FAQ’s

Employee’s Frequently Asked Questions

TransConnect “GAP”/Critical Illness/Accidental Injury Insurance

WHAT IS HAPPENING IN THE HEALTH INSURANCE INDUSTRY TODAY?

For the last 15 years, we’ve seen double digit health insurance premium increases just about every year. Employers have been forced to pay higher and higher health insurance premiums while still asking more from Employees in payroll deductions.

But, that’s not the only problem. In addition to insurance premiums going up, many Employees are now finding that their cost to use their health insurance has gone up as well. Deductibles are higher than ever.

Unfortunately, deductibles have gotten to the point where most of us can’t handle the threat of an in-patient hospital stay. Most health plans today are set up so an inpatient stay will cost an Employee $2,000 or more! Who has that kind of money? As a result, everyone is looking for a “sensible solution” to higher premium and higher utilization costs.

We can’t wait for a solution from Washington. We all need “cost” relief now!

Your Employer has decided to “modify” your Health Insurance program this year. As a result, we believe you will agree these modifications can give you and your family the “sensible coverage” solution you have been waiting for.

EXPLAIN THIS CONCEPT TO ME IN ONE SENTENCE

The GAP Insurance concept is straight forward:

Increase the deductible on your existing health plan and buy a 2nd insurance plan to fill the new deductible “gaps” giving your employees “1st dollar” coverage for less money without having to change Insurance Carriers.

OK, SO EXPLAIN THESE CHANGES YOU HAVE MADE TO OUR PLAN.

With the help of your Employer, we have:

1. MADE A CHANGE TO YOUR EXISTING HEALTH PLAN(S)
a. Increased deductible to $5,000Single and $10,000 Family
b. Increased coverage after deductible to 100%.

EFFECT:
a. By increasing deductibles, we lowered premium costs, but also increased your cost exposure.
b. By increasing coverage after your deductible to 100%, we improved your health plan protection.

2.   ADDED THREE NEW INSURANCE COVERAGES.
a.   TransConnect GAP Deductible Insurance-$5,000
b.   Transamerica Critical Illness Insurance.-$5,000
c.   Transamerica Accidental Injury Insurance

EFFECT:
a.   GAP Insurance covers most inpatient hospital/outpatient surgical deductibles up to $5,000 inpatient/$2,500 outpatient.
b.   Critical Illness Insurance provides $5,000cash benefits to you or family member upon diagnosis of 5 critical illnesses.
c.   Accidental Injury Insurance provides cash benefits for emergency treatment, follow-up, medical equipment and physical therapy. Accidental injury Ambulance coverage also included up to $350.

SO, HOW DO I USE THIS NEW GAP INSURANCE PROGRAM?

Hospital Services-
Present your Transamerica and Health Insurance cards upon entering Hospital or in advance when arranging for hospital admittance.
1.   Hospital will contact both Health Insurance Carrier(HIC) and Transamerica to verify coverage.
2.   Hospital will send bill for services to both Transamerica and HIC will send you an Explanation of Benefits (EOB).
3.   Fax EOB to Transamerica and they will pay Provider all approved deductibles covered under the plan. (Inpatient Mental Health benefits not covered under GAP plan.)

Outpatient Surgical Services. (Free Standing center for x-ray, MRI, or surgical services up to $2500).
Present your Transamerica and HIC cards upon entering Free Standing Test or Surgical Center or in advance when arranging for an approved outpatient service.

4.   Surgical/X-ray Facility will contact both HIC and Transamerica to verify coverage.
5.   Surgical/X-ray Facility will send bill for services to both Transamerica and HIC.
6.   HIC will send you an Explanation of Benefits (EOB).
7.   Fax EOB to Transamerica and they will pay Provider all approved deductibles covered under the plan. (Outpatient Mental Health/ Outpatient Laboratory Tests benefits not covered under GAP plan.)

HOW DO I USE THIS NEW ACCIDENT INSURANCE PROGRAM?

Complete the Transamerica Health Multipurpose Claim package found in your Benefits package (also available on line). Be sure to complete all four parts and forward to the address on the claim form. If you need help when completing any document, have questions about what documents need to be submitted, or need a claims package, Transamerica Claims Center Representatives can help you. Please call them Monday through Friday between 7AM and 6PM, Central Time at 800-251-7254.

HOW DO I USE THIS NEW CRITICAL ILLNESS INSURANCE PROGRAM?

WHAT DOES THIS PROGRAM NOT COVER?

This FAQ piece is meant to be “informative only”. It is not meant to change or fully articulate all provisions of the master policy. For more information, please refer to the master policy.

Typical services not covered under the Transamerica GAP plan:

a.   Doctors Office visits. This is provided under a co pay arrangement with Health Insurance Carrier (HIC) health plans.
b.   Prescription Drug coverage This is provided under a co pay arrangement with HIC health plans.
c.   Mental/Nervous/Drug Treatment. Inpatient or Outpatient services are subject to the HIC deductible then covered 100% thereafter. Also, additional coverage is often provided under an EAP plan arrangement with many employers. See your HR department for more information.
d.   Outpatient lab tests. These non x-ray tests are subject to the deductible, then covered 100% thereafter. Observation: lab test charges typically are under $20 and generally viewed as a manageable out of pocket expense, similar to doctor’s office visit or RX co- pays. Remember, MRI tests are covered when performed in a free standing facility..
e.   Speech/Physical/Chemo therapies. All therapy services are subject to the deductible then covered 100% thereafter. Observation: With the addition of our Accident and Critical illness coverage, we fill most deductible “gaps” in the Physical/Chemo/Radiation therapy area.
f.   Emergency room- charges for sickness are NOT covered; charges for accident ARE covered.   Observation: Most HIC health plans have emergency room coverage with co-pays. Our accident plan provides additional emergency cash benefits up to $2,000.

ARE THERE ANY WAITING PERIODS ON THIS COVERAGE?

Transamerica Gap and Accident coverage have no waiting periods. Critical Illness coverage has a 30 day waiting period before any benefits are payable.

ARE THERE ANY” PRE EXISTING CONDITION” LIMITATIONS ON THIS COVERAGE?

Transamerica Gap and Accident coverage have no pre-existing limitations. Critical Illness coverage has a 12 month waiting period before benefits are payable only for a covered condition you are currently being treated for (Cancer, Heart Attack, Stroke, End Stage Renal, Major Organ Transplant)
However, coverage is available for any new separate critical illness after the initial enrollment 30 day waiting period.

Remember, if you have questions about coverages, documents that need to be submitted, or need a claims package, Transamerica Claims Center Representatives can help you. Please call them Monday through Friday between 7AM and 6PM, Central Time at 800-251-7254.

CAN I CONTINUE THIS COVERAGE WHILE ON COBRA?

You can use this coverage anywhere as long as you are covered on another health plan elsewhere and you continue to pay premiums.

Chelten Benefits Group