The following is a list of Frequently Asked Questions regarding Simple Health Solutions and Limited Medical plans. Click on any of the questions to read the answer. If you have additional questions about implementing Simple Health Solutions at your ministry, please contact Jeff Gater at Envoy Financial at (888) 879-1376, extension 209 or by email.
1. What is a limited medical program? (Back to Top)
Limited Medical is not a major medical plan, it is a plan designed to cover the most basic of well care type needs, visits to the Dr. testing and diagnostics, prescription benefits and emergency room care. It is a great way of taking care of the everyday medical needs and preventative care.
2. Why should I offer a limited medical plan? (Back to Top)
There are a number of reasons that a limited medical plan can be of benefit to your ministry, including:
- Your employees will have coverage even if they are already being treated for a medical condition.
- Your employees can see any provider of their choice.
- Your employees may use the plan regardless of any other health insurance they have.
- Your employees don't have to meet deductibles or make co-payments for most benefits.
- Your employees receive an ID card as proof of coverage.
3. What does a limited medical plan cover? (Back to Top)
Depending on the level of care selected, limited medical plans provide access to medical care professionals including doctors, urgent care facilities, labs, diagnostic facilities, hospitals, surgery, outpatient facilities, rehabilitation facilities, substance abuse facilities, and other providers. A limited medical plan is not comprehensive coverage - there are limits on how much the coverage pays for specific services and there are annual maximums. Unlike comprehensive coverage, a limited medical plan has no deductibles to reach before coverage or payment occurs, but there are caps or ceilings on how much payment will be made for specific medical services.
4. How is limited medical different from comprehensive or major medical plans? (Back to Top)
A limited medical plan is not comprehensive coverage - there are limits on how much the coverage pays for specific services and there are annual maximums. Unlike comprehensive coverage, a limited medical plan has no deductibles to reach before coverage or payment occurs, but there are caps or ceilings on how much payment will be made for specific medical services.
5. Why should I as an employer offer access to medical insurance? (Back to Top)
Ministries that offer a health care benefit are more attractive to prospective employees and help to retain those already serving in the ministry. Providing access to healthcare at even the most basic level is a way of caring for the flock.
6. Do I have to pay for the plan and for coverage for my employees? (Back to Top)
As an employer, you do not have to pay for coverage for your employees. You are free to participate to whatever degree you determine is appropriate and affordable. Some employers simply provide their employees access to the program as a means of providing access to medical care. Other employers pay for a specific level of care as a means of providing more than simple access, but provide some measure of coverage for their employees. Still others contribute a specific dollar amount on behalf of each employee to subsidize the cost and the employee then chooses the level of care they determine is appropriate to their needs.
7. What does the implementation process look like? (Back to Top)
It is a simple process.
- You fill out the online plan setup form on the Envoy Financial web site.
- Envoy Financial handles establishing the plan with Symetra Financial, who provides the plan.
- Envoy Financial provides you a form to complete that provides us with census information for your employees.
- Once the plan document is returned by Symetra to us, we notify you that the plan is active and available.
- Envoy Financial contacts your employees regarding enrolling in the program.
- Your employees receive their enrollment documents and benefit card directly from Symetra. This process takes about 30 days unless you are paying for the benefit and then it is usually two weeks.
8. Can employees visit their current health care provider using their Select Benefits ID card? (Back to Top)
Yes, participants may visit any doctor of their choice. Select Benefits does not have networks or preferred provider lists. Please see the employee certificate for the definition of a doctor.
9. Is there a contract period? (Back to Top)
The plans run for a one year period with an automatic renewal.
10. Are the rates guaranteed? (Back to Top)
Prices are fixed for the term of the agreement.
11. How does the renewal process work? (Back to Top)
Unless you wish to discontinue the plan the renewal will automatically take place.
12. How are my employees reimbursed for expenditures? (Back to Top)
A check will be sent directly to your employee, unless they have directed it to the service provider.
13. How do I provide this benefit to new employees? (Back to Top)
Simply by informing them of the benefit and forwarding their enrollment information to Envoy LifeCare.™
14. When will the coverage go into effect for my employees? (Back to Top)
If you as the employer are paying for coverage for your employees, the coverage can go into effect in as few as 15 days. If you are only making this program available to your employees and they are enrolling in the program, a realistic timeframe is 45-60 days. This is dependent on the enrollment paperwork being completed by your employees and being returned to Envoy Financial for processing.
15. How are benefits paid? (Back to Top)
Your employees will receive payment by check in the mail for all claims unless they make arrangements with their medical care provider to receive the payment directly.
16. What if my employees have other health coverage? (Back to Top)
Simple Health Solutions does not negate or diminish any other health care coverage you or your employees may have.
17. Is there a limited provider network? (Back to Top)
Yes, but your employees are free to see any doctor they choose. When participants use care providers who are in the network, the fee charged for services may be fully or mostly covered by the limited medical plan reimbursement as fees have been negotiated with these providers. When participants use care providers who are not part of the network, participants are responsible for whatever fee they charge. The reimbursement will remain the same and will not change based on the fee charged.
18. How do my employees pay for Simple Health Solutions? (Back to Top)
An additional benefit included with the Simple Health Solutions program is the Envoy Access Card, a money management tool that saves you administrative payroll overhead. You simply deposit your employee's paycheck to the Envoy Access Card and then the premiums for Simple Health Solutions are automatically deducted from their card. Click the link for more information about the Envoy Access Card.
19. What are "discounted services"? (Back to Top)
The fees charged by in-network care providers have been negotiated and are often provided at discounted rates compared to standard rates. The services provided are not discounted, only the fees.
20. Who do my employees contact if they have questions about the program? (Back to Top)
Select Benefit Administrators of America (SBAA) is available at 1-800-497-3699 from 6:30 a.m. to 5:00 p.m., Monday through Friday, Central Standard Time for customer service inquiries. The SBAA mailing address is: PO Box 440, Ashland, WI 54806 and their fax number is 1-715-682-5919
21. How do my employees submit a claim? (Back to Top)
Participants present their health care provider with their Select Benefits ID card and ask the provider to file the claim directly with SBAA. SBAA will process the claim and send payment directly to the provider. Participants will receive an explanation in the mail showing what was paid and what, if applicable, is their responsibility. If the health care provider will not submit insurance information, participants may file the claim directly with SBAA. Participants will need a copy of the itemized bill from the provider listing dates of service, procedure codes and diagnosis codes. Participants can ask the health care provider for Health Care Financing Administration (HCFA) forms for doctor’s office visits and Universal Billing (UB92) forms for hospital care. Participants can mail or fax claim forms to SBAA, attention: Claims Department. SBAA will reimburse participants directly.
22. How can employees get information on continuing their medical benefits if they leave this ministry? (Back to Top)
Employees may contact SBAA directly at 1-800-497-3699. They will handle all of their continuation of benefits administration.
23. When is my employee's enrollment due? (Back to Top)
For employee contributory and buy-up plans, employees have 31 days from their eligibility date to enroll in the plan. If, after the 31-day period, they decide they would like benefits, the employee must submit a Proof of Good Health form. The employee is then subject to medical underwriting for life and disability income insurance benefits only.
24. How do participants find out where they can fill prescriptions if our policy includes Prescription Drug coverage? (Back to Top)
Participants should refer to the pharmacy list included with their employee certificate. They may also contact the SBAA toll-free number at 1-800-497-3699.
25. How do employees add dependents to the policy? (Back to Top)
Participants need to fill out a new enrollment form within 31 days of the eligibility date and give it to you (employer).
26. How do employees use Select Benefits if they already have a major medical policy? (Back to Top)
Select Benefits does not have a coordination of benefits provision. This policy pays regardless of any other coverage participants may have, enabling participants to offset expenses as a result of an illness or injury.
27. If employees have a change in name, address or if there is an error on their Select Benefits ID card, who do they contact? (Back to Top)
All participants should call SBAA toll free at 1-800-497-3699 for assistance.
28. An employee needs to see the doctor for their annual wellness exam. The doctor usually orders tests. What does the plan cover for this type of visit? (Back to Top)
The Simple Health Solutions plan pays $65 per visit up to 15 visits per person per calendar year maximum for doctor's office visits, diagnostic X-rays & lab visits, and preventive care visits. This includes preventive care such as an annual wellness exam. If a doctor orders covered diagnostic testing, the plan pays an additional $65 per test.
29. What happens if a doctor recommends a major test like a MRI? Is the employee covered? (Back to Top)
Yes, the Simple Health Solutions plan pays $75 per test for major diagnostic tests such as MRI, Cat Scan, mammography, etc. up to 4 tests per person, per calendar year. For a complete list of tests, please refer to the policy.
30. If an employee has to go to the emergency room, are they covered? (Back to Top)
Yes, the Simple Health Solutions plan pays $75 per visit up to a $150 calendar year maximum for any eligible treatment received in an emergency room. This applies whether the participant is going because of an accident or illness.
31. Is the employee covered if they have to stay overnight in the hospital? (Back to Top)
Yes, the Simple Health Solutions plan has a daily hospital stay benefit of $300 for a maximum of 30 days per calendar year, 500 days per lifetime. If a participant have to stay in the Intensive Care Unit, the benefit doubles to $600 per day.
32. Does an employee have coverage if they have to go in to the hospital for surgery? (Back to Top)
Yes, the Simple Health Solutions plan has a surgical schedule that pays a specified dollar amount per surgery. All surgeries are performed and paid according to the surgical schedule. (Participants will be mailed a copy of the schedule along with their Select Benefit ID card after they enroll.) Anesthesia charges are paid at 25% of the amount shown in the surgical schedule. If participants stay overnight in the hospital, they will also receive a benefit of $300 per day up to 30 days per calendar year.
33. An employee has to go in for outpatient surgery. Will the plan cover the facility charge? (Back to Top)
Yes, the Simple Health Solutions plan pays $250 per person, per surgery for the facility charge up to a maximum 1 surgery per calendar year. For a definition of an outpatient surgical facility, please refer to the policy.
34. What is covered under the Generic Drug Benefit? (Back to Top)
This benefit pays 100% of the cost for generic drugs after participants pay the $10 co-pay for each filled prescription. There is no calendar year maximum and it is only available for generic prescription drugs (not brand name) issued and dispensed by a licensed pharmacist. Name brand prescription drugs will receive a discount.
35. What kind of coverage do employees have if they get in an accident? (Back to Top)
The Simple Health Solutions plan pays up to $1,000 per person, per calendar year for covered treatment provided by a doctor within 90 days of an accident. This benefit does not cover treatment received in an emergency room.
36. Does the plan include vision benefits? (Back to Top)
Yes, participants have $50 to use for one routine eye exam every calendar year. Participants also get $100 to use towards a pair of eyeglasses or $75 for contact lenses every two consecutive calendar years.
37. What kind of coverage do employees have if they need to go to the dentist? (Back to Top)
The Simple Health Solutions Select Benefits plan pays $50 per visit for regular and preventive dental exams and cleanings. For major work (crowns, inlays, etc.) participants have a benefit of $200 per visit. These procedures have a calendar year maximum of $500 per person. Periodontal work has a lifetime maximum of $1,500 per person. If participants need to see an orthodontist, they have $150 per visit up to a $250 per person lifetime maximum.
38. What happens if employees are injured off-the-job, or get sick, and can't return to work? (Back to Top)
The Simple Health Solutions Select Benefits plan includes a weekly disability income benefit. This pays 66 2/3 % of the participant's base weekly income up to a $100 maximum, after a 7-day elimination period, reduced by other income benefits for which they may be eligible. Dependents are not eligible for this benefit.
39. How does the life insurance benefit work? (Back to Top)
The Simple Health Solutions plan includes a $15,000 term life insurance policy. That means participants have coverage as long as they remain enrolled in Simple Health Solutions Select Benefits. If something were to happen to the participant, the beneficiaries named on their enrollment form would receive the $15,000 death benefit. This amount is free from federal income tax.
40. What does the Accidental Death & Dismemberment benefit mean? (Back to Top)
The Simple Health Solutions plan includes a $15,000 Accidental Death and Dismemberment benefit for employees. This means if participants are hurt or killed in an accident, the plan may pay $15,000 to help cover costs resulting from their accident. This benefit is not available for dependents.
41. How does the Pharmacy Discount work? (Back to Top)
When your employees get their Simple Health Solutions Select Benefits ID card, they will see the name RESTAT on the back. RESTAT works with pharmacies across the county to provide discounts for prescriptions. After they enroll, your employees will be mailed a list of pharmacies that they can visit to receive the discount. They simply show their Select Benefits ID card when they go to have a prescription filled to get the reduced price.
42. If something happens to an employee, will their dependents still have coverage? (Back to Top)
Select Benefits includes a Survivor Benefit. This means that if a participant die while covered under the plan, their dependents continue to receive coverage without paying premium for up to two years after their death. This is as long as the plan remains in force and their spouse or child meets the eligibility requirements of the policy.
