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Georgia Health Insurance - Affordable Health Insurance Quotes in Georgia

How the Lumenos Health Insurance Plan Works

The Lumenos plan is an innovative approach to health benefits that puts you in charge of the money you spend for health care services and helps you get the most out of your company- sponsored health coverage. With the Lumenos plan, you have flexibility and control in choosing the health care services you and your family members receive - and in determining how the cost of these services is paid.

Health Reimbursement Account (HRA)

Through the Lumenos plan, the company makes an annual allocation to a Health Reimbursement Account (HRA) for you and your covered dependents (the HRA is a bookkeeping account, and not a trust of any sort). You can use your HRA to pay for Covered Services not otherwise covered by the Traditional Health Coverage such as the cost of routine medical expenses like office visits and lab tests, as well as preventive care - including health screenings, physicals and other covered services, for you and your eligible dependents.

In addition, you can use your HRA to cover other Lumenos plan costs including: any covered services above the Reasonable and Customary amount, services beyond the annual benefit maximums and coinsurance you incur in your Traditional Health Coverage.

The HRA is only available for IRC Section 213(d) Qualified Medical Expenses, and even these are subject to the terms of the benefit plan; you can never take amounts out of the HRA in cash for other than the reimbursement of expenses covered under the Lumenos plan.

IMPORTANT! Any HRA amounts that you use to cover expenses above the Reasonable and Customary amount or for services beyond the annual benefit maximums will not count toward your annual out-of-pocket maximum.

The annual company allocation to your HRA is:

$500 - single coverage
$1,000 - family coverage (combined family limit)

NOTE: If you join the Lumenos plan at any time other than at the beginning of the Plan year (January 1, 2006), the initial amount allocated to your HRA will be prorated based on the number of months left in the Plan year.

The HRA approach gives you the opportunity to build your available health care dollars over time. If you don't use the full amount of your HRA each Plan year, the remaining amount can be rolled over and used the next Plan year.

NOTE: If you experience a change in family status during the Plan year that results in a reduction in coverage (i.e. from family to single), your allocation will not change until the beginning of the next Plan year. If the change in family status results in an increase from in coverage (i.e. from single to family, you will receive an additional allocation equal to the difference between the levels (i.e. single to family) allocation. If your participation in the Lumenos plan ends for any reason, any balance in your account will be forfeited back to the company.

Bridge

If you use your annual company allocation to your account and you need additional services from the Traditional Health Coverage, you will have to pay a specified out-of-pocket amount before the Traditional Health Coverage begins. This is called your Bridge.

Your Bridge is:

$500 -single coverage
$1,000 - family coverage

If you have been in the Lumenos plan for more than a year, you may have money saved up in your account from previous years. If so, you may have enough to cover your Bridge - and therefore not pay anything out of your pocket before the Traditional Health Coverage begins.

Choice of Providers

Providers Who Offer Lumenos Discounts

Providers Who Do Not Offer Lumenos Discounts

Traditional Health Coverage

In addition to your account, the Lumenos plan offers additional health coverage to protect you and your family in case you incur significant health care expenses or if your expenses exceed your annual company allocation. This coverage begins once you have used the entire annual company allocation on covered services and pay your Bridge.

Coinsurance

When using the Traditional Health Coverage, you pay a certain percentage of the cost of covered services through coinsurance. Generally, the Traditional Health Coverage pays 60% to 90% of the cost of most covered services, and your coinsurance amount is 10% to 40% up until a limit called the coinsurance maximum. The coinsurance maximum is the most you pay in coinsurance expenses for covered services in a Plan year.

The annual coinsurance maximums for the Traditional Health Coverage are:

$1,000 -single coverage
$2,000 - family coverage

Member Advance

In some cases, you will see an "advance" listed on the Explanation of Benefits (EOB) you receive in the mail after receiving medical services. If necessary, an advance may need to be made to your account to cover the cost of medical expenses. This occurs when a claim has been paid but there are insufficient funds in your account to cover the entire expense. When there is an advance, your payment will automatically deduct the cost of the advance from a future claim (including claims for preventive care services) in order to reconcile your account.

Out-of-Pocket Maximum

The Lumenos plan's out-of-pocket maximum is the most that you will pay toward covered health expenses in a Plan year. Once you reach the out-of-pocket maximum under the Lumenos plan, the Plan pays 100% of covered services for providers who offer discounts and 100% of Reasonable and Customary charges for providers who do not offer discounts.

The Lumenos plan's out-of-pocket maximums are:

$1,500 - single coverage
$3,000 - family coverage

IMPORTANT! Amounts you pay toward the cost of certain medical services will not count toward your annual out-of-pocket maximum. These include any cost you pay:

for any service that is not a covered service under the Traditional Health Coverage
toward expenses that are in excess of Reasonable and Customary charges
toward expenses that are in excess of annual maximums

Lifetime Benefit Maximum

All benefits paid under any Lumenos plan (whether as an active employee or retiree) apply towards the Lifetime Maximum described herein. You and your covered dependent(s) each have a lifetime benefit maximum of $2,000,000 under the Plan. This is the total amount of benefits you can receive under the Plan in a lifetime. Once you or your covered dependent reach this limit, you are responsible for the full cost of any additional services you or your dependent(s) may receive.

Inpatient Admission

To help assure that your treatment is Medically Necessary under the terms of your health plan, We have partnered with FutureHealth to provide admission and concurrent review of inpatient admissions for hospital (medical and surgical), rehabilitation, skilled nursing facility, psychiatric hospital and detoxification facility. Transplant services require pre-certification before scheduling the procedure. For these services you or your physician must notify the plan at the number listed on the back of your Lumenos ID card prior to admission.

In case of an emergency, notify the plan within 48 hours of your admission by calling the number listed on the back of your Lumenos plan ID card.

This notification process assists us in helping you manage your health care. If you have a serious or chronic condition, a Personal Health Coach will be available to help you or your dependent in coordinating resources.

NOTE: Under federal law, benefits for any hospital stay in connection with childbirth for the mother or the newborn cannot be restricted to less than:

48 hours - following a normal vaginal delivery
96 hours - following a cesarean section

Although you are encouraged to call, neither you nor your physician needs to pre-notify the plan for any length of stay less than these periods for childbirth. However, the physician, after consulting with the mother, may discharge the mother or newborn before the 48- or 96-hour timeframe noted above.

Online Health Site

The Lumenos plan offers online health and financial tools to help you manage your health and make the best use of your health care dollars.

Health Tools

The Lumenos plan offers several resources designed to help you stay healthy, deal with an illness or injury and prepare for a medical procedure or treatment, including:

Doctors Plus Directory
My e-Checkup
My Family Health File
Personal Health Coach
24-Hour Nurse Advice

Whether you're going for a routine check-up, managing a medical condition or getting ready for surgery, the Lumenos Online Health Site delivers the information and support you need around these topics and more.

Doctors Plus Directory

The Doctors Plus Directory will help you locate - and find information about - doctors and other health care services in your area. Whether you need a specialist, a pharmacy, a hospital, vision care, a chiropractor or a nutritionist, you'll find it in one place. In addition, this directory will help you:

find out which providers offer discounts
find an estimate on how much you'll typically be charged for certain services
get background information about physicians
view provider recommendations from other consumers
get directions and a handy map

To access the Doctors Plus Directory, log in to www.lumenos.com. By entering your user name and password, you will be able to access the secure site and search for providers and pertinent information regarding ratings, discounts, etc. You can also obtain a hard copy of the Doctors Plus Directory by calling Customer Service at (866) 835-6863.

My e-Checkup

Evaluate your overall health, help identify risks and find out how to help optimize your health. Use My e-Checkup to prepare for a routine physical - evaluate your health online, print out your family health history to share with your doctor, and find out what questions you should ask and what tests your doctor should perform.

My Family Health File

Store your family's medical records online at one secure, convenient location. Well- managed records help you and your doctor plan your preventive care and treatment.

Personal Health Coach

Through a partnership with FutureHealth Corporation, the Lumenos plan can provide you a Personal Health Coach. A Personal Health Coach is a registered nurse who assists you in receiving available health care services when you are faced with a serious illness or ongoing health problem. If the claims review indicates you might benefit from having a Personal Health Coach, one will contact you to discuss your needs.

This confidential service is designed to help you use your benefits most effectively, answer health care questions, arrange for treatment, coordinate your care and help you follow through with your doctor's instructions. The Personal Health Coach will work with you to coordinate your health care.

24-Hour Nurse Advice Line

Nurse Line is staffed 24 hours a day seven days a week by registered nurses. Nurses provide you and your family members with health care education and decision support for routine health conditions.

Financial Tools

The Lumenos plan offers online financial tools to help you keep track of your health care dollars. Plus you can track your claims for covered services. You can review what you've spent on health care, view your HRA balance or look up the status of a particular claim any time of the day.

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