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 | Prescription Benefits | 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: 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 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.


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: 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.

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.


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.


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 — Prescription Benefits

Q: What prescriptions are covered on my plan?
Q: How can I save on prescriptions?
Q: What is the difference between brand and generic prescriptions?
Q: What are preferred and non-preferred brand-name drugs?
Q: What happens if I use a brand-name drug when a generic is available?
Q: What is a specialty pharmaceutical?
Q: How does the prior authorization program work?
Q: Why should I use CVS/Caremark, the pharmacy benefit manager?
Q: Why do some drugs have quantity limits?
Q: What is step therapy?


Q: What prescriptions are covered on my plan?

To better understand the prescriptions covered on your plan, use the 2015 Prescription Drug Guide to help you quickly find:
  • Generic, specialty, preferred brand and non-preferred brand drugs by category
  • Which drugs require preauthorization
  • The cost sharing on drugs that may be covered by your plan

View the 2015 prescription drug guide PDF Icon

Note: This drug list provides summary information and is subject to change. For a complete listing of benefits, exclusions and limitations, please refer to your plan benefit details.


Q: How can I save on prescriptions?

With an Assurant Health plan, there are a few ways you can save on prescription drugs.
  • Use the CVS Caremark prescription program
  • Take advantage of generic prescriptions

Learn more about how you can save on prescription drugs


Q: What is the difference between brand and generic prescriptions?

Generic drugs are chemically the same as their branded counterparts. They are also the same in dosage, safety, strength, form and intended use. Generic drugs are only available after the FDA approves them. When filling your prescription, your pharmacist can substitute a generic drug for a brand-name drug when the generic is rated by the FDA as equivalent and also where it is permitted by your doctor and state law.


Q: What are preferred and non-preferred brand-name drugs?

  • A preferred brand-name drug is considered a preferred brand-name drug based on its proven clinical and cost effectiveness.
  • A non-preferred brand-name drug is a medication where there is a more cost-effective drug available that is clinically the same.



Q: What happens if I use a brand-name drug when a generic is available?

If you choose to use a brand-name drug, rather than its generic or bio-similar equivalent, you will be responsible for paying the brand-name cost-sharing amount, such as deductibles or copays. You will also be responsible for paying the difference in cost between the brand-name drug and its generic or bio-similar equivalent (this is called an ancillary charge). The ancillary charge will not be reimbursed by Assurant Health, nor does it count toward satisfying any coinsurance, deductible or other out-of-pocket limit. Not applicable in all states.


Q: What is a specialty pharmaceutical?

These are prescription drugs used to treat rare or certain chronic diseases, such as rheumatoid arthritis, HIV/AIDS, multiple sclerosis, cancer, hemophilia and hepatitis C. Usually, these are not dispensed at a local retail pharmacy. If you have a complex condition that requires a specialty pharmaceutical (a specialty medication) - you can maximize the benefits of your plan, by using Assurant Health's designated specialty pharmacy, CVS Caremark.

Learn more about specialty pharmaceutical coverage


Q: How does the prior authorization program work?

The Prior Authorization program encourages appropriate and cost-effective use of drugs, and:
  • A physician, a patient, or a person appointed to manage the patient’s care must request prior authorization before drugs that require a prior authorization may be considered for coverage under a member’s pharmacy benefits plan. If the request is approved, the drug will then be covered at the applicable costs associated with the member’s plan
  • The Prior Authorization program is based upon current medical findings, FDA-approved manufacturer labeling information and cost
  • The drugs requiring prior authorization are subject to change

Learn more about the pharmacy preauthorization process

For more information, call the customer service number on the back of the member ID card. For a prior authorization request, call the Prior Authorization number on the back of the member ID card.


Q: Why should I use CVS/Caremark, the pharmacy benefit manager?

As your pharmacy benefit manager, CVS/Caremark brings you discounts on prescriptions and processes prescription claims. Their nationwide network has more than 65,000 independent and chain pharmacies, including CVS, Target, Walgreens, Walmart and Rite Aid stores.

You can save an average of 30-40% on prescription drugs at a CVS/Caremark participating pharmacy; any drug discount will already be applied. Your pharmacist will charge you the amount you’re responsible for paying (such as any applicable copay, coinsurance or deductible). Make sure your plan provides coverage by reviewing the Prescription Drug Card Program information in your insurance contract, or by contacting us.

In most states, CVS/Caremark will deliver to your home any prescription drugs you’re using on a long-term basis. It’s convenient, and you may even save money. Call CVS/Caremark or visit caremark.com for more information.

You can learn more about how to manage your prescriptions with CVS Caremark by visiting our Current Customers web page at assuranthealth.com.



Q: Why do some drugs have quantity limits?

Your plan may limit the amount of a drug you can receive at one time. These limits help your doctor and pharmacist check that the drugs are used appropriately while promoting patient safety. We use medical guidelines, FDA approval and guidance from drug makers to set these quantity limits.


Q: What is step therapy?

With step therapy, you must try one or more alternate drugs before a Step-therapy drug. The alternate drugs are FDA-approved, treat the same condition(s) and may also be available to you at a lower copay or coinsurance level.

MEMBERS — Billing and Claims

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


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.
  • 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.

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: 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: 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.

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.

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.

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.