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Transparency in Coverage

Welcome to Sidecar Health, a health plan designed to be transparent. We are excited You chose Us and want You to understand the ideas, words, and documents We make available to help You use Our product. Our innovative approach to health insurance is intended to empower You to make healthcare decisions fully aware of the cost of covered services and without network restrictions. We want You to be fully informed of the benefits payable by this plan.

 

In the following paragraphs, Sidecar Health and its affiliates are referred to as “We” or “Us” and Our members and their enrolled dependents are referred to as “You."

Out-of-Network Liability and Balance Billing

Sidecar Health does not use a provider network.

Sidecar Health plans do not use a network of preferred or contracted providers. You can receive medical services and prescription drugs from any licensed provider, including any licensed pharmacy or healthcare provider.

 

The plan pays a Benefit Amount for each covered service.

This plan will pay the "Benefit Amount" for each covered service.

 

Regardless of the provider's charge, the plan pays the Benefit Amount subject to any cost-sharing obligations You have. Preventive care is not subject to cost-sharing. The portion of a provider’s charge exceeding the Benefit Amount is not cost-sharing and is not applied to Your maximum out-of-pocket. For example, if You have an outstanding deductible and You receive care from a provider who charges $100 for a service for which the Benefit Amount is $90, then $90 will be applied to Your deductible and You will be responsible for the entire $100 charge. The $10 which the provider’s price exceeds the Benefit Amount is a “balance bill” and not cost-sharing and so does not accrue toward Your plan’s out-of-pocket maximum.

 

You can view the Benefit Amount for each covered service.

You may view the Benefit Amount for each covered service on Our app or website. In some instances, You will be able to see the Benefit Amount for a set of services. For example, if You need knee surgery, You will see a list of all of the standard Benefit Amounts that go along with that service.

 

You are responsible for the difference between the Benefit Amount and the provider’s charge.

You may use the cost estimator tool to view the Benefit Amount for each prescription drug or healthcare service and see what providers charged other Sidecar Health members for such care. You are encouraged to call providers before seeking services. You should ask the provider for their cash price, self-pay, “instant pay,” or “point of service” price for care.

 

You are responsible for any amount charged by a provider in excess of the Benefit Amount. The portion of the provider’s price exceeding the Benefit Amount is considered a “balance bill.” If You choose to see a provider who charges more for a covered service than the Benefit Amount, You are responsible for the balance billing, except in certain situations. Instances when You will not be responsible for balance billing include: emergency and ambulance services, when something unexpected occurs during Your planned or scheduled service, and when You are unable to find a provider in Your area who charges at or below the Benefit Amount, in the aggregate, for services You need. At those times Sidecar Health will work with You and/or Your provider regarding the billed charges.

 

The plan pays the Benefit Amount even if it exceeds the provider’s charge. In these instances, You may keep the savings to be used toward future expenses, premium charges, or You may request a check for the amount.

 

Providers may bill You if they charge an amount greater than the Benefit Amount.  We pay the Benefit Amount. You are responsible for the balance billing, except in certain situations as described above.

Enrollee Claim Submission

You are responsible for submitting a claim to Sidecar Health, including notice of claim and proof of loss.

A claim is a request that Sidecar Health pay Benefit Amounts to You because You incurred costs (or a “loss”) for covered services provided to You. You can give notice to Sidecar Health of this cost, or loss, by using Your Benefit Card. Whether or not You use the Benefit Card to provide notice of Your claim, You must still submit proof of loss (sometimes referred to as proof of claim) to Us within the time limits specified below.

 

We do not require You to use a specific claim form to show proof of loss. Instead, proof of loss is shown by submitting a Medical Invoice to Sidecar Health. A “Medical Invoice” is the fully itemized bill or document given to You by a provider after receiving covered services. The Medical Invoice must include all of the following information:

  1. the CPT codes for the service(s);
  2. the reason for the service(s) (including all ICD-10 diagnosis codes);
  3. the amount charged for such service(s);
  4. the provider’s name and National Provider Identifier (NPI) number;
  5. the patient’s name; and
  6. the date(s) of the service.

Making sure Your provider includes this information on the Medical Invoice helps ensure We will not need more information to pay Your claim. You may upload a picture of the Medical Invoice through the Sidecar Health Portal.

 

You may also mail the Medical Invoice to Us at this address:

 

Sidecar Health Insurance Company

340 S. Lemon Ave.

Suite 7028

Walnut, CA 91789

 

If You have questions about the claim submission process, You may call Your Member Care team at 1-877-553-8246.

 

Sidecar Health will issue You a Benefit Card.

We will issue a Benefit Card to You and each person covered under Your plan. Once You receive the Benefit Card, You will be asked to link the Benefit Card to a credit card, debit card or other account of Your choice (Your “Personal Account”).

 

You can choose to use the Benefit Card, but it is not required.

If You use the Benefit Card to pay for covered services before You meet Your plan’s out-of-pocket maximum, the Benefit Card will withdraw funds from Your Personal Account to pay the amount charged by the provider (the “Swipe Amount”). If Your Personal Account does not contain funds sufficient to pay the Swipe Amount, the charge will be denied.

 

The Benefit Card has a “Swipe Limit,” which is the maximum dollar amount that can be charged to the Benefit Card without obtaining pre-approval of the Swipe Amount. The Schedule of Benefits in Your plan documents shows the Swipe Limit.

 

Each covered service has a Benefit Amount. We will treat every charge to the Benefit Card as an “Estimated Benefit” for the service. You are responsible for submitting the Medical Invoice to Us within 90 days of receiving care. After We receive the Medical Invoice and adjudicate, or process, the claim, We will finalize the Benefit Amount based on the itemized or bundled covered services You received.

 

You can choose not to use the Benefit Card.

You do not have to use the Benefit Card to pay for covered services. You can pay for services that You receive with any payment method You prefer. You are responsible for submitting the Medical Invoice to Us and We will adjudicate the claim. Subject to any cost-sharing You have, We will deposit the Benefit Amount into Your Sidecar Health Account.

 

You are responsible for notifying Us of the claim.

We must receive notice of claim (loss) within 90 days of the date of the covered service or as soon as reasonably possible. Notice is given by or on behalf of You to Us by (1) using the Benefit Card; (2) submitting a claim (Medical Invoice) in the Sidecar Health Portal; or (3) mailing a written claim to Us, as set forth below.

 

You can send the Medical Invoice to:

 

Sidecar Health Insurance Company

340 S. Lemon Ave.

Suite 7028

Walnut, CA 91789

 

You may elect to give notice of claim in a different manner from one claim to the next.

 

If a notice of claim is not accompanied by a Medical Invoice, You must still submit a Medical Invoice to Us within 90 days of the date of loss. Use of the Benefit Card provides Us notice that a claim for benefits will be made by a person covered by the plan, but this is not the same as You submitting an actual claim. You must provide proof of loss to Us within 90 days of the date of the covered service.

 

You must submit a Medical Invoice to Us.

You must give Us written proof of loss within 90 days of the date of the covered service or as soon as is reasonably possible. Proof of loss furnished more than one year late will not be accepted unless You were legally incapacitated in that year.

 

Proof of loss may be delivered to Us by either (i) uploading a picture of the Medical Invoice through the Sidecar Health Portal or (ii) mailing Your Medical Invoice to Us at the address listed above.

 

If You have questions about the claim submission process, You can call Our Member Care team at 1-877-553-8246.

 

You can use funds in Your Sidecar Health Account however You wish.

Funds in Your Sidecar Health Account may be used to cover medical expenses, pay for future premiums, or be received as a direct payment to You in the form of a check.

 

If You use the Benefit Card and the Swipe Amount exceeds the Benefit Amount, You owe Us the difference.

If You use the Benefit Card and if the Swipe Amount paid by Us exceeds the Benefit Amount (or “net benefit amount” in the case of Our Standardized Plan Options as described below) for the applicable covered service, then We will invoice You the balance. You may reimburse Us such difference either by submitting an electronic payment through the Sidecar Health Portal or by mailing a check to Us.  If You fail to reimburse Us within 30 days of the date on which We notify You of the reimbursement amount through the Sidecar Health Portal, We may suspend Your use of the Benefit Card.

 

In addition, fraud or an intentional misrepresentation of a material fact by You in an attempt to secure benefits or coverage when using the Benefit Card shall be fraud in the inducement of Your contractual relationship with Us and shall result in termination of coverage for You subject to 31 days written notice by Us. For termination of coverage with a retroactive effect, 31 days advance written notice will be provided to You. This decision may be appealed through the Grievance process.

Grace Periods and Claims Pending

You have a grace period to pay premiums.

In general, Your payment for each month of coverage is due on the first day of that month. After You make Your first premium payment, if You fail to make a premium payment by the due date, You will be granted a grace period.

 

A grace period is a designated period of time immediately following the due date of Your monthly premium during which You have the opportunity to pay Your delinquent bill without losing Your healthcare benefits. If Your premium is paid during the grace period, coverage will remain in effect. If Your premium is not paid during the grace period, coverage will terminate as explained below.

 

Failure to timely pay premium payments is not a special open enrollment event for later coverage under the plan.

 

If Your coverage is terminated for not paying Your premium, and You request reinstatement, all past due and current premium must be paid in full to be reinstated.

 

There is a standard grace period.

After You make Your first premium payment, there is a grace period of 10 days during which to make Your past-due premium payment if You fail to pay Your premium by the due date. During the grace period, Your health care coverage remains in force. If Your premium is not paid by the end of the grace period, Your coverage will be cancelled after the last day of the grace period, and coverage will be terminated effective the day after the last day of paid coverage. You will be responsible for any expenses incurred during the grace period and will be billed for any expenses paid by Us during that time if You fail to make Your past-due premium payment.

 

There is a longer grace period if You receive Advanced Payment of the Premium Tax Credit (APTC).

If a You are receiving an APTC, and made at least one full month’s premium payment during the calendar year, You will be provided a grace period of three (3) months if You miss Your premium payment. Your coverage will remain in force during the grace period, and We will pay all appropriate claims for services rendered during the first month of the grace period. However, We will suspend payment of expenses for covered services during the second and third months of the grace period. We will not deny these claims for non-payment of premium, but we will withhold payment of these claims until You pay all past-due premium. You continue to be responsible for each month’s premiums during the grace period.

 

If Your past-due premium payment is not paid by the end of the three-month grace period, Your coverage will be terminated after the last day of the grace period, effective the last day of the first month of the grace period. At that time We would deny all claims that were suspended during the second and third months of the grace period and You will be billed for any expenses paid by Us during that time.

Retroactive Denials

Claims may be subject to retroactive denials.

If You are found to be no longer eligible for coverage by Sidecar Health, a claim may be “reversed” (reprocessed and denied retroactively, even after it has been paid), meaning You become fully responsible for payment to the provider. In most cases, You can prevent a retroactive denial by paying Your premiums on time and by promptly notifying Us or (if applicable) Your marketplace of changes in Your eligibility status.

Recoupment of Overpayments

You may recoup overpayments made by You.

If You believe that We overbilled You for Your premium, or made any other error in billing or payment, please contact Us at 1-877-553-8246.

Medical Necessity and Prior Authorization and Enrollee Responsibilities

We rely on Medical Necessity.

We pay claims in accordance with the plan documents, including whether the services received by You were “Medically Necessary.” We will determine Medical Necessity upon receipt of Your Medical Invoice for a covered service. In some cases, We may require Your medical records to determine Medical Necessity.

 

The fact that a provider may prescribe, order, recommend or approve a service, treatment, or supply does not make it Medically Necessary or a covered service and does not guarantee the payment of a Benefit Amount.

 

If You use Your Benefit Card to pay at the point-of-service, We will determine Medical Necessity of the covered service upon receipt of the Medical Invoice, and inform You if We determine the service was not Medically Necessary. In such event, We will deny the claim and You will have the right to appeal Our determination.

 

We do not use prior authorization.

Our plans do not require prior authorization for any covered service.

 

We require pre-approval for certain Benefit Card transactions.

The Benefit Card can be used to pay for covered services at the point-of-service or point-of-care, up to the Swipe Limit.

 

To use the Benefit Card to pay for a covered service that exceeds the Swipe Limit, You must obtain Our prior approval for such transaction. To request pre-approval, submit to Us a provider’s pre-bill or such other evidence that is equivalent to a Medical Invoice. (See more on pre-bills below.)

 

To obtain pre-approval for use of the Benefit Card to pay for a covered service that exceeds the Swipe Limit, contact Us by telephone at 1-877-553-8246. The Swipe Limit is stated in Your plan’s Schedule of Benefits.

 

Pre-approval of use of the Benefit Card does not guarantee benefits.

Our pre-approval to use the Benefit Card for an amount that exceeds the Swipe Limit does not guarantee either payment of benefits or the amount of benefits. Eligibility for, and payment of, benefits are subject to all terms and conditions of the Policy.

Drug Exception Timeframes and Enrollee Responsibilities

There are no drug exception timeframes or enrollee responsibilities.

This plan does not use a prescription drug formulary. To view the Benefit Amount for any particular FDA-approved prescription drug, You may visit Our website.

Explanation of Benefits (EOBs)

We will provide You an Explanation of Benefits.

An Explanation of Benefits (EOB) is a statement that We will send to You after We adjudicate Your claim. The EOB is not a bill. Instead, the EOB explains the Benefit Amount payable by the plan for each covered service You receive and any financial responsibility that You bear (which You may owe to Us). The EOB also provides You with information about Your appeal rights if You disagree with how We processed the claim(s).

Coordination of Benefits (COBs)

We will coordinate benefits if You are enrolled in more than one health insurance plan.

If You are enrolled in more than one health insurance plan, those plans work together through a process called “coordination of benefits” to make sure You get the most from Your coverage. One plan is designated as Your primary plan and pays Your claims according to its rules, Your secondary plan then pays toward the remaining cost according to its rules, and so on. This process prevents duplication of payment across Your plans.

How to Use Your Individual Major Medical Plan*

Here’s how to find Your provider.

As a Sidecar Health member, You may see any licensed provider who accepts direct payment for services. Call the provider You want to see. Confirm they accept cash payment for services and ask what they charge for Your type of visit.

 

To price shop, call a provider You used in the past and a few other local providers before receiving health services, and ask for their cash-pay or self-pay price. For more complex procedures, it’s helpful to get those prices in writing. Look up the services You’re seeking on the Sidecar Health app or website to determine the Benefit Amount for those services. You’ll get the same Benefit Amount(s) no matter which provider You see. You can always look up a service’s Benefit Amount on the Sidecar Health app or website before You get care.

Before You leave Your provider’s office, get an itemized Medical Invoice describing the services You received and paid. This invoice should:

 

  1. the CPT codes for the service(s);
  2. the reason for the service(s) (including all ICD-10 diagnosis codes);
  3. the amount charged for such service(s);
  4. the provider’s name and National Provider Identifier (NPI) number;
  5. the patient’s name; and
  6. the date(s) of the service.

At the pharmacy, ask for a bill that displays the NDC codes as well as the dosage and supply of the medication You are purchasing. Take a picture of Your Medical Invoice and send it to Sidecar Health. For prescription drugs, also sending a picture of the bottle or box the medication came in may help Us take care of Your claim more quickly.

If You’ve shopped around and can’t find an available provider who charges the Benefit Amount in Your area, call Member Care. We’ll work with You to locate someone in Your area who charges the Benefit Amount, or help You get to a provider who does. Be sure to let Us know whether You’re looking for routine care or if Your need is more urgent. If You’re experiencing an emergency, call 9-1-1 and get to an emergency room first!

 

Check out Our Help Desk for Frequently Asked Questions (FAQs).

 

We offer Standardized Plan Options in accordance with federal law.

Consistent with requirements in the Plan Year Notice of Benefit and Payment Parameters Final Rule, Sidecar Health is offering Standardized Plan Options (SPOs) in Bronze, Silver, Silver CSR, and Gold on-Exchange for PY2023 in addition to Our deductible-only plans. We also offer mirrored off-Exchange SPOs. The SPO plans all include some combination of copayments, coinsurance and deductibles as part of the benefit design. All SPOs include various covered services for which You are able to access care prior to meeting Your deductible, some which require You to pay a copayment or coinsurance. Other covered services are subject to a copayment or coinsurance after You meet the deductible until You satisfy Your out-of-pocket maximum. You are still able to keep the savings when You shop smartly for Your care, will be subject to balance billing if You select providers who charge more than the Benefit Amount, and have access to the full range of consumer protections described in this Transparency in Coverage and other plan documents.

 

In these instances, the Sidecar Health app or website will display the Sidecar Health Benefit Amount as well as a “net benefit amount,” which is the amount You owe after copayments or coinsurance is applied.

 

Your Benefit Card has Swipe Limits.

Our Benefit Card is designed to protect You from charging large expenses to Your Sidecar Health account without first knowing the Benefit Amount. Therefore, in a provider’s office and at a pharmacy, the swipe amount will be limited to amounts set forth in Your Schedule of Benefits.

 

Your plan provides preventive care services without cost-sharing.

Need a well child visit for Your toddler? Time for Your annual physical or OB/GYN appointment? Preventive services are covered without cost-sharing on Your plan.

Schedule Your service, then call Member Care before You go. We will activate the Benefit Card so it charges Sidecar Health directly, regardless of whether You’ve met Your deductible. Upload the Medical Invoice for the visit. If You receive covered services during the visit that are not preventive care or that exceed the Benefit Amount, or if You receive services not covered under this plan, You may be responsible for any appropriate cost-sharing charges and/or balance bill amounts.

 

Here’s how You access emergency services.

We know in an Emergency You don’t have time to shop for care. Under the federal No Surprises Act and similar state surprise billing laws and regulations, Sidecar Health works with Your emergency or ambulance services provider to ensure You are not subject to any balance billing above Your appropriate cost-sharing limit. If You have to go to the Emergency Room, show them Your Sidecar Health virtual I.D. card, and instruct the provider facility to bill Us directly. For emergency and ambulance services, You should know providers are legally prohibited from billing You or holding You liable for any amount that exceeds “in-network” cost-sharing.

 

We encourage You to submit pre-bills for complex or expensive services.

Submitting a pre-bill to Sidecar Health helps You be ready for planned healthcare services or prescription drugs that cost more than the swipe limit. Your medical practitioner or provider facility may want You to make a deposit prior to receiving an inpatient service, such as a joint replacement, or an outpatient service such as a breast biopsy. Even if they don’t require any payment in advance, it’s a good practice to ask for a pre-bill. Submitting Your pre-bill to Us before You receive the service allows Sidecar Health to review the pre-bill, and alert You to any charges or services You can reasonably expect are typically provided along with the procedure You’re getting. Submitting a pre-bill can also help You anticipate a possible side effect or outcome. Finally, We will provide You with the Benefit Amounts associated with each of the charges. We recommend You go over the pre-bill carefully with Your provider so You know what to expect.

 

We have protections for unplanned events.

In healthcare, We try to plan for all potential outcomes. But sometimes You can’t anticipate every aspect of a planned procedure or healthcare service. Submit Your pre-bill for Our review of Your planned inpatient or outpatient procedure. When You submit Your proof of loss, We will compare Your pre-bill with Your final Medical Invoice to determine whether something unexpected, for which You did not have time to shop for care and could not have been reasonably anticipated, happened during that covered service. In the event something unexpected happened during Your planned service, such as a different, higher cost, anesthesiologist provided Your anesthetic care, We will work with Your provider to ensure You don’t pay more than the Benefit Amount for that service.

 

*Sidecar Health offers several products, including Our Access (Excepted Benefits) Plan, Our Individual and Large Group major medical plans, and self-funded ASO products coordinated through employers. The majority of the information provided here applies to all Our products. However, because it is an Excepted Benefits product under the Affordable Care Act, some protections (such as for emergency services and unplanned events) afforded to Our major medical plans are not included in the Access Plan. Please carefully review Our Access Plan information for specific requirements, exclusions and limitations for that product.