amblyopia (or “lazy eye”), proper eye movement and eye alignment, how the eye reacts to light and darkness, and other eye health problems.They also recommend that your child’s next eye exam should take place sometime between the ages of 3 and 5, and then every year after that. During these exams, the doctor will conduct a comprehensive eye exam as well as vision screening tests.

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When does coverage end?

An insured Member’s coverage ends when the Member is no longer eligible (as defined above), premiums are discontinued (subject to the grace period), when the policy terminates, or when the Member is no longer in good standing with the association, whichever occurs first. Coverage on a dependent ends on the earliest date they no longer meet the definition of an eligible dependent or on the date the Primary Member’s coverage terminates, whichever occurs first.

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My child gets a vision screening at school, so there is no need for an eye exam, right?

A vision screening does not take the place of an eye exam. They generally check a child’s ability to see far away and check for color blindness, but a comprehensive eye exam will evaluate the entire structure of the eye and also allow the doctor to view nerves and blood vessels, providing a glimpse into a child’s overall health. Eye doctors will also check for farsightedness, which is more common in younger children.

 

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What happens if I apply for this insurance and then change my mind and decide that this policy does not fit my needs?

You have the right to review your policy within 10 days from the date you have applied. After you apply, you will automatically receive an email for you to review your application and certificate. If you do wish to terminate the coverage after you have reviewed the certificate, you will need to contact the customer service department by phone. We also require a written request with the policy holder’s signature. If you have provided the correct information within the 10 day time frame, a refund of premiums, minus the administration fees will be issued and your policy will be deemed void, as though it had never been issued.

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How often should I get an eye exam?

As with any type of ongoing health care, annual eye exams are a good rule of thumb unless otherwise directed by your doctor.

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Is Same-Sex Marriage, Domestic Partnerships, or Civil Unions allowed with these plans?

Yes and no; each state has enacted laws that determine eligibility under the plan. Call our toll free number to find out what is available in your particular state.

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How long does an eye exam typically take?

The time can vary, but it will usually take between 30 minutes and one hour. If your eyesight requires multiple tests or if you have a more complex problem, the exam may run longer or require subsequent visits. Plan for an hour to be on the safe side.

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Do I have to use a vision PPO provider to receive benefits?

No. All members and their covered dependents have the freedom to choose any licensed vision provider. The PPO providers available to you have agreed to negotiated fees, so out-of-pocket costs for the member are often much lower than using a non-participating provider.

We highly recommend using a vision provider within the network to experience the best value and lowest out of pocket costs.

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Why does the eye doctor perform so many tests?

Eye doctors perform various tests to examine all parts of the eye, as well as to gauge your overall health. Some procedures are designed to evaluate your vision, others allow the doctor to look at the structure of the eye, and still others help detect specific diseases. Visit www.EyeSiteOnWellness.com for additional information and videos about what to expect during an eye exam.

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How can I find a provider participating in the network?

Provider directories can be accessed via the website, www.RealtorsInsuranceMarketplace.com. Members can search for a specific provider by name, or search for a provider by an address or zip code location. Provider directories are updated on a daily basis. The Provider Relations Department has a toll free number (800.755.8844) to verify participating providers and answer questions about participating providers.

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Can I get the same quality of care at a retail provider as I can at an independent doctor?

Absolutely. In fact, many of the optometrists who practice in retail settings share space with an optical store but operate separately. All optometrists, regardless of the setting of their practice, must meet the same state licensing and credentialing requirements. In addition, due to the finite number of optometry schools in the United States, optometrists are trained consistently regardless of the practice model they eventually choose.

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Do you require a pre-authorization for any claims?

No. Ameritas does not require pre-authorization. However, pretreatment estimates are available anytime a member would like to know how the plan will cover their services. This can be a valuable tool for Members to use in budgeted their out of pocket expenses. Information regarding pretreatment can be found on the backside of the Ameritas claim form or by calling Ameritas’ toll free Claim Customer Service lines. Once the pretreatment estimate is processed, a copy of the estimate is sent to the member and the vision provider.

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What are the different types of corrective lenses?

Corrective Lenses

Single Lenses

A single vision lens has just one power. It is focusing at one range. For a nearsighted person who cannot see far away, the lens is a “minus lens” which is thick on the edge, thin in the middle. For a person who is farsighted or has difficulty reading, the lens is a “plus lens” which is thick in the middle, thin on the edge.

Bifocal Lenses

Bifocal lenses are typically for the presbyopic patient who has a hard time seeing both distance and up close. This requires two different vision corrections in the glass. The near and distance pieces of the lenses are called “segments.” The top part of the lens is usually used for distance and the bottom part is used for up-close work.
A popular option is the no-line bifocal in which the line between segments is not visible. This creates a more youthful appearance, although there may be an additional cost for this option.

Trifocal Lenses

Trifocal lenses accommodate a person who has a visual need at three distances: far away, at an intermediate distance, and up close.

Lenticular Lenses

Lenticular lenses consist of an array of optical elements called lenticules. These lenses are designed to treat eye conditions that are more serious than simple myopia, hyperopia, presbyopia, or astigmatism. They are occasionally prescribed after cataract surgery for patients without intraocular implants; however, advances in surgical procedures have resulted in fewer prescriptions for Lenticular lenses.

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How does the plan handle pre-existing conditions?

The plan does not limit pre-existing conditions.

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What types of bifocals are there?

No-line bifocals: contain a lens with two powers.

Progressive bifocals: gradually change from the top of the lens to the bottom.

 

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How does the plan treat work in progress?

Any procedures started prior to the member’s effective date of coverage will not be eligible under the plan.

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What is MDLIVE?

With MDLIVE, you can access a doctor from your home, office, or on the go- 24/7/365. Our Board Certified doctors can visit with you either by phone or secure video to help treat any non-emergency medical conditions. Our doctors can diagnose your symptoms, prescribe medication, and send prescriptions to your pharmacy of choice.*

* Please note: Some state laws require that a doctor can only prescribe medication in certain situations and subject to certain limitations.

MDLIVE Prescription Policy

Doctors providing consultations for MDLIVE members offer prescriptions for a wide range of products that deliver direct medicinal value. These include, but are not limited to, drug classes such as antibiotics and antihistamines. Convenience prescriptions for maintenance medicines may also be obtained in cases where a member is in transition to a new insurance plan or doctor.

It is important to note that MDLIVE is not a drug fulfillment warehouse. In the event a doctor does prescribe medication, he/she will usually limit the supply to no more than thirty days. Patients with chronic illnesses should visit their primary care doctors or other specialists for extended care. MDLIVE doctors do not issue prescriptions for substances controlled by the DEA, for non-therapeutic use, and/or those which may be harmful (potential for abuse or addiction).

For a current list of DEA controlled substances, visit http://www.deadiversion.usdoj.gov/schedules/

 

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What are the types of lens options?

Lens Options

Glass:  Lenses that have great clarity and are more resistant to scratching, however, they are heavier. • Plastic: Lenses that are lighter weight and more comfortable, however they scratch more easily.

Progressive: Lenses that are line-free. The power gradually changes from distance correction to arm’s length to reading, moving invisibly from the top to the bottom of the lens. Standard progressive lenses use older technology, while premium progressive lenses use more current technology. Premium progressive lenses allow for a smoother blending in the lens as the prescription changes and may also provide clearer peripheral vision.

Plano: Lenses that do not have any correction and are often used for cosmetic purposes.

High-Index: Lenses that have a higher index of refraction, meaning light travels faster through the lens to reach the eye than with traditional glass or plastic. They are denser so the same amount of visual correction occurs with less material. This allows the lens to be thinner and look better cosmetically.

Polycarbonate: The most durable lens on the market. They are especially popular for children’s prescriptions and industrial safety glasses because of the protection they provide against breakage.

Photochromic: Lenses that change from light to dark depending on the intensity of ultraviolet light exposure. This option is often sold under the “Transitions” brand.

Polarized: Lenses that reduce the glare from water and other flat surfaces making the outdoor experience more pleasant and easier on the eye. Boaters and fishermen appreciate this type of lens.

UV Protection: A treatment is applied to lenses to block the harmful portion of ultraviolet light in sunlight.

Scratch-Resistance: A coating applied to plastic lenses to increase their resistance to scratching and pitting. While no lens is ever entirely “scratchproof,” a scratch-resistant coating reduces the chance of lens scratching.

Anti-Reflective: A coating applied to lenses to reduce the intensity of reflections. Bright lights from cars or computer screens, for example, are minimized. They also reduce the intensity of reflections that other people see on the front surface of the lenses so they are more cosmetically appealing.

Solid Tints and Dyes: Lenses with solid color tints and dyes have the same color density throughout. Plastic lenses can be dyed, while tinted glass lenses are made from colored glass. These options may be selected for cosmetic purposes or to reduce the amount of light coming through the lenses.

Plastic Gradient Dyes: Lenses with plastic gradient dyes are usually dark at the top and gradually lighten toward the bottom of the lens. This option is typically for cosmetic purposes.

High-Luster Edge Polish: Glass and plastic lens edges can be polished to a high luster resulting in clear and shiny lens edges. This option is often selected with rimless frames to disguise the edges of the lenses, especially with thicker lenses.

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How does Drug Card America work?

The Drug Card America Card is a non-insurance discount card that provides saving solutions for individuals and family members living in their home. The purpose of providing you with this card is to minimize your “out-of-pocket” expenses for your prescriptions. This program offers up to 60% savings on select generics and up to 15% savings on select name brand prescriptions. The discount fees are honored at participating pharmacy providers. To see which pharmacies in your area accept the card, please click here.

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Do the plans include any waiting periods before benefits are available?

No.  The vision plans do not have any waiting periods for any of the benefits available.

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Is MDLIVE appropriate for every medical condition?

No. MDLIVE is designed to handle non-emergency medical issues. You should not use MDLIVE if you are experiencing a medical emergency. In case of a medical life threatening emergency, you should dial 911 immediately.

 

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What are frames?

Lenses provide function, and frames provide style. There are all kinds of frames on the market that vary in size, shape, and color. Some people prefer bigger, some smaller, but what is most important is that the frame works with the style of lens.

Members often request prescription safety glasses, sunglasses, or ski goggles. It is important for members to verify whether these items are covered under their specific plan benefits.

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Who will benefit using Drug Card America?

Members can use the card for his/her personal benefit or the benefits of his/her spouse, dependent children and any permanent resident in the member’s household.  There is no cost to join, just print off the card and enter your name and family members that wish to save on prescriptions.

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If I have coverage through my spouse or another plan, does your plan coordinate benefits?

Yes. If you have coverage other another group vision plan, Ameritas will coordinate the benefits between the two plans.   If you are covered as a dependent under a spouse’s plan, the NAR plan would be considered “Primary” for you as the NAR member, and “Secondary” under your spouses plan.   Your spouse would be considered “Primary” under their own coverage and”Secondary” under your NAR plan.   Note:  by coordinating benefits, the benefit between the two plans would equal no more than 100% of the total cost of the service.

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What are the types of contact lenses and definitions?

Contact Lenses

Contact Lenses – Necessary: When eyeglasses do not achieve the best visual potential, contact lenses may become necessary. This can be due to keratoconus, corneal trauma, or postsurgical irregularity in the corneal surface.

Contact Lenses – Elective: Many patients choose to wear contact lenses even though glasses achieve a full visual correction. This is considered an elective situation.

Contact Lens Options

Soft Contacts

  • Daily Wear: Lenses are worn during the day and removed each night to be cleaned and disinfected.
  • Extended Wear: Lenses are worn at night, but they must be removed for cleaning and disinfecting at least once a week.
  • Disposable: Lenses are worn during the day and removed at night. They don’t need to be cleaned or disinfected, but are used for the recommended time-frame and then discarded.

Rigid Contacts

  • Gas Permeable: Rigid lenses that, unlike “hard lenses” of the past, allow oxygen to pass through to the eye to keep it healthy. Gas permeable lenses provide better vision, durability, and deposit resistance than soft contact lenses.
  • Ortho-K: A type of lens used to reshape the cornea so that when removed, regular vision is improved, although the effect is temporary. These lenses are also referred to as “night time contacts.”

Specialized Contacts

  • Toric: Lenses are specially shaped and fitted to treat astigmatism.
  • Multifocal: Correct nearsightedness, farsightedness, and astigmatism.
  • Tinted: Contacts can be tinted, either for cosmetic or therapeutic purposes. An example of a therapeutic purpose is to enhance color perception to help compensate for color blindness.

 

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What savings do I get as a participant with Drug Card America?

This program offers up to 60% savings on select generics and up to 15% savings on select name brand prescriptions.

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What does REALTORS Vision Insurance cost?

Members of the NAR have access to exclusive plans and rates for vision insurance that provides benefits for eye exams, frames, lenses, contacts, and more.  To get a quote; simply complete the quote request form on www.realtorsinsurancemarketplace.com or call our customer service team at 877-267-3752.

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Why should I buy a REALTORS® Dental Insurance plan through NAR?

Many self-employed find it difficult to buy individual dental insurance. And if a plan can be found, the pricing for an individual plan can be very expensive. REALTORS® Insurance Marketplace is proud to offer REALTORS® Dental Insurance, an group dental plan offered exclusively to REALTORS® that brings members a choice of affordable plan options. We encourage members to review the four plan choices to consider which plan best fits their budget and dental care needs.

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How do I sign up for MDLIVE and activate my MDLIVE account?

You can easily sign up and activate your account by using one the following methods:

1. Go online and visit: mdlive.com/sas
2. Call our toll free number: 1-888-632-2738
3. Download our Mobile App, available on the iTunes store and Google Play.

 

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When can I start using my benefits with Drug Card America?

You can start to save instantly.  Just print off the card, enter your information and give to a participating pharmacy.  They will enter you in their system as belonging to the Drug Card America group.  You begin to save immediately.

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Who files a claim under my coverage?

Simply provide your ID card to your vision provider. While all PPO providers are required to file claims on your behalf, many non-participating providers offer claim filing services as well. Once the claim is filed, you will receive an Explanation of Benefits (EOB) from the administrator explaining what was paid and what you owe the provider.

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How do I locate a participating provider in the network for Drug Card America?

There are two ways to locate participating providers, You can do an online pharmacy lookup (click here) or Call SASid customer service at toll free 1-877-267-3752.

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Will I receive an ID card?

The ID cards and policy are mailed out to your residence, typically within 3 days via USPS. You should receive the policy and ID cards within two weeks.  If your provider does not accept the insurance you may obtain a claim form and submit the claims directly to Ameritas for processing.

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When is MDLIVE available?

MDLIVE is available 24 hours a day, 7 days a week, and 365 days a year, even on holidays. Use MDLIVE anytime you have a non-emergency medical condition, are unable to see your primary care provider, or when you simply prefer a convenient, cost effective alternative to the emergency room, urgent care center, or clinic.

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Is Drug Card America an insurance program?

No. This is not an insurance program. It is simply a way to obtain substantial savings on all of your prescription needs.

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How do I cancel my coverage?

Vision insurance policy cancellation procedure:

We are confident that this vision plan is the best plan available of its kind. We do care about you and your health and it is our job to make sure that your have secured vision insurance that will benefit your needs. If you have not obtained other insurance and have questions about this plan and the benefits it can provide for you and your family, please contact our customer service department at 1-800-279-2290.

If you are confident that this vision insurance is not going to give you the benefits you need and you have met your twelve month commitment, or you have obtained new group vision coverage, you can terminate this plan. In order to avoid any future payments to be drafted from your account. We do require a hand written signature no later than five days before the next scheduled draft date.

If you are requesting to cancel your plan and are within your 10 day right to review period, your hand written request is required within ten days from the effective date requested on your application. If required information is received in a timely manner, a refund of your premiums paid minus any enrollment fees will be issued to the account on file.

Scan and Email request with signature to: adminefax@sasid.com
or
Fax # : 608-531-2707
or
Mail request to:
InsuranceTPA.com/SASid
PO Box 998
Janesville WI 53547

 

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Where is MDLIVE available?

MDLIVE is available in every state. Our network of Board Certified doctors will be provided to you based on the state you are located. You can start using MDLIVE immediately after you activate your account. Be sure to fill out your medical history profile to better prepare your MDLIVE doctor for your appointment.

 

 

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Is there a maximum use of the benefits with Drug Card America?

No. Unlike insurance, utilization is encouraged. You and your family may use the benefits as many times as needed. There are no limitations on usage.

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How are future rate increases handled?

No individuals can be singled out for cancellation or rate increase under the policy. The National Association of Realtors (NAR) is the Policyholder and if there is a rate increase all policyholders which participate with this group policy will be properly notified.

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Is there a claim form to fill for Drug Card America?

No. There are no claim forms or other paperwork to file. You receive your discount at the time of service and you must pay the provider the discounted amount in full at the time services are rendered.

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How do I get my provider to be added to the network?

If your provider is not a member of the Ameritas provider network, you have several options. You can select a new provider that is in the network or discuss with your provider the possibility of becoming a member of the EyeMed network. You or your provider may contact the Provider Relations Team at 800-755-8844.

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Is there a pre-existing condition exclusion for Drug Card America?

No. Remember, this is not insurance.

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How do I file a claim?

PPO providers will automatically file the claim for you. Many non-participating vision providers may file claims for you as well, however filing claims when using non-participating provider is ultimately the responsibility of the member. The claim filing process is very easy. Claim forms can be printed from our site, or generic forms that most vision providers offices have on hand can also be used.

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Is my specific prescription discounted under Drug Card America?

Discounts vary and can range anywhere from 0% – 60% depending on the type of prescription, brand name, generic name and the location of the specific pharmacy.

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How long does it take to process my claim?

Most vision claims are processed in 5 business days or less. Once processed, an Explanation of Benefits will be sent to you.

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How many drugs are covered under the Drug Card America prescription discount card?

All FDA-approved prescription medications are eligible for a discount. However, discounts are based on several criteria such as; type of prescription, brand name, generic name and the location of the specific pharmacy. Be sure to ask your pharmacist if your specific drug is discounted under this program.

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Where are claims submitted?

Claims can be sent to:
Ameritas Group Vision Claims
P.O. Box 82520
Lincoln, NE 68501

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What is a brand name drug?

A brand name drug is approved by the Food and Drug Administration (FDA), and is supplied by one company (the pharmaceutical manufacturer). The drug is protected by a patent and is marketed under the manufacturer’s brand name.

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How do I qualify (eligible) for this plan?

 

  • be over age 18, unless a dependent of a member – There is no age limit to qualify for these plans
  • be an NAR member
  • Association Executive members and their staff

 

 

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How do I make changes to my vision insurance plan?

For customer service, billing, and plan change questions please contact our customer service department at 1-800-279-2290.

Our office hours are M-T 7:00 AM to 7:00 PM (5:00 PM on Friday) central/standard time.

 

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What is a generic drug?

When a drug patent expires other companies may produce a generic version of the brand name drug. A generic medication, also approved by the FDA, is basically a copy of the brand name drug and is marketed under its chemical name. A generic drug may have a different color or shape than its brand name counterpart, but it must have the same active ingredients, strength, and dosage form (i.e., pill, liquid, or injection), and provide the same effectiveness and safety as its brand name counterpart.

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What happens if my expiration date changes on my credit card I have been using?

If any billing changes need to be made, you will need to contact the customer service dept by phone at 1-800-279-2290.

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Are generic drugs as safe as brand name drugs?

Yes. The FDA requires that all drugs be safe and effective and that their benefits outweigh their risks. Since generics use the same active ingredients and are shown to work the same way in the body, they have the same risks and benefits as their brand name counterparts.

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Who is an eligible dependent?

a. an Insured’s spouse.

b. each unmarried child less than 26 years of age, (less than 30 years of age for discharged military dependents), for whom the Insured or the insured’s spouse, is legally responsible, including:

  1. natural born children;
  2. adopted children, eligible from the date of placement for adoption;
  3. a grandchild that is a dependent of, and under interim court-ordered custody of the Insured;
  4. children covered under a Qualified Medical Child Support Order as defined by applicable Federal and State laws.

c. each unmarried child age 26 or older who:

  1. because of a handicapped condition that occurred before attainment of the limiting age, is incapable of self-sustaining employment; and
  2. is dependent on his or her parents or other care providers for lifetime care and supervision.

 

“Dependent on other care providers” is defined as requiring a Community Integrated Living Arrangement, group, home, supervised apartment, or other residential services licensed or certified by the Department of Mental Health and Development Disabilities, the Department of Public Health, or the Department of Public Aid.

Coverage of such child will not cease if proof of dependency and disability is given within 31 days of attaining the limiting age and subsequently as may be required by us but not more frequently than annually after the initial two-year period following the child’s attaining the limiting age. Any costs for providing continuing proof will be at our expense.

 

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What happens if my payment was declined?

You will be notified by phone or email and you will also receive a letter in the mail. Your policy will be in danger of lapsing.

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Can I ask the pharmacy to substitute a generic drug for the drug prescribed by my doctor?

Each state has a law that allows pharmacists to substitute less expensive generic drugs for many brand names. However, if your doctor specifies that a brand name must be dispensed, then the pharmacist may not substitute the generic. Sometimes an acceptable generic is available that your doctor may not be aware of. In this case, your pharmacist may be able to consult with your doctor to suggest an effective medication that costs less.

 

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When should I enroll my dependents?

Eligible dependents should be enrolled at the time of application. If you would like to add dependents at another time, you may but they will have their own waiting period (6 months for major services and 12 months on ortho) to satisfy. Dependents enrolled at a later date will take effect at the following month renewal date.

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How long do I have to make a missed payment?

Your policy gives you 31 days from the due date to post a new payment. If a payment has not been posted within that time, your policy will terminate due to nonpayment. Your insurance coverage dates will reflect the approved payments made.

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Are newly acquired dependent children covered?

Your child or children born after your enrollment/effective date will be effective from the moment of birth (If they already have already enrolled dependents) and will remain in effect for 31-days. An adopted child or child placed with you for the purpose of adoption will be covered for 31-days from the date of adoption or placement. To continue the child’s coverage You must send us written notice directing us to add the child or children to your coverage. We must receive this notice within the 31-days after the child’s date of birth, adoption or placement. Any required additional premium must accompany your notice. If you do not send us the required notification and any additional premium, the child’s coverage will end after the 31-days.

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What are the customer service telephone numbers and hours of operation for the claims department?

If you have any questions please call:
Ameritas Group Claims Department at 800-487-5553
Representatives are available Monday – Thursday 7:00 am to 12:00 am (Central Standard Time)
and Friday 7:00 am to 6:30 pm (Central Standard Time)

Visit the Ameritas website at:
www.ameritasgroup.com

 

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Where are the plans available?

To see if the plans are available in your state, simple register at the www.RealtorsInsuranceMarketplace.com website or call the toll free number provided. If you receive a quote from the website then the plans are available in your state. If the plans are not available we will set up a reminder to contact you once it is available.

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Where are REALTORS® Dental Insurance plans available?

To see if the plans are available in your state, simply register by clicking here or calling 877-267-3752. If you receive a quote from the website then the plans are available in your state. If the plans are not available we will set up a reminder to contact you once it is available.

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How do I qualify (eligible) for REALTORS® Dental Insurance?

  • be over age 18, unless a dependent of a member – There is no age limit to qualify for these plans
  • be an NAR member

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Who is an eligible dependent on REALTORS® Dental Insurance?

  • an Insured’s spouse.
  • each unmarried child less than 26 years of age, (less than 30 years of age for discharged military dependents), for whom the Insured or the insured’s spouse, is legally responsible, including:
    1. natural born children;
    2. adopted children, eligible from the date of placement for adoption;
    3. a grandchild that is a dependent of, and under interim court-ordered custody of the Insured;
    4. children covered under a Qualified Medical Child Support Order as defined by applicable Federal and State laws.
  • each unmarried child age 26 or older who:
    1. because of a handicapped condition that occurred before attainment of the limiting age, is incapable of self-sustaining employment; and
    2. is dependent on his or her parents or other care providers for lifetime care and supervision.

“Dependent on other care providers” is defined as requiring a Community Integrated Living Arrangement, group, home, supervised apartment, or other residential services licensed or certified by the Department of Mental Health and Development Disabilities, the Department of Public Health, or the Department of Public Aid.

Coverage of such child will not cease if proof of dependency and disability is given within 31 days of attaining the limiting age and subsequently as may be required by us but not more frequently than annually after the initial two-year period following the child’s attaining the limiting age. Any costs for providing continuing proof will be at our expense.

 

You can enroll your child or children born after your enrollment/effective date will be effective from the moment of birth (If they already have already enrolled dependents) and will remain in effect for 31-days. An adopted child or child placed with you for the purpose of adoption will be covered for 31-days from the date of adoption or placement. To continue the child’s coverage You must send us written notice directing us to add the child or children to your coverage. We must receive this notice within the 31-days after the child’s date of birth, adoption or placement. Any required additional premium must accompany your notice. If you do not send us the required notification and any additional premium, the child’s coverage will end after the 31-days.

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If I had dental coverage through another plan or will be losing coverage soon, can the waiting periods be waived?

Yes.   If you have had coverage within two months of enrolling in one of the NAR dental plans, the six month waiting period on Type 3 procedures and the 12 month waiting period on orthodontic benefits can be waived.   When enrolling, you will need to indicate that prior dental coverage existed for you and/or your covered dependents.   An ID card or EOB from the prior dental plan can be included to verify prior coverage and allow us to authorize the waiver of the waiting periods.

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If I have dental coverage through my spouse or another plan, does your plan coordinate benefits?

Yes.   If you have coverage other another group dental plan, Ameritas will coordinate the benefits between the two plans.   If you are covered as a dependent under a spouse’s plan, the NAR plan would be considered “Primary” for you as the NAR member, and “Secondary” under your spouses plan.   Your spouse would be considered “Primary” under their own coverage and”Secondary” under your NAR plan.   Note:  by coordinating benefits, the benefit between the two plans would equal no more than 100% of the total cost of the service.

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How do I make changes to my REALTORS® Dental Insurance plan?

For customer service, billing, and plan change questions please contact our customer service department at 1-800-279-2290.

Our office hours are M-F 8:30 to 5:00 central/standard time.

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When does REALTORS® Dental Insurance coverage begin?

Coverage becomes effective next day (12:01 am) following the date the completed enrollment form is received and approved, or a specified date in the future (not more than 30 days in advance), provided that full premium for the coverage has been received.

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When does REALTORS® Dental Insurance coverage end?

An insured Member’s coverage ends when the Member is no longer eligible (as defined above), premiums are discontinued (subject to the grace period), when the policy terminates, or when the Member is no longer in good standing with the association, whichever occurs first. Coverage on a dependent ends on the earliest date they no longer meet the definition of an eligible dependent or on the date the Primary Member’s coverage terminates, whichever occurs first.

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Will I receive an ID card for my REALTORS® Dental Insurance?

The ID cards and policy are mailed out to your residence, typically within 3 days via USPS. You should receive the policy and ID cards within two weeks.  If your provider does not accept the insurance you may obtain a claim form and submit the claims directly to Ameritas for processing.

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What does MCE mean?

Maximum Covered Expense (MCE): a simple, easy to understand benefit at a very affordable rate. Members know exactly what the plan pays for each covered procedure, and they pay the difference between that amount and the dentist fees. The MCE increases based on the plan you select. The Value Plan has the lowest MCE and Platinum Plan offers the highest level. Additional out of pocket savings occur when a member uses an Ameritas Preferred provider.

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Is Orthodontia available with REALTORS® Dental Insurance?

Yes. Under the Platinum, Gold and Silver plans, orthodontic benefits are available for children. Benefits are payable for orthodontic programs that were started before the dependent’s 17th birthday. The Platinum, Gold and Silver plans provide a $1,000 lifetime maximum benefit per eligible dependent child.

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Is Anesthesia covered under the REALTORS® Dental Insurance plans?

Yes. Anesthesia is covered under the Platinum, Gold and Silver plans.

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Do I have to use a PPO dentist to receive benefits?

No. All members and their covered dependents have the freedom to choose any licensed dental provider. The PPO providers available to you have agreed to negotiated fees, so out-of-pocket costs for the member are often much lower than using a non-participating provider.

As an added comfort, all PPO dentists have passed an extensive screening to ensure not only a saving to the plan but high quality care.

Not every dentist is able to meet Ameritas’ standards. Only those who adhere to Ameritas’ credentialing and quality assurance requirements are able to join and remain in the network. This process includes:

  1. State insurance department verification to confirm that dentists are licensed, and to uncover whether any disciplinary action has ever been filed
  2. Review of malpractice insurance and that no malpractice suits have been filed
  3. Legal department and dental consultant review of any license disciplinary action or discovery of malpractice suits.
  4. Certification of adherence to quality assurance guidelines as mandated by state and federal entities, including OSHA and the Center for Disease Control.

Ameritas re-credentials and conducts quality assurance visits on network providers periodically to make sure they continue to work within accepted parameters.

To find a provider that is part of the PPO Network, click here. Members can search for a specific provider by name, or search for dentists by an address or zip code location. Provider directories are updated on a daily basis. The Provider Relations Department has a toll free number (800.755.8844) to verify participating providers and answer questions about participating providers.

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How does REALTORS® Dental Insurance handle pre-existing conditions and work in progress?

The plan does not limit pre-existing conditions. Simply knowing a dental procedure is needed does not prohibit the plan from providing coverage. As long as the procedure is not incurred prior to the member’s effective date of coverage, the procedure is eligible for benefits based on the plan coverage.

Any procedures started prior to the member’s effective date of coverage will not be eligible under the plan.

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Do the REALTORS® Dental Insurance plans include any waiting periods before benefits are available?

Yes. On the Platinum, Gold and Silver plans, a six(6) month waiting period applies to all Type 3 Procedures before benefits are paid. A twelve (12) month waiting period applies to all Orthodontic Procedures before benefits are paid.

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Why should I consider a REALTORS® Core Health Insurance (Limited Medical) plan?

There are several important reasons why people purchase limited medical (also known as mini-medical) plans. In summary; to save money, to access to “Guaranteed Acceptance” policy, and to supplement another plan which has high out of pocket expenses.

Here are a few possible scenarios:

 

  • I do not qualify for a Special Enrollment Period to enroll in Major Medical insurance outside Open Enrollment: REALTORS® Core Health Insurance plans are available year round. You can enroll in this plan at any time, but it is important to remember that you may be subject to the federal tax penalty.
  • I cannot afford traditional medical insurance: REALTORS®’s exclusive “guaranteed acceptance” plans will cover your everyday healthcare needs – but it’s important to recognize that they are not major medical insurance. REALTORS® Core Health Insurance offers limited medical plans that are affordable and available to everyone because they provide set and limited dollar coverage for each medical service needed. 
  • I have major medical insurance but it is too expensive: An excellent way to save on medical insurance is to supplement a major medical plan with a REALTORS® Core Health Insurance plan. We recommend that you keep your major medical plan but increase your deductible and buy a RCHI plan to complement your major medical coverage.

Why would you increase your deductible? Because a program such as RCHI’s Physician Only plan may offer equivalent coverage for your everyday healthcare needs (such as office visits and wellness visits) but at a much lower cost than your current coverage through your major medical plan – allowing you to change the terms of your major medical coverage and save money.

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What happens if I apply for this insurance and then change my mind and decide that this policy does not fit my needs?

You have the right to review your policy within 10 days from the date you have applied. After you apply, you will automatically receive an email for you to review your application and certificate. If you do wish to terminate the coverage after you have reviewed the certificate, you will need to contact the customer service department by phone. We also require a written request with the policy holder’s signature. If you have provided the correct information within the 10 day time frame, a refund of premiums, minus the administration fees will be issued and your policy will be deemed void, as though it had never been issued.

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What are the customer service telephone numbers and hours of operation for the REALTORS® Dental Insurance claims department?

If you have any questions please call:
Ameritas Group Claims Department at 800-487-5553
Representatives are available Monday – Thursday 7:00 am to 12:00 am (Central Standard Time)
and Friday 7:00 am to 6:30 pm (Central Standard Time)

Visit the Ameritas website at:
www.ameritasgroup.com

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How do I cancel my REALTORS® Dental Insurance coverage?

Dental insurance policy cancellation procedure:

We are confident that this dental plan is the best plan available of its kind. We do care about you and your health and it is our job to make sure that your have secured dental insurance that will benefit your needs. If you have not obtained other insurance and have questions about this plan and the benefits it can provide for you and your family, please contact our customer service department at 1-800-279-2290.

If you are confident that this dental insurance is not going to give you the benefits you need and you have met your twelve month commitment, or you have obtained new group dental coverage, you can terminate this plan. In order to avoid any future payments to be drafted from your account. We do require a hand written signature no later than five days before the next scheduled draft date.

If you are requesting to cancel your plan and are within your 10 day right to review period, your hand written request is required within ten days from the effective date requested on your application. If required information is received in a timely manner, a refund of your premiums paid minus any enrollment fees will be issued to the account on file.

Scan and Email request with signature to: adminefax@sasid.com
or
Fax # : 608-531-2707
or
Mail request to:
InsuranceTPA.com/SASid
PO Box 998
Janesville WI 53547

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Is REALTORS® Core Health Insurance major medical insurance?

These plans are not major medical coverage and are not intended to replace other medical coverage. If you have major medical insurance, you may save money by increasing your out-of-pocket (deductible) and use these plans to supplement coverage. However, you should not cancel your major medical coverage.

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What is the difference between Major Medical and Limited Medical (REALTORS® Core Health Insurance)?

It is important to understand the difference between major medical and limited medical insurance. 

Major Medical provides comprehensive and catastrophic coverage. Because the cost of medical services continues to rise, many major medical insurance companies have increased the out-of-pocket costs for consumers, making the everyday cost of healthcare expensive.

Limited Medical (RCHI) provides coverage for everyday illness and accident at affordable rates by offering specific benefits with capped limits of coverage.
Limited Medical plans are useful in many situations:

  • Not eligible for a Special Enrollment Period to enroll in Major Medical insurance outside Open Enrollment: REALTORS® Core Health Insurance plans are available year round. You can enroll in this plan at any time, but it is important to remember that you may be subject to the federal tax penalty.
  •  Save money by supplementing current Major Medical Plan – If you have a major medical plan you can save money by increasing your current plan’s deductible (out of pocket). Then take advantage of the Realtors® Core Health Plans value for your everyday healthcare needs. The “Physician Only Plan” covers office, wellness visits, x-ray/lab and accident benefits at an affordable price.
  • Uninsured due to affordability – If you have done your research and you simply cannot afford major medical then a limited medical plan may be a last option. Designed to offer benefits at a value.

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Do I qualify/am I eligible for REALTORS® Core Health Insurance?

To be eligible for any RCHI plan you must be an active member of the National Association of REALTORS® and:

  •  be over age 18, unless an eligible dependent of a member
  •  be under age 65 (persons over the age of 65 should look into a Medicare supplement or similar plan) reside in a qualified* state of United States

*Click here (or call 877-267-3752) and register to see if a plan is available in your state. If you receive a quote then your state is available. If your state is not available we will contact you once we get approval from your state department of insurance.

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Are REALTORS® Core Health Insurance plans available in every state and the U.S. territories?

Our goal is to have a plan available in every state and territory. Although coverage is available in the majority of states today, there are some still awaiting approvals from the state department of insurance. To see if the plans are available in your state, simply click here to register or call 877-267-3752.

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Do I have to be a United States citizen to be eligible for REALTORS® Core Health Insurance?

No, but you must be a permanent resident of the United States for 12 consecutive months and have a valid Social Security Number.

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What is the difference between the three exclusive REALTORS® Core Health Insurance plans developed for REALTORS®?

  • The Physician Only plan – Designed to supplement and complement major medical plans that have high out-of-pocket cost (deductibles, coinsurance, etc.). Increasing your major medical deductible and adding this RCHI plan may help you save money.
  • The Value plan – Offers both physician and hospitalization/surgery benefits. This plan was designed for someone who is on a limited budget. This plan can also supplement a major medical plan that involves a large out-of-pocket cost.
  • The Platinum plan – Offers the richest benefits of the three REALTORS® plans: It offers physician, hospitalization/surgery, and other benefits. This plan was designed for REALTORS® members who would otherwise not be able to get insurance (“uninsurable” due to pre-existing medical conditions or other issues).

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What are the medical underwriting requirements of REALTORS® Core Health Insurance plans?

All members of the National Association of REALTORS® and their eligible dependants who satisfy the eligibility requirements are automatically accepted. The plans are “Guaranteed Acceptance”, which means as long as you meet the eligibility requirements and provide timely payment of premium you will be accepted into the program. There are no medical questions or exams to qualify.

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Are Pre-existing Conditions covered under REALTORS® Core Health Insurance and is there a waiting period?

Benefits such as doctor office and wellness visits; accident, x-ray and laboratory benefits have no pre-existing limitation clause on these plans.

However, benefits under Hospital, ICU/CCU, Surgery or Anesthesia are not payable for any pre-existing condition for the first 12-months following an insured’s effective date.

There is a 30 day waiting period for services rendered for illness and sickness (illness or disease) from the effective date of the policy.

There is no (0 day) waiting period for accident related services.

NOTE: Please review your policy for any additional limitations and exclusions.

If you have access (states availability varies) to the PPO (prefered provider option) you may receive up to 40% on services covered and/or not covered (pre-existing, waiting period, excluded) by the REALTORS® Core Health Insurance plans.

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I have current medical conditions; do I still qualify for REALTORS® Core Health Insurance?

These plans are “Guaranteed Acceptance”; as long as you meet the eligibility requirements you qualify. The 12-month pre-existing condition provision, will apply to any Hospital, ICU/CCU, Surgery or Anesthesia.

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Do the REALTORS® Core Health Insurance plans cover pregnancy/maternity care?

No, these plans do not cover normal pregnancy. However, they do cover complications of pregnancy.  Also, if you utilize the PPO (Preferred Provider Option) you may recieve up to 40% discount on your pre and post maternity services.

The best option if you are planning to become pregnant and need coverage is to try to acquire a group policy through an employer or acquire an individual major medical policy. You can do this during Open Enrollment, or through a Special Enrollment Period (click here to learn more about special enrollment periods). You should plan ahead and access a major medical or group plan before you become pregnant. If you’re unsure what to do, always call a licensed benefit specialist who can advise you of your options at 877-267-3752.

If you are currently pregnant – you will need group coverage through an employer (which has maternity coverage). Individual major medical plans are a good option too, but you can only enroll during Open Enrollment or if you have a qualifying event that triggers a special enrollment period.

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What is the definition of Pre-existing Condition limitation under REALTORS® Core Health Insurance?

Pre-existing Condition means a medical condition, Injury or Sickness, not excluded by name or specific description, for which:

  1.  Medical advice, Consultation, care or treatment was recommended by, or received from, a Doctor within 12-months immediately prior to the Effective Date of coverage for a Covered Person; or
  2. Symptoms existed within 12-months immediately prior to the Effective Date of coverage for a Covered Person that would cause a reasonable person to seek Consultation, care, or treatment from a Doctor.

“Consultation” means evaluation, diagnosis, or medical advice given without the necessity of a personal examination or visit.

The Pre-existing Condition limitation only applies to Surgery, Anesthesia, Hospital, and ICU/CCU benefits.

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Can I have another medical insurance plan in addition to REALTORS® Core Health Insurance?

Yes, and it may be an excellent way for you to save money. For example; Jimmy is paying $800 for his $250 deductible major medical policy. If Jimmy increases his deductible to $1,500 his premiums go down to $550 per month. With his savings of $250 per month he is able to purchase the “Physician Plan” which will cover his Office/Wellness visits and Accident benefit. Because the plans are affordable, Jimmy has supplemented his current plan and saved money.

However, please note that you may not be covered under more than one REALTORS® Core Health Insurance plan per person.

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If I apply for an insurance plan, am I obligated to buy?

No. You are under no obligation to buy a health insurance plan when using our site.  After submitting your application you may cancel it at any time during the underwriting process.  When you submit an application you will typically include your credit card number, bank account information, or a check for the initial premium payment.  Most insurance companies will not charge your card, debit your account, or deposit your check until you are approved.  If you are charged or your check is cashed and you are denied for coverage or cancel your application prior to approval, the insurance company will issue a refund.  A few insurance companies will charge an application fee .  You will be notified at the time of application if the plan you chose require an application fee.  Please note that these fees are non-refundable.

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Will I receive an insurance ID card for REALTORS® Core Health Insurance?

You will receive instant access to printable RCHI ID cards once you enroll. To apply, click here. Also, plastic cards are mailed out to your residence within 3 days of enrollment via USPS. You should expect to receive them no later than two weeks.

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When does REALTORS® Core Health Insurance coverage begin?

Coverage becomes effective next day (12:01 am) following the date the completed enrollment form is received and approved, or a specified date in the future (not more than 30 days in advance), provided that full premium for the coverage has been received. Note: Please check your policy for information on pre-existing conditions, waiting periods and other limitations and exclusions.

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When does REALTORS® Core Health Insurance coverage end?

An insured Member’s coverage ends when the Member is no longer eligible (see your policy’s eligibility questions), premium payments are discontinued (subject to the grace period), when the policy terminates, Member reaches age 65, or when the Member is no longer in good standing with the association, whichever occurs first. Coverage on a dependent ends on the earliest date they no longer meet the definition of an eligible dependent or on the date the Primary Member’s coverage terminates, whichever occurs first.

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What are the payment options for REALTORS® Core Health Insurance?

Online payment is the most popular choice; you can arrange for manual payments each month or you can set up automatic payments that are withdrawn from your credit card or checking/savings account. You can check the status of your payments online. You may also set up email alerts to let you know when payments will be withdrawn. Another option is to have paper bills sent to your address of residence. Extra fees may apply for this payment option.

Monthly Options:

If you have chosen a payment method of Credit Card or EFT your payments will be deducted from that account given on the scheduled billing date each month. It is set up for you automatically so you have the peace of mind that your payments will not be missed.

If you choose the offline payment option, you will then be responsible for mailing in the payments each month on the scheduled billing date. Payment coupons will be sent to you to help you remember your billing date.  Extra fees may apply for this payment option.

 

Mail payments to:

Realtors® Core Health Plans
P.O. Box 998
Janesville, WI 53547

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Is there a place where I can go online to view my payment history?

Yes. All members have access to the customer service login. You will be able to view not only payment information, you will have access to view claim status, billing, cancellation procedure and even the links to view your certificate, plus more!

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I missed a payment for my REALTORS® Core Health Insurance plan. Is there a grace period?

Your policy gives you 31 days from the due date to post a new payment. If a payment has not been posted within that time, your policy will terminate due to nonpayment. Your insurance coverage dates will reflect the approved payments made.

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What happens if I review my REALTORS® Core Health Insurance application and notice that some of my personal information is incorrect?

If changes need to be made on an application, you will need to contact the customer service department at 1-800-279-2290 or send us an email from your customer service login.

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Who is an eligible dependent under REALTORS® Core Health Insurance?

Eligible Dependent means:

  1. Your lawful spouse; and
  2. Your child(ren) age 26 and younger.

“Child” includes stepchild, foster child, legally adopted child, a child of adoptive parents pending adoption proceedings, and natural child.

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Are newly acquired dependent children covered under REALTORS® Core Health Insurance?

Your child or children born after your enrollment/effective date will be effective from the moment of birth and will remain in effect for 31-days. An adopted child or child placed with you for the purpose of adoption will be covered for 31-days from the date of adoption or placement. To continue the child’s coverage You must send us written notice directing us to add the child or children to your coverage. We must receive this notice within the 31-days after the child’s date of birth, adoption or placement. Any required additional premium must accompany your notice. If you do not send us the required notification and any additional premium, the child’s coverage will end after the 31-days.

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When should I enroll my dependents under REALTORS® Core Health Insurance?

Eligible dependents should be enrolled at the time of application. If you would like to add dependents at another time, you may but they will have their own preexisting condition limitation (12/12) clause (see preexisting condition definition) and waiting period (30 days for sickness related conditions, 0 for accident) to satisfy. Dependents enrolled at a later date will take effect at the following month renewal date.

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How do I add a person to a REALTORS® Core Health Insurance plan after the effective date?

To add a person, you must:

  • Complete and submit a new enrollment application by clicking here for such person for approval; and
  • Contact billing (1-877-279-2290; or email rchi@sasid.com), request “Change Authorization Request Form”, complete form, and send in to SASid (PO Box 998, Janesville, WI 53546)
  • Pay any additional premium required

If the application for coverage of the new Eligible Dependent is approved, the Effective Date of such person’s coverage will be shown by an endorsement to your certificate.

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Can I use any doctor, clinic, or hospital with REALTORS® Core Health Insurance?

Yes. Covered members and dependents can use any licensed medical provider. Some states have a PPO (preferred provider option) available which may provide additional savings to the insured(s). We encourage members to use this valuable benefit when available.

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Is there a provider network of doctors (PPO option) with REALTORS® Core Health Insurance?

You may go to any licensed physician or hospital with these insurance plans. In some states there is a PPO network option (based on state availability) which can provide additional savings on your healthcare, if you choose to use it.

Preferred Provider Organizations (PPOs) have negotiated discounts with providers (doctors, hospitals, etc.) nationwide. By utilizing providers in these networks you can save money on your healthcare. The PPO networks are an option for you and are not mandatory, although it is typically in your best interest to use a PPO provider. Based on your state of residence REALTORS® Core Health Insurance Plans will add a PPO network (if available) to your plan automatically.*

The REALTORS® Core Health Insurance Plans utilize the MultiPlan PPO network.  The network has almost 900,000 providers nationwide.  When you request a quote or purchase a RCHI plan if the network shows up (“Quotes” or “My Plans”) then it is available to you (you will be able to search providers here also).  If the network does not show up then it is not available in your state at this time.  You may also call  877-267-3752 to find out if the network is available in your state.

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Will these REALTORS® Core Health Insurance plans cover all of my medical expenses?

No, limited plans are very clear in what they cover. If it is not on the schedule page of benefits then it is likely not covered. It is important that you review the plan details for exclusions and limitations information. Call a representative at 1-877-CORE-PLAN to discuss your options.

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Are prescriptions covered under REALTORS® Core Health Insurance?

All plans include a discount prescription drug card. You can save up to 50% on generic brands and up to 15% on brand names.

The definition of a generic drug is: A generic drug is a medication that has met the standards set by the Food and Drug Administration (FDA) to assure its bioequivalency to the original patented brand name medication. Once a generic drug is approved by the FDA as being bioequivalent, its level of safety, purity, strength and effectiveness is the same as the brand name product.

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How do I cancel my REALTORS® Core Health Insurance policy?

Policy cancellation procedure:

(1) Fax (or scan and email) us a written request for cancellation a minimum of 5 days prior to the billing date. U.S. Mail is an option as well, but remember that the request must be received 5 days prior to the current month’s billing  date. The automatic billing date is the date of the 1st payment made. Any requests received less than 5 days prior to the current month’s billing date will be processed for cancellation before the next month’s billing date.

(2) Include:
-the policy holder’s Name & Address
-the policy holder’s Date of Birth
-the policy ID number
-the date the policy is to be cancelled
-the reason for cancellation
-the policy holder’s signature

(3) Our fax number is 608-755-7955 Alternate Fax 253-595-6901. Our Mailing address is:

Insurance TPA
PO Box 998
Janesville, WI 53547

(4) Attn. Customer Service and Billing Dept.

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What is the best health insurance plan for me?

Choosing between different health insurance plans isn’t always easy.  There is no one “best” plan for everyone.  the est match for your and your family may be different that the best match for someone else.  In order to help you answer this question, here are a few things to consider:

1. Are you going to need long term coverage or just something for short term?
If you are between jobs for 1-6 months,  you may want to look int our short term coverage options.  Alternatively, if you have no prospects of receiving group health insurance coverage through an employer, you may value the stability and increased benefits offered through an individual or family health plan option.
2. Are you looking for basic coverage or more comprehensive coverage?
Some insurance plans offer basic coverage to cover  you in case of a major accident or illness.  These insurance plans typically have a lower month premium than plans with more comprehensive coverage and may be appropriate  for people who intend to use their insurance primarily in the event of a serious illness or accident.
3. Would you rather pay for your services before you use them or when you use them?
Typically, the higher the monthly premium that you pay, the less you will pay per doctor’s visit in co-payments and deductible.s  if you choose a health insurance plan with a low monthly premium, you’re likely to have a higher co-payment or deductible.  If you don’t anticipate making frequent  use of your health insurance coverage, a higher deductible plan with a lower monthly premium may suit you best.

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How can I view quotes and shop online through your website?

Shopping with us is simple.  After entering your zip code and some basic information about yourself, and your family if applicable, you will be provided with a list of health insurance plans available in your area.  You may refine these results or sort and organize them in various ways (deductible, co-insurance, price).  You will also have the opportunity to select several of them at a time to make more detailed  plan comparisons. Once you have selected a plan, you will fill out an application, providing more information about yourself, and your family if applicable, and health history.  Once your application is complete, we will work with the insurance company to help you receive a quick coverage determination.

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What is Temporary Health Insurance?

Temporary Health Insurance (A.K.A. Short Term Medical) is an ideal type of medical insurance for those who are: unemployed, in between jobs, recent college graduates, in need of an alternative to COBRA. You will see that this coverage provides many features while maintaining a very competitive premium structure.

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Who is eligible for short term medical coverage?

You and your spouse under age 65 (and not eligible for Medicare) and you and your spouse’s unmarried dependent children under age 19 (or under age 25 if a full-time student) who have a social security number and can answer “No” to the seven health questions on the application. Children age 19 and over should apply separately.

 

Child-only coverage is available for ages 2 through 18. The application must be completed and signed by the parent or legal guardian.

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How does short term medical coverage work?

The benefit options for covered expenses are per insured person per coverage period. First, you meet your deductible. Choose from four options: $250, $500, $1,000 or $2,500. Then we pay 80% or 50% of the next $5,000 of covered expenses.

After this, we pay 100% of covered expenses up to your lifetime maximum of $1 million per certificate.

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What is individual and family health insurance?

Individual and family health insurance is a type of health insurance coverage that is made available to individuals and families, rather than to employer groups or organizations. Given the option, most people would prefer to have their employer provide group health insurance coverage. But, if this is not an option for you, it is still important for you to seek coverage. You may be pleasantly surprised with the variety and affordability of the individual and family health insurance options available.

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Do I have the option to select my doctors, hospitals, and medical providers with short term medical insurance?

Yes. You have the freedom to go to any of the doctors and hospitals of your choice. This plan is not an HMO or PPO.

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How long may I be insured under this short term medical plan?

STM is issued on a temporary need and expires at the end of the period applied for (up to 6 months at a time). If the need for temporary health insurance continues, you may apply for another new STM* coverage period. Your application is subject to the eligibility and underwriting requirements. Furthermore the coverage is not continuous. Any condition that incurred expense during the last coverage period will be treated as a Pre-Existing Condition, and excluded under the next coverage period. Applicants over the age of 64 are not eligible to re-apply for coverage.
*Only if an STM Plan is available in your resident state at that time; plan benefits, premium and features may vary.

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What kinds of individual and family insurance plans are available?

Individual and family health insurance plans are usually described as either “indemnity” or “managed-care” plans.  Put broadly, the major differences concern choice of healthcare provider, out of pocket costs and how bills are paid.  Typically, indemnity plans offer a broader selection of healthcare providers than managed care plans.  Indemnity plans pay their share of the costs for covered services only after they receive a bill (which means that you may have to pay up front and then obtain reimbursement from your health insurance company),

There are several different types of managed-care health insurance plans.  These include HMO, PPO and POS plans.  Managed-care plans typically make use of healthcare provider networks.  Health care providers within a network agree to perform services for managed-care plan patients at pre-negotiated rates and will usually submit the claim to the insurance company for you.  In general, you will have less paperwork and lower out-of-pocket costs with a managed care health insurance plan and a broader choice of healthcare providers with an indemnity plan.

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Are pre-existing conditions covered under short term medical insurance?

This plan does not provide benefits for pre-existing conditions, work related conditions, and preventive care. If you or a dependent have an existing health condition, you may want to consult with your independent insurance agent prior to applying for or changing health/medical insurance. Insurance fraud is a crime. Any person who, with intent to defraud or knowingly facilitates a fraud against an insurer, submits an application or files a claim containing false, deceptive and/or incomplete information is subject to civil and criminal prosecution.

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How does a PPO plan work?

As a member of a PPO (Participating Provider Organization) plan, you will be encouraged to use the insurance company’s network of doctors and hospitals.  These healthcare providers have been contracted to provide services to the health insurance plan’s members at a discounted rate.  You typically won’t be required to pick a primary care physician but will be able to see doctors and specialists within the network at your own discretion.

You will probably have an annual deductible to pay before the insurance company starts cover your medical bills.  You may also have a co-payment for certain services or be required to cover a certain services or be required to cover a certain percentage (coinsurance) of the total charges for your medical bills.

With a PPO plan, services rendered by an out-of-network physician are typically covered at a lower percentage than services rendered y a network provider.

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Are there expenses not covered under this short term medical plan?

Yes, this plan is designed to protect you in the event of an illness or injury and is not meant to cover routine exams and preventive care. Short Term Medical is for temporary coverage only and therefore does not include some of the benefits a permanent health plan offers. Please refer to the Exclusions and Limitations section of this web site.

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How does an HMO plan work?

Though there are many variations, HMO (Health Maintenance Organizations) plans typically enable members to have lower out-of-pocket healthcare expenses but also offer less flexibility in the choice of physicians or hospital than other health insurance plans.  As a member of a HMO, you will be required to choose a primary care physician (PCP).  Your PCP will take care of most of your healthcare needs.  Before you can see a specialist, you will need to obtain a referral from your PCP.

With an HMO, you will likely have coverage for a broader range of preventive healthcare services than you would through another type of plan.  You may not be required to pay a deductible before coverage starts and your co-payments will likely be minimal.  With an HMO plan, keep in mind that you will  have no coverage for services rendered by a non-network provider or for services rendered without a proper referral from you PCP.

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Can I get a refund of my premium if I am not satisfied with this short term medical plan?

Once you receive your Certificate of Insurance, carefully review all information. If you are not satisfied for any reason, return the Certificate of Insurance (within 10 days of receipt) with your written request for cancellation to InsuranceTPA.com. Coverage will be cancelled as of the effective date and you’ll receive a full premium refund (minus admin fees), no questions asked. Send written request for cancellation with your signature to:

InsuranceTPA.com
PO BOX 998
Janesville, WI  53547

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How does a POS plan work?

A POS (Point of Service) plan combines some of the features offered by HMO and PPO plans.  As with an HMO, members of a POS plan are required to choose a primary care physician (PCP) from the plan’s network of providers.  Services rendered by your PCP are typically not subject to a deductible.  Also, like HMOs, a POS plan typically offers coverage for preventative care visits.

You may recieve a higher level of coverage for services rendered or referred by your PCP.  Services rendered by a non-network provider may be subject to a deductible and will likely be covered at a lower level.  If services are rendered outside of the network, you will likely have to pay up front and submit a claim to the insurance company yourself.

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How is short term medical coverage billed?

After submitting your enrollment form with first month’s premium, you will then be billed monthly or you can choose to prepay. You indicate on your enrollment form how you wish to pay for your coverage. You may elect to be billed for the monthly premiums (plus the administration fee), OR you can select one of the other two payment methods: (1) Automatic Pre-authorized Bank Withdrawal; or (2) Credit Card – MasterCard and Visa are accepted.

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How does an indemnity plan work?

A traditional Indemnity plan offers a great deal of freedom in choosing which doctors and hospitals to use, but will probably involve higher out-of-pocket costs and more paperwork.  Under an Indemnity plan, you may see whatever doctors or specialty you like, with no referrals required.  Though you may choose to get the majority of your basic care from a single doctor, your insurance company will not require you to choose a primary care physician.  An Indemnity plan may also require that you pay up front for services and then submit a claim to the insurance company yourself.

You may have an annual deductible that will need to be met before the insurance company begins to pay on your claims.  Once your deductible has been met, the insurance company will typically pay your claims at a set percentage of the “usual and customary” (UCR) allowance for that services. The UCR rate is the amount that healthcare providers in your area typically charge for any given service.

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When does short term medical coverage begin?

The insurance can be effective as early as 12:01 a.m. the next day after the transmission date. However, the applicant can choose a later effective date not to exceed 60 days from transmission date. Coverage ends on expiration date listed in your coverage document.

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How does a HSA work?

Legislation establishing Health Savings Accounts (HSA) took effect on January 1, 2004.  HSAs and HSA eligible health insurance plans are becoming more and more popular.  Here are the basics:

  • A HSA is a tax-favored savings account that may be used in conjunction with a HSA-elgibile high deductible health insurance plan to pay for qualifying medical expenses.
  • Choosing an HSA-elgible plan may help you save money.  Typically, the monthly premium on an HSA-elgible high deductible plan is less expensive than the monthly premium for a lower deductible insurance plan.
  • Contributions to an HSA may be made pre-tax, up to a certain annual limit.
  • Funds in the HSA may be invested at your discretion.  unused funds remain in the account and accrue interest year-to-year, tax free.
  • Not all high-deductible plans are elgibile for use in conjunction with a HSA.

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Can I change my deductible on my short term medical plan?

No, Deductible changes cannot be made after the policy has been issued.

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Can I add additional family members to my short term medical plan?

No, to add additional family members you need to have the new family members apply on a separate policy.

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What is a co-payment?

A “co-payment” or “co-pay” is a specific charge that your health insurance plan may require that you pay for a specific medical service or supply.  For example, your health insurance plan may require a $30 co-payment for an office visit or brand-name prescription drug, after which the insurance plan pays the remainder of the charges.

For more information about co-payments, click here.

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What is a deductible?

A “deductible” is a specific dollar amount that your health insurance company may require that you pay out-of-pocket each year before your health insurance plan begins to make payments for claims.  Not all health insurance plans require a deductible.  As a general rule, though there are may exceptions, HMO plans typically do not require a deductible, while most Indemnity and PPO plans do.

To see more information about deductibles, click here.

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Can I change my effective date on my short term medical plan?

No, once the policy has been issued you cannot change the effective date.

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How long can I purchase short term medical coverage?

The minimum amount of days you can purchase is 30.  You may purchase coverage for up to 6 months.  After the 6 months you may apply for a new short term medical plan.

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What is the difference from monthly payment option compared to single payment option with a short term medical plan?

Month-to-month coverage is available for persons who do not know how long they will need coverage.  Coverage is provided month-to-month until you terminate coverage (written request) or you reach the 6 month maximum coverage.

Single payment coverage option is the exact number of days of coverage you want.  This option works great if you know exactly the amount of days of coverage you need.  For example; if you have group coverage starting in 45 days you can purchase 45 days of temporary health insurance coverage to satisfy the gap.  Single payment option also provides a discount in the rates.

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What is a coinsurance?

“Coinsurance” is a term used by health insurance companies to refer to the amount that you are required to pay for a medical claim, apart from any co-payments or deductible.  For example, if you health insurance plan has a 20% coinsurance requirement then a $100 medical bill would cost you $20.00 and the insurance company would pay the remaining $80.00.

 

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After my short term medical coverage ends, may I apply again for additional months?

Temporary Health Insurance plans are not renewable.

 

However, if your temporary need continues beyond your policy period, you may apply for a new plan under the following circumstances:

  • No claims were incurred under a previous Short Term Medical plan.
  • There has been no significant change in your health.
  • You still meet the eligibility requirements to obtain a new policy

Any previous or current health condition or symptom will be considered a pre-existing medical condition that will not be covered under a new plan. There is no continuous coverage between plans — therefore your new plan will not provide benefits for any condition or symptom which began during a previous plan. In addition, no benefits are available for any period in which you are not covered by a Short Term Medical plan.

 

To obtain an additional plan, you must complete a new enrollment form. If the enrollment form is approved, a new plan will be issued.

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What is the difference between in-network and out-of-network providers?

An in-network provider is one contracted with the health insurance company to provide services to plan members for specific pre-negotiated rates.  An out-of-network provider is one not contracted with the insurance plan.  Typically, if you visit a physician or other provider within the network, the amount you will be responsible for paying will be less than if you go to an out-of-network provider.  Though there are some exceptions, in many cases, the insurance company will either pay less or not pay anything for services you receive from out-of-network providers.

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Can I insure just my child(ren)?

When getting quotes for your child(ren) only, enter the child’s gender and birth date in the “Applicant” or first row.  Additional children should be entered below that field in the “Child” rows, but not the “Spouse” field.  However, many health insurance companies require one policy per child.  So if you have more than one child, try entering just the one child to see a larger selection of plans and prices.  You are free to apply for each child separately.

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Is a Short Term Medical plan considered “creditable coverage” under HIPAA?

Under HIPAA, Short Term Medical coverage is generally considered creditable coverage to help satisfy any pre-existing condition period.* Previous creditable coverage includes: 

  • A group health plan
  • Health insurance coverage
  • Part A or Part B of title XVIII of the Social Security Act (Medicare)
  • Title XIX of the Social Security Act, other than coverage consisting solely of benefits under section 1928 (Medicaid)
  • Chapter 55 of title 10, United States Code (Champus)
  • A medical care program of the Indian Health Service or of a tribal organization
  • A state health benefits risk pool
  • A health plan offered under chapter 89 of title 5, United States code (Federal Employee Health Benefit Plan)
  • A public health plan (as defined in regulations)
  • A health benefit plan under section 5(e) of the Peace Corps Act

* State reform legislation may vary; consult your state for specific rights and requirements.

 

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Does NAR offer a national Major Medical group insurance plan?

In an effort to find a healthcare solution, many members turn to NAR hoping that the Association offers a national group major medical insurance plan. Although group medical insurance plans are available to corporations for their employees, “A” rated insurance companies have been reluctant to offer such plans on a national scale to associations for their members, particularly when the members are independent contractors and participation in a plan is voluntary. This is because of the complexity and administrative burden of offering a group insurance program that meets the differing requirements of the fifty states. Click here to learn more.

If you are in need of Major Medical; SASid (the administrator of REALTORS® Core Health Insurance) has experts which can provide you with a recommendation.

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How does the Members Major Medical Plans system work?

It’s simple and fast… members can shop, compare, and enroll in Major Medical insurance online or over the phone with a licensed representative.  We have a dedicated team of helpful, licensed insurance representatives who will not pressure you to buy. Our team is here to help you understand, compare, and strategize your options.

Quote, Compare, Sort, and Apply.  The Members Major Medical Insurance Marketplace will shop top-rated carriers nationwide.

 

Quote:  Insurance carriers include, but are not limited to:

  • Blue Cross Blue Shield (varies per state)
  • Aetna
  • United Health (Golden Rule)
  • Celtic
  • Kaiser
  • Additional regional and state insurance companies

Compare:  PPO, HMO, or Indemnity Plans available on the exchange include:

  • Health Savings Account (HSA) Qualified plans
  • High Deductible (Catastrophic Plans)
  • and more…

Sort:  The Member Major Medical Insurance Marketplace allows you to quickly sort plans by multiple variables, including:

  • Carrier
  • Deductible(s)
  • Price (lowest to highest)
  • Types of plans and more
  • Types of coverage (Prescription, Maternity)

Enroll:

You can enroll online or speak to a licensed insurance representative by phone.  It takes only minutes to enroll with most major insurance companies.

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How does health care reform affect me?

The Affordable Care Act (ACA) mandates that all Americans must have minimal major medical coverage (this is also known as essential benefits) or pay a penalty.

We know that finding the right health insurance can be tough, and that health care reform can be confusing. We understand the mandates of the Affordable Care Act and the ongoing changes in health care reform. Rest assured. We are experts, so you don’t have to be!

Give us a call. Our licensed benefit specialists are available to personally consult and advise you on your individual insurance needs. We help NAR members navigate the complex and often confusing world of PPOs, HMOs, HSAs, supplement plans, and more.  We can help you understand what you need to do and the options that are best for your situation.

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What is a Qualified Health Plan?

A Qualified Health Plan, or QHP, is a plan that meets the standards set forth by the ACA.  Only by purchasing a QHP (or continuing on one you’re already a member of) can you escape the yearly penalty.

REALTORS® Insurance Marketplace will offer health insurance plans that are certified as qualified health plans, or QHPs. These QHPs must be licensed and accredited, and must meet certain requirements for transparency. To become certified, a QHP must meet a minimum set of criteria, including the following:

  • Coverage, at a minimum, of a comprehensive package of benefits, known as essential health benefits, or EHB
  • Benefit design standards, including non-discrimination requirements and limits on cost-sharing
  • Network adequacy standards

We encourage you to contact a licensed SASid representative at 877-267-3752 who will help you decide which exchange (public or private) and/or health plan is going to suit your needs best.

NOTE: Some plans offered on the RIM are not considered QHPs. Purchasers of such plans who don’t also have a QHP will have to pay a penalty.  Sometimes this can be a favorable strategy when looking to save money.

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What are Essential Health Benefits (EHB)?

These are services that Qualified Health Plans (QHPs) are required to cover under the Affordable Care Act.   Essential health benefits, as defined in Section 1302(b) of the Patient Protection and Affordable Care Act, will include at least the following general categories:

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance use disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventive and wellness and chronic disease management
  • Pediatric services, including oral and vision care.

Women’s preventive health services were defined in detail via federal regulations published August 1, 2011, requiring broad coverage, without copayments or deductibles of:

  • Annual preventive-care medical visits and exams
  • Contraceptives (products approved by the FDA) – with exemptions for religious employers and a temporary enforcement safe harbor.
  • Mammograms
  • Colonoscopies
  • Blood pressure tests
  • Childhood immunizations
  • Domestic violence screenings for interpersonal and domestic violence should be provided for all women
  • H.I.V. screenings
  • Breast feeding counseling and equipment, including breast pumps at no charge.
  • Gestational diabetes in pregnant women screening
  • DNA tests for HPV as part of cervical cancer screening

Coverage provided for the essential health benefits package will provide bronze, silver, gold, or platinum level of coverage (described below).  A health plan providing the essential health benefits package will be prohibited from imposing an annual cost-sharing limit that exceeds the thresholds applicable to HSA-qualified HDHPs.   Small group health plans providing the essential health benefits package will be prohibited from imposing a deductible greater than $2,000 for self-only coverage, or $4,000 for any other coverage (annually adjusted thereafter).  Such limits will be applied in a manner that will not affect the actuarial value of any health plan, including a bronze level plan (described below). Consistent with the immediate reforms described above, plans providing the essential health benefits package will be prohibited from applying a deductible to preventive health services.

PPACA will require the Secretary to define and periodically update coverage that provides essential health benefits. The Secretary will ensure that the scope of essential health benefits is equal to the scope of benefits under a typical employer-provided health plan (as certified by the Chief Actuary of the Centers for Medicare and Medicaid Services).   A health plan will be allowed to provide benefits in excess of the essential health benefits defined by the Secretary.

However, if a state requires such additional benefits in QHPs, the state must reimburse individuals for the additional costs of those benefits.

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What Do the Bronze, Silver, Gold and Platinum designations mean?

All major medical health insurance plans for individuals and small employers will be assigned a bronze, silver, gold and platinum benefit level.  A Catastrophic option will also be available to those under the age of 30.

These new Catastrophic, bronze, silver, gold and platinum benefit levels actually refer to a plan’s actuarial value level… or “AV.”

You’re probably wondering, What is actuarial value?

The easiest way to explain it is to say that it is the percentage of total average costs for the benefits a plan covers within a given year.

So, a plan with a 70% actuarial value would typically cover 70% of the costs and the customer would typically be responsible for 30% of the costs after the plan’s out of pocket expenses have been met.

The different “AVs” have metallic designations:

  • A bronze plan is 60 percent
  • A silver plan is 70 percent
  • A gold plan is 80 percent
  • A platinum plan is 90 percent

Insurers may also offer catastrophic-only coverage to eligible individuals under the age of 30, which would have higher cost-sharing than the standard Metallic plans.

“Metal levels” are designed to allow consumers to compare plans with similar levels of coverage, based on monthly premiums, provider networks, and other factors with the goal of helping consumers make more informed decisions. The graphic below also helps explain these metallic levels:

 

 

Metalic Levels

 

 

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What is the difference between a Public exchange and a Private exchange?

The Affordable Care Act provides public exchanges (or marketplaces).  You as a consumer have the option to shop for your health insurance through either type of exchange and there are pros and cons associated with both.  The REALTORS® Insurance Marketplace (RIM) offers both exchanges (public and private).

Below is a snapshot of the differences between the Public and Private:

Marketplace Differences

Public

Private

Who sponsors it? Government entity – either a state or the federal government.  Depending on where you live; each state has decided to build its own exchange or default to the Federal.  Insurance agents can offer and enroll consumers into the public exchange. Private company such as the NAR Members health insurance exchange.
What does it offer? Primarily health, dental, and/or vision insurance through multiple carriers which have been approved by the government. Health, dental, vision, plus an array of other insurance products ranging from supplemental to life to critical illness to more – through multiple carriers
Who uses it? Primarily individuals buying insurance and small businesses with up to 100 employees Primarily individuals, self-employed people, employees, and retirees of sponsoring organizations.
Who pays? Consumer, small employer, or both (federal subsidies are available to individuals with household incomes up to 400% of federal poverty level). Consumers (both employed and self-employed individuals) and employers
Is coverage Guaranteed Acceptance? Yes, all plans on the public and private exchanges are guaranteed acceptance (meaning you cannot be turned down based on medical history). Yes, all plans on the public and private exchanges are guaranteed acceptance (meaning you cannot be turned down based on medical history).
 “What types of plans are offered?”  All plans must include minimum essential health benefits.  Plans are from various insurance companies and will offer five levels; Catastrophic (Only available to individuals under the age of 30), Bronze, Silver, Gold, and Platinum. All plans must include minimum essential health benefits.  Plans will vary based on plan design, geographical location, and insurance company.  You will find different insurance companies and offerings on private exchanges.  Many insurance companies have opted out of public exchanges.
Will all insurance companies from my state be represented on each exchange?  I guess the point we are trying to make here is that it is beneficial to explore both public and private exchanges.  No. Some insurance companies have decided to be on the public exchange, others on the private exchange, and still others on both. It is beneficial to explore both public and private exchanges.

No. Some insurance companies have decided to be on the public exchange, others on the private exchange, and still others on both. It is beneficial to explore both public and private exchanges.

In general, private exchanges will offer more selection and options (more plan designs), which means lower costs.  However, you cannot get a subsidy on a private exchange – only on a public exchange.

To see what your state is doing regarding public marketplace (exchange) you should register for a quote on the www.RealtorsInsuranceMarketplace.com website.  We encourage you to contact a licensed SASid representative at 877-267-3752 who will help you decide which exchange (public or private) and/or health plan best suits your needs.

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How do I find my exchange?

You can either go to http://www.realtorsinsurancemarketplace.com/products/member-health-insurance-exchange/ or you can contact SASid’s professionally licensed staff at 877-267-3752 for advice and/or direction navigating your options.

State-based health insurance marketplaces, or exchanges, are a component of the Affordable Care Act (ACA).   States had the option of a) building a fully state-based marketplace, b) entering into a state-federal partnership marketplace, or c) defaulting to a federally facilitated marketplace.

Types of Public Exchanges (Marketplace):

  • StateBased Marketplace (SBM) – State is responsible for all functions (QHP, Premium fees, oversight/Monitoring, eligibility/enrollment, IT, outreach/education, consumer complaint, In‐Person assistance and the call center).
  • Partnership Marketplace – Marketplace is operated by the federal government, however State retains responsibility for Plan Management and/or Consumer Assistance functions.
  • Federally‐facilitated Marketplace – All functions are the responsibility of the federal government.


Remember, products and insurance companies may be different per exchange.

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What and when is Open Enrollment for the Affordable Care Act?

Individuals may enroll in a Qualified Health Plan during various timeframes throughout the year. The timeframes are the open enrollment period, and special enrollment periods (SEP).

  • The Open Enrollment period for 2017 coverage started on November 1, 2016 and runs through January 31st, 2017. During this timeframe you will be able to change your coverage at will, for any reason.
  • SEPs occur throughout the year, based on individuals’ special circumstances.

Special Enrollment Periods

Under certain circumstances, individuals may change QHPs outside of the annual open enrollment period. These SEPs are based on certain triggering events or exceptional circumstances. Events that permit a SEP include, but are not limited to:

  • Gaining or becoming a dependent;
  • Gaining status as a citizen, national, or lawfully present individual;
  • Loss of minimum essential coverage (e.g., loss of Medicaid eligibility, termination of a QHP), except if enrollment is terminated based on failure to pay premiums;
  • Loss of affordable employer-sponsored coverage;
  • Determination that an individual is newly eligible or ineligible for premium tax credits or a change in eligibility for cost-sharing reductions;
  • Permanent move to an area where different QHPs are available;
  • Other exceptional circumstances identified by the Marketplace.

In most cases, SEPs will extend for 60 days from the date of the triggering event. Under certain circumstances, such as the pending loss of minimum essential coverage due to the termination of a QHP, a SEP may begin before the triggering event takes place.

Special Enrollment Period for Marriage

As mentioned in triggering events, a SEP exists for marriage. This means that, if a qualified individual gets married, he or she has the chance to either enroll in a QHP for the first time, or add a spouse to the plan without waiting for the annual open enrollment period.

  • If a marriage occurs and the Individual Marketplace is notified before the last day of the month when the marriage occurred, coverage will begin the 1st of the following month.
  • If a marriage occurs and the Individual Marketplace is notified after the end of the month when the marriage occurred, coverage will begin the 1st of the month following the notification.

The Individual Marketplace would need to be notified within 60 days of a marriage for a spouse to be covered. If the 60-day deadline is missed, the spouse cannot enroll until the plan’s annual open enrollment period.

Special Enrollment Period for Birth or Adoption

Another important SEP exists for the birth or adoption of a child.

The effective date of coverage can be the date of the birth or the official date of adoption as long as the Individual Marketplace is notified in a timely manner.

The Individual Marketplace would need to be notified within 60 days of a birth or adoption for dependents to be covered. If the 60-day deadline is missed, the dependents cannot be enrolled until the plan’s annual open enrollment period.

Premiums would be pro-rated for the month, based on when the child was added to the policy.

NAR members should contact SASid’s professionally licensed staff at 877-267-3752 for advice and/or direction navigating their options.  Products and insurance companies may be different per exchange.

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Could there be rate increases on my health insurance?

Yes. Rates are reviewed on an annual basis and undergo a formal rate review process. All rate increases must be reviewed by the state insurance departments and receive approval before insurance companies can apply them to you. If your plan is going to experience a rate increase, your insurance company will notify you. You will have the opportunity to continue at the increased rate or select a different plan during open enrollment. Renewals take effect January 1st of the following year.

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Can I receive a subsidy for my health insurance under the Affordable Care Act?

Possibly.  It depends on your household income and the number of people living with you.

The Affordable Care Act (ACA) includes tax credits or subsidies for individuals and families to use toward qualified health plans found on public exchanges.  Subsidies will be available to qualified individuals and families that have previous reported incomes in the range of 138% to 400% above the Federal Poverty Level.  The below chart shows federal poverty guidelines based on family size:

Eligibility for Premium Tax Credits

Eligibility for the premium tax credit is based on household income and access to minimum essential coverage. The following summarizes the key eligibility standards for premium tax credits (tax credits that reduce the cost of insurance premiums).

You must meet the following criteria to be eligible for a premium tax credit:

  • You are not eligible for minimum essential coverage — including employer-sponsored coverage, Medicaid, CHIP, Medicare, and other forms of coverage — other than through the individual insurance market, unless your employer-sponsored coverage is not affordable or does not provide minimum value (based on by ACA standards).
  • You have an annual household income that is between 100% and 400% of the Federal Poverty Level (FPL), or below 100% of FPL for lawfully present non-citizens who are ineligible for Medicaid by reason of immigration status.
  • You are part of a tax household that will file a tax return for the coverage year and, if the tax household includes a married couple, that will file a joint return
  • You are eligible for coverage through a QHP

If you need guidance on the tax credits and subsidies SASid representatives are available to help you understand your best options.

Below is information on a subsidy estimate tool created by the Kaiser Family Foundation. It will provide you with an estimate tax credit.

The Kaiser Family Foundation health insurance cost and savings calculator

The health insurance costs and savings calculator we link to below provides only an estimate. Your final premiums and costs may differ from the estimates, perhaps significantly, depending on where you live and the coverage you select. You’ll learn your final costs for specific plans when you apply in the Health Insurance Marketplace.

Before you use the Kaiser Family Foundation calculator, there are a few important things to know:

  • The calculator provides a rough estimate of costs for insurance, based on national averages and factors that may not apply to you. It will give you an idea of what someone with circumstances like yours could pay for health insurance.
  • The calculator accounts for some factors that may determine plan costs in the Marketplace: age, family size, and tobacco use. Individual plans will weigh these factors differently to determine final prices.
  • The estimate doesn’t account for differences based on where you live, which will significantly affect Marketplace prices and offerings.
  • The prices are based on a plan in the Silver category. Plans in different categories will likely have higher or lower premiums.  (Plans found on public exchanges offer “metallic plans” with categories of Bronze, Silver, Gold, and Platinum.  These were developed and designed by the government based on essential offerings for qualification.)
  • You won’t be able to get your exact costs for a specific plan until you fill out a Marketplace application during Open Enrollment. Then you’ll see all of the plans available to you, compare features and prices side-by-side, choose a plan, and enroll. You should expect that your final cost will be different from the rough estimate provided here.

The calculator was created by the Kaiser Family Foundation, a non-profit research organization, for use by the general public. The Kaiser Family Foundation is solely responsible for the tool. The Kaiser Family Foundation has no connection with Kaiser Permanente or any health care provider.

SASid did not participate in the creation of this calculator. SASid does not warrant or guarantee the accuracy of estimates provided by the calculator.

If you’re ready to see the estimates, visit the Kaiser Family Foundation website and use the Kaiser Family Foundation’s health insurance costs and savings calculator.

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What do I do if my situation changes during the year?

There are special enrollment periods for people who have life changes or other situations.  These include losing minimum essential coverage; gaining a dependent or becoming a dependent through marriage, birth, adoption or placement for adoption; becoming a citizen, national or lawfully present individual; or becoming newly eligible for a premium tax credit or cost-sharing assistance.

If one of these life changes happens to you, you’ll have 60 days to go back to the Insurance Marketplace to enroll in a Qualified Health Plan (QHP).

If you missed your 60 days; there are still other insurance plans you can enroll into such as Temporary Health Insurance or REALTORS® Core Health Insurance.  Understand, though, that these plans do not meet the standards of a QHP and a penalty may still apply.

Members should contact SASid’s professionally licensed staff at 877-267-3752 for advice and/or direction navigating their options.  Products and insurance companies may be different per exchange.

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How does the Affordable Care Act (ACA) affect my HSA?

The Affordable Care Act did make some changes to Health Savings Accounts – also called HSAs – and how they will work:

  1. First, the law eliminated one’s ability to use money in their HSA account to buy over-the-counter drugs.
  2. The second big change is that the law increased the penalty for withdrawing funds from your HSA before you reach age 65. The early withdrawal penalty increased from 10% to 20%.

HSA-compatible plans are available for purchase through public and private exchanges (private only available during the annual Open Enrollment period) such as the REALTORS® Insurance Marketplace.

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Do I need to be on the same health insurance plan as my spouse?

No.  There is no requirement in the Affordable Care Act that spouses be on the same plan.

However, if you want to qualify for a premium tax credit to lower the cost, be aware that subsidies are based on your total household income level.

So, even though your spouse will not be covered by the subsidized insurance plan, their income will be calculated when determining the level of subsidy for which you are eligible.

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Am I eligible for the Affordable Care Act plans?

Basically, what puts the “affordable” in the Affordable Care Act plans is the presence of subsidies, which are available only on plans purchased via a public exchange. There are eligibility requirements if a person wants to receive these subsidies.

To qualify a person:

  • Must live in the U.S.
  • Be a U.S. citizen or national, or be lawfully present in the US
  • Have a household income between 133% and 400% of the Federal Poverty Level and
  • Cannot be currently incarcerated

If you do not meet these requirements, you may still apply for health insurance under the Affordable Care Act, but you would not qualify for government subsidies to help you pay for the coverage.  In this case you are probably better off purchasing through a private exchange during the Annual Open Enrollment period or through a private insurance agent (because there are more plans and carrier options in the private market).

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Can I still go on COBRA?

Yes, regulation has not changed for those who lose their job and wish to stay on their employer’s health insurance plan for up to 18 month – which is essentially how COBRA works.

What’s nice about the Affordable Care Act is that is gives people on COBRA the ability to apply for individual coverage without concern that their application can be declined.

Plus, people who opt out of COBRA and buy an individual insurance policy may qualify for low-income subsidies to help the pay for cost of their plan.

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Does the Affordable Care Act (ACA) provide any advantages to small businesses?

Yes, depending on your situation, ACA can make it possible for companies that may have previously been unable to afford insurance benefits to now offer it to their employees. Read on to learn more.

Small Business Health Options Program (SHOP) Features

Under the Affordable Care Act, during the first year of operation, small businesses that qualify for coverage through a SHOP will be able to offer their employees a single Qualified Health Plan (QHP) option. SHOPs will offer qualified small groups access to QHPs in each state, and will provide flexibility in the amount that members of the small group contribute toward the total premium.

To qualify for SHOP coverage, a business must:

  • Be located in a SHOP’s service area (generally a state)
  • Offer coverage to all full-time employees (those working an average of 30 or more hours per week)
  • Have at least one eligible employee on payroll
  • Have 50 or fewer full-time equivalent (FTE) employees on payroll
    • This methodology includes part-time employees, but not seasonal employees (those working fewer than 120 days per year)
    • While the Federally-facilitated SHOPs (FF-SHOP) must determine eligibility using the definitions above, State-based SHOP Marketplaces have flexibility in their counting approaches

The premium tax credits (subsidies) and cost-sharing reductions offered to individuals are not available to employers and families covered through a SHOP. However, employers meeting certain size and average wage requirements-see Shop Benefits section below—may receive a small business tax credit on their tax returns of up to 50% of the employer’s contribution to the premium.

 

SHOP Benefits

The SHOP Marketplace provides consumers, both employers and employees, with many benefits.

Only QHPs will be offered through the Marketplaces. Buyers will be assured that the available plans meet network adequacy and benefit design standards of the SHOP.

Premiums for the employers and employees will not be based on their health or medical history, but can only vary based on age, family composition, geographic area, and tobacco use.

A SHOP provides unbiased information and comparison tools for consumers. The tools available through the Marketplaces will help consumers with “apples to apples” comparisons among health plans.

The small business tax credit applies to small businesses with up to 25 FTE employees that pay employees an average annual wage below $50,000 and that contributes 50% or more towards employees’ health insurance premiums.

NAR members who are owners of small businesses should contact SASid’s professionally licensed staff at 877-267-3752 for advice and/or direction navigating their options.  Products and insurance companies may be different per exchange.

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What are Grandfathered Health Plans?

As used in connection with the Affordable Care Act: A group health plan that was created—or an individual health insurance policy that was purchased—on or before March 23, 2010. Grandfathered plans are exempted from many changes required under the Affordable Care Act. Plans or policies may lose their “grandfathered” status if they make certain significant changes that reduce benefits or increase costs to consumers. A health plan must disclose in its plan materials whether it considers itself to be a grandfathered plan and must also advise consumers how to contact the U.S. Department of Labor or the U.S. Department of Health and Human Services with questions. (Note: If you are in a group health plan, the date you joined may not reflect the date the plan was created. New employees and new family members may still be added to grandfathered group plans).

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Do small employers have to pay a tax or penalty for not offering health insurance to employees?

No. Under the Affordable Care Act, businesses with fewer than 50 full-time equivalent employees are not required to provide health insurance to their employees—nor will they face  tax penalties if they decide not to do so.

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Will I qualify for a Premium Tax Credit?

The Affordable Care Act provides a new tax credit to help you afford health coverage purchased through a government Marketplace.  Please contact one of our licensed representatives at SASid to help you determine your options.

Premium Tax Credit explained:  Advance payments of the tax credit can be used right away to lower your monthly premium costs. If you qualify, you may choose how much advance credit payments to apply to your premiums each month, up to a maximum amount. If the amount of advance credit payments you get for the year is less than the tax credit you’re due, you’ll get the difference as a refundable credit when you file your federal income tax return. If your advance payments for the year are more than the amount of your credit, you must repay the excess advance payments with your tax return.

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Wouldn’t it be better for me to just pay the penalty for not purchasing a Qualified Health Plan?

The answer depends on your personal situation and whether or not you are comfortable paying a tax penalty.  Sometimes it can be favorable for an individual or family to purchase a non-qualified health plan and pay the penalty.  You should contact a SASid representative at 877-267-3752  to discuss your situation.

The Affordable Care Act (ACA) includes a provision called the individual shared responsibility payment, or more commonly known as the “individual mandate” or tax penalty. It is applied to individuals and families who do not have a Qualified Health Plan for longer than 3 months (these 3 months do not need to be consecutive), and this took effect Jan. 1, 2014.

Estimates from the Congressional Budget Office and Joint Committee on Taxation believe around 6 million Americans will choose to pay a penalty each year instead of purchasing health insurance.

Here is what you need to know about the Tax Penalty and how it is applied:

 

How to avoid the penalty-

To avoid paying the tax, individuals and families must purchase a health insurance plan which includes a minimum of 10 essential benefits.  These plans are known as Qualified Health Plans (QHP).  People who have other coverage through their employer or enrolled in government subsidized health plans (Medicare, Medicaid, CHIP, or TRICARE) do not need to worry about the tax.

Also, those uninsured individuals with incomes so low they aren’t required to file a federal tax return who cannot find coverage that cost less than 8% of their income do not face a penalty.  Others exempt from the penalty include members of Indian tribes, people whose religion objects to health insurance, undocumented immigrants, Americans living abroad, members of a health sharing ministry and people who are currently incarcerated.

 

The Penalty Amount-

The penalty for going without health insurance is either a flat fee or percentage of taxable income; based on whichever is greater.

For 2017, the Flat Fee is $695 per adult and $347.50 per child (up to $2,085) and the Percentage of Income is 2.5%.

 

Prorated Penalty-
If you were uninsured for less than three months of the year you will not need to pay the penalty.  After three months the tax applies to each month within a calendar year that you did not have coverage for yourself or a member of your household.  Insurance companies will provide documentation to prove you had coverage.

 

No criminal penalties-

Individuals who do not comply with the individual mandate to carry a Qualified Health Plan face no criminal penalties or threat of liens and seizures by the IRS.

 

How is the Penalty Amount Applied?-

The penalty will be determined when you file your income tax return and deducted from any potential refund. For 2017 plans, they will look at 2016 modified adjusted gross income (MAGI). The MAGI is different from Adjusted Gross Income (AGI) as it includes other deductions such as tuition fees or up to one-half of self-employment tax.

 

Should I consider a Non-Qualified Health Plan?-

Many people will consider plans which do not meet the 10 minimum essential benefits; referred to as Non-Qualified Health Plans.  These plans include limited indemnity medical, short term medical plans, and others.  Because they do not meet the federal government’s minimum standards these plans can be significantly cheaper.  Some experts believe many Americans will purchase a Non-Qualified Health Plan and pay the tax penalty in cost-saving efforts.

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What is a deductible?

deductible is the amount of expenses that must be paid out of pocket before an insurer will pay any expenses.  In general usage, the term deductible may be used to describe one of several types of clauses that are used by insurance companies as a threshold for policy payments.

Deductibles are typically used to deter large number of trivial claims that a consumer can be reasonably expected to bear the cost of. By restricting its coverage to events that are significant enough to incur large costs, the insurance firm expects to pay out slightly smaller amounts much less frequently, incurring much higher savings. As a result, insurance premiums are typically cheaper when they involve higher deductibles.

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What is a copay or copayment?

In the United States, copayment or copay (co-pay)is a payment defined in the insurance policy and paid by the insured person each time a medical service is accessed. It is technically a form of coinsurance, but is defined differently in health insurance where a coinsurance is a percentage payment after the deductible up to a certain limit. It must be paid before any policy benefit is payable by an insurance company. Copayments do not usually contribute towards any policy out-of-pocket maxima whereas coinsurance payments do.

Insurance companies use copayments to share health care costs to prevent moral hazard. Though the copay is often a small portion of the actual cost of the medical service, it is meant to prevent people from seeking medical care that may not be necessary (e.g.: an infection by the common cold). The underlying philosophy is that with no copay, people will consume much more care than they otherwise would if they were paying for all or some of it.

However, a copay may also discourage people from seeking necessary medical care and higher copays may result in non-use of essential medical services and prescriptions, thus rendering someone who is “insured” effectively “uninsured” because they are unable to pay higher copays. If the insured cannot afford the copay, they effectively have no insurance (high copays can cause a false sense of security). Thus there is a balance to be achieved: a high enough copay to deter unneeded expenses but low enough to not render the insurance useless.

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What is a gatekeeper?

Under some health insurance arrangements (mainly HMO or POS plans), a gatekeeper is responsible for the administration of the patient’s treatment; the gatekeeper coordinates and  authorizes all medical services, laboratory studies, specialty referrals and  hospitalizations.

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What is an indemnity plan?

A type of medical plan that reimburses the patient and/or provider as expenses are incurred.

Typically an indemnity plan will pay a set amount of benefit (example: $1,000 per day in hospital) described in the policy.

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What is a preferred provider organization (PPO) plan?

An indemnity plan where coverage is provided to participants through a  network of selected health care providers (such as hospitals and physicians). The enrollees may go outside the network, but would incur larger costs in the form of higher deductibles, higher coinsurance rates, or nondiscounted  charges from the providers.

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What is an exclusive provider organization (EPO) plan?

A more restrictive type of preferred provider organization plan under which employees must use providers from the specified network of physicians and hospitals to receive coverage; there is no coverage for care received from a non-network provider except in an emergency situation.

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What is a health maintenance organization (HMO)?

A health care system that assumes both the financial risks associated with providing comprehensive medical services (insurance and service risk) and the responsibility for health care delivery in a particular geographic area to HMO members, usually in return for a fixed, prepaid fee. Financial risk may be shared with the providers participating in the HMO.

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What is a point-of-service (POS) plan?

A POS plan is an “HMO/PPO” hybrid; sometimes referred to as an “open-ended” HMO when offered by an HMO. POS plans resemble HMOs for in-network services. Services received outside of the network are usually reimbursed in a manner similar to conventional indemnity plans (e.g., provider  reimbursement based on a fee schedule or usual, customary and reasonable charges).

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What is a physician-hospital organization (PHO)?

Alliances between physicians and hospitals to help providers attain market share, improve bargaining power and reduce administrative costs. These entities sell their services to managed care organizations or directly to employers.

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What is a fully insured plan?

A plan where the employer contracts with another organization to assume financial responsibility for the enrollees’ medical claims and for all incurred administrative costs.

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What are managed care plans?

Managed care plans generally provide comprehensive health services to their members, and offer financial incentives for patients to use the providers who belong to the plan. Examples of managed care plans include:

  • Health maintenance organizations (HMOs),
  • Preferred provider organizations (PPOs),
  • Exclusive provider organizations (EPOs), and
  • Point of service plans (POSs).

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What is a maximum plan dollar limit?

The maximum amount payable by the insurer for covered expenses for the insured and each covered dependent while covered under the health plan.

  • Plans can have a yearly and/or a lifetime maximum dollar limit.
  • The most typical of maximums is a lifetime amount of $1 million per individual.

NOTE:  The Affordable Care Act has removed the ability for insurers to limit plan amounts.

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What does maximum out-of-pocket expense mean?

The maximum dollar amount a group member is required to pay out of pocket during a year. Until this maximum is met, the plan and member shares in the cost of covered expenses. After the maximum is reached, the insurance carrier pays all covered expenses, often up to a lifetime maximum.

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What is a medical savings accounts (MSA) or health savings account (HSA)?

Savings accounts designated for out-of-pocket medical expenses. In an MSA, employers and individuals are allowed to contribute to a savings account on a pre-tax basis and carry over the unused funds at the end of the year. One major difference between a Flexible Spending Account (FSA) and a Medical Savings Account (MSA) is the ability under an MSA to carry over the unused funds for use in a future year, instead of losing unused funds at the end of the year.  Unlike FSAs, most MSAs are combined with a high deductible or catastrophic health insurance plan.

Click here for a more information regarding HSA/MSA

 

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What is an insurance premium?

Agreed upon fees paid for coverage of medical benefits for a defined benefit period. Premiums can be paid by employers, unions, employees, or shared by both the insured individual and the plan sponsor.

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What is a primary care physician (PCP)?

A physician who serves as a group member’s primary contact within the health plan. In a managed care plan, the primary care physician provides basic medical services,  coordinates and, if required by the plan, authorizes referrals to specialists and hospitals.

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What is a third party administrator (TPA)?

An individual or firm hired by an employer to handle claims processing, pay providers, and manage other functions related to the operation of health insurance.  The TPA is not the policyholder or the insurer.

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What are usual, customary, and reasonable (UCR) charges?

Conventional indemnity plans operate based on usual, customary, and reasonable (UCR) charges. UCR charges mean that the charge is the provider’s usual fee for a service that does not exceed the customary fee in that geographic area, and is reasonable based on the circumstances. Instead of UCR charges, PPO plans often operate based on a negotiated (fixed) schedule of fees that recognize charges for covered services up to a negotiated fixed dollar amount.

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What are flexible spending accounts or arrangements (FSA)?

Accounts offered and administered by employers that provide a way for employees to set aside, out of their paycheck, pretax dollars to pay for the employee’s share of insurance premiums or medical expenses not covered by the employer’s health plan. The employer may also make contributions to a FSA. Typically, benefits or cash must be used within the given benefit year or the employee loses the money. Flexible spending accounts can also be provided to cover childcare expenses, but those accounts must be established separately from medical FSAs.

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What is a flexible benefits plan (Cafeteria plan) (IRS 125 Plan)?

A benefit program under Section 125 of the Internal Revenue Code that offers employees a choice between permissible taxable benefits, including cash, and nontaxable benefits such as life and health insurance, vacations, retirement plans and child care. Although a common core of benefits may be required, the employee can determine how his or her remaining benefit dollars are to be allocated for each type of benefit from the total amount promised by the employer. Sometimes employee contributions may be made for additional coverage.

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What is REALTORS® Insurance Marketplace?

REALTORS® Insurance Marketplace is a comparative shopping site, just for members of the NATIONAL ASSOCIATION OF REALTORS®. Here, members can find a full roster of insurance plans and wellness products. Offerings include a private Major Medical health insurance exchange, a short term health insurance plan, a limited liability supplemental health insurance plan, accident deductible protection coverage, dental plans, vision plans, a free prescription drug savings card, and helpful links to additional insurance plans that offer savings to NAR members.

REALTORS® Insurance Marketplace is powered by SASid (Smart and Simple insurance development), in partnership with the NATIONAL ASSOCIATION OF REALTORS®, through the REALTOR Benefits® Program.

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How does REALTORS® Health Insurance Marketplace work?

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REALTORS® Insurance Marketplace makes health insurance easy to understand and convenient to buy. The Marketplace is a comparative shopping site that provides NAR members with a roster of health, dental, vision, and supplemental insurance plans and products, including a private Major Medical health insurance exchange, just for NAR members.

The private Members Health Insurance Exchange is an easy-to-use mini-site within this website. Here, members can easily obtain quotes and purchase insurance directly online or over the phone with assistance from a licensed benefits specialist.

Here’s how it works:

  • Insert your geographic and demographic information into the Marketplace quoting engine.
  • Based on the information you’ve provided, you will be shown the options available to you on both NAR’s private exchange for members, and either the federal government exchange or your state-based exchange. You can quote, shop, and enroll directly online.
  • If you would like assistance you can call a licensed benefit specialist at 877-267-3752. They are available to you both during the enrollment process and afterwards as well, if you need help later on. Personal consultations are always complimentary.

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