Preferred Plan Advance^SM FAQs

Q.	Does each member of the family get four office visits up front?
A.	Yes, the coverage is applied to each family member.  Each member would receive the same up-front benefits and be subject to the same coinsurance and deductible.  However, the maximum out-of-pocket expense would never exceed the contractual stoploss maximum for a family of three or more.
Q.	What happens after the member uses their first four office visits?  Do they have to pay for future visits?
A.	After the member has used their first four office visits, their next visit is subject to the deductible, and we pay the PPO contractural percentage (if within the PPO network) of the allowed amount.
Q.	Are the office calls counted according to date of service?
A.	No, the office calls are counted according to the date that we receive and process the claim.  The number of office calls is based on a calendar year.
Q.	If a member joins Advance in July, does that mean they will be covered for four office calls July through December?
A.	It depends.  If they are new to Asuris Northwest Health, yes—they will have four covered office calls for the second half of the year.  They will get another four office calls while they are covered with Advance in the following year. If they transferred to Advance from another Asuris Northwest Health plan and had not met their deductible by the end of June, any office calls they paid for in the first six months won’t count as office calls under Advance.  That means they will have four office calls covered July through December.  The member paid for them, so the office calls don’t count against the Advance benefits.  We will, however, give the member credit on Advance for whatever they paid toward their deductible from January through June. If we covered any office calls this year under the member’s previous plan (for example, if they were on a PPO plan and met their deductible), then those Asuris-covered office calls will count against the member’s first four covered Advance office calls.  Let’s say Asuris Northwest Health covered one office call for a member sometime between January and June.  If the member starts on Advance on July 1, they will be covered for three office calls July through December (Asuris Northwest Health has already paid for one office call for the member in this calendar year). The same is true for the first $500 in outpatient diagnostic x-ray and lab services and any preventive care maximum the member may have per calendar year.
Q.	I have an employee who is pregnant, and she will be seeing her OB/Gyn often.  Will she use up her first four office calls with her first four OB/Gyn office calls?
A.	No, we look at maternity as one extended course of care.  Think of it as one nine-month-long service.  Maternity office calls are just part of the overall care the member receives.  She would not be expected to pay a copay for each office call, nor will those office calls count toward her first four covered office calls.  When her provider bills for the entire course of care, your employee will receive a breakdown of services and charges.  She will pay her deductible, and then we will split the rest of the covered services with her. (Please refer to specific plan provisions).
Q.	What about the office calls related to a surgery?  Will each one count toward a member’s first four covered office calls?
A.	No, like maternity (see above), if a doctor visit is part of the overall care related to a surgery (such as pre-op and post-op visits), the doctor should not charge a copay.  If the member does not pay a copay, then we count it as part of the overall service rather than as an office call.
Q.	What if the member is hospitalized?  Will Advance cover only 80% of the bill?
A.	While the member pays 20% (if within the PPO network), they do not pay more than the deductible and the contractual $2,500 or $5,000 out-of-pocket maximum.  Advance’s catastrophic coverage will take care of the rest.
Q.	What if the member needs to see a naturopath or other alternative-care provider?
A.	The member’s first four office calls can apply to the PPO or participating provider of their choice.  Remember, there is no PCP or referral requirement on this plan.
Q.	Does the member pay a copay only on the first four visits?
A.	No, all office visits require a copay.
Q.	Is it possible for the member to pay the deductible even before hitting four office visits?
A.	Yes, any services that occur during the office call and fall outside of the $500 diagnostic lab and X-ray or preventive coverage are subject to the deductible and paid at 80% (if within the PPO network).
Q.	Is this plan available for large groups?  Can the copay amount or the number of visits be changed?
A.	A large group is welcome to purchase this product, but they will not be able to customize it.
Q.	Which of Advance’s initial benefits cover the member’s routine annual exam?
A.	Typically, the routine annual exam falls under the preventive care benefit.
Q.	What is the chance that a member’s doctor is in the Asuris Northwest Health PPO network?
A.	The Asuris Northwest Health PPO network is one of the state’s largest networks, so there is a good chance that the member will not have to change doctors.
Q.	What if the member goes out of the PPO network?
A.	If the member has to leave the PPO network, they still have coverage.  The member will be responsible for 50% of all allowed charges if they see a participating provider.
Q.	How does Advance cover mammograms?
A.	The state requires health plans to cover mammograms.  They are covered under the outpatient diagnostic x-ray and laboratory services benefit.
Q.	What happens to well-baby visits after a child reaches the plans annual preventive care maximum?
A.	The services are not covered.
Q.	If the member’s plan has an annual maximum preventive care benefit, what happens after the preventive care maximum is reached?
A.	The remainder of the member’s preventive care costs is the member’s responsibility.  (The preventive care benefit covers well-baby, annual exams and cancer screenings—except mammograms—and immunizations.)

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