Below are some questions frequently asked by EBS clients.  We hope they help clarify any questions you may have, but if you're in need of further assistance please contact EBS directly.

1. How do I file claims for my Flexible Spending Account?
2. My employer offers a Flexible Spending Account, but I am single and healthy. How would the FSA benefit me?
3. My medical claim has been denied. Can I appeal?
4. Can I change my medical insurance election mid-year?
5. What is the difference between HMO, POS, PPO and EPO?
6. I am 65 and have Medicare. Should I also enroll in the medical plan offered by my employer?
7. When should I consider Long Term Care Insurance?
8. What are my rights under COBRA?

1. How do I file claims for my Flexible Spending Account?

Click here to download the Flex Spending Account claim form. Complete the form and mail or fax it back to EBS at:

MAILING ADDRESS:
Employee Benefit Solutions
P.O. Box 421
Ossining, NY  10562

FAX: (914) 762-6508

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2. My employer offers a Flexible Spending Account, but I am single and healthy.  How would the FSA benefit me?

FSAs are voluntary programs that allow employees to pay for un-reimbursed medical and/or dependent day care expenses with pre-tax dollars.  Although this type of plan does not benefit everyone, it covers such a large variety of expenses that it proves to be a benefit to many employees.  Flex plans cover items that are frequently not included in standard insurance plans such as:

• Vision, including purchase of glasses, contact lenses and contact lens solution
• Orthodontia
• Home modifications for handicapped individuals
• Items that have limited coverage under medical plans such as visits to a psychiatrist, chiropractor or other therapist
• Co-pays and deductibles that are applied to regular covered expenses
• Over-the-counter medications, such as Asprin or Tylenol
  

If you do not incur medical expenses, however, you should not enroll in a Health Care Spending Account. 

Transit accounts are frequently included as part of a Flexible Spending Arrangement.  If you use any sort of mass transit, or if you must pay for parking at the office, you can take advantage of the pre-tax savings under the transportation account.

Use the links below to review more complete listings of items covered under an FSA:

• Flex medical & dental expense guide
• Flex dependent care expense guide
• Transit & parking expense guide

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3. My medical claim has been denied.  Can I appeal?

It is possible to appeal a claim, but the first step is to check your booklet-certificate to see if there is a contractual reason for the denial.  If there is no apparent reason for the denial or if it is a situation that warrants special consideration, the first step is to write to the insurance company requesting a review.  The request must be in writing and must state the reason you feel the charge should be covered.  The insurance company will either agree with your request and pay the claim or uphold their original decision and include specific information about how to use the external appeals process through the state insurance department.  Click here to contact EBS for additional information.

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4. Can I change my medical insurance election mid-year?

Although there are exceptions, most medical and dental insurance plans have Open Enrollment once a year.  It is at this time employees have the option to change their elections.  If an employee has a life status change (gets married or divorced, has a new baby, etc.) a change can be made as long as the employer is notified within 31 days of the event.  Otherwise, you must wait until open enrollment to make the change.

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5. What is the difference between HMO, POS, PPO and EPO?

• HMO is a Health Maintenance Organization.  These plans typically require the insured to use only providers that participate in the plan, and a referral is needed before visiting a specialist.

• POS signifies Point Of Service.  This type of plan allows you to use any provider, but benefits are greatly reduced for providers who do not participate in the network.  You make your decision at the Point of Service whether to use a network or out-of-network provider.  Like the HMO, a referral is usually necessary when a specialist is needed.

• PPO means Preferred Provider Organization.  This plan is the most flexible of all the options.  Like the POS, you may use any provider with better benefits available for network providers, but unlike the POS, you never need a referral.

• EPO, Exclusive Provider Organization, is similar to the HMO in that you are limited to network providers, but with the EPO, you do not need referrals.

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6. I am 65 and have Medicare.  Should I also enroll in the medical plan offered by my employer?

This is not an easy question to answer as it differs from one person to another depending on individual circumstances, but there are some general guidelines.  If an employer has fewer than 20 employees, Medicare is Primary, which means Medicare pays first.  Any group insurance plan pays second.  In this case, it is important that you maintain Medicare.  The group insurance would cover charges such as prescriptions that are not covered by Medicare.  The group insurance plan may or may not be important to you.

If your employer has 20 or more employees, the group insurance plan is primary, and Medicare is secondary.  In this case, you may or may not need Medicare.  It is important to keep in mind, however, that Medicare imposes strict penalties if you do not enroll during one of several designated enrollment periods.  You should check with your local Social Security office for the current rules.

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7. When should I consider Long Term Care Insurance?

The best time to apply for Long Term Care Insurance (LTCI) differs greatly from one person to another.  Although an insurance company has the right to increase premiums, an increase must be approved by the state insurance department and must apply to an entire block of policies (not just one policy) so increases are rare.  For this reason, it may be wise to get a policy prior to age 60 when the premiums are low so it will be easier to budget after retirement.

LTCI is subject to medical underwriting.  If you have a family history of debilitating illnesses, you may want to apply early (age 40 – 60) while you are in the best of health.

LTCI has many options and policies differ tremendously from one insurance company to another.  You should discuss your current situation with someone versed in LTCI before making a decision.  Contact EBS for detailed information or a quote.

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8. What are my rights under COBRA?

COBRA is a law that identifies the requirements to continue coverage under a group insurance plan when an employee terminates.  There are many limitations and restrictions in this regulation.  If you have a specific question relating to COBRA, you should either contact your Human Resource Department or click here to review the COBRA Guidelines.  To get a quote for COBRA administration for your group plan Contact EBS.
 

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