Health insurance can be confusing, especially if you are purchasing health insurance coverage on your own for the first time. That’s why we want to help you understand your options when it comes to health insurance, including common health coverage and medical terms used in plan documents.
Our goal is to provide you with the resources and tools you need to choose health insurance coverage that is right for you, your family, your business, your needs and your budget.
What benefits and services are included in, and excluded from my coverage?
To view a list of your covered benefits and services, refer to your plan materials. These materials include items such as a Schedule of Benefits (SOB), Evidence of Coverage (EOC), Certificate of Insurance (COI), Provider Policy or Pharmacy Rider.
What is an SBC?
A Summary Benefits of Coverage (SBC) document is a document designed to provide concise information to consumers and employers in a uniform format so that you can better understand your coverage.
What is an HSA?
A Health Savings Account (HSA) combines high deductible health insurance with a tax-favored savings account. The funds in the savings account can be used towards qualified medical expenses including co-payments, deductibles and services that are not covered by an HSA-qualified health plan.
Which doctors and hospitals can I access for care?
Your health insurance coverage features a network of healthcare providers to which you have access for care. You can typically find your network name on your member ID card or your plan materials.
How much will I pay for services?
Each health insurance plan has different copayment and coinsurance amounts for covered benefits and services so you can choose the plan that is right for you. Specific plan information can usually be found in your plan materials.
What does Coordination of Benefits (COB) mean?
Coordination of Benefits (COB) is necessary when an individual has healthcare coverage from more than one source. COB refers to the process that determines which plan pays first, which pays second, and so on. The Ohio Revised Code establishes the many rules about the order in which payments are made. The Plan or Policy that pays first is called the Primary plan. The Primary plan must pay benefits in accordance with its policy terms without regard to the possibility that another plan may cover some expenses. The plan or policy that pays after the Primary plan is called the Secondary plan. The Secondary plan may reduce the benefits it pays so that payments from all plans do not exceed 100% of the total allowable expense.
What is the Affordable Care Act?
The healthcare reform law, known as the Affordable Care Act (ACA), was signed into law in March 2010 and is bringing many changes to the way consumers shop for and purchase health insurance and the plans and benefits offered by health insurance companies.
What are some changes under the ACA?
Some of the changes under the ACA include that all individuals are required to have health insurance or pay a tax penalty and individual and family health insurance plans are effective through the end of a calendar year. This means you must shop for and purchase individual health coverage each year during the open enrollment period.
When can I purchase health insurance?
The Open Enrollment Period (OEP) to shop for and purchase individual health insurance coverage ended January 15. If you enrolled between December 16, 2022 and January 15, 2023, coverage will begin February 1, 2023.
What if I need health insurance outside of the OEP?
Outside of the OEP, you can only enroll in a plan if you have a Qualifying Event that creates a Special Election Period (SEP). Voluntarily quitting other health coverage or being terminated for not paying your premiums is not considered loss of coverage. Losing coverage that is not minimum essential coverage is also not considered loss of coverage. Qualifying life events that create a special enrollment period include: Getting married; Having, adopting or placing of a child; Permanently moving to a new area that offers different health plan options; or Losing other health coverage (for example due to a job loss, divorce, loss of eligibility for Medicaid or CHIP, expiration of COBRA coverage, or a health plan being decertified).
How do I estimate my household income?
In order to estimate your premium subsidy amount, you will need to provide your expected annual household income for the year you want coverage, not last year’s income. Income is counted for you, your spouse, and everyone you’ll claim as a tax dependent on your federal tax return. Include their income even if they don’t need health coverage. If you are unemployed make sure you include your unemployment compensation.
What type of individual and family plans does SummaCare offer?
SummaCare’s 2023 plans are a Preferred Provider Organization (PPO) plan type available to individuals and families living in Summit, Stark, Portage and Medina counties and feature the SCConnect network. Plans are categorized into metal tiers to help you understand how you and SummaCare will split the costs of your health care. Percentages shown can include a combination of deductibles, copays and coinsurance.
Which doctors and hospitals can I use with SummaCare Individual & Family Plans?
SummaCare Individual and Family plans feature the SCConnect network. This network provides access to many of the area’s finest doctors, hospitals and providers including Summa Health System, Mercy Medical Center (Canton) and Akron Children’s Hospital.
How do I know if my doctor or hospital is in-network?
Search the SCConnect network to find a doctor, hospital and/or facility.
What if I see a doctor who is not in-network?
Using doctors, hospitals and/or providers outside of the network will be subject to the out-of-network deductible and out-of-pocket maximum.
How do I obtain information about member rights and responsibilities?
As a SummaCare member, you have the rights and responsibilities which can be viewed at www.summacare.com/about-us/member-rights-and-responsibilities.
What benefits and services are included in, and excluded from my coverage?
To view a list of your covered benefits and services, please view the plan materials in your member account. You may also request materials online or call SummaCare Member Services at the number listed on the back of your member ID card to request a copy of your Schedule of Benefits, Evidence of Coverage, Certificate of Insurance, Provider Policy or Pharmacy Rider.
What are my copayments and other charges I am responsible for?
For copayment and/or coinsurance information specific to your plan, please refer to your Schedule of Benefits (SOB). You may view your (SOB) by logging in to your member account. You may also request materials online or call SummaCare Member Services at the number listed on the back of your member ID card to request a copy of your SOB.
What benefit restrictions apply to services obtained outside SummaCare’s service area?
To review out-of-network benefit restrictions, please refer to your Evidence of Coverage, Certificate of Insurance or Provider Policy. You may request materials online or call SummaCare Member Services at the number listed on the back of your member ID card to request a copy.
How do I obtain language assistance?
SummaCare provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact Member Services at the number listed on the back of your member ID card.
How do I submit a claim for covered services?
If you receive care from an In-Network provider, you do not need to submit a claim for the covered services. If you receive care from an Out-of-Network provider, please complete and submit a Medical Claim Form
How do I obtain information about practitioners who participate in the SummaCare network?
You can search for practitioners who participate in the SummaCare network by using our online tool.
How do I obtain primary care services, including points of access?
Find a primary care physician by using our online tool. You can search for a primary care physician by selecting "Family Medicine (PCP)," "General Practice (PCP)," "Internal Medicine (PCP)," or "Pediatrics (PCP)."
How do I obtain specialty care, behavioral health services and hospital services?
Find a hospital, specialist or behavioral healthcare provider by using our online tool.
How do I obtain care after normal office hours?
If you need medical advice after normal office hours, call SummaCare's 24-Hour Nurseline at 800.379.5001. If you need emergency care, call 911 or go to the nearest hospital.
How do I obtain emergency care and what is SummaCare’s policy on when to directly access emergency care or use 911 services?
An emergency is defined as a medical condition that manifests itself by acute symptoms of sufficient severity, including severe pain, that a prudent layperson with an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in any of the following: placing the health of the individual or the health of a pregnant woman or her baby in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any body organ or part. If you experience symptoms that meet the definition of an emergency, call 911 for emergency assistance or go to the nearest emergency room. If your condition does not warrant emergency care, consider alternatives.
How do I obtain care and coverage when I’m out of SummaCare’s service area?
If you are traveling outside the SummaCare service area, please refer to your member ID card to find your applicable wrap network(s).
How do I voice a complaint?
A complaint may be voiced by calling SummaCare Member Services at the number listed on the back of your member ID card. You may also submit a complaint in writing by submitting a letter, fax or email to SummaCare describing the complaint.
How do I appeal a decision that adversely affects coverage, benefits or my relationship with SummaCare?
Members have 180 calendar days from the date when notification of an initial/prospective determination was issued to appeal a decision. Appeals can be submitted in writing and emailed (appeals@summacare.com) to the attention of SummaCare Appeals mailed (Appeals Department P.O Box 1107 Akron, OH 44309-1107) or FAX at 330.996.8545.
If you are dissatisfied with the outcome of your appeal, you may have the right to an independent review if the services requested are deemed non-covered services (excluded), not medically necessary or are considered experimental and you have a terminal illness. Medical appeals will be reviewed by a state accredited Independent Review Organization (IRO), which is a group of independent doctors and nurses. The Ohio Department of Insurance (ODI) will review benefit appeals.
How does SummaCare evaluate new technology for inclusion as a covered benefit?
SummaCare is committed to providing members with access to the most up-to-date treatment and state-of-the-art care that is both safe and effective. This commitment requires thoughtful evaluation of emerging new technologies on an ongoing basis for inclusion in the SummaCare benefit package. SummaCare's Health Services Management staff queries the following sites on a monthly basis to assess for new medical technologies: Medscape, Hayes Directory, Agency for Health Care Policy and Research, Center for Medicare and Medicaid Services and American Medical Association.
How do I obtain information about utilization management, case management and other health programs?
SummaCare provides members with appropriate medical services, valuable health benefits, programs, and discounts to help members live healthier lives. To learn more about utilization management and how to enroll in the health & wellness programs go to summacare.com/member/health-and-wellness.
Why do some services require prior authorization and/or need to be reviewed for medical necessity?
Certain services require prior authorization in order to be covered under your health plan. We review requests to determine whether the services are medically necessary according to generally accepted standards of care. The services that require prior authorization are usually ones that have a high likelihood of excessive or inappropriate use.
We must receive the request for prior authorization before the services are provided, except in emergency situations. Emergency services, whether provided by a preferred (in-network) provider or a non-preferred (out-of-network) provider, do not require prior authorization.
Who is responsible for obtaining prior authorization?
When you receive care from preferred (in-network) providers, the provider is responsible for obtaining prior authorization, but you should confirm with your primary physician or specialist that prior authorization was requested. If you choose to receive your care from non-preferred (out-of-network) providers, you are responsible for obtaining the necessary prior authorization for the services.
How do I get prior authorization?
To request prior authorization, call the number on the back of your SummaCare Identification Card. You can ask for a list of services requiring prior authorization (open list by calling SummaCare Member Services at 330.996.8515 or toll-free at 800.753.8429 (for TTY call 711).
What happens if I don’t get prior authorization?
When you receive care from a preferred (in-network) provider, the provider is responsible for obtaining prior authorization, when necessary. If the preferred (in-network) provider fails to get prior authorization, we will not pay for the services and the provider cannot bill you for them. Emergency services, whether provided by a preferred (in-network) provider or a non-preferred (out-of-network) provider, do not require prior authorization.
When you receive care from a non-preferred (out-of-network) provider, you are responsible for obtaining all necessary prior authorizations. If the proper prior authorization is not completed, the service will be reviewed for medical necessity and to determine if it is a covered service. If the service is determined to be not medically necessary or not a covered service, the claim will be denied. You have the right to appeal the decision if you do not agree with the decision. You will be responsible for meeting the non-preferred (out-of-network) provider deductible and for all copayments and coinsurance and any balance billing from the non-preferred (out-of-network) provider. Your level of coinsurance is a lower reimbursement level than what it would be if you had used a preferred (in-network) provider.
How quickly will SummaCare respond to requests for prior authorization?
Once we receive all the clinical information we need to make a decision, we will do so as quickly as your situation requires. The time frames below reflect how quickly we are required to respond:
The time frames above may be extended if we need additional information or for other reasons beyond our control. If we need more time, we will notify you and/or the provider. We will let you know what additional information is needed, or why the extension is needed and the date we expect to make a decision.
What is a Comprehensive Formulary?
A comprehensive formulary is a list of all covered drugs selected by SummaCare in consultation with a team of healthcare providers. The formulary represents the prescription therapies believed to be a necessary part of a quality treatment program. SummaCare will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a network pharmacy and other plan rules are followed.
SummaCare covers both brand name drugs and generic drugs. Generic drugs have the same active-ingredient formula as brand name drugs. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.
Can the Formulary Change?
Generally, if you are taking a drug on our formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released.
If we remove drugs from our formulary or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.
Are there procedures related to my prescription drug benefits that I should be aware of?
Yes. SummaCare Drug Formularies indicate if a drug has limitations such as Prior Authorization, Step Therapy or Quantity Limits. Below is what is required should your medication have one of these limitations:
The SummaCare Drug Formulary also indicates Specialty Drugs with an asterisk (*). Specialty drugs are expensive prescription drugs that require special handling and storage and are not always readily available at a retail pharmacy. Specialty Drugs are used to treat chronic or genetic conditions including, but not limited to, Multiple Sclerosis, Psoriasis, Rheumatoid Arthritis and Viral Hepatitis. All Specialty Drugs require prior authorization. Most SummaCare prescription drug benefits limit Specialty Drugs to a 30 day supply and will only cover them when filled through our contracted specialty pharmacy.
For more information, please refer to your Prescription Drug Rider and the SummaCare Drug Formulary or go to www.summacare.com/member/drug-benefits
What Pharmacies Are Included?
Learn what pharmacies are in our network and search for pharmacies by using our Find Your Pharmacy tool.
Please review the Notice of Privacy Practices, which describes how medical information about you may be used and disclosed and how you can get access to this information.
