This page has been established to help answer frequently asked questions (FAQ's ) this page has been established. This is a good place to check on answers to your questions - it may even save you a phone call or an e-mail! Have a question that is not here? Send us an e-mail or contact us by phone or fax.
The following information is subject to change without notice. This information is not intended to provide legal advise.
How can
I check the status of a claim?
Call your Client Service Representative.
They can advise you on the status
of any processed claims, as well as
those that are still pending. If you
would like check on the status of
your claim Click
here.
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I've
lost my ID card. What do I do?
If your coverage is through your
employer, contact your human resources
department. You can also obtain replacement
ID cards with our help. Please Click
here.
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What number should I call to reach
a Client Service Representative?
Please call 847-478-5101 or the Customer Service phone number on the back of your ID card.
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How
can I obtain a quote on individual
or family coverage?
Click
here. Just read over the available
information, answer a few quick questions,
and in a few business days you will
receive a no obligation quotation
on an individual or family policy.
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What
is the difference between traditional
health insurance and managed care?
With traditional ( indemnity ) insurance,
you can select any doctor or hospital
at the time service is needed. You
do not need a referral to see a doctor.
Under managed care, doctors, hospitals
and other health care providers contract
with the health plan to form networks
that deliver health care services.
Normally, you will select providers
from within those networks to get
the maximum coverage available through
the health plan. Some managed care
plans, such as point-of-service (
POS ) plans and health maintenance
organizations ( HMO ) require you
to select a primary care physician.
In an HMO, the primary care physician
coordinates your care and refers you
to specialists. In POS, the primary
care physician has the same function,
but you have the option to go directly
to a specialist at a lower benefit
level.
Managed care plans reestablish the
role of "family doctor" by encouraging
a steady relationship between you
and your primary care physician (
usually a family practitioner, internist
or pediatrician ). In addition to
knowing and caring about you, today's
primary care physician coordinates
any specialty care and services you
might need. He or she manages the
medical resources available by guiding
you through tests and treatments.
If you need a specialist, he or she
refers you to one as appropriate.
With traditional health insurance,
providers bill you or your insurance
company for each service preformed.
You usually pay a deductible and percentage
of the provider's fees. You are usually
reimbursed for 80 percent of the usual
charges for covered services. You
are liable for additional billing
if the health plan does not pay the
full charges.
Under a managed care plan, network
providers generally bill the plan
for covered services. Non-network
providers bill you directly. You usually
pay a co-pay ( flat fee ) for services
within the health plan's provider
network. If you use providers or services
outside of the network, you may have
to pay a deductible and a percentage
of the charges or you may receive
no coverage at all, depending upon
the type of managed care plan you
participate in.
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What
does COBRA stand for and what does
it mean?
The Consolidated Omnibus Budget Reconciliation
Act (COBRA) of 1986 is a federal
law that applies to employers with
20 or more employees. The law requires
that employers offer employees and/
or their dependents continuation
of medical, drug, and dental coverage
at group rates in certain instances
where there is a loss of group insurance
coverage. It is the employer's responsibility
to notify the administrator, the
employee and/or dependent within
31 days of the qualifying event,
and to inform the insurance carrier
of the qualifying event within 31
days. An administrator has 14 days
to notify the employee and/or dependent.
COBRA requires the employee to notify
the employer within 60 days of their
intention to extend coverage through
COBRA.
Examples of COBRA-qualifying events,
(not all-inclusive):
- Termination
of employment or reduction in hours
of employment.
- Ceasing
to be an eligible dependent under
the plan due to death of the employee,
divorce or legal separation, or
employee being entitled to Medicare.
- Termination
of retiree coverage when the former
employer discontinues retiree coverage
within one year before or one year
after filing for Chapter 11 bankruptcy.
If you have more questions on COBRA
and would like to research additional
information on the subject Click
here.
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I've
searched your website, but I still
can't find the information I'm looking
for.
At BDM Combined, Inc., we're
committed to using the Internet as
a tool to provide you with the superior
customer service you deserve and
expect. If you have been unable to
find an answer to your question here
at our web site, send us an email and every effort will be made to promptly
respond to your inquiry.
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Who
is eligible to apply for coverage
under group policy?
An employee and dependents may apply
for coverage under your group plan
after meeting the eligibility requirements,
which include a waiting period and
a weekly hourly requirement.
The employee must generally work 30
hours or more per week ( unless elected
otherwise by the employer group )
and be actively at work at the place
of employment on the effective date
of coverage. Dependents may apply
for coverage only if the employee
is covered under the group plan.
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How
do I enroll a new employee?
When a new employee becomes eligible
to apply for coverage under your group
plan, have the employee complete and
submit an employee enrollment form
for consideration. Employees enrolling
for short-term disability, life and
accidental death and dismemberment
coverage more than 31 days after their
eligibility date, or after 60 days
from the termination of their prior
carrier, must also complete the evidence
of insurability, or medical questions,
section of the application.
Commonly
missed enrollment information includes:
employee's full name, Social Security
number, type of coverage, date of
birth for employee and dependents,
beneficiary information, evidence
of insurability ( if applicable ),
date, and signatures.
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An
employee was recently married. When
can the spouse be added?
Immediately. However, an employee
enrollment form must be received within
30 days of the marriage to have coverage
effective from the date of the marriage.
If the enrollment form is received
more than 30 days after the date of
marriage or enrolls more than 30 days
after the termination of the prior
carrier, the spouse is considered
a late applicant and subject to evidence
of insurability.
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An
employee just had a baby. When can
the baby be added?
If single or employee-and-spouse coverage
is in force, an employee enrollment
form must be received within 30 days
after the baby's birth. The effective
date will be the date of birth. If
the enrollment form is received after
30 days of the date of birth or enrolls
more than 30 days after the termination
of the prior carrier, the newborn
is considered a late applicant, and
subject to evidence of insurability.
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An employee was recently
terminated or quit the job. What information about COBRA or Continuation am
I required to send to them?
COBRA has very precise rules for employees, spouses and dependents. Please contact us to go through the details.
For a sample COBRA letter for an employee, please Click Here.
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What
is Precertification?
A program designed to eliminate unnecessary
days in the hospital by reviewing
elective hospitalization prior to
the patient's admission. It ensures
that the services are necessary and
an inpatient setting is appropriate.
Some insurance companies will asses
penalty or benefit reduction if precertification
procedures are not followed.
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What
is HIPAA?
In general, HIPAA (Health Insurance
Portability and Accountability Act)
sets federal standards to:
- Restrict pre-existing condition
exclusion periods to ensure portability
of health care coverage between
group plans and group to individual
plans;
- Require insurers participating
in the small group market to offer
and renew coverage to all employers
in that market without excluding
from enrollment any eligible worker
due to health status;
- Prevent discrimination against
individuals eligible to enroll and
continue to enroll in the group
market; and guarantee renewal in
multi-employer plans and multiple
employer welfare arrangements (MEWAS);
and
- Prevent fraud and abuse in health
care, simplify administrative procedures,
and coordinate Medicare benefits.
The effective date of the new federal
requirements was the plan year beginning
July 1, 1997 for both group and individual
health plans.
Highlights of the key provisions of
HIPAA that impact employers follow.
(1) Portability
and pre-existing condition exclusions
HIPAA ensures portability from group
to group plans and group to individual
plans.
Employers choosing to offer insurance
and insurers will be permitted to
impose pre-existing condition exclusions
only for a maximum of 12 months from
the date of enrollment - or 18 months
for late enrollees - for conditions
for which medical advise, treatment,
or diagnosis was received or recommended
within the previous six months. The
exclusion period, however, will be
reduced by the total amount of time
an enrollee was continuously (without
a break in coverage of more than 63
days) covered prior to enrollment.
(2) Certification
and disclosure requirements
Group health plans are required to
provide certain certification information
in order to verify continuous coverage
requirements. Written certification
must be provided in order to assist
future employers or insurers in determining
creditable continuous coverage for
application in determining pre-existing
condition exclusions. The certification
will include documentation on coverage
under the group health plan, COBRA
coverage (if applicable), and waiting/affiliation
periods used under the plan. The information
must be provided at the time an employee
becomes ineligible for group coverage,
exhausts the COBRA benefit, or upon
the request on behalf of an individual
no later than 24 months after group
or COBRA coverage has ended.
(3) Nondiscrimination
requirements
Employers and insurers cannot base
health plan eligibility - or continued
eligibility - for an individual or
dependent on any of the following
health related factors: health status,
medical condition (physical and mental),
claim experience, medical history,
receipt of health care, genetic information,
evidence of insurability (including
conditions arising out of domestic
violence), or disability. HIPAA specifies
that this provision does not (A) require
employers to offer certain benefits;
(B) prevent establishment of limitations
on levels of benefits or coverage
for similarly situated individuals;
or (C) prevent premium discounts or
rebates, or modifying copayments or
deductibles as part of a health promotion/disease
prevention program.
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PPO
Frequently Asked Questions (FAQ)
Preferred
Provider Organization (PPO)
A plan that contracts with medical
providers who agree to provide medical
care on a discounted basis. When members
use the contracted network providers
they receive higher benefits.
The following information is subject
to change without notice. This information
is not intended to provide legal advice.
What
is a network?
A network is a group of doctors and
hospitals ( providers ) with whom
insurance companies have agreements
with to provide services. The provider
directory lists the network of providers
available to you. Visit your insurance company's website to find a provider near you.
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Do
I need to select a primary care physician?
No.
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What
is a provider?
A physician, hospital, group practice,
nursing home, pharmacy or any individual
or group of individuals that provides
a health care service.
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What
is a medical emergency?
An emergency is defined as a serious
medical condition or symptom ( including
severe pain ) resulting from injury,
sickness or mental illness which arises
suddenly and requires immediate care
or treatment, generally received with
24 hours of onset, to avoid jeopardy
to the life or health of a member.
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What
doctors may I see?
There is an extensive network of providers
you may use. Visit your insurance company's website to find a provider near you. You may also choose to receive
care from non-network providers, but
out-of-pocket costs will be higher.
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Do
I have to file claims?
When you receive care from a network
provider, you do not need to file
a claim. Your provider handles this
paperwork. However, when you receive
care from a non-network provider,
you are required to file a claim.
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HMO Frequently Asked Questions
(FAQ)
Health Maintenance Organization
(HMO)
An organization that provides comprehensive
health care for members who prepay
a premium. Providers share the risk
of the cost of care with the HMO.
The following information
is subject to change without notice.
This information is not intended to
provide legal advice.
What
is a network?
A network is a group of doctors
and hospitals ( providers ) with whom
insurance companies have agreements
with to provide services to members.
The provider directory lists the network
of providers available to you. Visit your insurance company's website to search for a provider
online.
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to HMO Frequently Asked Questions (FAQ)
What
is a primary care physician?
A physician, the majority of whose
practice is devoted to internal medicine,
family/general practice or pediatrics.
This physician provides the overall
coordination of your medical care.
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May
I change my primary care physician?
You may change your primary care
physician at any time by contacting
your insurance company's member service
department. For a list of primary
care physicians for your carrier visit your insurance company's website.
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What
is a provider?
A physician, hospital, group practice,
nursing home, pharmacy or any individual
or group of individuals that provides
a health care service.
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What
is a site or IPA?
PA stands for Independent Practice
Association or Individual Practice
Association. An IPA or site is an
organization that establishes a network
of providers. Health benefit plans
may contract with the site or IPA
rather than directly with each provider
(doctor) who is a member of the IPA.
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Do
I need a referral to see a specialist?
Yes, your primary care physician
will coordinate all of your care including
office visits to specialists, other
providers and hospital admissions.
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What
is a medical emergency?
An emergency is defined as a serious
medical condition or symptom ( including
severe pain ) resulting from injury,
sickness or mental illness which arises
suddenly and immediate care or treatment,
generally received with 24 hours of
onset, to avoid jeopardy to the life
or health of a member.
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Can
I see doctors outside my primary care
physician's Medical group or IPA?
Yes, you may see specialists outside
your primary physician's group with
a referral. However, these specialists
must be part of the network of providers
with whom your insurance company has
agreements to provide services to
members.
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What
is a Health Reimbursement Arrangement
(HRA)?
Health Reimbursement Arrangements
fall under Section 105 of the IRS
Code. HRAs are employer funded medical
expense plans, and are typically
coupled with a high deductible health
plan. Basically, the way it works
is that you select a higher deductible
health plan and save 20%-50% in premiums.
From those savings, you establish
an HRA for each covered employee,
which provides coverage for the higher
out of pocket expenses. This will
make the higher deductible seamless
to your employees. You do not have
to pre-fund the account. You can
make deposits as employees submit
claims. Therefore, the less your
employees spend, the more your company
saves.
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What
is a Flexible Spending Account (FSA)?
Flexible Spending Accounts are Section
125 Cafeteria Plans also known as
FSAs. Flexible Spending Accounts are
a simple and convenient solution for
paying out of pocket health and dependent
care expenses with pre-tax dollars.
These accounts can be funded by the
employee, employer or both. Flexible
Spending Accounts provide tax savings
for both the employer and the employee.
Employers save on FICA and FUTA taxes
and employees will increase their
take home pay and save on taxes. This
is a win – win situation for
employers and employees. There is
a FSA Debit Card available as an optional
feature. Employees can use the card
to pay for eligible expenses. Flexible
Spending Accounts save your company
money and provide great benefits for
your employees.
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