-1- Proposal to provide Medical and Dental benefits to the Employees of:
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
-1-
Proposal to provide Medical and Dental benefits to the
Employees of:
Underwriting requirements
The following underwriting guidelines apply in order to qualify for coverage:
A minimum of 50% employer contribution to the employee rate
A minimum participation of at least 5 employees enrolled in the SIMNSA Plan
Eligible employees are defined as employees working at least 30 hours per week and considered full
time
Employees must be working within San Diego or Imperial County
Enrollee must be considered a Mexican National. Definition to be provided at time of enrollment and is
also located in all plan materials.
All groups with eligible employees are required to provide the most recent DE9C that shows a full
quarter of data.
New groups must submit the first month’s premium payment along with a copy of the Master Group
Application.
Leased employees, contracted 1099 employees, seasonal, temporary or substitute employees are not
eligible for coverage.
Plan Rating
The age of each family member is used to determine a separate rate for each family member. If a family has
more than three children under the age of 21, then each additional child over three will have a $0 monthly
premium. A member’s age as of the effective date of the group contract will be used for the full contract year,
and then updated as needed at renewal.
We are Unique - Choice of Physicians and Providers without PCP election!
Members of SIMNSA are allowed to use any Participating Physicians within the cities of Tijuana, Mexicali and
Tecate to obtain health care services Members are provided with a Provider Directory listing primary care
physicians in those service areas. The list of primary care physicians includes pediatricians, obstetricians,
gynecologists, general and family practitioners, and internal medicine specialists. If a Member requires
specialty services, the Member’s primary care physician will refer the Member to a specialist. A list of
specialist providers will be provided upon request. For female Members, benefits for services performed by a
Participating gynecologist for the diagnosis and treatment of gynecological problems may be rendered without a
referral from a primary care physician.
If emergency services or out-of-area urgent care services are required, the Member may go to any emergency
room or urgent care center, even if it is not listed in the Provider Directory. Emergency Services and Urgent
Care Services are covered by SIMNSA anywhere in the world, subject to the limitations set forth in the
Member’s evidence of coverage and disclosure form.
Members will receive an identification card that they must present every time a Member presents for health care
services. Members may also be asked to present a second form of identification with a picture on it. Members
will not be subject to a pre-existing condition exclusion or waiting period prior to eligibility for coverage except
for any waiting period imposed by their employers.
Please contact us directly should you have any questions regarding this proposal. All enrollment meetings must
be scheduled with our office at least 48 hours in advance. An enrollment specialist will bring all of the material
required which includes all enrollment material, applications, group contract and master application. Thank you
for allowing us the opportunity to present our services to your client.
-4-
SISTEMAS MEDICOS NACIONALES DENTAL PLAN 1-2
SCHEDULE OF BENEFITS
COVERED SERVICES CO-PAY
DIAGNOSTIC AND PREVENTIVE SERVICES 01100 Oral examination, diagnostic, consultation No Charge 01120 Office visit & periodic oral examinations No Charge 01130 Emergency oral examinations No Charge 01210 Complete series x-rays No Charge Infection control - per visit No Charge 00220 Single periapical film No Charge 00230 Each additional film No Charge 00460 Pulp vitality tests No Charge Teeth cleaning (prophylaxis-treatment to include scaling and polishing/eligible every six months): No Charge 01110 Adult No Charge 01120 Child No Charge 01203 Topical fluoride (up to age 18) No Charge SPACE MAINTAINERS: 01510 Unilateral fixed $20.00 01520 Unilateral removable 25.00 08210 Removable appliance therapy (thumb-sucking appliance) 25.00 AMALGAM RESTORATIONS, PRIMARY TEETH: 02110 Cavities involving one tooth surface $ 5.00 02120 Cavities involving two tooth surfaces 8.00 02130 Cavities involving three surfaces 10.00 AMALGAM RESTORATIONS, PERMANENT TEETH: 02140 Cavities involving one tooth surface $ 5.00 02150 Cavities involving two tooth surfaces 8.00 02160 Cavities involving three tooth surfaces 10.00 02161 Cavities involving four or more tooth surfaces 10.00 02210 Silicate cement - per restoration 15.00 02330 Acrylic or plastic restoration 15.00 CROWNS - PER UNIT: PLUS ADDITIONAL COST OF NOBLE METAL (GOLD) 02740 Porcelain (molars not included) $50.00 02751 Porcelain with non-precious metal (molars not included) 50.00 02753 Acrylic 45.00 02754 Acrylic with metal 45.00 02791 Full cast non-precious metal 15.00 02810 3/4 Crown 50.00 02910 Recement inlay 5.00
-5-
02920 Recement crown 5.00 02930 Prefabricated stainless steel crown - primary 15.00 02931 Prefabricated stainless steel crown - permanent 15.00 02950 Pin build-up 45.00 02952 Cast metal post 45.00 ENDODONTICS 03110 Pulp capping direct (no final restoration) $ 5.00 03120 Pulp cap indirect (no final restoration) 10.00 03220 Vital pulpotomy 10.00 03310 1 canal 30.00 03320 2 canals 40.00 03330 3 canals 50.00 03410 Apicoectomy/anterior (per root) (periapical) 50.00 03411 Apicoectomy/per tooth, each additional root 50.00 03940 Recalcification 5.00 03999 Culturing canal 5.00 PERIODONTICS: 09110 Palliative (emergency) treatment $ 7.00 04210 Gingivectomy/gingivoplasty - per quadrant 25.00 04211 Gingival or gingivoplasty, per tooth 8.00 04220 Gingival curettage - per quad 18.00 04250 Mucogingival surgery - per quad 36.00 04260 Osseous surgery - per quad 36.00 PROSTHETICS: 05110 Complete upper $63.00 05120 Complete lower 63.00 05211 Upper partial - resin base (including any conventional clasps, rests and teeth) 63.00 05212 Lower partial - resin base (including any conventional clasps, rests and teeth) 63.00 05213 Partial upper - cast metal with resin saddles (include any conventional clasps, rests and teeth) 63.00 05214 Partial lower - cast metal base with resin saddles (include any conventional clasps, rests & teeth) 63.00 05410 Adjust complete denture - upper 10.00 05411 Adjust complete denture - lower 10.00 05421 Adjust partial denture - upper 10.00 05422 Adjust partial denture - lower 10.00 05510 Repair broken complete denture base 15.00 05520 Replace missing or broken teeth 10.00 05610 Repair resin acrylic saddle or base 20.00 05630 Repair or replace broken clasp 20.00 05640 Replace broken teeth - per tooth 10.00
-6-
05650 Add tooth to existing partial denture (first tooth) 15.00 Each additional tooth 5.00 05660 Add clasp to existing partial denture 5.00 05730 Reline complete upper denture (Chairside) 15.00 05731 Reline complete lower denture (Chairside) 15.00 05740 Reline upper partial denture (Chairside) 15.00 05741 Reline lower partial denture (Chairside) 15.00 05750 Reline complete upper denture (Laboratory) 18.00 05751 Reline complete lower denture (Laboratory) 18.00 05760 Reline upper partial denture (Laboratory) 18.00 05761 Reline lower partial denture (Laboratory) 18.00 Reconstruction (jump per denture, including impression) 35.00 05820 Stayplate - upper or lower 10.00 06940 Stressbreakers 15.00 BRIDGES - PER UNIT (PLUS ADDITIONAL COST OF NOBLE METAL) 06211 Pontic - Cast predominantly base metal $60.00 06241 Pontic - Porcelain fused to predominantly base metal 70.00 06251 Pontic - Resin with predominantly base metal 60.00 06930 Recement bridge 10.00 05281 Removable (unilateral) bridges: One piece casting, per unit 15.00 Steel facing 50.00 ORAL SURGERY: 07110 Single tooth $ 8.00 07120 Each additional tooth 8.00 07210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone/or section of tooth 15.00 07220 Removal of impacted tooth - Soft tissue 30.00 07230 Removal of impacted tooth - Partially bony 35.00 07240 Removal of impacted tooth - Completed bony 50.00 07285 Biopsy of oral tissue - Hard No Charge 07286 Biopsy of oral tissue - Soft No Charge 07310 Alveoplasty in conjunction with extractions per quadrant 15.00 07960 Frenulectomy (Frenectomy or Frenotomy) - separate procedure 25.00 07510 Incision and drainage of abscess-intraoral soft tissue No Charge ADJUNCTIVE GENERAL SERVICES 09110 Palliative (Emergency) treatment of dental pain $ 5.00 09215 Local anesthesia No Charge 09241 Sedative base No Charge 09310 Consultation (Diagnostic service provided by dentist other than practitioner providing treatment) No Charge 09430 Post operative visit No Charge 09440 Office visit - after regularly scheduled hours 10.00
-7-
09999 Broken appointment (Less than 24-hour notice) 10.00 ORTHODONTICS: 03000 Full banded case - adult $ 50.00 copay/visit03001 full banded case - child 50.00 copay/visit*
Orthodontic lenghts of treatment are normally 24 months ; However some may extend or conclude sooner, the copayment shall be paid each time the patient is required to receive service for the orthodontic treatment which is usually once a month. Additional charges may apply in case of patient negligence with installed braces. Metal brackets included. Cosmetic brackets not covered.
Plan I-2, Dental Plan Rates
Employee $15.50
Employee + Spouse $25.75
Employee + Child (ren) $34.65
Employee + Family $42.75
Exclusions & Limitations a. Services which, in the opinion of the attending dentist are not necessary
for the patient’s dental health. In all cases where the patient selects a plan of treatment that is considered unnecessary by the attending dentist, any additional cost is the responsibility of the patient;
b. Implants; c. Aesthetics – services for appearance only, or to correct congenital
conditions; d. Myofunctional therapy – procedures for training, treating or developing
muscles in and around the jaw or mouth; e. Treatment for malignancies or neoplasms (tumors); f. Dispensing of drugs not normally supplied in dental office; g. Any dental procedure or service rendered while patient is hospitalized; h. Prosthodontics – replacement will be made of an existing appliance
(dentures, etc.) only if it is unsatisfactory. Prosthodontic appliances will be replaced only after five years have elapsed from the time of delivery. Lost or stolen appliances are the responsibility of the member;
i. Service compensable under Worker’s Compensation or Employer’s Liability Laws may be subject to reimbursement;
j. Services provided or paid by any governmental agency or under any governmental program or law, except as to charges which the person is legally obligated to pay. The exception extends to any benefits provided under the U.S. Social Security Act and its Amendments;
k. Charges for services provided for temporomandibular joint (TMJ) dysfunctions;
l. Charges for services prior to the date the person became covered and was eligible for benefits under this plan, or for charges “incurred” following termination of coverage;
m. Non-emergency services rendered by any nonparticipating dentist; n. Procedures, appliances, or restoration that are necessary to alter occlusion,
or a full mouth rehabilitation.
SUMMARY OF P-5-15
BENEFITS AND SCHEDULE OF COPAYMENTS
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Annual Deductible: None
Pre-Existing Conditions: Covered
Lifetime Maximum: None TYPE OF SERVICE PATIENT CO-PAY (U.S. DOLLARS)
PHYSICIAN SERVICES
Office Visits – IPA Facility 100% Covered After $5.00 Copayment
tnemyapoC oN ,derevoC %001 secivreS lacigruS
tnemyapoC oN ,derevoC %001 noegruS tnatsissA
tnemyapoC oN ,derevoC %001 tsigoloisehtsenA
Annual Physical Examinations
(After 90 days of participation)
100% Covered, No Copayment
OUTPATIENT SERVICES
tnemyapoC oN ,derevoC %001 secivreS yrotarobaL
tnemyapoC oN ,derevoC %001 secivreS ygoloidaR
Home Health Care – If required, available for post-operative care only
100% Covered, No Copayment
Speech, Physical and Occupational Therapy 100% Covered After $10.00 Copayment
tnemyapoC oN ,derevoC %001 sisehtsorP
Massage Therapy 100% Covered After $10.00 Copay
HOSPITAL SERVICES
Hospital Room and Board 100% Covered, No Copayment
Intensive Care Unit 100% Covered, No Copayment
Operating Room and Recovery 100% Covered, No Copayment
Ancillary Services 100% Covered, No Copayment
URGENT CARE SERVICES
In Plan’s Area
Urgent Care Services
100% Covered After $25.00 Copayment (Waived if Member is Admitted)
Supplies and Treatment Room 100% Covered, No Copayment
Out-of-Area
Urgent Care Services 100% Covered After $50.00 Copayment
EMERGENCY SERVICESi
In and Out of Plan’s Area
100% Covered After $100.00 Copayment
(based on usual and customary charges)
AMBULANCE SERVICE
Ambulance Service 100% Covered, No Copayment
PRESCRIPTION DRUGSii
Prescription Drugs (including insulin, glucagon and prescription medications for treating diabetes
100% Covered After $15.00 Copayment
DURABLE MEDICAL EQUIPMENT
Durable Medical Equipment
(including equipment and supplies for the management and treatment of diabetes)
100% Covered, No Copayment
MENTAL HEALTH AND SUBSTANCE ABUSE
Outpatient 100% Covered After $5.00 Copayment
Inpatient 100% Covered, No Copayment
MATERNITY CARE (At Participating Facility)
Prenatal and Postnatal Visits 100% Covered After $5.00 Copayment
Delivery Including Cesarean Section 100% Covered, No Copayment
Newborn Including Well Baby Care 100% Covered, No Copayment
PREVENTIVE CARE SERVICES
Pap Smears 100% Covered, No Copayment
Mammogram 100% Covered, No Copayment
Immunizations 100% Covered, No Copayment
Birth Control Methods 100% Covered, No Copayment
Testing and Treatment for Phenylketonuria 100% Covered, No Copayment
All Cancer Screening Tests consistent with professionally recognized standards of practice, including annual screening for cervical cancer and screening for prostate cancer and breast cancer, including mammograms.
100% Covered, No Co-payment
EYE CARE SERVICES
Office Visits 100% Covered After $5.00 Copayment
Eye Examinations 100% Covered After $5.00 Copayment
Eye Surgery 100% Covered, No Copayment
EXCLUSIONS AND LIMITATIONS
Please refer to your Evidence of Coverage Booklet for an explanation of what is not covered under the Plan.
i For emergency services received outside the Plan’s Network, the Member must notify the Plan within 48 hours after care is received, unless it is not reasonably possible to do so. The services will be reviewed retrospectively by the Plan to determine whether services are eligible for coverage.
SUMMARY OF P-10-15
BENEFITS AND SCHEDULE OF COPAYMENTS
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.
Annual Deductible: None
Pre-Existing Conditions: Covered
Lifetime Maximum: None
TYPE OF SERVICE PATIENT CO-PAY (U.S. DOLLARS)
PHYSICIAN SERVICES
Office Visits – IPA Facility 100% Covered After $10.00 Copayment
Surgical Services 100% Covered, No Copayment
Assistant Surgeon 100% Covered, No Copayment
Anesthesiologist 100% Covered, No Copayment
Annual Physical Examinations
(After 90 days of Participation) 100% Covered, No Copayment
OUTPATIENT SERVICES
Laboratory Services 100% Covered, No Copayment
Radiology Services 100% Covered, No Copayment
Home Health Care – If required, available for post-operative care only
100% Covered, No Copayment
Speech, Physical and Occupational Therapy 100% Covered After $10.00 Copayment
Prosthesis 100% Covered, No Copayment
Massage Therapy 100% Covered After $10.00 Copay
HOSPITAL SERVICES
Hospital Room and Board $100/day copayment
Intensive Care Unit 100% Covered, No Copayment
Operating Room and Recovery 100% Covered, No Copayment
Ancillary Services 100% Covered, No Copayment
URGENT CARE SERVICES
In Plan’s Area
Urgent Care Services
100% Covered After $25.00 Copayment (Waived if Member is Admitted)
Supplies and Treatment Room 100% Covered, No Copayment
Out-of-Area
Urgent Care Services 100% Covered After $50.00 Copayment
EMERGENCY SERVICESi
In and Out of Plan’s Area
100% Covered After $100.00 Copayment
(based on usual and customary charges)
AMBULANCE SERVICE
Ambulance Service 100% Covered, No Copayment
PRESCRIPTION DRUGSii
Prescription Drugs (including insulin, glucagon and prescription medications for treating diabetes
100% Covered After $15.00 Copayment
DURABLE MEDICAL EQUIPMENT
Durable Medical Equipment
(including equipment and supplies for the management and treatment of diabetes)
100% Covered, No Copayment
MENTAL HEALTH AND SUBSTANCE ABUSE
Out patient 100% Covered After $10.00 Copayment
Inpatient 100% Covered, No Copayment
MATERNITY CARE (At Participating Facility)
Prenatal and Postnatal Visits 100% Covered After $10.00 Copayment
Delivery Including Cesarean Section 100% Covered, No Copayment
Newborn Including Well Baby Care 100% Covered, No Copayment
PREVENTIVE CARE SERVICES
Pap Smears 100% Covered, No Copayment
Mammogram 100% Covered, No Copayment
Immunizations 100% Covered, No Copayment
Birth Control Methods 100% Covered, No Copayment
Testing and Treatment for Phenylketonuria 100% Covered, No Copayment
All Cancer Screening Tests consistent with professionally recognized standards of practice, including annual screening for cervical cancer and screening for prostate cancer and breast cancer, including mammograms.
100% Covered, No Co-payment
EYE CARE SERVICES
Office Visits 100% Covered After $10.00 Copayment
Eye Examinations 100% Covered After $10.00 Copayment
Eye Surgery 100% Covered, No Copayment
EXCLUSIONS AND LIMITATIONS
Please refer to your Evidence of Coverage Booklet for an explanation of what is not covered under the Plan.
i For emergency services received outside the Plan’s Network, the Member must notify the Plan within 48 hours after care is received, unless it is not reasonably possible to do so. The services will be reviewed retrospectively by the Plan to determine whether services are eligible for coverage.
ii Coverage is provided for drugs determined by the Participating Physician to be medically necessary. Drugs obtained at non-participating pharmacies are not covered unless medically necessary for a covered emergency.
SIMNSASmall Group Premium Rates PMPM Effective 1‐1‐2014
For New ACA‐Compliant Benefit Plans
Plan NameAge Band P‐5‐15 P‐10‐15
0 66.48$ 65.17$ 1 66.48$ 65.17$ 2 66.48$ 65.17$ 3 66.48$ 65.17$ 4 66.48$ 65.17$ 5 66.48$ 65.17$ 6 66.48$ 65.17$ 7 66.48$ 65.17$ 8 66.48$ 65.17$ 9 66.48$ 65.17$ 10 66.48$ 65.17$ 11 66.48$ 65.17$ 12 66.48$ 65.17$ 13 66.48$ 65.17$ 14 66.48$ 65.17$ 15 66.48$ 65.17$ 16 66.48$ 65.17$ 17 66.48$ 65.17$ 18 66.48$ 65.17$ 19 66.48$ 65.17$ 20 66.48$ 65.17$ 21 104.69$ 102.63$ 22 104.69$ 102.63$ 23 104.69$ 102.63$ 24 104.69$ 102.63$ 25 105.11$ 103.04$ 26 107.20$ 105.10$ 27 109.71$ 107.56$ 28 113.79$ 111.56$ 29 117.14$ 114.85$ 30 118.82$ 116.49$ 31 121.33$ 118.95$ 32 123.84$ 121.42$ 33 125.41$ 122.96$ 34 127.09$ 124.60$ 35 127.93$ 125.42$ 36 128.76$ 126.24$ 37 129.60$ 127.06$ 38 130.44$ 127.88$ 39 132.11$ 129.52$ 40 133.79$ 131.17$ 41 136.30$ 133.63$ 42 138.71$ 135.99$ 43 142.06$ 139.27$ 44 146.25$ 143.38$ 45 151.17$ 148.20$ 46 157.03$ 153.95$ 47 163.63$ 160.42$ 48 171.16$ 167.81$ 49 178.60$ 175.09$ 50 186.97$ 183.30$ 51 195.24$ 191.41$ 52 204.35$ 200.34$ 53 213.56$ 209.37$ 54 223.51$ 219.12$ 55 233.45$ 228.87$ 56 244.23$ 239.45$ 57 255.12$ 250.12$ 58 266.74$ 261.51$ 59 272.50$ 267.16$ 60 284.12$ 278.55$ 61 294.17$ 288.40$ 62 300.77$ 294.87$ 63 309.04$ 302.98$ 64+ 314.06$ 307.90$
Group Master Application *
Group Number (internal use only) Requested Effective Date Requested Renewal Date ______________________________________________________________________________
Medical Plan Code (internal use only) ___ Rates (internal use only) ____ ____ ____ Dental Plan Code (internal use only) ___ Large Group ___ Small Group ___
NOTE:Your prior coverage should NOT be cancelled until you have been notified that your application for group insurance has been accepted. No agent can bind coverage, set an effective date, or waiver or alter any provision of this application. Insurance is not in effect until the date established by SIMNSA. _____________________________________________________________________________________________ Exact Legal Name of Company Telephone Number Federal Tax ID # _______________________________________________________________________________________________________ Street Address Nature of Business _____________________________________________________________________________ City State Zip Code Group Administrator _____________________________________________________________________________ Mailing Billing Address(if different from above) Address of Administrator (if applicable) _______________________________________________________________________________________________________ Prior Carrier Name : Group Contact Person : Phone # _______________ Fax # _________________ Number of hours required per week to be E-Mail ________________________________ Eligible for benefits: ________________
Coverage for domestic partners (Subject to SIMNSA’s affidavit requiring proof of 5 years.
_______Yes _______No Employer Contribution-Medical: There is a required minimum employer contribution of the greater of the two scenarios: either 50% of the SIMNSA single rate, OR a required equal DOLLAR amount that the employer contributes to the least expensive non-SIMNSA Plan offering, not to exceed 100% of the SIMNSA single premium. Please indicate below what your contribution will be for this plan: Employer Contributes ______of Employee’s Prem. Employer Contributes ______of Dependent(s) Prem. ________________________________________________________________________________________________________ Length of Waiting Period for New Employees/Rehires: [ ]30days [ ]60days E-Bill Email address______________ The Plan offering is not considered final until a signed Employer Group Application is received verifying the above conditions of offering. SIMNSA reserves the right to rescind the contract, or re-rate the inforce rates at any time if the above conditions are determined to be untrue. Employer Broker Plan Representative _______________________________________________________________________ * Final group contract will be drafted and will require additional signatures prior to effective date of coverage
Clinics are open 7 days a week
Grupo MEDYCA in Tijuana is open until midnight
No appointments necessary, walk-ins are welcome
Patients can cross back FASTER using the medical pass lane
No PCP election required
All providers have access to the online medical records
SENTRI pass reimbursement program
Transportation van available in Mexicali
Clinic wait time is reduced by use of an electronic monitoring system/employee
Massage therapy is available for all members
Spa services are discounted for members
“One stop” medical clinic where all services can be rendered
Members have access to online appointment scheduling system
Extensive network of providers 300+
Employers can receive their monthly statements via EBILL system
Related Documents
