How Core Health Plans Work

Core Health provides limited medical indemnity insurance plans that offer insurance benefits to help with the everyday cost of medical treatment.

Benefits include:

• Single or Family Coverage
• No Medical Questions or Physical Exams
• Doctor Office Visits (adult and child)
• Hospitalization Benefits
• Emergency Room Benefits
• Surgery Benefits
• Advanced Studies Benefits
• $1 Million Lifetime Maximum
• Accidental Medical Benefits
• Freedom to choose any provider
• And more...

Core Health Plans are Assignable Benefits not Direct Reimbursement:

Assignable benefits are when your provider bills the insurance company directly for reimbursement of your claims.  This is good, when you visit a provider (doctor, hospital, etc...) you want to be able to show them an insurance card.  If you present them with an assignable benefits card (like Core Health) it will instruct them to bill the insurance company directly; where the insurance company will process the claim and send you a Explanation of Benefits (EOB).  Many limited medical plans in the marketplace only offer direct reimbursement where they are paying you benefits only after you have paid the provider first.  With Core Health Insurance plans you can walk into provider offices with confidence.  You will receive a professional ID card that you can present and the provider will have instructions on who to bill for your services.

How does a PPO work*?

Preferred Provider Organizations (PPO) have negotiated discounts with providers (doctors, hospitals, etc...) nationwide.  By utilizing providers in these networks you can save significant money on your healthcare.  The PPO networks are an option for you and is not mandatory; although it is typically in your best interest to use a provider.  Based on your state of residence Core Health Plans will add a PPO network (if available) to your plan automatically*.

1. Member has sickness, illness, or wellness need.

2. Member finds a provider within the PPO that he/she has decided to visit.

3. Member does not find a provider in the network and chooses to go outside the network for coverage.

4. Member receives care and provider sends claims to Insurance company for payment.

   A.  If a provider is "in the Network", the insurance company processes a provider pre-agreed discount to the provider fees billed to the member. Next the insurance company pays its portion of the bill based on the benefits set forth in the Plan Certificate. The member and provider receive an explanation of the benefits ("EOB") and the provider bills the member for any additional amounts due on the discounted services.

   B.  If the provider is not in the Network, there are no pre-agreed provider discounts. The insurance company pays its portion of the fees (benefits set forth in the Plan Certificate).  The member will then be billed by the provider for the balance of the provider fees, which are not discounted and usually result in a higher member payment."

5. Insurance Company notifies member what benefits were paid to provider.

6. Provider notifies client of remaining balance.  Balance should be lower if member used a PPO provider.

* Not all states have PPO access.  Get a quote to see if a PPO has been assigned to your state.

Example of PPO vs. Out of Network Savings:

Bob has a wrist injury and needs out-patient surgery.  He has accumulated 2 X-Rays, 3 Office Visits, and 1 Out Patient Surgery Procedure.  The total procedure cost $3,050 and he has the Core Health Gold Plan.  Here is an example of how the plan could work:

Summary:

If Bob uses the PPO and has the Core Health Gold Benefit his total to pay is: $235

If Bob has the Core Health Gold Plan and does not use PPO provider, he has to pay: $1,550

If Bob does not have the Core Health Gold Plan, he has to pay: $3,050

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