Health Solutions High Deductible Health Plan

Q. How does the plan work?
A. Members can start using their benefits by calling the provider of their choice to set up an appointment. When they go to a provider for treatment, the provider will file a claim form on the member’s behalf, and we will base payments on the level of coverage set by the plan your organization has selected.

Q. How are benefits covered?
A. Your plan includes yearly deductibles, out-of-pocket maximums and coinsurance. Each of these determines how benefits are covered on your plan.

1. Yearly Deductible: the amount that must meet before claims are paid.
2. Aggregate Family Yearly Deductible: On a plan with an aggregate family deductible, the family deductible is the combined amount that the entire family must meet before claims are processed.
   
3. Embedded Family Yearly Deductible: On a plan with an embedded family deductible, two individual deductible amounts must be met, which when added together equal the total family deductible amount. Benefits are then paid for the family member that meets the individual deductible amount first. Costs for everyone else in the family will be combined to meet the individual deductible amount before benefits are paid.
4. Out-of-Pocket Maximum: the maximum amount a member pays for the calendar year. Once met, the member will no longer pay for their portion of the coinsurance. In a family, only two members must meet this amount. Out-of-pocket maximums do not include any amounts over what the plan covers or any amounts charged for services that were not pre-certified.
5. Coinsurance: the percentage BEST Life pays for a category of procedures. Some procedures are covered at a higher percentage than others, and there is a different coinsurance for services rendered by a non-network provider.

Your plan’s Certificate of Insurance provides a detailed summary of the above for each category of procedures. We encourage our members to become familiar with the Certificate of Insurance before they use their benefits.

Q. How are Preventive Care Services covered?
A. If you are on a Grandfathered plan, your plan includes an in-network preventive care maximum. This benefit covers annual routine physical exams, annual woman care exams and mammograms at 100% up to your plan’s set maximum amount. Baby/Child Wellness (preventive pediatric services) is covered at 100% up to a set maximum amount per year. Any preventive care services received after you’ve reached your maximum amount or by a non-network provider will be applied to your plan’s deductible and coinsurance.

If you are on a Non-Grandfathered plan, your plan covers annual routine physical exams, annual woman care exams and mammograms at 100% in and out-of-network. Baby/Child Wellness (preventive pediatric services) is covered at 100% as well.

A list of Preventive Services covered on your plan is available here.

Please refer to your Certificate of Insurance and mandated amendments for more information on how Preventive Care Services are covered on your Plan.

Q. How are prescriptions covered?
A. Your plan provides a CVS Caremark Discount Only card, and allows you to apply your prescription costs to the plan's deductible and then coinsurance.

To receive a discount, present your CVS Caremark Discount Only card to a pharmacy within CVS Caremark's network. A discount will be applied at the register. Then, send your receipts along with a completed HDHP Prescription Claim Form to the BEST Life's Claims Department for processing.

Q. Are there any services that require a prior approval?
A. Prior approval or “pre-certification” is required for inpatient admissions, outpatient surgery procedures, MRIs, CAT scans, PET scans, nuclear imaging and transplants. If pre-certification is not obtained before these services are rendered, there may be a reduction of benefits and/or additional financial responsibility to the member. Your Certificate of Insurance lists what the member’s financial responsibility would be if a pre-certification is not obtained.

Instructions for obtaining a pre-certification are provided on the back of the member ID card, and in most instances, the member’s provider will process the pre-certification on their behalf.

Q. Why see a network provider?
A. On this plan members can select any licensed health care professional, but will save money with a network provider.

Your plan is designed to cover more costs for services provided by a network-contracted provider. This is done through a lower in-network deductible, a higher in-network coinsurance and an in-network preventive care maximum. In addition, members who get treatment from a network provider will receive discounts for the services covered by your plan.

(To ensure that your employees receive in-network savings, please have them ask the provider if he or she is part of the network before they make an appointment.)

Q. How do I find a network provider?
A. We encourage members to refer to their ID cards to find out which network they can use and how to contact the network. Members can also go to the “Provider Look-up” link on this site, or call our Customer Service Department at 800.433.0088 for assistance.

Q. Are members covered when outside their “home” service area?
A. Members can choose to go to any network or non-network provider in the country and still receive coverage. If the member wants to receive in-network coverage while away from home, BEST Life provides a PHCS Healthy Directions wraparound network.

When a member or a covered dependent is outside their primary PPO network’s coverage area, they can take advantage of in-network benefit levels and negotiated discounts by going to a PHCS Healthy Directions Network doctor.

To access the PHCS Healthy Directions Network, members call the phone number listed on the back of their BEST Life ID card, or log on to www.multiplan.com.

Q. How do members file a claim?
A. Network providers will file a claim on a member’s behalf. If a member is asked to file a claim, they can download a medical claim form by clicking on the “Forms” link on this site.

Completed forms should be mailed to:

BEST Life and Health Insurance Company
PO Box 890
Meridian, ID 83680-0890

Q. How do I order additional ID cards?
A. Members can order additional ID cards by calling Customer Service at 800.433.0088 or via email at cs@bestlife.com.