Key Terms
Ambulatory surgery – Surgery performed at an ambulatory surgical facility (a licensed public or private facility), which does not provide services or accommodations for a patient to stay overnight.
Coinsurance – The percentage of covered healthcare costs a member pays after the deductible is met. For example, with 20% coinsurance, the member pays 20% of the allowed amount for covered services, and the insurance plan pays the remaining 80%. Coinsurance continues until the out-of-pocket maximum is reached.
Copay – An fixed amount of money that a participant is required to pay each time he or she visits a health care provider or fills a prescription.
Deductible – The annual out-of-pocket amount that a plan participant is responsible for paying before the health plan covers his or her medical costs according to the terms of the plan. Until a person meets the annual deductible, he or she pays the full cost of health care services received, unless the service is not subject to the annual deductible as stated in the benefit schedule.
Freestanding Laboratory – A freestanding laboratory is an independent clinical or diagnostic testing facility not physically attached to or owned by a hospital, operating as a separate entity.
Your ASBAIT member website at Meritain Health – Your online health information website and your personal connection to your plan. Here you can order prescriptions, find health care providers, research health topics and get answers to your questions about health care. The personal information used to access www.meritain.com is confidential. You may need the information on your ID card to log in for the first time.
Provider network – Organization that negotiates special, lower rates for health care services provided by physicians and other care providers who are within the network. Providers who belong to a network are called participating or in-network providers.
Usual and customary charge – Your plan reimburses charges from non-participating or out-of-network providers that are equal to, or less than, usual and customary charges. Usual and customary charges are the amounts most frequently charged for the same service:
- In the same geographic area; and
- By other providers in the same or similar medical area.
The fees charged by non-participating providers may exceed the usual and customary charges recognized by your plan. In such cases, Meritain Health will process an amount equal to the usual and customary charge for the health care service you received, and you will be reimbursed for a portion of that amount according to your plan’s out-of-network benefits.
Claims and Customer Service
Balancing health care costs: What you pay and what the plan pays.
Your Summary of Benefits (SOB) shows how much you pay for care, and how much the plan pays. It’s a listing of what is and isn’t included in your benefits plan. For more detailed information, see your Summary Plan Document (SPD).
For example: After you pay your annual deductible and any up-front copays, the plan begins to pay a percentage of your provider’s charges, for example 80 percent. The remaining percentage, for example 20 percent, is your responsibility—your “out-of-pocket” costs. You’re protected from financial hardship by a maximum out-of-pocket amount each year—the most you’ll have to pay before the plan covers costs at 100 percent.
Claims and customer service
Your ASBAIT claims are administered by Meritain Health. All claims adjudication and customer service inquiries are handled by Meritain Health staff members. Correspondence regarding your claims will be sent from our office. The goal of our Customer Service department is to ensure that school employees understand their plan features and receive immediate assistance regarding claims issues, from a highly-qualified and trained staff member. You will be treated with respect, as we are responsible to you for first call resolution with results. It is our goal to not only meet, but exceed your expectations. If you have any questions regarding your benefit plan(s) please contact Meritain Health Customer Service at 602-789-1170, or toll free at 866-300-8449.
Claim submission – You can submit your claims online using your the Meritain member website (www.meritain.com) and clicking on the submit claims tab or you can mail your claim forms and attachments to:
Meritain Health P.O. Box 853921 Richardson, TX 75085-3921
Cost Estimator Tool
The Transparency in Coverage Final Rule requires group health plans and health insurance carriers to disclose the enrolled member’s cost-sharing liability for covered items or services on an internet website and in paper form (if requested).
The member self-service internet tool will include:
- Cost-sharing liability (deductible, co-insurance, etc.)
- Accumulated amounts
- Out-of-network allowed amount for the covered item or service
- Negotiated rate for in-network services
- Any prerequisite for the covered item or service
The tool is accessible through the Meritain Health member website. Members may also call the customer service number on their ID cards to request assistance. The tool provides 500 items and services that are prescribed in the regulations. The tool will eventually be expanded to include all covered items and services.