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AdvanceSM Prior Service Information
Q: What happens when an existing Asuris Northwest
Health group moves from their current Asuris plan
to Advance at any time of the year other than January?
A: All Asuris contracts contain a prior service clause, which credit prior amounts from previous Asuris contracts (such as deductible, stoploss or benefit maximums). Asuris deductibles, stoploss amounts and benefit maximums are based on a calendar year.
For example: A member used $500 for outpatient rehabilitation therapy services under a prior contract underwritten or administered by Asuris and then transfers to a new Asuris contract with a $1,500 per year maximum for outpatient rehabilitation therapy services. The member would be allowed the balance of $1,000 under the new contract for any additional benefit for outpatient rehabilitation therapy used during that year.
This same prior service clause applies to Advance.
Scenario 1 – Moving from the 80/80/50 plan
| On a Previous 80/80/50 Plan |
On an
Advance Plan |
| A member is covered under a previous Asuris contract with a $500 deductible and has seen their doctor twice so far that year. The total allowed amount for both office calls was $200, which went toward meeting the deductible amount. |
In June, the member’s group moves to Advance with a $500 deductible.
The $200 they had previously paid toward their deductible will be credited to their new contract (meaning they have to pay $300 more to accumulate to their deductible before meeting the deductible).
The member then goes to the doctor again in July, and the doctor bills for an office call.
Since the previous office calls had applied to the deductible and Asuris had not actually paid for any office calls under the prior contract, this office call will fall into tier one and count as one of the first four office calls under Advance. It will be paid at 100% after the copay and will not be subject to the deductible. |
Scenario 2 – Moving from a PPO 100/80/60/25 Plan
| On a Previous 100/80/60/25 Plan |
On an
Advance Plan |
| A member is covered under a previous Asuris contract (with office calls not subject to the deductible) and has seen a doctor five times so far that year. Since there is no deductible to meet, Asuris has paid for five office calls. |
In October, the member’s group moves to Advance with a $500 deductible. The member then goes to see the same doctor again in November, and the doctor bills for an office call. Since Asuris has already paid for five office calls this year, the office call falls into tier two. It is subject to the copay and deductible and then paid at 80%.
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