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European Health Insurance Card
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POS and PPOs
Point of Service (POS)
POS plans give you a combination of an HMO plan and a FFS plan. Like a traditional HMO, you have a PCP who will make referrals to other providers within the plan when needed. You have no deductible when seeing a physician within the network and will pay a small co-pay (around $10) for each office visit. If you want to go to a physician outside the network, you're free to do so without consulting your primary care physician. But, when going outside the network you'll usually have to pay a deductible (around $300 for an individual) as well co-insurance (usually 30 to 40 percent) as you do with FFS plans. You save money if you stay within the network, but you have the flexibility to go outside the network if you need to. However, if you choose to go outside the network, you're in charge of all paper work needed in order to get reimbursed for the expenses.
A common POS plan insurance card. |
Preferred Provider Organization (PPO)
A PPO is a group of doctors and hospitals that provide medical service only to a specific group or association. The PPO may be sponsored by a particular insurance company, by one or more employers, or by some other type of organization. The most obvious difference between HMOs and PPOs is that members aren't required to work through a PCP in order to get referrals. In addition, members aren't limited to care from PPO physicians; they're free to go outside the PPO group. The insurance company may reimburse you for 100 percent of care obtained from network physicians, but will only reimburse you 80 percent for non-network treatment. Like POSs, there is a deductible if you go outside the network. An additional benefit of the PPO, however, is that there's a maximum on out-of-pocket expenses. An out-of-pocket expense maximum, or cap, is the amount that you have to meet in order for the insurance company to pay 100 percent of your policy's benefits. Your out-of-pocket expenses that go toward this cap include any deductible and co-insurance payments. Unfortunately co-payments and your monthly insurance premium do not count.
What's Typically Covered?
With preventive care as the focus, all general "well" visits are typically covered. Managed care plans won't pay for services not deemed medically necessary, but each plan's definition of medically necessity might be different. For plans that cover prescription drugs, there may be requirements for specific drugs (such as generic vs. name brand).
Pros and Cons
The primary benefits for managed care are the lower costs for preventive care with some plans not even requiring a copay. The drawbacks of HMOs are fewer choices in doctors and facilities, as well as having to go through a primary physician in order to see specialists. Drawbacks of PPOs include higher fees for those doctor's outside of the network, which at times can be substantial.
No matter what plan you have, prescription benefits can be confusing. Find out more about how these benefits work in the next section.
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Appointments
Please bring the following information with you to your appointment:
- UNL Student ID (Required)
- Health insurance card with information regarding health insurance status, which must include: name and address of insurance company; insurance subscriber number; insurance group number; and name of policy holder.
- Information regarding all medications you are currently taking and any other pertinent health care information.
Make a claim
NRMA Health Insurance is here to help you protect your most valuable asset – your health. One of the ways the Fund does this is by making it simple and convenient for you to claim your health benefits. You can choose the most convenient way to submit your claims: by mail or with a swipe of your NRMA Health Insurance card at any provider with a HICAPS or IBA facility.
How to make a claim
The claims process is simple and straightforward. It varies slightly depending on which of the following services you are claiming for:
Hospital Cover claims
- Before you go into hospital, or a day facility, ask your doctor for the anticipated Medicare item number/s for your treatment
- Call 133 234 to confirm that your treatment is covered and that the hospital or day facility that you have chosen has an agreement with the Fund, so that you don’t run up unnecessary expenses
- Check the Fund’s list of current Agreement Hospitals to see if your chosen hospital is listed
How to pay?
- The Fund pays the hospital directly
If your hospital has an agreement with the Fund, the hospital will send the bill to the Fund at the end of your stay. Your account will then be paid and you will be advised of the details. If there are any charges payable by you, such as long distance phone calls and newspapers, the hospital will bill you separately - You pay the hospital any excess or co-payment
If you have chosen a Hospital Cover with an excess or co-payment, the hospital may ask you to pay either of these upfront or they may bill you after they have received the balance of the payment from the Fund
What you need to know
- There will be no benefit paid for excluded services so you are responsible for paying for those
- Generally, health funds do not cover out-patient treatment – which is medical treatment given where you aren’t formally admitted into hospital. This includes things like emergency room treatment and consultations with a specialist before a labour admission
- You must hold Hospital Cover for a certain length of time (the ‘waiting period’) before you can make a claim. You can however, claim immediately for accidents where the treatment or service is covered by your level of cover
- You should also check the policy booklet for what’s not covered
Gap Cover Claims
What is Gap Cover? The Federal Government sets a fee that they will pay for doctor’s services under the Medical Benefits Schedule. Medicare pays for 75% of that set fee on your behalf, and the Fund pays the remaining 25%. If a doctor charges above that set fee, the extra amount (known as the ‘medical gap’) is not covered by Medicare but it is covered in full or in part by the Fund if the doctor participates in the Fund’s Gap Cover Scheme.
Gap Cover Scheme, you will either:
- Have no gap
- Or you will know up front what you have to pay
You don’t pay the gap cover directly yourself. There are two claims methods available:
- Your doctor can send the claim directly to the Fund
- If the account is sent to you, write ‘Gap cover’ on it, together with your Medicare number and forward it to:
NRMA Health Insurance Claims
GPO Box 5295
Brisbane QLD 4001
What you need to know
- Doctors operate independently from hospitals, so ask your doctor prior to your admission about their fees for your hospital treatment and whether they will participate in the Fund’s Gap Cover Scheme
- Don’t forget to ask about the fees of other practitioners that may be involved in your hospital treatment, eg anaesthetist, pathologist and so on
- If there are any gaps for you to pay, ask for a written cost estimate. This is known as ‘informed financial consent’
- Check the Fund’s list to see if your hospital is included in the Fund’s Gap Cover Scheme
Extras Cover Claims
For day-to-day extra health services, such as dental, optical and others, there are three ways to claim:- The Fund pays the service provider
A cheque is made out to your service provider. You need to pay any outstanding balance - Easy Claim
When you have paid a bill in full, your Extras benefit can be paid directly into your nominated bank account, in which case you will receive a letter confirming the payment details. You have immediate access to the funds - HICAPS or IBA ‘on the spot’ payment
These electronic claim payment systems are very convenient, quick and easy and are available at participating dentists, opticians, physios, chiropractors and podiatrists. Just look for the HICAPS or IBA logos. You swipe your NRMA Health Insurance card and your benefit will be deducted from your bill. You just pay the balance
What you need to know
- Easy Claim
If you want the convenience of Easy Claim but haven’t filled in the Easy Claim authority section on the application form, call 133 234 and request a Change of Details form. Fill in Part F on the form and post it to:
NRMA Health Insurance Claims
GPO Box 5295
Brisbane QLD 4001 - Waiting periods
You must hold Extras Cover for a certain length of time before you can make a claim. The time is called the ‘waiting period’ and different services have different waiting periods - Limits
The limit is the maximum amount you can claim in a service category per person and per calendar year. Limits also apply to the number of times benefits are payable for the same service and per calendar year unless otherwise stated
Jeffrey A. Polak Owner
Welcome!
At ABC Insurance Group, our goal is to bring to you the most reliable, immediate, accurate service possible. First and foremost we will provide you and your family with the best asset protection available at the a most reasonable premium available. As an independent insurance agency we are able to shop the insurance market with "A" rated companies and tailor coverage to your specific needs. With such a dynamic insurance market here in Florida, it is crucial to have the ability to shop companies that have the capacity and aptitude to provide quality protection for you and your family at the best value for your money.
ABC Insurance Group is a full-service multi-line agency. We provide Home, Auto, Boat, Umbrella, Life, Annuity, Disability Income, and Health insurance. All coverage's are provided by "A" rated companies.