Log into your Zenefits account and click on the Medical, Dental, or Vision Insurance card. This will take you to the Overview page. On the right side of the page, you'll find a link that says Member Services & Claims Info.
Clicking the link will show you:
Under the Affordable Care Act, services considered to be "preventive care" are 100% covered with an in-network doctor for these services. Refer to the plan's Summary of Benefits and Coverage for any additional details around this benefit.
Some examples of preventive care include:
There are different services covered for adults, women, and children. For a comprehensive list of preventive health services, please refer to the U.S. Department of Health & Human Services website here.
An insurance plan's Out-of-Pocket (OOP) maximum is how much someone will have to spend on healthcare before the insurance carrier will cover 100% of their medical expenses.
For example, if an employee selects a plan with a $5,000 OOP max and spends $5,000 out of pocket by mid-year, any medical costs that are incurred for the rest of the plan year will be 100% covered by their insurance company.
The OOP maximum does not carry over from plan year to plan year -- it resets with the plan year, much like deductibles.
Employees can view their plan's OOP maximum from the Medical Overview page under the Benefits Summary section.
The amount applied to the OOP maximum may vary depending on whether medical expenses were incurred inside or outside of the plan's network.
An HMO plan requires you to designate a Primary Care Physician (PCP) and are not available to out-of-state employees, or employees who live outside of the carrier's established network area.
Alternatively, a PPO plan offers nationwide coverage and enrollees can see any doctor any time with a PPO plan; a referral from a Primary Care Physician (PCP) is not necessary.
Some carriers provide pediatric dental coverage through their medical coverage. This coverage is only available for children under the age of 18 who are enrolled in the medical plan.
If you need assistance selecting a health insurance plan, please contact your insurance carrier or insurance broker for further assistance. Your broker's contact information can be found on the lower right side of your Zenefits dashboard upon logging in to your account, under Benefits Contacts.
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