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Transparency in Coverage

Welcome to Sidecar Health, a health plan designed to be transparent.  We are excited that You have chosen Us and want You to understand the ideas, words, and documents that You may read when You use this product.  Our innovative approach to health insurance is intended to empower You to make health care decisions without network restrictions and 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’s 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 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.  Until Your deductible is met, the Benefit Amount for each covered service is applied to Your deductible.  There is no deductible for preventive care.  After Your deductible is met, the plan pays You the Benefit Amount for each covered service.  The Benefit Amount will be the same for any provider regardless of what the provider charges.

 

You can view the Benefit Amount for each covered service.

You may view the Benefit Amount for each covered service on Our website.

 

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

You are responsible for any amount charged by a provider in excess of the Benefit Amount.  The plan pays the Benefit Amount even if it exceeds the provider’s charge.

 

You can use the cost estimator tool to view the Benefit Amount for each prescription drug or healthcare service and see what providers have charged other Sidecar Health members for such care.  You are encouraged to call providers before seeking services.  You can ask the provider for their cash price for care.

 

Providers may bill You if they charge an amount greater than the Benefit Amount.  We pay the Benefit Amount.

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 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 that You use a specific claim form to evidence proof of loss.  Instead, proof of loss is shown by submitting to Us a Medical Invoice.  A Medical Invoice is the fully itemized bill or document provided 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.

 

You can upload a picture of the Medical Invoice through the Sidecar Health Portal.

 

Alternatively, You can 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 can call Our Member Care team at 1-877-653-6440.

 

Sidecar Health will issue You a Benefit Card.

We will issue a Benefit Card to You and each person covered under Your plan.  The Benefit Card will be linked 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 have met Your plan deductible, 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.  After We receive the Medical Invoice and adjudicate the claim, We will finalize the Benefit Amount.

 

Regardless of the Swipe Amount, until You have met Your deductible, 100% of the Benefit Amount for the covered service will be applied to Your deductible.  Charges for preventive care will not be applied to Your deductible.

 

Once the deductible has been met, the plan will pay 100% of the Swipe Amount, up to the Swipe Limit, for covered services charged to the Benefit Card.  We will invoice You for the balance if the Swipe Amount is greater than the adjudicated Benefit Amount. We are not required to pay any amount in excess of the Benefit Amount. If the Swipe Amount is less than the Benefit Amount, We will deposit the balance into Your Sidecar Health Account.

 

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 deductible, 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 30 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 in the Sidecar Health Portal; or (3) mailing a written claim to Us, as set forth below.

 

If using the Benefit Card, notice of claim is deemed given when an electronic transaction for a covered service is initiated by using the Benefit Card.

 

Alternatively, You may provide notice of claim through the Sidecar Health Portal by uploading a picture of the Medical Invoice to Us.

 

Finally, You may provide notice of claim by mailing Us a copy of the Medical Invoice.  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 had no legal capacity 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 1-877-653-6440.

 

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 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

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 health care 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.

 

Extended Grace Period for Covered Person(s) receiving APTC

If You purchased an individual plan through the health insurance marketplace and You are receiving advance payments of tax credits (“APTC”) in accordance with the Affordable Care Act, after You make the first premium payment, You are given a grace period of three (3) months if You fail to make a premium payment by the due date.  Your coverage will remain in force during the grace period. However, We will suspend payment of expenses for covered services during the second and third months of the grace period. If Your past-due premium payment is paid by the end of the grace period, We will pay for suspended expenses.

 

If Your past-due premium payment is not paid by the end of the three-month grace period, Your coverage will be terminated effective the last day of the first month of the grace period. You will be responsible for any expenses incurred during the second and third months of the grace period and will be billed for any expenses paid by Us during that time.

 

Standard Grace Period

For members not receiving APTC, after You make Your first premium payment, there is a grace period of 30 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.

 

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.

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 that 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 by You

If You believe that We have overbilled You for Your premium, or made any other error in billing or payment, please contact us at 1-877-653-6440.

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 prior to submitting a Medical Invoice to Us, We will determine Medical Necessity of the covered service upon receipt and inform You if We determine that 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.

 

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 1-877-653-6440.  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

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)

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)

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.