Agent Training Presentation Agent Training - October 2010

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AAgent gent TTraining raining PPresentationresentation

Agent Training - October 2010

Insured by American Medical and Life Insurance (AMLI)

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National Congress of National Congress of EmployersEmployers A national organization that represents the needs and A national organization that represents the needs and

concerns of America's growing small business concerns of America's growing small business workforce through advocacy, information and serviceworkforce through advocacy, information and service

NCE is leading a campaign for tax reform, NCE is leading a campaign for tax reform, deregulation of small business, and building support deregulation of small business, and building support for expanding health coverage and retirement for expanding health coverage and retirement planningplanning

Includes valuable consumer benefits package Includes valuable consumer benefits package

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Administrative PartnerAdministrative Partner

Benefit Transact Benefit Transact Web site – 24/7Web site – 24/7 On line contractingOn line contracting Each agent receives their own web site!Each agent receives their own web site! On line enrollment portalOn line enrollment portal BillingBilling Policy FulfillmentPolicy Fulfillment Customer ServiceCustomer Service Agent Back OfficeAgent Back Office

– Manage your businessManage your business– Email your clientsEmail your clients

Marketing materialsMarketing materials Pre-approved marketing piecesPre-approved marketing pieces

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Insurance CarrierInsurance Carrier

American Medical and Life American Medical and Life Insurance CompanyInsurance Company

Incorporated in 1964 in New York Incorporated in 1964 in New York (Home Office NYC)(Home Office NYC)

www.usamli.comwww.usamli.com

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Claims AdministrationClaims Administration

TPA: TPA: Hammerman and GainorHammerman and Gainor Address:Address:

– American Medical and Life Insurance American Medical and Life Insurance Co.Co.

– P.O. Box # 1353P.O. Box # 1353– Chicago, IL 60690Chicago, IL 60690

Member Services:Member Services:– (888) 264-1512(888) 264-1512

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HIPAA Qualified?HIPAA Qualified?

This plan is NOT HIPAA Qualified for providing creditable This plan is NOT HIPAA Qualified for providing creditable coverage certificates when leaving the program. coverage certificates when leaving the program. (as of (as of November 1, 2010)November 1, 2010)

AMLI WILL accept prior creditable coverage for members AMLI WILL accept prior creditable coverage for members enrolling INTO the program.enrolling INTO the program.

Proof of prior creditable coverage should be faxed to the Proof of prior creditable coverage should be faxed to the number on the NCE Advantage web site. number on the NCE Advantage web site.

– No GAP in coverage for 63 days or less No GAP in coverage for 63 days or less (may increase in (may increase in some states)some states)

Members who enter this plan presenting a Certificate of Creditable Coverage will receive credit toward this plan’s pre-existing conditions limitation.

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Product OverviewProduct Overview

The plans offer valuable association and insurance The plans offer valuable association and insurance benefits for consumers who:benefits for consumers who:

– May not qualifyMay not qualify for full comprehensive major for full comprehensive major medicalmedical

– Can not affordCan not afford full comprehensive major medical full comprehensive major medical

– Looking to Looking to reduce the costreduce the cost of current medical of current medical premiumpremium

– A reasonable alternativeA reasonable alternative (not replacement) for (not replacement) for more costly Major Medical programsmore costly Major Medical programs

– GUARANTEED ISSUE – NO UNDERWRITING REVIEWGUARANTEED ISSUE – NO UNDERWRITING REVIEW

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Provider AccessProvider Access

NCE Advantage utilizes the MultiPlan NetworkNCE Advantage utilizes the MultiPlan Network– maximize the client’s savingsmaximize the client’s savings– reduce out-of-pocket expensesreduce out-of-pocket expenses

All plans pay the same dollar amounts whether or not the All plans pay the same dollar amounts whether or not the network is utilized, and there is no reduction in benefitsnetwork is utilized, and there is no reduction in benefits

If a network provider is used, the claim is electronically re-If a network provider is used, the claim is electronically re-priced and a significant discount is realized by the insuredpriced and a significant discount is realized by the insured

550,000 practitioners in all 50 states!550,000 practitioners in all 50 states!

The link to find a provider 24/7 on line is available on the The link to find a provider 24/7 on line is available on the NCE Advantage websiteNCE Advantage website

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Eligibility Eligibility Association:Association:

Dues paying members between ages 18 and 64Dues paying members between ages 18 and 64

Dependent children under the age of 19Dependent children under the age of 19

– No child only applications. A 19 year old cannot add a sibling as a No child only applications. A 19 year old cannot add a sibling as a dependentdependent

Members not eligible for MedicareMembers not eligible for Medicare

Insurance:Insurance:

Member’s unmarried dependent children with proof of full time student status Member’s unmarried dependent children with proof of full time student status between the ages of 19 and 26between the ages of 19 and 26

Members not in full-time service of the Armed Forces (military)Members not in full-time service of the Armed Forces (military)

Members that are legal residents of United StatesMembers that are legal residents of United States

Members not receiving disability benefits or Worker’s CompensationMembers not receiving disability benefits or Worker’s Compensation

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States Available (28) States Available (28)

AlabamaAlabama ArkansasArkansas ArizonaArizona DelawareDelaware DCDC FloridaFlorida GeorgiaGeorgia HawaiiHawaii Idaho Idaho (Unified Life Insurance Company)(Unified Life Insurance Company)

IllinoisIllinois LouisianaLouisiana MichiganMichigan MississippiMississippi MissouriMissouri

NebraskaNebraska NevadaNevada New MexicoNew Mexico OhioOhio OklahomaOklahoma PennsylvaniaPennsylvania Rhode IslandRhode Island South CarolinaSouth Carolina TennesseeTennessee Texas (No AME)Texas (No AME) Virginia Virginia (Unified Life Insurance Company)(Unified Life Insurance Company)

West VirginiaWest Virginia WisconsinWisconsin WyomingWyoming

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BenefitBenefit(PER INSURED)(PER INSURED)

BenefitBenefitDescriptionDescription

(Maximums are(Maximums arePer Policy Yr)Per Policy Yr)

300300 500500 750750 10001000 10001000PlusPlus

Doctor Office Visits Doctor Office Visits Per VisitPer VisitMaximum Visits – Maximum Visits –

PER PER INSUREDINSURED

$50$5033

$50$5033

$50$5033

$75$7533

$75$7555

Preventive Care TestPreventive Care Test Per VisitPer VisitMaximum Visits Maximum Visits

(Tests)(Tests)

$50$5011

$50$5011

$100$10011

$150$15011

$150$15011

Diagnostic Lab and X-rayDiagnostic Lab and X-ray Per DayPer DayMaximum DaysMaximum Days

N/AN/A $50$5022

$50$5033

$75$7533

$75$7555

Hospital ConfinementHospital Confinement Per DayPer DayMaximum # of Maximum # of

DaysDays

$300$3003030

$500$5003030

$750$7503030

$1,000$1,0003030

$1,000$1,0003030

ICU/CCUICU/CCU Per DayPer DayMaximum # of Maximum # of

DaysDays

$500$5001010

$750$7501010

N/AN/A N/AN/A $1,000$1,00055

Surgery Surgery % of RBRVS*% of RBRVS*Annual MaxAnnual Max

50%50%UnlimitedUnlimited





AnesthesiaAnesthesia % of Surgery% of Surgery 20%20% 20%20% 20%20% 20%20% 20%20%

Accident Accident (Not available in Texas)(Not available in Texas)

Ded (Per policy Ded (Per policy yr)yr)

Payment atPayment at MaximumMaximum

$100$10080%80%$1,000$1,000

$100$10080%80%$2,500$2,500

$100$10080%80%$2,500$2,500

$100$10080%80%$5,000$5,000

$100$10080%80%$5,000$5,000

Inpatient Mental HealthInpatient Mental Health Per DayPer DayMaximum DaysMaximum Days

$150$1506060

$250$2506060

$375$3756060

$500$5006060

$500$5006060

Outpatient Mental HealthOutpatient Mental Health Per VisitPer VisitMaximum # of Maximum # of

VisitsVisits

$25$252020

$25$252020

$25$252020

$25$252020

$25$252020

Inpatient Substance Inpatient Substance AbuseAbuse

Per DayPer DayMaximum DaysMaximum Days

$150$1506060

$250$2506060

$375$3756060

$500$5006060

$500$5006060

Outpatient Substance Outpatient Substance AbuseAbuse

Per VisitPer VisitMaximum # of Maximum # of

VisitsVisits

$25$252020

$25$252020

$25$252020

$25$252020

$25$252020

Life Insurance Benefit Life Insurance Benefit (not insured by (not insured by AMLI)AMLI)

On Primary Member On Primary Member OnlyOnly

$5,000$5,000 $5,000$5,000 $5,000$5,000 $5,000$5,000 $5,000$5,000

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Plan RatesPlan RatesMONTHLY RATESMONTHLY RATES 300300 500500 750750 10001000 1000 Plus1000 Plus

MemberMember $163$163 $216$216 $230$230 $279$279 $328$328

Member & SpouseMember & Spouse $275$275 $383$383 $410$410 $508$508 $606$606

Member & ChildrenMember & Children

(unlimited)(unlimited)

$254$254 $349$349 $374$374 $462$462 $551$551

Member & FamilyMember & Family

(unlimited)(unlimited)

$356$356 $499$499 $536$536 $669$669 $801$801

One time enrollment fee is not included.One time enrollment fee is not included.

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Plan HighlightsPlan Highlights

Guaranteed IssueGuaranteed Issue First Dollar Coverage – No Co-paysFirst Dollar Coverage – No Co-pays Creditable Coverage Satisfaction for Pre-X Creditable Coverage Satisfaction for Pre-X

for members entering the programfor members entering the program– No GAP in coverage for 63 days or less No GAP in coverage for 63 days or less (may (may

increase in some states)increase in some states)

No Lifetime Maximum Benefit AmountNo Lifetime Maximum Benefit Amount 30-Day Free Look Period30-Day Free Look Period On Line Enrollment On Line Enrollment

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Benefit HighlightsBenefit Highlights

In-Patient Hospital ConfinementIn-Patient Hospital Confinement Preventive Care TestsPreventive Care Tests ICU/CCU Stays (most plans)ICU/CCU Stays (most plans) Doctor’s Office Visits (including specialists)Doctor’s Office Visits (including specialists) Diagnostic Laboratory and X-RayDiagnostic Laboratory and X-Ray Accidents Accidents (not available in Texas)(not available in Texas) Mental Health and Substance AbuseMental Health and Substance Abuse Surgery with anesthesia rendered by a licensedSurgery with anesthesia rendered by a licensed

anesthesiologist or Certified Registered Nurseanesthesiologist or Certified Registered NurseAnesthetist (CRNA) Anesthetist (CRNA)

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Doctor Office VisitsDoctor Office Visits

Covers charges for and require a doctor’s Covers charges for and require a doctor’s office visit due to injuries received in a office visit due to injuries received in a covered accident OR sicknesscovered accident OR sickness

Includes Chiropractors (office visit only – Includes Chiropractors (office visit only – manipulations are not covered under this manipulations are not covered under this benefit)benefit)

A A Doctor or PhysicianDoctor or Physician means a legally qualified means a legally qualified practitioner of the healing arts acting within practitioner of the healing arts acting within the scope of his or her license and is not an the scope of his or her license and is not an Immediate Family MemberImmediate Family Member

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Preventive Care Tests Preventive Care Tests BenefitBenefit Policy will pay the preventive care test benefit, shown on the certificate schedule, if any Policy will pay the preventive care test benefit, shown on the certificate schedule, if any

covered person incurs charges for and has covered person incurs charges for and has one of only the following preventive care one of only the following preventive care tests listed below performed per year:tests listed below performed per year:

1.1. Blood test for triglyceridesBlood test for triglycerides2.2. Bone marrow testingBone marrow testing3.3. Breast ultrasoundBreast ultrasound4.4. CA 15-3 (blood test for breast cancer)CA 15-3 (blood test for breast cancer)5.5. CA 125 (blood test for ovarian cancer)CA 125 (blood test for ovarian cancer)6.6. CEA (blood test for colon cancer)CEA (blood test for colon cancer)7.7. Chest X-rayChest X-ray8.8. Colonoscopy or virtual colonoscopyColonoscopy or virtual colonoscopy9.9. Eye exam performed by a licensed optometrist or ophthalmologistEye exam performed by a licensed optometrist or ophthalmologist10.10. Fasting blood glucose testFasting blood glucose test11.11. Flexible sigmoidoscopyFlexible sigmoidoscopy12.12. Hemoccult stool analysisHemoccult stool analysis13.13. Mammography (baseline and annual screenings)Mammography (baseline and annual screenings)14.14. PSA (blood test for prostate cancer)PSA (blood test for prostate cancer)15.15. Pap smear or Thin Prep Pap TestPap smear or Thin Prep Pap Test16.16. Serum Protein Electrophoresis (blood test for myeloma)Serum Protein Electrophoresis (blood test for myeloma)17.17. Stress test on a bicycle or treadmillStress test on a bicycle or treadmill18.18. Child Screening Services from birth to age 21 (if covered under the plan). Schedule set by Child Screening Services from birth to age 21 (if covered under the plan). Schedule set by

the American Academy of Pediatricsthe American Academy of Pediatrics

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Diagnostic Lab and X-Diagnostic Lab and X-rayray Medically necessary diagnostic Medically necessary diagnostic

tests and x-rays performed in a tests and x-rays performed in a doctor's office, hospital or doctor's office, hospital or outpatient facility. E.g. MRI, CAT outpatient facility. E.g. MRI, CAT Scan, EKG. Scan, EKG.

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Inpatient Hospital Inpatient Hospital ConfinementConfinement Charges for a confinement in the Charges for a confinement in the

hospital due to injuries received hospital due to injuries received in a covered accident or sicknessin a covered accident or sickness

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ICU/CCUICU/CCU

Charges for a confinement in a hospital ICU/CCU due Charges for a confinement in a hospital ICU/CCU due to injuries received in a covered accident OR sicknessto injuries received in a covered accident OR sickness

A Hospital Intensive Care Unit that meets the A Hospital Intensive Care Unit that meets the definition above may include Hospital units with the definition above may include Hospital units with the following names:following names:

– Intensive Care UnitIntensive Care Unit– Coronary Care UnitCoronary Care Unit– Neonatal Intensive Care UnitNeonatal Intensive Care Unit– Pulmonary Care UnitPulmonary Care Unit– Burn UnitBurn Unit– Transplant UnitTransplant Unit

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Surgery (Surgeon)Surgery (Surgeon)

If insured has a surgical procedure due to a covered If insured has a surgical procedure due to a covered accident OR sicknessaccident OR sickness

Covers cost of “primary surgeon charges” onlyCovers cost of “primary surgeon charges” only

The procedure must be performed by a Physician and The procedure must be performed by a Physician and require anesthesia administered by a licensed require anesthesia administered by a licensed anesthesiologist or certified registered nurse anesthetistanesthesiologist or certified registered nurse anesthetist

Outpatient is covered, but must require an anesthesia that Outpatient is covered, but must require an anesthesia that meets the definition abovemeets the definition above

Reimbursements are based on the Medicare/RBRVS benefits Reimbursements are based on the Medicare/RBRVS benefits scheduleschedule

Maternity is considered a surgery and is covered Maternity is considered a surgery and is covered under this benefit. under this benefit.

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MaternityMaternity

Delivery is paid under the surgery benefitDelivery is paid under the surgery benefit

The maternity related expense would work the same as any The maternity related expense would work the same as any other illness. The provider bills would be processed under other illness. The provider bills would be processed under any benefit that qualifies. (surgery, x-ray, lab, as shown on any benefit that qualifies. (surgery, x-ray, lab, as shown on the physician billing). The hospital stay would fall under the the physician billing). The hospital stay would fall under the hospital benefits and paid according to the hospital benefit hospital benefits and paid according to the hospital benefit schedule. Any doctor office visits would fall under the schedule. Any doctor office visits would fall under the doctor office visits benefit.doctor office visits benefit.

There is a surgical RBRVS scheduleThere is a surgical RBRVS schedule

Not subject to pre-xNot subject to pre-x

Newborn is covered for 31 daysNewborn is covered for 31 days

Insured must add newborn as a dependent within 31 days if Insured must add newborn as a dependent within 31 days if they want coveragethey want coverage

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AnesthesiaAnesthesia

Anesthesia administered by a licensed Anesthesia administered by a licensed anesthesiologist or certified registered anesthesiologist or certified registered nurse anesthetistnurse anesthetist

– Does not cover basic anesthesia Does not cover basic anesthesia administered by a doctor (mole removal, administered by a doctor (mole removal, etc.)etc.)

Payable as a percentage (20%) of the Payable as a percentage (20%) of the surgical allowancesurgical allowance

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Accident Accident (N/A in TX)(N/A in TX)

Benefit pays after the other policy benefits have been exhaustedBenefit pays after the other policy benefits have been exhausted

If a Covered Person is injured in a Covered Accident, this Accident If a Covered Person is injured in a Covered Accident, this Accident Medical Benefit will cover any remaining expenses, not covered by Medical Benefit will cover any remaining expenses, not covered by the policy according to the Schedule of Benefits and Policy the policy according to the Schedule of Benefits and Policy ProvisionsProvisions

Costs must be incurred within 90 days of accident or injuryCosts must be incurred within 90 days of accident or injury

Benefits paid for:Benefits paid for:– Hospital Room and Board (General Nursing)Hospital Room and Board (General Nursing)– Hospital Services and SuppliesHospital Services and Supplies– Operating and Recovery RoomOperating and Recovery Room– Physician Charges, Private Duty NursePhysician Charges, Private Duty Nurse– Diagnostic tests, x-rays, labDiagnostic tests, x-rays, lab– Anesthetic and Prescription DrugsAnesthetic and Prescription Drugs– Rental of Durable Medical EquipmentRental of Durable Medical Equipment– Artificial limbs, eyes and other prosthetic devicesArtificial limbs, eyes and other prosthetic devices– Casts, splints, trusses, crutches and bracesCasts, splints, trusses, crutches and braces– Oxygen and rental of equipment for oxygenOxygen and rental of equipment for oxygen– Physiotherapy given by a licensed physical therapist Physiotherapy given by a licensed physical therapist

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Inpatient Mental Inpatient Mental Health and Substance Health and Substance AbuseAbuse

Each day of confinement if Each day of confinement if confined to a hospital or licensed confined to a hospital or licensed institution to provide treatment for institution to provide treatment for mental illness or substance abusemental illness or substance abuse

There are mental and substance There are mental and substance abuse providers in the MultiPlan abuse providers in the MultiPlan networknetwork

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Outpatient Mental Outpatient Mental Health and Substance Health and Substance AbuseAbuse Treatment received as an Treatment received as an

outpatient in an outpatient facility outpatient in an outpatient facility as a result of mental illness or as a result of mental illness or substance abusesubstance abuse

There are mental and substance There are mental and substance abuse providers in the MultiPlan abuse providers in the MultiPlan networknetwork

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NCE Association Discount Benefit NCE Association Discount Benefit HighlightsHighlights

Pharmacy Discount CardPharmacy Discount Card $5,000 Life Insurance $5,000 Life Insurance (Primary Member)(Primary Member)

– Term Life (Lincoln National)Term Life (Lincoln National)– Guaranteed Issue, no waiting periodGuaranteed Issue, no waiting period

Vision, Dental and HearingVision, Dental and Hearing Alternative CareAlternative Care WellnessWellness Long-Term Care ServicesLong-Term Care Services Infertility TreatmentInfertility Treatment

27272727

CategoryCategory Products/ServicesProducts/Services Typical SavingsTypical Savings

PharmacyPharmacy Prescription drugsPrescription drugs Average 20% retail; 50% Average 20% retail; 50% mail ordermail order

Vision CareVision Care Optometry, laser vision correction, Optometry, laser vision correction, mail-order productsmail-order products

5 - 50%, 5 - 50%, Annual exams for $40 maxAnnual exams for $40 maxLaser vision correction: 5-Laser vision correction: 5-15%15%

Dental careDental care General and cosmetic dentistry, General and cosmetic dentistry, orthodontics, specialty careorthodontics, specialty care 10-35%10-35%

Alternative Alternative CareCare

Chiropractic, acupuncture, massage Chiropractic, acupuncture, massage therapy, naturopathytherapy, naturopathy 20%20%

WellnessWellness Weight management, smoking Weight management, smoking cessation, fitness equipmentcessation, fitness equipment 10-50%10-50%

Long-term Long-term Care Care ServicesServices

Nursing and assisted living facilities, Nursing and assisted living facilities, home health care, hospice/respite, home health care, hospice/respite, homemaker and personal carehomemaker and personal care

5-30%5-30%

HearingHearing Hearing aidsHearing aids Lower of 30% off MSRP or Lower of 30% off MSRP or $300 off total retail price$300 off total retail price

Infertility Infertility TreatmentTreatment Reproductive endocrinology, IVFReproductive endocrinology, IVF 5-20%5-20%

NCE Consumer Discount Benefits

28282828

Beauty and Skin Beauty and Skin CareCare

Aura Cacia, FamilyMeds, Gaiam ,MotherNature.com, SalonWish, Spa FinderAura Cacia, FamilyMeds, Gaiam ,MotherNature.com, SalonWish, Spa Finder

Books and Books and Other Other MediaMedia

Free Spirit Publishing, Gaiam, HealthJourneys, McGraw Hill Professional, Memory LaneFree Spirit Publishing, Gaiam, HealthJourneys, McGraw Hill Professional, Memory Lane

Family and Family and HouseholdHousehold

ActiveForever, Allergy Control Products, CareGifters, Cirrus Healthcare, Familymeds, ActiveForever, Allergy Control Products, CareGifters, Cirrus Healthcare, Familymeds, Gaiam, Memory Lane, Online OrganizingGaiam, Memory Lane, Online Organizing

Fitness Clubs & Fitness Clubs & ActivitiesActivities

Anytime Fitness, Global Fit, LivingFit, My GymAnytime Fitness, Global Fit, LivingFit, My Gym

Fitness Fitness Equipment Equipment & Apparel& Apparel

Big Fitness, Champion Apparel, Danskin, Foot Solutions, Gaiam, Heart Rate Monitors Big Fitness, Champion Apparel, Danskin, Foot Solutions, Gaiam, Heart Rate Monitors USA, NordicTrack, Pedometers USA, Pro Form, Sierra Trading Post, Walkstyles, USA, NordicTrack, Pedometers USA, Pro Form, Sierra Trading Post, Walkstyles, WeiderWeider

Life Life ManagemeManagementnt

ActiveForever, eGetgoing, Gaiam, HealthJourneys, LivingEasy, LivingFit, LivingSmart, ActiveForever, eGetgoing, Gaiam, HealthJourneys, LivingEasy, LivingFit, LivingSmart, McGraw-Hill Professional, OnlineOrganizing.com, Pathway GenomicsMcGraw-Hill Professional, OnlineOrganizing.com, Pathway Genomics

Medical Medical Supplies Supplies and and EquipmentEquipment

ActiveForever, CareGifters, FamilyMeds, Foot Solutions, Medical Products DirectActiveForever, CareGifters, FamilyMeds, Foot Solutions, Medical Products Direct

NutritionNutritionEden Foods, FamilyMeds, Frontier Natural Products Co-op, Ideal Health, Eden Foods, FamilyMeds, Frontier Natural Products Co-op, Ideal Health,

MotherNature.com, Octavia Tea, Vital Choice SeafoodMotherNature.com, Octavia Tea, Vital Choice Seafood

Pet CarePet Care Allergy Control Products, FamilyMeds, Gaiam, MotherNature.com, Sierra Trading PostAllergy Control Products, FamilyMeds, Gaiam, MotherNature.com, Sierra Trading Post

Relaxation Relaxation ResourcesResources

Aura Cacia, Gaiam, Healing Rhythms, Health Journeys, LivingEasy, MotherNature.com, Aura Cacia, Gaiam, Healing Rhythms, Health Journeys, LivingEasy, MotherNature.com, SalonWish, Spa FinderSalonWish, Spa Finder

Senior CareSenior CareActiveForever, Allergy Control Products, CareGifters, FamilyMeds, Medical Products ActiveForever, Allergy Control Products, CareGifters, FamilyMeds, Medical Products

Direct, Memory LaneDirect, Memory Lane

Smoking Smoking CessationCessation

Cirrus Healthcare, FamilyMeds, Free and Clear, LivingFree, Quit SmartCirrus Healthcare, FamilyMeds, Free and Clear, LivingFree, Quit Smart

Vision CareVision Care Eyeglasses.com, VisionDirectEyeglasses.com, VisionDirect

Weight Weight ManagemeManagementnt

Ideal Health, Jenny Craig, LivingFit, LivingLean, McGraw Hill Professional, NutriSystem, Ideal Health, Jenny Craig, LivingFit, LivingLean, McGraw Hill Professional, NutriSystem, Structure House, ThinkLightStructure House, ThinkLight

NCE Consumer Savings Benefits

2929

Medical Benefit Medical Benefit ProvisionsProvisions Pre-Existing Conditions Pre-Existing Conditions

– Policies have Policies have preexisting conditions limitationspreexisting conditions limitations. . Preexisting conditions are not covered until the policy has Preexisting conditions are not covered until the policy has been in effect for more than twelve (12) months. A been in effect for more than twelve (12) months. A preexisting condition is a condition, physical or mental, preexisting condition is a condition, physical or mental, regardless of cause or condition, for which medical advice, regardless of cause or condition, for which medical advice, diagnosis, care or treatment was recommended, or diagnosis, care or treatment was recommended, or received from a physician within a six month period received from a physician within a six month period preceding the effective date of coverage of a covered preceding the effective date of coverage of a covered person.person.

– Those who enter the plan presenting a Certificate of Those who enter the plan presenting a Certificate of Creditable Coverage will receive credit towards this Creditable Coverage will receive credit towards this Plan's preexisting conditions limitations.Plan's preexisting conditions limitations.

– Information of where to send Certificate of Information of where to send Certificate of Creditable Coverage is provided on the web site.Creditable Coverage is provided on the web site.

3030

Limitations and Limitations and ExclusionsExclusions Benefits will not be paid for:Benefits will not be paid for:

– Treatment, services or supplies which:Treatment, services or supplies which:

Are not Medically NecessaryAre not Medically Necessary Are not prescribed by a Doctor as necessary to Are not prescribed by a Doctor as necessary to

treat Sickness or injurytreat Sickness or injury Are experimental/investigational in nature, Are experimental/investigational in nature,

except as required by lawexcept as required by law Are received without charge or legal obligation Are received without charge or legal obligation

to payto pay Is provided by an immediate family memberIs provided by an immediate family member

3131

Additional Limitations Additional Limitations and Exclusionsand Exclusions Benefits will not be paid for by sickness or Benefits will not be paid for by sickness or

injuries caused by (except as specifically injuries caused by (except as specifically provided for in the policy)provided for in the policy)

– Dental ProceduresDental Procedures– Alcoholism or Drug AddictionAlcoholism or Drug Addiction– Mental IllnessMental Illness– Elective Procedures and Cosmetic SurgeryElective Procedures and Cosmetic Surgery– Felony or Illegal Occupation Felony or Illegal Occupation – Manipulations of the Musculoskeletal System Manipulations of the Musculoskeletal System – Suicide, Attempted Suicide or Self-Inflicted InjuriesSuicide, Attempted Suicide or Self-Inflicted Injuries– War or Act of WarWar or Act of War– Worker’s CompensationWorker’s Compensation

3232

Effective Date and Effective Date and BillingBilling Effective dates are the 1st and 15Effective dates are the 1st and 15thth of each of each

monthmonth

On line enrollment must be submitted by the On line enrollment must be submitted by the 2020thth of the prior month to obtain a first of the of the prior month to obtain a first of the month effective date and the 5month effective date and the 5thth of the same of the same month for a 15month for a 15thth effective date effective date

Payments can be made via credit card or EFTPayments can be made via credit card or EFT– Visa, MC, Discover, AmexVisa, MC, Discover, Amex

Future drafts will occur 10 days prior to Future drafts will occur 10 days prior to effective date month.effective date month.

3333

Fulfillment MaterialsFulfillment Materials

Insured will receive an instant email Insured will receive an instant email when application is submitted, with when application is submitted, with a copy of their NCE Benefits a copy of their NCE Benefits Package and ID CardsPackage and ID Cards

AMLI will mail a AMLI will mail a separate packageseparate package including a schedule of benefits. including a schedule of benefits. The certificate of coverage will be The certificate of coverage will be available on line and information on available on line and information on how to download and access the how to download and access the certificate will be in the AMLI certificate will be in the AMLI welcome letterwelcome letter

3434

Sales TipsSales Tips

DO NOT Represent Limited Medical DO NOT Represent Limited Medical as:as:

– ““Same as your employer plan”Same as your employer plan”– Just like “Major Medical”Just like “Major Medical”– No “deductibles” or “co-payments” No “deductibles” or “co-payments”

(sounds too much like a major med (sounds too much like a major med plan)plan)

– ““Full Benefits”Full Benefits”– A “PPO”A “PPO”

3535


Clearly explain the limited nature of the plan:Clearly explain the limited nature of the plan:

– ““This limited health benefits plan does not provide This limited health benefits plan does not provide comprehensive medical coverage. It is a basic or comprehensive medical coverage. It is a basic or limited benefits policy and is not intended to cover all limited benefits policy and is not intended to cover all medical expenses. This is not designed to cover the medical expenses. This is not designed to cover the costs of serious or chronic illness. It contains specific costs of serious or chronic illness. It contains specific dollar limits that will be paid for medical services dollar limits that will be paid for medical services which may not be exceeded. If the cost of services which may not be exceeded. If the cost of services exceeds those limits, the beneficiary and not the exceeds those limits, the beneficiary and not the insurer is responsible for payment of the excess insurer is responsible for payment of the excess amounts.”amounts.”

3636


Clearly explain the limited nature of the plan – it is financial Clearly explain the limited nature of the plan – it is financial assistance, not complete coverageassistance, not complete coverage

Explain the key elements of:Explain the key elements of:– Guarantee IssueGuarantee Issue– Accepting Certificate of Creditable Coverage for new membersAccepting Certificate of Creditable Coverage for new members– Plan will not issue Certificate of Creditable Coverage for members leaving Plan will not issue Certificate of Creditable Coverage for members leaving – Pre existing condition limitationPre existing condition limitation

Go through the plan of benefits in detail with the consumer, Go through the plan of benefits in detail with the consumer, including the affiliation with the NCE Associationincluding the affiliation with the NCE Association

Explain how the discount network works (do not quote specific Explain how the discount network works (do not quote specific savings percentages!)savings percentages!)

Explain the claims submission process, billing, and customer serviceExplain the claims submission process, billing, and customer service

Explain the 30 day free look provisionExplain the 30 day free look provision

3737

Agent AppointmentAgent Appointment

An agent MUST be licensed in their resident An agent MUST be licensed in their resident state and any non-resident state in which the state and any non-resident state in which the consumer “resides” consumer “resides”

A licensed and appointed agent must be the A licensed and appointed agent must be the person personally making the saleperson personally making the sale

Agents must pay their own appointment feeAgents must pay their own appointment fee

All agents need to provide proof of E&O All agents need to provide proof of E&O coveragecoverage

3838

Member Services for Member Services for Agents and MembersAgents and Members

Member Services Representatives are available from 8:30 a.m. CST to 5:30 p.m. CST by phone or email

You may leave a Voicemail – and your call will be returned within two business hours

Documents

Agent Training Presentation Agent Training - October 2010