Embed Size (px)
Citation preview
National Sales and Account ManagementMay 2013
Summary of Benefit and Coverage (SBC)Job Aid
2
SBC Job Aid
Color Key Action
Editable May be personalized based on group requirements, such as name, website, and contact information. May be modified and/or edited by AAM.
Not Editable Language is determined by HHS mandate and cannot be edited or changed.
ValidateThe Regional Associate Account Manager (RAAM) and Associate Account Manager (AAM )to validate the benefit and cost share information. To include days limits and benefit maximums in the Limitations and Exceptions column as well.
How to use this tool:This job aid has been created to provide you with the information needed to accurately request edit and validate the SBC. The circled numbers for each section correlate to the National Universal Request form (NURF). Each section is color coded and the color key is located below:
Header Section
1 2
3 4
Disclaimer Section
6
a b
5a b
c
4
4
Options are: Individual + family, member + family, All Coverage Tiers
KP identifier and group name must be in bold 16 point font
EXCEPTION - NW – will display contact information pursuant to Marketing Collateral requirement
HMO – includes DHMO productsMAS will include jurisdiction (MD, VA, DC)
HDHP – for HDHP compatible (HSA) plansEPO – for Self Funded plansPOS – for Point of Service PlansPPO – for PPO PlansOOA – for Indemnity Plans
1
Customer Coverage Period- use MM/DD/YYYY format. [If End Date is unknown, user Coverage Period beginning on or after (MM/DD/YYYY)]
2
3
5 Group personalized website KP group Microsite or KP website
b
6Name of the company the employees will contact for more details on coverage and cost
a
Phone number of the company in 6a.
SBC Job Aid Numbers 1- 6
appears on first page only, unless otherwise requested
3
Disclaimer SectionHeader Section
4
Footer Section
7
8
9 a b c
d
TTY/TTD is only provided in some regions and when the employees are instructed to call Kaiser Permanente
a b
SBC Job Aid Numbers 7-9
What is the overall deductible? $XX individual / $XX family Include major categories that are not
subject to the deductible
Are there other deductibles for specific services?
$ XX individual / $XX family If less than 3 service specific deductibles
– must end the entry with There are no other specific deductibles.
Is there an out–of–pocket limit on my expenses?
Yes. $XX individual / $XX family
8
9
77
8
What is not included in the out–of–pocket limit?
• We will always display the 3 required items: Premiums, balance-billed charges (except for CA), and health care this plan doesn’t cover
• Additional entries may include: deductibles and/or copayments
Is there an overall limit on what the plan pays?• The answer is always “NO”
Do I need a referral to see a specialist?• Yes. Written approval is required to see most
specialists.• EXCEPTION - CO – you can have a consultation
without referral
Are there services this plan doesn’t cover?• Yes. Only indicate no if services are covered
regardless of medical necessity
• Group personalized website• KP group Microsite or KP website
a
Does this plan use a network of providers?
• If KP website in 8a – Regional # will be used
• If Group personalized website – provide # for 8a.
b
Additional language cannot be personalized or edited
SBC Job Aid Numbers 7- 8
5
4
9 • Kaiser Permanente or• Name of the company
answering questions on behalf of the group
a
b • Regional specific phone number or number of the company personalized in 9a.
• Website specific to the answer provided in 9a
• Phone number to request a glossary . A Kaiser Permanente or the number personalized by the company who can provide a glossary to their employees
d
c
Regionally Specific Member Services Numbers for SBC’s
CA 1-800-278-3296
CO 1-855-249-5005
GA 888-865-5813
HI 1-808-432-5955(Oahu) or 1-800-966-5955 (Neighbor islands)
MAS 1-855-249-5018
NW 503-813-2000 or 1-800-813-2000
OH 800.686.7100
For Your Reference
SBC Job Aid Number 9
6
appears on the first and last page only, unless otherwise requestedPage numbers are displayed on all pages
Footer Section
7
11
Information will vary by region
Information will vary by region
Common Medical Events 10
8
10 11
Information will vary by region
Common Medical Events Section Con’t
10
EXCEPTION: NW & OH use the words “Participating Provider & Non-Participating Provider” in column headings
Validate the benefit and cost share information against the sold plan Cost Sharing Standards are as follows: XX% coinsurance, $XX per visit
(Word copayment is not added), No charge (if covered and at no cost) or Not covered
Validate the days limits and benefit maximums against the sold plan Validate any cost shares reflected in this column against the sold plan The wording in this section can vary by region. The Regional SBC teams will manage this language to be compliant
with all regional/state/federal requirements. Language is based on variable content from health plan data. Any
change in language MUST be escalated to the Regional SBC team for review and approval.
SBC Job Aid Numbers 10-11
11
9
7
16
Services You May Need and Limitations and Exception Detail specific to the Common Medical Events SectionOther Practitioner office visit = We will reflect Chiropractic and Acupuncture coverage when rider is purchased
Exception: NW will show alternative treatment offering as part of their HMO plan designDiagnostic test and Imaging - displayed as “ per test” or “per encounter” Preventive Care/Screening/immunization – Displayed are the Routine Physical, Preventive Screening & Preventive immunizations Drugs - All Rx categories will display both the retail and mail order benefit (if group has MOI)For Women’s Preventive Service plans, generic drugs limitations & exceptions will also include: No charge for contraceptives (subject to formulary guidelines). For Outpatient Surgery and Hospitalization categories - For copayment plans: If there is one charge for both facility and physician charges, then physician/surgeon fees will display: Included in facility feeEmergency room services – We populate benefit for both the plan and non plan provider columnsEmergency medical transportation - Displayed as: XX% coinsurance OR $XX per trip. We populate benefit for plan and non plan provider columnsUrgent Care - We populate benefit for plan and non plan provider columns. Limitation & Exception: Non-participating provider urgent care covered only if you are temporarily outside of our service area.Mental Health and Substance Abuse outpatient services = Displayed individual and group cost share (not applicable in HI)Prenatal and Postnatal care - Limitation & Exception : “After confirmation of pregnancy” or “cost sharing for first postnatal visit only”Rehabilitation Services – Where appropriate we can provided the outpatient and inpatient benefitDurable Medical Equipment - Limitation and Exception: “Coverage is limited to items on our DME formulary” (exception: HI, as they have very limited DME outside of diabetic DME)Eye Exam When there is a cost share, benefit is displayed as “XX% coinsurance OR $XX per visit for refractive exam”
SBC Job Aid Numbers 10&11 - Additional Supporting Information
10
11
Excluded Services & Other Covered Services Section 12
Your rights to Continue Coverage Section
11
Common Medical Events Section Con’t
13
7
16
Excluded Services and Other Covered Services
• All 13 Services must appear in either “Services Your Plan does NOT cover” or “Other Covered Services”
• They must be in alphabetical order within each box
• Services listed as Not Covered in the Common Medical Events chart must be added to “Services Your Plan does NOT cover” on page 1 in the last box of the “Why this Matters” section
CORE LIST OF 13 SERVICES
1. Acupuncture 2. Bariatric surgery3. Chiropractic care 4. Cosmetic surgery 5. Dental care (Adult)6. Hearing aids7. Infertility treatment8. Long-term care9. Non-emergency care
when traveling outside the U.S.
10.Private-duty nursing11. Routine eye care
(Adult) 12.Routine foot care 13.Weight loss programs
For more information on your rights to continue coverage:
• Regionally specific phone number
• Group personalized phone number
13
12
Your Rights to Continue Coverage
• The wording must be replicated as provided by Health and Human Services (HHS), only the phone number may be updated
SBC Job Aid Numbers 12-13
12
13
Language Access Services Section
Your Grievance and Appeals Rights Section
15
14
1
State Consumer Assistance Information State Consumer Assistance Information
CA
Cal i fornia Department of Managed Health Care Help Center 980 9th Street, Sui te 500Sacramento, CA 95814 (888) 466-2219http://www.healthhelp.ca .govhelpl [email protected] .gov
MD
Maryland Offi ce of the Attorney Genera lHeal th Education and Advocacy Unit200 St. Paul Place, 16th FloorBaltimore, MD 21202(877) 261-8807http://www.oag.s tate.md.us/[email protected] tate.md.us
OR
Oregon Insurance Divis ionOregon Heal th Connect1435 NE 81st Avenue, Sui te 500Portland, Oregon 97213-6759(855) 999-3210http://www.oregonheal thconnect.orgheal [email protected]
DC
Dis trict of Columbia Healthcare FinanceOffi ce of the Ombudsman899 North Capitol St, NE Room 6037Washington, DC 20002(877) 685-6391heal [email protected]
GA
Georgia Offi ce of Insurance and Safety Fi re Commiss ionerConsumer Services Divis ion2 Martin Luther King, Jr. DriveWest Tower, Sui te 716Atlanta , Georgia 30334(800) 656-2298http://www.oci .ga .gov/ConsumerService/Home.aspx
Consumer Assistance Programs (CAP) in CA, NW, GA, MAS; no CAP for other regions)
Your Grievance and Appeals Rights
• The wording must be replicated as provided by Health and Human Services (HHS)
For questions about your rights, this notice, or assistance contact the plan at :
• Regionally specific phone number
• Group personalized phone number
14
SBC Job Aid Number 14
14
1
Language Access Services
All 4 language access disclaimers must be displayed
Spanish (Español): Para obtener asistencia en Español, llame alTagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag saChinese (中文 ): 如果需要中文的帮助 , 请拨打这个号码Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne’
• Regionally specific phone number
• Group personalized phone number
SBC Job Aid Number 15
15
15
16
Footer Section (see more details on slide #5) : • Appears on first and last page only, unless otherwise requested• Page numbers displayed on all pages
SBC Job Aid – Coverage Examples
The Coverage Example Page will display “Total amounts are based on subscriber only coverage” in space designated by HHS
– KP does not require pre-notification for maternity or diabetic care, no additional information is required for this
Do NOT change ANYTHING on this page
Cost share benefit updates may change Patient and Plan liability amounts
SBC Job Aid
17
4
SBC Job Aid - Other Helpful Information
Minimum Essential Coverage:
Minimum Value Statement:
Please work closely with your NA UWC on any of these types of requests
19
Naming Conventions by Process
Step #2 – Saving the Completed NURF in SC on WHQ record:
NURF: NURF_Group Name_Contract Effective Year_Date Saved [YYMMDD].pdfExample: NURF_Marriott_2014_130513.pdf
Step #1– Saving critical documents to complete the NURF:
NPS: Customer Name_Contract Effective Year_Region Abbreviation_Sold Plan Type_NPS.pdfExample: Marriott_2014_CA_Hi Ded 1000_NPS.pdf
Benefit Summary: BS_Group Name_Contract Effective Yr_Region _Sold benefits abbreviation_Population.pdfExample: BS_Marriott_2014_GA_Hi Ded 1000_Salary.pdf
CRTS (for CA only): CRTS_Group Name_Contract Effective Year_Sold benefits abbreviation_Population.pdfExample: CRTS_Marriott_2014_Hi Ded 1000_Salary.pdf
Step #3 – Saving and sending SBC to Customer:
SBC: Group Name_Contract Effective Year_Region Abbreviation_Sold Plan Type_SBC.pdfExample: Marriott_2014_CA_Hi Ded 1000_SBC.pdf
Miscellaneous Documents and Critical Information:
Name/type of documentGroup Name Contract year
Region Benefit /Plan Type Population
