Health Plan FAQ

Here are some general questions employers ask about health plans and benefit coverage.

If you don’t find the information you’re looking for below, please call us at 952-896-4872, and we'll do our best to answer your questions.

What is a partially insured or self-funded plan?

A partially-insured health plan (or a “self-funded” plan) is one in which the employer assumes the financial risk for providing health care benefits to its employees. A self-funded employer pays for employee medical costs as they are incurred instead of paying a fixed premium to an insurance company for fully-insured coverage.

Self-funded employers use HealthEZ for claim processing, shopping for stop-loss insurance coverage, provider network access and utilization review services.

What is a letter of medical necessity (LMN) and who generates it?

This is a letter from your provider that explains why a particular treatment is considered necessary.

What does it mean when a health plan states it covers preventive services?

Preventive services are when a person goes to the doctor and they are not sick. The patient is going to the doctor for a preventive check-up, which includes visits for mammograms, prostate screening, pap smear, etc. These services are usually done once a year.

What is the difference between routine and preventive services?

Preventive services are your yearly wellness physicals or tests/screenings you have done on a yearly basis, such as mammograms, eye exams, Pap smear, prostate screening, etc. Routine services are services done on a routine basis such as high blood pressure check, diabetes check, thyroid check, etc.

What is a PBM?

A PBM is a prescription benefits manager. A PBM offers you medications at a discounted cost either through your local pharmacy or mail order.

What is a COCC?

A COCC is a certificate of creditable coverage. This proves your participation in a health plan and gives the length of participation. You will need this if you move to another health plan in order to show that you did not have a lapse in coverage.

What is a pre-existing condition?

A pre-existing condition is a medical condition you may have been treated for prior to your coverage with HealthEZ. This would include conditions for which you may be using medications to treat.

How are claims for pre-existing conditions handled?

If you have had a lapse in coverage of no more than 63 days, HealthEZ will need a copy of your certificate of creditable coverage (COCC). If a COCC is not received, HealthEZ will contact you by mail for additional information regarding treatment dates and providers. HealthEZ will also contact your providers to determine if you have been treated for any conditions that could be considered pre-existing.

What is a (PPO) and how does it affect my benefits?

PPO stands for "Preferred Provider Organization." A PPO contracts with providers of medical care for a discounted rate on their services. Providers under such contracts are referred to as preferred providers or participating providers. Usually, the benefits with a participating provider are significantly better than with a non-participating provider.