4

Add / Edit Benefit Plans

4.1

Click the Benefit Plan category button on the Scenario page.

4.2

Do one of the following:

  • Add a benefit plan to the scenario by clicking New.
  • Edit an existing benefit plan in the scenario by selecting it from list of plans under the Benefit Plan category button, then click Edit.

ESL displays either a blank Benefit Plan window, or a Benefit Plan window containing the information for the selected plan.

4.3

Give the plan a name in the Description / Name field.

4.4

Click the button to the right of the Enrollment Percent field to display the Utilization window.

4.5

Specify plan utilization as follows, then click OK.

Percent
Check this box to set utilization by percentage, then enter the desired percent values in the field for each plan.
Enrollment
Check this box to set utilization by enrollment numbers, then enter the desired enrollment in the field for each plan.
4.6

Check the box by each benefit included in the plan. Checking a box causes its corresponding section in the benefit plan window to appear.

4.7

If the plan includes Medical, check the appropriate Benefit Plan Type box.

4.8

If the plan includes Medical, specify deductible and co-insurance information as follows.

Deductible
Deductible amount for in and out of network care.
Deductible Limit
Sets the deductible limit for in and out of network care.
Co-insurance Percentage
Specify co-insurance percentage for in and out of network care here.
Co-Insurance Maximum
Specify co-insurance maximum amounts for in and out of network care here.
Co-Insurance Max Unlimited
Check Yes if co-insurance maximums are unlimited. Otherwise check No. Specify the limitation for both in and out of network care.
Co-Insurance Limit
Sets the co-insurance limits for in and out of network care.
Maximum Out-of-Pocket
Specify maximum out of pocket amounts for in and out of network care in these fields.
Include Deductible
Check Yes if deductibles are included in maximum out-of-pocket amounts. Otherwise check No.
Second Coins Percentage
Second co-insurance percentage for in and out of network care goes here.
Wellcare Benefits
Use these drop-downs to specify wellcare benefits for in and out of network care.
Include Organ Transplants
Check Yes if the plan covers organ transplants. Otherwise check No.
Transplant Benefit Limit
Enter the maximum amount covered for transplants in this field.
No Limit
Check the box corresponding to the plan limit.
Vary Utilization by Co-Insurance Level
Check the box corresponding to the desired setting.
Infertility Benefit Included
Check Yes if the plan includes infertility coverage. Otherwise check No.
Pre-Certification
Check Yes if the plan requires pre-certification. Otherwise check No.
Concurrent Review
Check the box corresponding to the desired setting.
Extension of Benefits
Check the box corresponding to the desired setting.
Discharge Planning
Check the box corresponding to the desired setting.
Large Case Management
Check the box corresponding to the desired setting.
Dependent Participation
Enter the number of dependents in the plan in this field.
Employer Dependent Contribution
Specify how much the employer contributes to dependent coverage in this field.
4.9

If the plan includes Medical, specify co-pay information as follows

Primary Physician Office Visit
Use these fields to specify co-pay amounts for office visits for in and out of network care.
Specialist
Use these fields to specify specialist co-pay amounts for in and out of network care.
Max Number of Copays
Use these fields to specify the maximum number of co-payments required per year for in and out of network care.
Hospital Stay: Inpatient per Stay
Use these fields to specify co-pay amounts per stay for in and out of network  inpatient hospital care.
Hospital Stay: Inpatient per Day
Use these fields to specify co-pay amounts per day for in and out of network inpatient hospital care.
Outpatient Surgical Center
Use these fields to specify co-pay amounts for in and out of network outpatient surgical visits.
CT Scan / MRI
Use these fields to specify co-pay amounts for in and out of network CT or MRI scans.
Emergency Room
Use these fields to specify co-pay amounts for in and out of network emergency room visits.
Include Med. Copays in Coins OOP Max
Check Yes to include co-payments in the co-insurance maximum out of pocket. Check No to exclude co-payments from the co-insurance maximum out of pocket.
4.10

If the plan includes Medical, specify mental health coverage as follows

Inpatient Annual Day Limit
Specify the annual Day limit for inpatient treatment here.
Outpatient Coverage
Specify outpatient coverage here.
Ultimate Co-Insurance
Specify co-insurance coverage here.
Maximum Benefit
Specify the maximum mental health benefit here.
Maximum Visits
Specify the maximum number of mental health care visits covered in a year.
4.11

If the plan includes Medical, specify substance abuse coverage as follows

Inpatient Annual Day Limit
Specify the annual Day limit for inpatient treatment here.
Outpatient Coverage
Specify outpatient coverage here.
Ultimate Co-Insurance
Specify co-insurance coverage here.
Maximum Benefit
Specify the maximum mental health benefit here.
Maximum Visits
Specify the maximum number of mental health care visits covered in a year.
4.12

If the plan includes Medical, specify supplemental accident benefit coverage as follows

Included Benefit
Check Yes if supplemental accident is included in the plan coverage. Otherwise check No.
Deductible
Specify the supplemental accident benefit deductible here.
Deductible Waived And Co-Insurance Applied
Check Yes if deductibles are waived for supplemental accident benefit and co-insurance is immediately applied. Otherwise check No.
4.13

If the plan includes prescription coverage, specify coverage details as follows

Generic Co-pay
Co-payment for generic medications goes here.
Formulary Co-pay
Co-payment for formulary medications goes here.
Non-Formulary Brand Co-pay
Co-payment for non-formulary brand name medications goes here.
Specialty
Check Yes if specialty medications are covered. Otherwise check No.
Specialty Co-pay
If specialty medications are covered, enter the co-payment for them here.
Maximum OOP
Maximum out of pocket for medications goes here.
Comine with Medical
Check Yes to make prescription coverage part of the plan's medical coverage. Check No to keep prescription coverage as a separate benefit.
4.14

If the plan includes dental coverage, specify coverage details as follows

Deductible
Deductible amount for dental coverage goes here.
Deductible Applies to Class I
Check Yes if the deductible applies toward preventive dental care. Otherwise check No.
I. Preventative
Specify the co-insurance for preventive dental care in this field.
II. Basic Restoration
Specify the co-insurance for basic restorative dental care in this field.
III. Major Restoration
Specify the co-insurance for major restorative dental care in this field.
Annual Maximum Benefit (Class I-III)
Specify the maximum amount payable for preventive, basic restorative, and major restorative dental care in this field.
Orthodontia Coverage
Check Yes if orthodontics are covered. Otherwise check No.
Co-insurance
Specify co-insurance for all dental work not considered preventive, basic restoration or major restoration.
Lifetime Maximum Benefit
Maximum amount payable for dental coverage.
Include Adults
Check Yes if adults are included in dental coverage. Check No if adults are excluded from coverage.
4.15

Click Save.