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Frequently Asked Questions

Below you'll find a list of frequently asked questions related to using your Assurant Health plan. You can also view the full list of frequently asked
questions
to see other questions and answers related to health care reform, plans for individuals and families and plans for small businesses.

ASSURANT HEALTH MEMBERS
Understanding Your Plan | Finding Providers in Your Network | Billing and claims | Renewals

MEMBERS — Understanding Your Plan

Q: How do I know which major medical plan I have?
Q: What is now covered by my major medical plan?
Q: What preventive services are covered under my plan?
Q: Why are maternity and pediatric dental and vision now included on major medical plans?
Q: When does my calendar year deductible start over?
Q: What is the name of my network?
Q: Which physicians and hospitals are members of my network?
Q: What does out of network mean?
Q: What is preauthorization?
Q: What is a predetermination?
Q: What is a specialty pharmaceutical?
Q: Does my surgery/hospital stay need preauthorization?
Q: How do I get my surgery/hospital stay preauthorized?
Q: How long do I have to submit a bill/claim?
Q: Do I need a 1095 tax form from Assurant Health, in order to file my taxes?


Q: How do I know which Individual major medical plan I have?

Grandfathered plans: Plans effective on or before the passage of the Affordable Care Act laws on March 23, 2010. Grandfathered plans are exempt from many changes required under the Affordable Care Act and customers can retain their “grandfathered” status if their plan has not had significant changes.

Non-grandfathered plans: Plans issued after March 23, 2010. Plans with non-grandfathered status must conform to all applicable reform requirements as of the first plan year after January 1, 2014. This also includes plans sold prior to the passage of health care reform laws if certain changes were made to the plan.

Extended plans: Plans issued in states that are allowing non-grandfathered plans to continue for a designated extended period of time. Extended plans may also be referred to as Grandmothered plans.

Metallic plans: Major medical plans with effective dates of January 1, 2014 or later. Metallic refers to the series of plan types that meet the essential health benefit requirements as defined by the Affordable Care Act. Bronze, silver, gold and platinum refers to the progressively increasing range of coverage levels and corresponding pricing structure.

Learn more about the differences between these plans


Q: What is now covered by my major medical plan?

Major medical plans effective on or after January 1, 2014 provide coverage for essential health benefits. Essential health benefits include the following categories of benefits, which are not subject to annual dollar limitations:
  • 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 disorders
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including dental and vision care

The specific benefits considered in these categories may vary by state.

Learn more about Assurant Health plans that cover essential health benefits


Q: What preventive services are fully covered under my plan?

Major medical plans that are compliant with the Affordable Care Act may cover the following in-network preventive services, depending on your age.
  • Blood pressure, diabetes and cholesterol tests
  • Many cancer screenings, including mammograms and colonoscopies
  • Counseling on topics such as contraception, breastfeeding, quitting smoking, losing weight, eating healthy, treating depression and reducing alcohol use
  • Annual eye exams and dental checkups and cleanings for children under age 19
  • Routine vaccinations against diseases such as measles, polio or meningitis
  • Certain female contraceptives
  • Counseling, screening and vaccines to ensure healthy pregnancies
  • Flu and pneumonia shots
  • Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked
  • Depression screening for adults

Learn more about preventive services that are fully covered on major medical plans

Note: Short term medical plans do not pay for preventive services.


Q: Why are maternity and pediatric dental and vision now included on major medical plans?

Maternity and pediatric dental and vision are two of the categories of essential health benefits provided under the Affordable Care Act. Individual major medical and fully-insured small business plans must offer all categories of the essential health benefits, as required under the Affordable Care Act.

Learn more about other essential health benefits covered on major medical plans


Q: When does my calendar year deductible start over?

The calendar year begins January 1 and ends December 31, each year.


Q: What is the name of my network?

This information is printed on your health insurance ID card, along with a telephone number for you to contact if you need more assistance.

Note: If you purchased an Assurant Health plan through the Marketplace, your network is named “Aetna Signature Administrators® PPO.”


Q: Which physicians and hospitals are members of my network?

Visit the Assurant Health network page to learn more about the network associated with your Assurant Health plan. You can find the network listed on your ID card. You may also contact your provider's office and ask if the physician is a member of the network. Always verify whether your provider is a member of the network in order to maximize your health insurance benefits.


Q: What does out of network mean?

This refers to doctors, hospitals, pharmacies, and other providers who do not belong to a health plan’s network, and therefore do not include network discounts.


Q: What is preauthorization?

Sometimes called “prior authorization” or “prior approval,” this is a decision by your insurance company or plan that a health care service, treatment, prescription drug or durable medical equipment is medically necessary. Your health insurance or plan may require preauthorization for certain medical services before you receive them, except in an emergency. However, preauthorization isn’t a promise that your health insurance or plan will cover the cost.

Your health insurance ID card shows the preauthorization telephone number, and a full listing of the services that require preauthorization can be found in your health insurance policy. Please follow the preauthorization procedure in order to maximize your benefits.

Learn more about preauthorization


Q: What is a predetermination?

A predetermination of benefits is a written request for verification of benefits. We review these requests based on policy provisions, and send an explanation of your potential health insurance benefits. You may request a predetermination before your medical procedure, although a predetermination of benefits is generally not necessary.


Q: What is a specialty pharmaceutical?

These are types of prescription drugs that may:
  • Be used to treat rare or certain chronic diseases
  • Have a highly targeted, cellular mechanism of action
  • Require injection or other parenteral or unique method of administration
  • Require special administration and monitoring
  • Be regularly supplied by designated specialty pharmacy providers

View Assurant Health’s 2015 Prescription Drug Guide PDF Icon


Q: Does my surgery/hospital stay need preauthorization?

In most cases, preauthorization is a requirement for specific services listed in your health insurance policy. Please review your health insurance policy for details.


Q: How do I get my surgery/hospital stay preauthorized?

Your health insurance ID card shows the preauthorization telephone number. A full listing of the services that require preauthorization can be found in your health insurance policy. Please follow the preauthorization procedure in order to maximize your benefits.


Q: How long do I have to submit a bill/claim?

Please submit the claim as soon as you can. Assurant Health cannot consider any claim received more than 15 months after the date of service.


Q: Do I need a 1095 tax form from Assurant Health, in order to file my taxes?

Form 1095-B is a tax form for consumers which is intended to provide proof that an individual is covered by a Qualified Health Plan (QHP) and has paid the required premium for that insurance plan.

Health insurance carriers are not required to provide 1095-B tax forms to their customers for 2014. To indicate you were enrolled in a Qualified Health Plan in 2014, simply check the appropriate box on your federal income tax form.

If you’d like written confirmation of the coverage you held and the premiums you paid for 2014, please contact us and we can provide that to you.

If you have specific questions regarding how the new requirements impact your tax return, please consult with a qualified tax advisor.

Additional resources:

MEMBERS — Finding Providers in Your Network

Q: What is the name of my network?
Q: Which physicians and hospitals are members of my network?
Q: What is a PPO network?
Q: What does out of network mean?
Q: How can I get an updated network directory?
Q: What is CVS Caremark?


Q: What is the name of my network?

This information is printed on your health insurance ID card, along with a telephone number for you to contact if you need more assistance.

Note: If you purchased an Assurant Health plan through the Marketplace, your network is named “Aetna Signature Administrators® PPO.”


Q: Which physicians and hospitals are members of my network?

Visit the Assurant Health network page to learn more about the network associated with your Assurant Health plan. You can find the network listed on your ID card. You may also contact your provider's office and ask if the physician is a member of the network. Always verify whether your provider is a member of the network in order to maximize your health insurance benefits.


Q: What is a PPO network?

Formally known as a “Preferred Provider Organization,” this is a type of network that contracts with a wide range of medical providers, such as hospitals, doctors and specialists. When you have a health plan that has a PPO network, you pay less if you use providers that belong to the plan’s network. You can still use doctors, hospitals, and providers outside of the network, but you won’t get any network discounts and there could be higher cost-sharing limits for using providers outside the network. Note: Assurant Health sells PPO plans on the Health Insurance Marketplace with a broad national network that does not require a referral to see a specialist.

Learn more about the value of a PPO network


Q: What does out of network mean?

This refers to doctors, hospitals, pharmacies, and other providers who do not belong to a health plan’s network, and therefore do not include network discounts.


Q: How can I get an updated network directory?

Please contact the number printed on your health insurance ID card. Always verify whether your provider is a member of the network in order to maximize your health insurance benefits.

Learn more about networks available through Assurant Health


Q: What is CVS Caremark?

CVS Caremark is the vendor Assurant Health uses to process your prescription drug claims. In other words, they are an outside company we contract with to administer your prescription drug benefits on our behalf.

MEMBERS — Billing and Claims

Q: How long do I have to submit a bill/claim?
Q: How do I get a claim form for my prescriptions?
Q: Where do I send claims?
Q: Can I fax in a claim?
Q: How long does it take to process a claim?
Q: How do I appeal a claim denial?
Q: My network physician wasn't in the office. I saw the "on call" physician. Will this be paid as a network claim?
Q: The clinic was a network provider. Why wasn't the physician paid as a network provider?
Q: I was on vacation and had to see a physician. Will you pay my claim at the network rate?
Q: What do I do if my physician or hospital is billing me for the amount not covered as over the “Maximum Allowable Amount” or the “Reasonable and Customary Amount?”
Q: My physical therapy/chiropractic claim was denied as maintenance care. What does that mean?
Q: What does out of network mean?


Q: How long do I have to submit a bill/claim?

Please submit the claim as soon as you can. Assurant Health cannot consider any claim received more than 15 months after the date of service.


Q: How do I get a claim form for my prescriptions?

Usually, the pharmacy will submit prescription claims for you. Otherwise, to order claim forms, simply contact the Assurant Health phone number located on your medical ID card.


Q: Where do I send claims?

Refer to the back of your health insurance ID card for claims submission information.


Q: Can I fax in a claim?

Yes. Our fax number is (608) 741-4989.


Q: How long does it take to process a claim?

The amount of time it takes to process a claim depends on the information submitted. In general, you should receive an Explanation of Benefits within 3-4 weeks. If additional information is required to process a claim, we will notify you, and the claim could take longer to process.


Q: How do I appeal a claim denial?

If you believe your claim has been processed incorrectly, please contact our Customer Services Department. If you do not agree with the denial of a claim, please send an appeal in writing to Assurant Health, Correspondence Department, P.O. Box 624, Milwaukee, WI, 53201-0624. Note any extenuating details, include any documentation pertaining to the appeal, and keep a copy for your records.


Q: My network physician wasn't in the office. I saw the "on call" physician. Will this be paid as a network claim?

If the physician you saw is a member of your network, we will consider the charges at the network rate of payment. If the physician you saw is not a member of your network, we will consider the charges at the non-participating provider rate of payment.


Q: The clinic was a network provider. Why wasn't the physician paid as a network provider?

Each physician contracts individually with the network. If the physician you saw is not a member of your network, we will consider the charges at the non-participating provider rate of payment.


Q: I was on vacation and had to see a physician. Will you pay my claim at the network rate?

If the physician you saw is a member of your network, we will consider the charges at the network rate of payment. If the physician you saw is not a member of your network, we will consider the charges at the non-participating provider rate of payment. However, if it was an emergency, charges will be processed at the in-network rate of payment.


Q: What do I do if my physician or hospital is billing me for the amount not covered as over the “Maximum Allowable Amount” or the “Reasonable and Customary Amount?”

If you see an out-of-network provider, the amount we pay will be the Maximum Allowable Amount or the Reasonable and Customary Amount. These amounts are determined by factors set forth in your insurance policy. Generally, we pay the amount charged by the majority of providers in your geographic area. You are responsible for paying the amount over the Maximum Allowable Amount.


Q: My physical therapy/chiropractic claim was denied as maintenance care. What does that mean?

Maintenance care means that the care that you are receiving is no longer improving your medical condition.


Q: What does out of network mean?

This refers to doctors, hospitals, pharmacies, and other providers who do not belong to a health plan’s network, and therefore do not include network discounts.

MEMBERS — Renewals

Q: How will I be notified about receiving my new ACA-compliant plan?
Q: If I purchase a major medical plan compliant with the Affordable Care Act, will it renew automatically? If yes, when?
Q: Can I keep my doctors if I move to a major medical plan offered by Assurant Health?
Q: Why is my major medical plan renewing January 1?
Q: When my major medical plan renews, is anything changing?
Q: Am I eligible for financial assistance (subsidies)?
Q: What if I now qualify for financial assistance (subsidies)?
Q: Can I keep the grandfathered status on my current individual major medical plan?
Q: Why isn’t my deductible available anymore?
Q: How will I be notified that my grandfathered plan will renew in 2016?
Q: What causes my premium to change?
Q: If I purchase a small group fully-insured plan compliant with the Affordable Care Act, will it renew automatically? If yes, when?
Q: Is anything changing on my plan?
Q: Am I covered when I go out of the United States?
Q: I don’t know if I can afford a major medical plan. What are my options?
Q: Does Assurant Health offer plans in all of the metal levels?


Q: How will I be notified about receiving my new ACA-compliant plan?

Those receiving a new ACA-compliant major medical plan will begin to receive notice of their current plan being discontinued ninety days in advance.1 Approximately sixty days before you receive your new plan, you’ll receive a chart that reviews a number of plan options, including premiums. Thirty days before, you and your employees will receive packets with everything you need for the new plan.

1Varies by state.


Q: If I purchase a major medical plan compliant with the Affordable Care Act, will it renew automatically? If yes, when?

Individual major medical plans with effective dates January 1, 2014 or later will renew every January 1. This is based on the federal guidelines.


Q: Can I keep my doctors if I move to a major medical plan offered by Assurant Health?

All of our major medical plans provide access to a PPO network of doctors and hospitals. For many, it’s likely that you’ll find the doctor or hospital you want within our PPO networks because there is a greater choice of providers. However, you can check to see if your provider is included by looking at the networks available in your state. In most cases, Assurant Health customers who currently have a major medical plan will be able to keep their current network of doctors. If your doctor is not in the network, your plan may still provide coverage for these services, however, higher deductibles and cost sharing may apply to out-of-network providers. In addition, you may get billed by your provider for the amount over what we pay as the maximum allowable amount.


Q: Why is my major medical plan renewing January 1?

  • If your plan is renewing January 1 and your plan isn’t grandfathered and hasn’t been extended, then you have an Affordable Care Act-compliant major medical plan. These plans have bronze, silver, gold and platinum levels, and also a catastrophic plan available to those under 30 or those with a hardship exemption.
  • To comply with the Affordable Care Act regulations, all metallic and Catastrophic ACA compliant plans must renew on January 1 each year, regardless of the plan’s effective date. This is a regulation all insurance companies must follow.
  • If your plan is grandfathered or has been extended and you are renewing on January 1, that means January 1 is your plan’s anniversary date.
  • Regardless of the type of plan you have, your plan will only renew once every 12 months.


Q: When my major medical plan renews, is anything changing?

  • If your plan is changing, your renewal letter will include a table comparing your current plan with your new plan, so you can see what has changed. These changes will not go into effect until your renewal date.
  • Your letter may also mention that we’ll be sending you new ID cards, a Summary of Benefits Coverage and a Benefit Summary. You can expect these additional documents to arrive a few weeks prior to your plan renewal.

You can also call our Customer Care Center (800-800-1212) if you have questions about these changes.


Q: Am I eligible for financial assistance (subsidies)?

Depending on your income, you may qualify for financial assistance that can be applied to a Marketplace plan offered through Assurant Health in the form of a premium tax credit (also known as premium subsidy) or a cost-sharing reduction.

See if you qualify for a subsidy


Q: What if I now qualify for financial assistance (subsidies)?

Your ability to apply for a new subsidized plan depends on the time of the year.
  • During open enrollment: If you now qualify for financial assistance in the form of a premium tax credit or a cost-sharing reduction, then you can apply for a subsidized plan on the Marketplace anytime during open enrollment.

    Use our subsidy estimator to check your eligibility.

    Also, talk to an Assurant Health sales expert to get help applying for a subsidized plan through the Marketplace. Call 800-647-9094.
  • Outside open enrollment: In order to apply for a subsidized plan outside open enrollment, you need to have a qualifying life event. If a change has occurred in your income or household status that makes you newly eligible for a premium tax credit or a cost-sharing reduction, then you likely have a qualifying life event. You’ll be able to apply for a new subsidized plan during a 60-day special enrollment period. Keep in mind, this is only a qualifying life event if you’re already enrolled in a major medical plan that is compliant with the Affordable Care Act.

    If you don’t have a qualifying life event, but are newly eligible for financial assistance, then you’ll have to wait to purchase a subsidized plan during the next open enrollment period.

If you still have questions about your financial assistance eligibility and you currently have an Assurant Health plan, you can contact us or your agent to discuss if you can purchase a new Assurant Health plan and where you can apply your premium tax credit or cost-sharing reduction.

Note: In Nevada, major medical plans can be purchased year round without a qualifying life event. If you apply without a qualifying life event outside open enrollment, your coverage will begin on the first day of the month after 90 days from the date you applied.


Q: Can I keep the grandfathered status on my current individual major medical plan?

In most cases, you will be able to keep your grandfathered plan, as long as there are no significant changes made to your plan. Your grandfathered plan qualifies as minimum essential coverage, meaning you won’t be subject to a tax penalty.


Q: Why isn’t my deductible available anymore?

Major medical plans effective on or after January 1, 2014 have to meet certain requirements of the Affordable Care Act. One of those requirements is that an individual’s out-of-pocket costs for covered in-network services must comply with new requirements. Because of this, certain deductible levels are no longer available.


Q: How will I be notified that my grandfathered plan will renew in 2016?

Grandfathered plans will receive notice of renewal similar to what has happened in the past. Generally, you will receive a letter 60 days before the renewal, letting you know what your new premium will be.


Q: What causes my premium to change?

At the time of renewal, rate increases are usually related to the following:
  • Increasing cost of medical care
  • Advancing medical technology
  • Increased use of services
  • Age ratings
  • Geography
  • Higher prescription drug prices


Q: If I purchase a small group fully-insured plan compliant with the Affordable Care Act, will it renew automatically? If yes, when?

Small Group Fully-Insured Plans with effective dates of 2014 or later will renew each year on the plan's anniversary.


Q: Is anything changing on my plan?

  • If your plan is changing, your renewal letter will include a table that compares your current plan with your plan as of your renewal date, so you can see what changed.
  • Your letter may also mention that we’ll be sending you new ID cards, a Summary of Benefits Coverage and a Benefit Summary.
  • You can also call our Customer Care Center if you have questions about these changes.


Q: Am I covered when I go out of the United States?

Unless specifically excluded by your contract, you are covered for the benefits listed in your health insurance policy. All health insurance policy provisions apply, including medical necessity and reasonable and customary. Our short term medical plans do not cover any treatment outside of the United States and its territories.


Q: I don’t know if I can afford a major medical plan. What are my options?

Depending on your income, you may qualify for financial assistance that can be applied to a major medical plan in the form of a premium tax credit (also known as a premium subsidy) or a cost-sharing reduction.

Check your subsidy eligibility to see if you qualify.

Some major medical plans may be more cost-effective, depending on your doctor visits, age or hardship exemptions. When comparing major medical plans, consider the following plan details that can be beneficial to you and your budget.
  1. Copay plans are a great way to help with day-to-day expenses, particularly if you don’t go to the doctor often.
  2. Plans with a higher deductible can help you save on your monthly premium, particularly if you are relatively healthy.
  3. Catastrophic plans are available if you are under age 30 or have a hardship exemption. These plans typically have a lower monthly premium, a $6,600 deductible and three primary care visits covered at 100% before meeting your deductible.
Learn more about these plan details

If you are looking for a health insurance plan outside open enrollment, you may be able to get a major medical plan, if you have a qualifying life event. Short term medical insurance is another option that offers you coverage and can be purchased throughout the year.

Learn more about affordable plans available outside open enrollment

Note: In Nevada, major medical plans can be purchased year round without a qualifying life event. If you apply without a qualifying life event outside open enrollment, your coverage will begin on the first day of the month after 90 days from the date you applied.


Q: Does Assurant Health offer plans in all of the metal levels?

Yes, Assurant Health offers major medical plans in all metal levels, including catastrophic-level plans.

Compare specific major medical plan levels