Underwriting
What is the timeframe for HBP with Secure Advantage?
6 Months+
In the PremierAdvantage Fixed Indemnity Plans, how much does Plan 1 pay for an Urgent Care visit?
$100 per visit (1 visit per year).
This benefit under the Health & Wellness PLUS plans rolls over unused amounts into the next policy year. What is it?
Doctor Office Visits — unused visits roll over to the next policy year.
Under the ACA, these 10 categories—such as maternity care, mental health services, and prescription drugs—must be covered by all compliant individual and small-group plans.
Essential Health Benefits?
Do short term plans have a true Max out of pocket?
No
A client had a herniated disc surgically corrected 14 months ago (full recovery), is this standard?
Yes — Standard.
Disc surgery requires 12+ months with full recovery.
Under PremierAdvantage, how many X-ray benefits are allowed per year under Plan 3?
4 per insured per policy year.
Mammograms are covered once per year, but what is the minimum age for a female insured to be eligible?
Age 35 or older.
This ACA affordability metric determines subsidy eligibility and is calculated using household size and modified adjusted gross income.
Federal Poverty Level (FPL)?
What Income is Obamacare based off of?
projected Modified Adjusted Gross Income (MAGI)
A client had two kidney stones, but the most recent one was 4 years ago and no issues since. Are they eligible?
Yes — Standard.
Multiple episodes are eligible after 2 years if fully recovered.
Under the PremierAdvantage Fixed Indemnity Plans, what is the lifetime certificate maximum per insured for all plans?
$5,000,000 lifetime maximum per insured.
How much does Plan 1 pay for a Physical Examination?
$125 for 1 exam per year.
This type of account lets you use pre-tax dollars for medical expenses, but the funds typically expire if not used by year-end.
FSA (Flexible Spending Account)?
In some states, adults with low income can qualify for Medicaid based solely on their income. But in these states, adults without children usually don’t qualify unless they meet specific categorical requirements like disability or pregnancy
What are non-expansion states?
A client had a Grand Mal seizure 4 years ago, is stable, and has been controlled on ONE medication with no episodes since. Are they eligible?
Yes — Standard.
Grand Mal/Tonic-Clonic controlled on one med with last episode over 3 years qualifies.
What is the annual prescription maximum under PremierAdvantage Plan 3?
$1,250 per policy year.
What is the minimum age at which a male insured qualifies for the PSA Test Wellness Benefit without needing a family history risk factor?
Age 50 (or 40 if they have a family history or other risk factor).
What does a Brand name medication have to be considered to be FDA approved for the generic version?
Bioequivalent
A screening colonoscopy is free, but the patient ends up paying thousands because polyps were removed.
What classification did the service change to?
Diagnostic
A client had their gallbladder removed 9 months ago (full recovery) and had two kidney infections, the last 19 months.
Eligible?
No — Decline (multiple kidney infections < 2 years).
Gallbladder surgery clears.
Kidney infections must be > 2 years apart.
When someone upgrades to PremierMed through the Well-GIST Rider, which type of conditions have their pre-existing condition limitation waived — meaning they are covered immediately under PremierMed?
Any pre-existing conditions that were disclosed on the original PremierAdvantage application or that manifested during PremierAdvantage coverage.
What classification under the ACA do the SecureAdvantage Health & Wellness PLUS plans fall under, and what major implication does that have?
They are “excepted benefit plans” and not minimum essential coverage, meaning they do not satisfy ACA requirements and do not cover all 10 essential health benefits.
This code set assigns a procedure number to services like suturing, office visits, imaging, and injections, and determines how much the insurer reimburses.
CPT code
A client thinks a referral automatically guarantees coverage for a specialist visit.
What additional approval may still be required?
prior authorization