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GAP insurance supplements group major medical plans by reimbursing out-of-pocket expenses for employeesand their dependents.
We fi ll in the GAP
2 – OptiMed GAP Supplemental Insurance Rev. 10/9/2020
> OptiMed GAP covers eligible expenses including deductible, coinsurance, and copays of the underlying major medical plan.
> OptiMed GAP plans can have both inpatient and outpatient benefi ts. Eligible expenses can include hospitalization, surgery, advanced diagnostics, simple labs, and physician services.
> Employees covered by the major medical plan are eligible, with options to add their dependents.
> OptiMed GAP may be written with PPO, POS, EPO, HMO and HDHP comprehensive medical plans.
> Guaranteed issue, employer contribution from 0 percent to 100 percent.
> OptiMed GAP may be designed for HSA plans.
> Up to two GAP plans may be sold per major medical plan.
> GAP plans available in most states to employers with as few as 5 employees enrolled.
> Non-insurance benefi ts included:• Telephonic doctor visits• Wellness Nurse Line• Workplace Wellness • Employee Assistance Program (EAP)• COBRA administration
Program Features
OptiMed plans have been developed by United Group Programs,
Inc. (UGP) to serve today’s employee benefi ts market.
UGP is a full-service employee benefi ts organization and Third Party Administrator (TPA) founded in 1968. UGP off ers self-funded and fully-insured products in most states and partners with carriers rated
A- (Excellent) or better by A.M. Best. OptiMed assures:
• Excellent customer service refi ned over fi ve decades, embedded with a strong educational component.
• A patient advocacy program for verifying benefi ts, providing fi nancial assistance advice, and helping negotiate bills.
About OptiMed: A United Group Programs Brand• Administrative services
that include eligibility re-views, claims processing, billing, COBRA and Section 125 plans.
OptiMed’s portfolio of health insurance products off er creative solutions that help brokers and employers address the challenging and ever-changing healthcare market.
800-482-8770
OptiMed GAP Supplemental Insurance – 3Rev. 10/9/2020
Customizable Benefits
GAP is a tool to manage the ever-increasing medical expenses for employers and employees. Regardless of the major medical structure, GAP can save employers and employees money. The challenge is creating the best combination of GAP and medical insurance. Put simply, GAP saves money and reduces
the risk of high out-of-pocket expenses. OptiMed GAP is customizable for ease in finding the best solution!
• Inpatient Coverage – covers eligible expenses if insured person in hospital confined under the regular care and attendance of a physician.
• Outpatient Coverage – covers eligible expenses for treatment at a licensed facility, including physicians office, diagnostic clinic, urgent care clinic, outpatient surgical center and others.
• Prescription Drug Rider – may cover generic only or generic plus brand drugs.
• Combined Benefits Option – offers one limit over both inpatient and outpatient eligible expenses.
• HSA Compatible Option – adds a deductible to satisfy IRS regulations and allow employer to offer GAP along with HSA qualified medical plans.
• Physician Services – professional fees of a physician performed where physician routinely practices on an appointment basis.
• Physician Office Copay – a number of copays and up to a standard copay amount will be covered when this benefit is selected.
Employers Want . . .
Lower employee benefits costs without sacrificing quality.
Creative alternatives.
Higher quality benefits to attract and retain employees.
Employees Need . . .
Benefits that fit their needs and needs of their families.
Ease of access to benefits.
Limited exposure to costly out-of-pocket expenses.
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4 – OptiMed GAP Supplemental Insurance Rev. 10/9/2020
GAP in Real LifeLab Tests
ServiceBilled
AmountNetwork Discount
Covered Amount Plan Paid
Applied to Deductible
Total Patient Responsibility
OptiMed Gap Paid
Injection of iodine contrast for radiology imaging 39.00 10.00 29.00 0.00 29.00 29.00 29.00
Thyroid stimulating hormone (TSH) blood test 192.00 53.76 138.24 0.00 138.24 138.24 138.24
Blood test to measure troponin levels 210.00 69.30 140.70 0.00 140.70 140.70 140.70
Complete blood count (CBC) with automated differential white blood cell count
70.00 28.00 42.00 0.00 42.00 42.00 42.00
A prothrombin time test is a blood test that measures how long it takes your blood to clot
34.00 7.82 26.18 0.00 26.18 26.18 26.18
TOTAL $545.00 $168.88 $376.12 $0.00 $0.00 $376.12 $376.12
Actual claims processed by OptiMed
Outpatient Minor Surgery
ServiceBilled
AmountNetwork Discount
Covered Amount Plan Paid
Applied to Deductible
Total Patient Responsibility
OptiMed Gap Paid
Outpatient Procedure 307.74 157.32 150.42 0.00 150.42 150.42 150.42
TOTAL $307.74 $157.32 $150.42 $0.00 $150.42 $150.42 $150.42
Emergency Room Visit
ServiceBilled
AmountNetwork Discount
Covered Amount Plan Paid
Applied to Deductible
Total Patient Responsibility
OptiMed Gap Paid
Emergency Room Visit 572.29 219.98 352.31 264.43 87.88 87.88 87.88
Performed Services 50.00 50.00 0.00 0.00 35.00 35.00 35.00
TOTAL $622.29 $269.98 $352.31 $264.43 $122.88 $122.88 $122.88
OptiMed GAP Supplemental Insurance – 5Rev. 10/9/2020
Value Added Benefits
WORKPLACE WELLNESS
Program designed by Kelly Springer,
RD, nationally acclaimed
nutrition expert.
• “Healthie” mobile app subscription for nutritional guidance, food journaling, exercise tracking and more
• Monthly nutrition newsletter with healthy recipes• Monthly WorkPlace Wellness videos• Biweekly “food morsels” 2-minute videos• Additional optional personalized and group
services may be purchased.
EMPLOYEE ASSISTANCE PROGRAM (EAP)An array of life management tools available online with interactivity to assist members with a variety of personal and/or work-related issues in a private, confidential, and convenient setting, including:
• Private Counseling sessions for issues affecting employees and dependents (up to 3 sessions)
• Family Care-giving Services for a variety of family matters (includes both information and referrals)
• Legal and financial services that involves 30-minute phone or in-personal consultation to help answer basic legal questions or simplify the process for obtaining legal assistance.
WELLNESS ADVICE LINE
COBRA ADMINISTRATION
SECTION 125 PLANS
• Registered nurses available 24/7 to answer questions related to:
• Weight loss• Smoking
cessation• First aid• Nutrition and diet• Stress
management• Disease• Exercise
• Elections are processed and coverage periods tracked; payments collected and remitted to carriers. COBRA notices provided.
• Plan setup that includes enrollment materials, payroll deduction, monthly non-discrimination testing, along with claim forms and a claim submittal process.
EXCEPTIONAL CUSTOMER CARE• Explanation of benefits and how to maximize benefit dollars provided.• High-dollar bill negotiation assistance• Assistance by phone or online in finding providers• Claims payment history provided• Toll-free assistance available in both English and Spanish
TELEMEDICINE
Common IllnessesTreated
• Respiratory infections - Sinusitis/Bronchitis• Urinary Tract Infections• Laryngitis / Sore Throat / Strep Throat• Pink Eye / Conjunctivitis• Seasonal Allergies• Cold & Flu• Indigestion / Diarrhea• Shingles• Poison Ivy• Minor Sprain & Muscle Strains• Motion Sickness
• Physician consultation by phone or teleconference, available 24/7/365.
• National network of U.S. licensed and board-certified physicians for treatment of non-emergent conditions.
• Patient medical information on file but kept totally private and secure.
• No appointment necessary and callbacks average about 12 minutes.
6 – OptiMed GAP Supplemental Insurance Rev. 10/9/2020
Increase deductibleto lower premiumSelect a higher-deductible plan to lower the cost.
Select the GAP PlanInvest a portion of the cost savings in an OptiMed GAP plan to “fi ll in the GAP” created by the higher deductible.
Add up the savingsCost savings from a high-deductible major medical plan with OptiMed GAP supplemental coverage.
$1,131,566
$695,144
Major Medical Premium$1,000 Deductible
150 Employees
HDHP Premium$5,000 Deductible
150 Employees
$176,856OptiMed GAP
$5,000 Inpatient, $2,500 Outpatient150 employees
Major Medical = $1,131,566 HDHP + GAP = - $872,000 ––––––––––––
Annual Savings = $259,566
This Is How We Do It
The average annual major medical insurance premium in 2019 was $7,188 for single coverage and $20,576 for family coverage. The average family premium has increased 54% since 2009 and 22% since 2014. High deducti ble health plans (HDHP) have become prevalent as employers try to save money.
(source: Kaiser Family Foundati on study)
This is an example used for illustrati ve purposes.Your Opti Med representati ve can help you determine your actual savings.
OptiMed GAP Supplemental Insurance – 7Rev. 10/9/2020
Adjust Variables To Meet Any BudgetInstant Rate Quotes Available Online
Employer benefit budgets struggle to keep pace with rising health insurance premiums. This is why OptiMed Gap is
so vital - it enables employers to reduce premiums through high-deductible major medical plans while limiting employee out-of-pocket expense through Gap secondary insurance. With many options available for you to get the right coverage at optimum premium, Gap’s customizability enables employers to find the sweet spot of healthcare premiums versus coverage.
OptiMed’s online rating tool provides instant rate quotes enabling adjustment in variables to meet any budget. Here’s how it works:
1. Apply for use of the rating tool at OptiRater.com.
2. Select Your Desired Level of Gap Coverage.
3. If the premium exceeds your budget, consider one or more of the following:
■ Place a deductible on Gap (or increase it).
■ If you had selected combined inpatient and outpatient benefits, separate them.
■ Select only inpatient benefits.
■ Reduce coverage levels.
■ Place coinsurance on Gap.
■ Eliminate prescription drug rider (if you had selected it).
4. Contact an OptiMed consultant for further assistance, if needed.
8 – OptiMed GAP Supplemental Insurance Rev. 10/9/2020
1. Opti Med Gap may be off ered on a voluntary basis or employer paid.
2. To be eligible for GAP, employees must be covered under the group’s comprehensive major medical plan (this does not include limited medical plans).
3. Only W2 employees are eligible for Opti Med GAP (1099 workers or contractors are not eligible.)
4. Opti Med GAP requires a minimum group size of fi ve (5) enrolled employees or 10 percent of eligible employees, whichever is greater.
5. Composite rates are available for groups of 25 or more.
6. To qualify for reimbursement, the specifi c conditi on must be covered under the insured’s major medical or comprehensive medical plan.
7. Opti Med GAP uses the primary medical plan’s EOB (explanati on of benefi ts) as a basis for determining what is covered.
8. Opti Med issues ID cards to all members.
9. Medical providers that accept benefi t assignment can fi le claims directly to Opti Med, relieving the member of the obligati on to fi le the claim.
10. If member needs to fi le a claim, claims can be fi led online, by mail using a downloadable claim form from Opti MedHealth.com, or can be emailed.
11. To help employers explain to their employees the benefi ts of Opti Med GAP enrollment, a 3-minute video is available in both English and Spanish on Opti MedHealth.com
12. No benefi ts paid during any period the employee does not have coverage under a Major Medical plan.
13. Unless state regulati on required or opti onally selected, no benefi ts for mental illness or functi onal or organic nervous disorders will be paid.
14. Prescripti on drugs are not covered. Generic and Brand drug are covered if opti onal prescripti on drug coverage is selected.
15. Physician offi ce service fees and/or copays may or may not be covered depending on plan requested.
Opti Med Gap plans come with exclusions and limitati ons and it is not available in every state. Please contact an Opti Med sales representati ve for more informati on on exclusions, limitati ons and state
availability. To review exclusions and limitati ons by individual carrier, log on to:htt ps://Opti medhealth.com/gap-exclusions/
This brochure is for marketing purposes only and not an off er for sale. Before any presentation of a proposal, please check with your OptiMed sales representative to be certain that the program being proposed is appropriate for the state intended. No off ering of OptiMed GAP should be given without the expressed approval of OptiMed, and any off ering will be based upon state availability, underwriting guidelines, and minimum group size and participation requirements being met. Provisions, benefi ts, exclusions or limitations may vary by state and by insurance carrier. Please consult with your OptiMed Group Sales Representative to confi rm that OptiMed is available in the state or states in which you may have an interest in off ering OptiMed GAP. OptiMed/UGP is the third-party administrator (TPA) that markets and administrates GAP for various A- or better rated carriers.
IMPORTANT INFORMATION
www.OptiMedHealth.com • [email protected]
800-482-8770
