Affordable Care Act (ACA) and Premium Saver FAQ
If a group adds a high-deductible major medical plan, would it still be in compliance if we added the Premium Saver?
The Premium Saver does not disturb the ACA compliance of a major medical plan. The major medical plan must stand on its own for ACA compliance given the Premium Saver is an excepted benefit.
Does the Premium Saver apply towards the affordability and minimum value requirements under ACA mandates?
The Premium Saver provides supplemental benefits to the major medical plan. The major medical plan must stand alone for maintaining affordability and minimum value coverage for ACA mandates. Note: Many agents understand how Premium Saver helps to make medical coverage affordable.
Is supplemental coverage exempt from the ACA requirements?
The Premium Saver is an excepted benefit and is exempt from many ACA requirements (certain taxes, certain reporting, reinsurance fees, minimum loss ratios, etc).
If an individual enrolls in an ACA plan, can I offer Premium Saver to this individual?
Premium Saver is a group-based product only. Stand-alone policies for individuals are not available.
Why doesn’t Premium Saver offer a Summary of Benefits and Coverage (SBC) to its groups?
The Premium Saver is not subject to this requirement because it is an excepted benefit. If an SBC was provided, we would be to susceptible to other ACA regulations.
Premium Saver FAQs
Updated in November 2019
1. What are the participation requirements?
Every participant, including dependents, covered by the group’s major medical plan(s), must participate and be enrolled with Premium Saver. If a group currently has a dual-option medical plan, including an HSA, those employees covered by the HSA do not have to participate. There are no age restrictions.
2. What is the minimum group size?
- In Florida, the minimum group size for Monitor Life Insurance Company of New York is 5 to 50 enrolled.
- In Florida, the minimum group size for both AmFirst and Standard Life Insurance Company is 51 enrolled.
- All Other States, the minimum group size is 5 employees enrolled.
3. What expenses are eligible for coverage?
The eligible expenses covered by Premium Saver follows the major medical coverage. Premium Saver covers the same expenses as the major medical plan except for the professional fee in a doctor’s office or medical clinic and outpatient prescription drugs. If the charge is not covered by the major medical plan, it is not covered by Premium Saver. Most groups select a Premium Saver plan which covers amounts applied to their deductible or co-insurance by the major medical plan.
4. What do you mean by the professional fees of a physician in a doctor’s office or medical clinic?
The professional fee of a physician is simply the fee charged by the physician. The professional fee is a covered Premium Saver expense except when incurred in a doctor’s office or outpatient medical clinic. The professional fee and the location of the service will be indicated by certain codes on the major medical explanation of benefits (EOB). Examples of professional fees not covered are the doctor’s fee in a doctor’s office visit or the psychiatrist fee in that office. Most agents pair the Premium Saver with a major medical plan with co-pays for doctor’s visits and outpatient prescriptions.
5. What about other expenses in the doctor’s office?
All expenses covered by the major medical plan in the doctor’s office or outpatient medical clinic are covered except for professional fees in a doctor’s office or outpatient medical clinic.
6. What about other expenses such as x-rays, labs, crutches, and chemotherapy in a doctor’s office?
These expenses are covered by Premium Saver if they are covered by the major medical plan.
7. How does the Premium Saver administrator know what the major medical plan covers?
The major medical explanation of benefits (EOB) details what the major medical plan pays. Claims are paid based on themajor medical EOB.
The insured should give the Premium Saver insurance card to the provider along with the major medical insurance card. The provider will first file against the major medical carrier. When the major medical carrier pays the benefit to the provider, the provider can electronically file the claim with Premium Saver. Most providers are glad to file electronically because they will get paid quicker.
9. What if the provider will not file electronically with Premium Saver?
The provider will file against the major medical carrier. When the major medical carrier pays the benefit to the provider, the provider simply sends MWG Administrators a copy of the major medical EOB along with an itemized bill (UB-04 or MS-1500).
10. Why do you need the itemized bill? Why can’t you just use the EOB to process the claim?
The provider’s itemized bill is needed to insure payment is sent to the correct provider. The itemized bill reflects the provider’s tax ID number which is needed to send payment.
11. Can the insured send in the EOB and itemized bill?
Yes, but payment will only be made to the provider, unless the insured proves they have paid the provider in full. Most claims issues occur when the insured files the claim. They frequently do not send in both forms or they send incorrect forms.
12. Will Premium Saver cover out-of-network charges?
Premium Saver pays the same for in or out-of-network charges. This is a front end advantage for the insured. While most major medical plans increase the deductible or co-insurance for out-of-network charges, Premium Saver does not. Premium Saver is designed to fit the in-network risk with a built in benefit amount or in-network expense, not the higher out-of-network risk.
13. Does the Premium Saver have a deductible cap after 2 or 3 family members meet the deductible?
Although Premium Saver requires each person to meet the deductible, it is rare for more than two family members to meet even a $500 medical deductible in a single year.
14. Can an agent offer employees more than one Premium Saver plan design?
If the group has more than 10 employees, two plans or a dual option can be offered. Groups with 25 or more employees can choose from up to three plans or a triple option.
15. Can Premium Saver be designed to cover co-pays?
Yes, if an alternate plan has a maximum out-of-pocket amount. Your MWG Broker Services representative can generate a proposal which covers deductible, co-insurance and co-pays except for professional fees in a doctor’s office or medical clinic and outpatient prescription drugs.
16. What is the Prior Plan Deductible Credit Rider?
This rider is included with all quotes and is designed to prevent the insured from having to meet two deductibles (Premium Saver and the major medical deductible) during the first year Premium Saver goes into effect.
For example, if the insured pays $300 of their major medical deductible in March and the group decides to install Premium Saver on June 1 of the same year, this rider would reduce the amount of Premium Saver deductible for that person for the year by $300. This rider gives the insured a deductible credit toward their Premium Saver annual deductible. The deductible credit is the amount incurred with major medical prior to Premium Saver going into effect during the first year of the Premium Saver plan.
17. What is the best way for a group to receive credit for the Prior Plan Deductible Credit?
Submit the information during the initial enrollment via a report from the major medical carrier or the member’s EOB.
18. Does Premium Saver offer a rider which provides an end-of-year deductible rollover credit?
While a few major medical carriers offer this feature, we DO NOT offer a rider with a deductible rollover credit. Although every effort is made to ensure the functions of Premium Saver closely mirrors the underlying major medical plan, there are several issues preventing us from offering a rider with a deductible rollover credit, at this time.
19. What is the Allied Service Rider (ASR)?
The ASR rider is included with all quotes and expands coverage. With the ASR, Premium Saver covers the same expenses covered by the underlying major medical plan with the exception of professional fees in a doctor’s office or outpatient medical clinic and outpatient prescription drugs. Examples of professional fees not covered are the doctor’s fee resulting from a doctor’s office visit or a psychiatrist’s fee resulting from a psychiatrist’s office visit.
20. What is the Professional Fee of a Physician Rider?
This rider covers the charge for a professional fee in a doctor’s office or outpatient medical clinic. After the member pays a copay, the rider covers the professional fee until the maximum number of visits is met or the Premium Saver benefit is reached. There are two options available: $30 co-pay with a maximum of six visits or a $40 co-pay with a maximum of three visits.
21. Is the Professional Fee of a Physician Rider per person or per family?
The number of visits is based on per person visits per benefit year. If there are three members in a family, each person gets six visits, totaling eighteen visits in one benefit year if each member uses the maximum per person visits allowed.
22. Is the Rx rider administered by MWG Administrators?
No. Rxedo is the administrator of the Rx riders. There is no affiliation between Premium Saver carriers and Rxedo.
23. Does the Rx annual maximum apply to Premium Saver?
24. Does the Rx annual maximum apply to the major medical MOOP?
Yes. If the pharmacy files Rxedo secondary, it will apply. If the pharmacy files Rxedo primary, it will not apply.
25. Does the Rx plan cover injectable drugs?
No, except for insulin.
26. Is there a mail order service with the Rx riders?
Yes, through Walgreens Mail Service. Visit www.WalgreensHealth.com for more information.
About the Author
Ryan Eaton is the Chief Marketing Officer and Executive Vice President of Morgan White Group. He has spent over 15 years with MWG in sales, management, or leadership roles. He currently manages a sales team that markets insurance products to over 22,000 agents in all 50 states. He is a husband and father of two boys and enjoys anything outdoors: sports, hunting, fishing, cooking out, and leading a father son Christian fellowship in his community.