Your Groups Proposed VEBA Health Plan (Effective Date: 07/01/2017)

Presented by
Corporate Solutions and Excel Benefits

Thank you for considering Corporate Solutions & Excel Benefits.

Please take the time to go through this brief presentation to learn
more about the VEBA health plan & how to properly fill out and submit
the provided personal health questionnaire (PHQ).
Presentation Outline
Section 1: What is a VEBA?
A general overview of pertinent VEBA plan information.
(Voluntary Employer Benefit Association)

Section 2: Which plans do the dentists choose from?

A general overview of the 2 selected plans to choose from.

Section 3: How do the dentists fill out and submit the personal health questionnaire?
A general overview how to properly and completely fill out the provided personal health
questionnaire (PHQ) form for submission.

Section 4: How to fill out simple employer application.

VEBA: Key features
A VEBA is form of trust fund permitted under United States federal
tax law whose sole purpose must be to provide benefits for the
beneficiary of the trust including health insurance.
Premium payment is deducted monthly from the contractors
service fee.

1099 laborers are eligible

VEBA: Key features Continued
Premium rates remain constant throughout the entire calendar
year.

Premium rates and medical benefits are available and consistent

throughout all 50 states.
Enrollees are entitled to use physicians and hospitals all throughout
the United States.
The program utilizes an extensive National PPO network.
VEBA: Key features Continued
Example: Lisa is a dentist whose residence is in San Antonio. She works
as a contracted dentist and travels to dental clinics all around the United
States. Under her VEBA plan, Lisa will have the same insurance
coverage and same premium rates whether she is in San Antonio or
working anywhere else in the United States.
Two Plans Comparison - Benefits
Plan Provisions Opt. 1 - $1500 Deductible Plan Opt. 2 - $2000 Deductible Plan

Lifetime Maximum Coverage Unlimited Unlimited

In-Network Annual Deductible

Individual: $1,500 / Family: $3,000 Individual: $2,000 / Family: $4,000
(Doesnt include copayments)

Non-Network Annual Deductibles

Individual: $3,000 / Family: $6,000 Individual: $5,000 / Family: $10,000
(Doesnt include copayments)

In-Network Out of Pocket Maximums Individual: $3,000 / Family $6,000 Individual: $6,000 / Family: $12,000

Non-Network Out of Pocket Maximums Individual: $6,000 / Family: $12,000 Individual: $12,000 / Family: $24,000

In-Network Office Visits Primary Care

$25 Co-payment, then Plan pays 100% $40 Co-payment, then Plan pays 100%
(exams or consultations)

Non-Network Office Visits Primary Care Deductible, then Plan pays 60% of allowed Deductible, then Plan pays 60% of allowed
(exams or consultations) amount amount

This comparison is for illustration purposes only. Complete benefit information and actual premium cost are subject to change according to the underwriting guidelines and will be in the group contract.
Two Plans Comparison - Benefits
Plan Provisions Opt. 1 - $1500 Deductible Plan Opt. 2 - $2000 Deductible Plan

In-Network Office Visits Specialist

$45 Co-payment, then Plan pays 100% $60 Co-payment then Plan pays 100%
(exams or consultations)

Non-Network Office Visits Specialist Deductible, then Plan pays 60% of allowed Deductible, then Plan pays 60% of allowed
(exams or consultations) amount amount

In-Network Office Services - basic services

with exam (does not include pain mqmt., Plan pays 100% Plan pays 100%
chemo, surqical)
Non-Network Office Services - basic services
Deductible, then Plan pays 60% of allowed Deductible, then Plan pays 60% of allowed
with exam (does not include pain mqmt.,
amount amount
chemo, surqical)

In-Network Wellness Care - Adult Plan pays 100% Plan pays 100%

Non-Network Wellness Care - Adult No Benefit No Benefit

This comparison is for illustration purposes only. Complete benefit information and actual premium cost are subject to change according to the underwriting guidelines and will be in the group contract.
Two Plans Comparison - Benefits
Plan Provisions Opt. 1 - $1500 Deductible Plan Opt. 2 - $2000 Deductible Plan

In-Network Wellness Care - Child Plan pays 100% Plan pays 100%

Non-Network Wellness Care - Child No Benefit No Benefit

Allergy Treatment - Injections & Serums No Benefit No Benefit

In-Network Allergy Treatment - Testing Plan pays 80% Plan pays 80%

Deductible, then Plan pays 60% of allowed Deductible, then Plan pays 60% of allowed
Non-Network Allergy Treatment - Testing
amount amount

Emergency Room - Facility (Co-payment

$200 Co-payment, then Plan pays 100% $300 Co-payment, then Plan pays 100%
waived if admitted)

This comparison is for illustration purposes only. Complete benefit information and actual premium cost are subject to change according to the underwriting guidelines and will be in the group contract.
Two Plans Comparison - Benefits
Plan Provisions Opt. 1 - $1500 Deductible Plan Opt. 2 - $2000 Deductible Plan

In-Network Ambulance: up to $5000 Plan pays 80% Plan pays 80%

Deductible, then Plan pays 60% of allowed Deductible, then Plan pays 60% of allowed
Non-Network Ambulance: up to $5000
amount amount

In-Network Birth Control / IUD Plan pays 100% Plan pays 100%

Deductible, then Plan pays 60% of allowed Deductible, then Plan pays 60% of allowed
Non-Network Birth Control / IUD
amount amount

This comparison is for illustration purposes only. Complete benefit information and actual premium cost are subject to change according to the underwriting guidelines and will be in the group contract.
Two Plans Comparison - Benefits
Plan Provisions Opt. 1 - $1500 Deductible Plan Opt. 2 - $2000 Deductible Plan

In-Network Chiropractic Services: Limit of 20 Plan pays 80% Plan pays 80%

Deductible, then Plan pays 60% of allowed Deductible, then Plan pays 60% of allowed
Non-Network Chiropractic Services: Limit of 20
amount amount

Generic - $10 Co-payment Brand Formulary - Generic - $10 Co-payment Brand Formulary -
In-Network Only Covered Prescription Drugs $30 Copay Br/Non-form - $60 Co-pay Spec $40 Copay Br/Non-form - $70 Spec Drugs 25%
Drugs $100 Co-pay Co-pay up to $300 maximum

Generic - $25 Co-pay Brand Form - $75 Co-pay Generic - $25 Co-pay Brand Form - $100 Co-
In-Network Only Mail Order Drugs
Br/ Non-form - $150 Co-pay pay Br/ Non-form - $175 Co-pay

In-Network Only Hospital Stay Deductible, then Plan pays 80% Deductible, then Plan pays 80%

Deductible, then Plan pays 60% of allowed Deductible, then Plan pays 60% of allowed
Non-Network Hospital Stay
amount amount
This comparison is for illustration purposes only. Complete benefit information and actual premium cost are subject to change according to the underwriting guidelines and will be in the group contract.
Two Plans Comparison - Rates
Coverage Tier Opt. 1 - $1500 Deductible Plan Opt. 2 - $2000 Deductible Plan

Individual Only $619 $573

Individual & Child(ren) $962 $863

Individual & Spouse $1,204 $1,105

Individual & Spouse & Children (Family) $1,276 $1,178

Premium rates are constant for each calendar year, that is they only can change on January 1st
of each year.
The premium payment is deducted from contractor fees every month. Participating dentists will be
contributing 100% to their own premiums e.g. a dentist who has Individual Only coverage under
the $2000 Deductible Plan will have $573 deducted from their service fees each month as long
This comparison is for illustration purposes only. Complete benefit information and actual premium cost are subject to change according to the underwriting guidelines and will be in the group contract.
Personal Health Questionnaire (PHQ)
The acceptability of each group is determined upon the answers in
the personal health questionnaire submitted by the members of the
group.

Acceptance or rejection of the group is determined largely by these

questionnaires.

It is absolutely important & necessary that all information filled

out by the members of the group be accurate and complete, as
indicated by the examples.
 How To Fill Out A PHQ: Group & Member Information

Plan selection is either the $1500 Deductible Plan or $2000 Deductible Plan,
whichever you choose.
How To Fill Out A PHQ: Dependent Information
Personal Health Questionnaire Summary
4 sections
Group & Member Information
Dependent Information
Medical Information
Signatures
Member and Group information section is straightforward. Make sure it is to be complete and accurate.
If applying for coverage that will include dependents, make sure to include all dependents in the
Dependent Information section.
Completely fill out medical information section.
Medical information pertains to the applicant and dependents if applying for dependent coverage.
If a question is marked yes, it is required to elaborate in the section provided.
Give dosages and frequency of medication used where applicable.
Do not circle boxes when marking them, use a check mark.
Do not forget to sign and date where needed.
Make sure to sign the waiver statement if waiving and indicate who is waiving and why
Make sure to ALWAYS sign to release medical records and ALWAYS sign the first statement about the
information being complete and accurate
Employer Application
Where and when to submit PHQ and Employer Application
MUST BE SUBMITTED BY SUNDAY 05/21/2017 FOR CONSIDERATION OF
COVERAGE

When the PHQ and Employer Application are filled out pleased submit to either...
Fax: 1-210-593-0087
Or
Email: mitchell.bigley@excelbenefits.biz

If you have any questions regarding the PHQ or Employer Application please do not
hesitate to contact us...
Phone: 210-593-1500
Email: mitchell.bigley@excelbenefits.biz
Thanks for viewing and we appreciate the chance to
serve you!