Sankaty Light Benefits - General Questions
What is the Sankaty Key Employee Health Care Cost Reimbursement Plan known as ExecSelect™?
The ExecSelect™ Plan is an employer paid, fully insured, health benefit plan that allows employers to provide insured reimbursements to key employees for certain medical expenses not covered by the employer’s base health care insurance plan (“Base Plan”) on a tax advantaged basis. The ExecSelect™ Plan has a maximum annual aggregate benefit of $100,000 per participant and an occurrence limit of 10% (or $10,000).
How Does the ExecSelect™ Plan work?
Our ExecSelect™ plan allows employers to provide health care cost reimbursement to selected key employees for out-of-pocket medical expenses not otherwise covered by their Base Plan, or other group plan or government plan. Employers can choose which employees they want to offer the plan to (typically high-level talent that drives and sustains business growth).
What Is the Premium Structure?
The employer pays a $500 Fixed Annual Premium for each selected key employee plan participant. This Fixed Annual Premium covers the key employee, spouse or domestic partner and dependent children up to age 27 (“Family”). The Fixed Annual Premium is invoiced and payable at the beginning of each plan year. There is no other fixed monthly or periodic premium charge.
When a participant incurs eligible medical expenses not covered by the Base Plan, they are submitted to Sankaty Light Benefits for reimbursement. The approved claim amount + 15.5% of the approved claim amount (the “Variable Premium”) is invoiced to and paid by the employer to Sankaty. Upon receipt of the Variable Premium, Sankaty Light Benefits then promptly reimburses the employee via direct bank deposit. The Fixed Annual Premium and the Variable Premiums are tax-deductible expenses for employers.
Does the employer’s underlying plan have to be employer based?
No. The underlying Base Plan can be an employer group plan, individual policy, spousal policy or Medicare. Also, all insured employees and dependents must be covered by an eligible underlying Base Plan during the entire period the Sankaty Lights Benefits coverage is in effect.
Who is covered under this policy?
The policy covers the designated key employee participant, his/her spouse or domestic partner and children up to age 27. Additionally, the employer may elect to extend ExecSelect coverage to retirees, members of the board of directors and surviving spouses.
Is there a required number of plan participants?
Yes. The ExecSelect™ plan requires a minimum of three key employee participants designated by the employer.
Is there a limitation on pre-existing conditions?
No. There are no limitations on pre-existing conditions for the covered employee and his/her eligible dependents.
Is there a waiting period for an employee to be approved for plan participation?
No. If an employer’s underlying Base Plan meets our eligibility requirements, the designated employee is promptly approved for ExecSelect™ plan participation.
Why should an employer choose the Sankaty ExecSelect™ Plan instead of an FSA, HRA, 105 Plan, and other company-funded health accounts?
HRAs, HSAs, FSAs and other such company-funded consumer health accounts may provide employees with funds for healthcare expenses – but these accounts are not health insurance, and are limited in the amount of employer funding as well as what medical expenses funds can be used for.
The ExecSelect™ plan, however, provides real health insurance coverage, benefits and value. It provides coverage for deductibles, co-pays, co-insurance and a broad range of other out-of-pocket medical expenses that are not covered by the company’s underlying Base Plan – plus provides superior tax advantages and savings to employers and employees. And unlike company-funded Base Plans, our ExecSelect™ can be offered to select employees at the employer’s discretion versus all employees.
Can an HSA (Health Savings Account) be used with the Sankaty Plan?
No. If the company’s base medical plan is a High Deductible Health Plan that incorporates an HSA, its employees are not eligible for Sankaty Light Benefits ExecSelect™ coverage.
Plan Coverage Questions
What is covered?
The ExecSelect™ Plan reimburses eligible medical expenses not otherwise covered by the employer’s basic health insurance. Generally, if an expense is medically necessary and qualifies under Section 213(d) of the IRS Code, it would be eligible for reimbursement under our ExecSelect™ plan. Some covered charges include, but are not limited to:
- Deductibles, co-pays, coinsurance payments,
- Prescription drugs
- Private-duty nursing and home health care
- Hospital expenses, including private-room charges
- Dental and orthodontic expenses
- Alcoholism and drug-abuse treatment and facilities
- Vision care, including all types of frames
- Inpatient and outpatient psychiatric care
- Charges for the diagnosis of infertility
- Charges for the treatment of infertility up to 10% of the annual maximum per calendar year
- Certain non-prescription drugs, including insulin.
- Medical supplies and equipment
- Speech therapy for speech loss or impairment due to illness or surgery
- Smoking cessation programs
- Chiropractic services
- Wigs purchased upon the advice of a physician for the mental health of a patient who has suffered hair loss due to a disease
- Prescribed Birth Control
- Lasik surgery
- Contact lenses
- Breast pumps and supplies
- Hearing aids
What is not covered?
The below items are not covered in the plan:
- No benefits are payable unless the individual is under the direct care of a legally qualified physician for reasonable and necessary treatment.
- Any premiums including, but not limited to Base Plan (or Cobra Continuation of the Base Plan), Medicare Part B, Medicare Part D, and Prescription Drug Plans
- Losses due to war
- Expenses the individual is not legally obligated to pay in the absence of insurance
- Charges for appointments not kept
- Hospitalization, services, treatments or supplies furnished by the U.S. or foreign government agency, unless otherwise prohibited by law
- Service contracts or warranties relating to vision care
- Custodial care
- Accident or illness for which the individual is entitled to benefits under any worker’s compensation or occupational disease law
- Health club dues or exercise equipment
- Blood storage
- Hospital charges for confinement in a long-term care unit or skilled nursing facility unless confinement commences within 14 days after discharge from a qualifying hospital confinement
- Baby-sitting, childcare, and/or nursing services for a healthy child. You cannot include any amount paid for childcare even if this enables you, your spouse, and/or dependent(s) to receive medical treatment.
Must the underlying Base Plan include vision, dental and hearing for Sankaty Light Benefits to cover the charges?
No. If vision, dental, and hearing are not covered by the underlying plan, ExecSelect™ will reimburse the charges.
Are Master Social Workers and Family Counselors covered under the Sankaty Plan?
Yes, master social services and psychologists are covered, even if the services are not covered by the underlying Base Plan.
Are elective procedures covered?
If an expense is medically necessary and qualifies under Section 213 (d) of the IRS code, it is eligible for reimbursement. Elective procedures that are not medically necessary are not covered.
What about Weight-Loss Programs?
ExecSelect™ covers expenses for weight-loss programs lose if they are treatments for specific diseases diagnosed by a physician such as obesity, hypertension, or heart disease. This includes fees paid for membership in a weight reduction group as well as fees for attendance at periodic meetings. A participant in ExecSelect™ cannot include membership dues in a gym, health club, or spa as medical expenses, but such participant can include separate fees charged there for weight loss activities.
A ExecSelect™ participant can include the cost of special diet food in medical expenses only if:
- The food doesn't satisfy normal nutritional needs,
- The food alleviates or treats an illness, and is substantiated by a physician.
- The amount eligible for reimbursement is limited to the amount by which the cost of the special food exceeds the cost of a normal diet.
How do participants submit a claim?
Claims can be submitted online or in paper form as suits the participant.
What is my group name and group number?
The participant’s group name is the name of the employer submitted on the application. The group number is the number assigned to the participant’s group and can be found on page 1 of the Sankaty Light Benefits ExecSelect™ Certificate of Insurance.
Do claims require supporting documentation?
Yes. The Explanation of Benefits (EOB) from the employer’s Base Plan is required for every medical claim to show the services provided first went through the company’s Base Plan. If the service provided is explicitly not covered by the Base Plan and was denied, participant must submit the company’s Base Plan description explaining the service is not covered. In addition, an itemized statement of services from the healthcare provider – that includes the patient’s name, date and type of service, diagnosis and charges – must be included with each claim. Prescription drug receipts must include patient name, name of prescription, date the prescription was filled and co-payment amount, if applicable.
Claims cannot be processed from balance forward/due statements, charge card receipts, or cancelled checks.
Must a participant upload all their supporting documentation separately?
No. Participants can upload all of the supporting documentation one time.
When is the deadline for submitting claims from the previous year?
Submitting claims is based off the employer’s policy year. Participants have 90 days past renewal to submit claims for the previous policy year.
How can participants set up direct deposit payments for their reimbursement?
Sankaty can send reimbursements by direct deposit if participants have submitted an ACH form or EFT form. These are available upon request from Sankaty.
Will participants get reimbursed faster if they submit claims online instead of mailing them?
Yes. Online submission of claims will have the effect of eliminating the time for mail to be delivered and processed.
For log in information, please refer to the confirmation email participants received when their Direct Deposit was initially set up. If a participant does not have Direct Deposit and would like to enroll, they should contact Sankaty to sign up. If a participant cannot find their confirmation email, they should please call Sankaty for assistance.
Will Sankaty Light Benefits accept and process claims for medical services rendered outside of the United States?
Yes. As long as the employer is domiciled in the United States and offers an eligible underlying Base Plan, a participant can incur a claim outside of the United States. In order to process these claims, the participant is responsible for translating the supporting documentation to English and converting the funds to American Dollars.