What is the Health Care Cost Reimbursement Plan?
The Health Care Reimbursement Plan is an employer-funded, health benefit plan that allows employers to reimburse employees for certain medical expenses on a tax-advantaged basis.
How Does the Sankaty Key Employee Health Care Cost Reimbursement Plan work?
Our plan allows employers to reimburse key employees for out-of-pocket medical expenses not otherwise covered by their base health insurance plan, 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).
The employer pays a $500 fixed Annual Premium for each selected plan participant. When a participant has eligible reimbursable expenses, they are submitted to Sankaty Light Benefits for reimbursement. The amount of the approved claim + 15.5% (the Variable Premium) is invoiced to and paid by the employer. Sankaty Light Benefits then promptly reimburses the employee via direct bank deposit. The Annual and Variable Premiums are tax-deductible expenses for employers.
Does the employer’s underlying plan have to be employer based?
No.The underlying health 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 health plan during the entire period the Sankaty Lights Benefits coverage is in effect.
What are Sankaty’s eligibility requirements of the employer’s base healthcare plan?
Full-time employees who are regularly scheduled to work 25 or more hours per week who are approved and covered under the employer's Base Health Plan.
Who is covered under this policy?
The policy covers the key employee selected by the employer, his/her spouse or domestic partner and children up to age 27.
Is there a required number of plan participants?
Yes. Our plan requires a minimum of three participants.
Is there a limitation on pre-existing conditions?
No. There are no limitations on pre-existing conditions for the covered employee and children up to the age of 27. Benefits may also be extended to retirees, members of the board of directors and surviving spouses as the employer may designate.
Is there a waiting period for an employer to be approved for plan participation?tead of an FSA, HRA, 105 Plan, and other company-funded health accounts?
No. If an employer’s underlying health care plan meets our eligibility requirements, the designated employee or participant is promptly approved for plan participation.
Why should I choose the Sankaty Key Employee Health Care Reimbursement Plan ins
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 Sankaty 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 healthcare plan – plus provides superior tax advantages and savings to employers and employees. And unlike company-funded or self-insured health plans, our plan can be offered to select employees at the employer’s discretion versus all employees.
Can I use an HSA (Health Savings Account) 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 coverage.
Plan Coverage Questions
What is covered?
The Sankaty Key Employee Health Care Reimbursement 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 insurance plan. Some covered charges include, but are not limited to:
- Deductibles, co-pays, 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
- 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
- Non-prescription drugs, except insulin.
- 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.
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 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?
We cover 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 you pay for membership in a weight reduction group as well as fees for attendance at periodic meetings. You cannot include membership dues in a gym, health club, or spa as medical expenses, but you can include separate fees charged there for weight loss activities.
You 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 I submit a claim?
Claims can be submitted online by going to our claims administration web portal.
What is my group name and group number?
Your group name is the name of your employer as submitted on the application. Your group number is the number assigned to your group and can be found on your Sankaty Light Benefits Certificate of Insurance.
Do claims require supporting documentation?
Yes. The Explanation of Benefits (EOB) from your company’s base health plan is required for every medical claim to show the services provided first went through your company’s primary plan. If the service provided is explicitly not covered by the base plan and was denied we will review your company plan description to verify. 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.
Do I need to upload my supporting documentation separately?
No. You can upload all of the supporting documentation one time in the claims administration portal.
When is the deadline for submitting claims from the previous year?
Submitting claims is based off your policy year. You have 90 days past your renewal to submit claims for the previous policy year. See below for how this affects your group:
|Renewal Date||Claims Deadline|
|January 1st||March 31st|
|February 1st||April 30th|
|March 1st||May 31st|
|April 1st||June 30th|
|May 1st||July 31st|
|June 1st||August 31st|
|July 1st||September 30th|
|August 1st||October 31st|
|September 1st||November 30th|
|October 1st||December 31st|
|November 1st||January 31st|
|December 1st||February 28th|
How can I set up direct deposit payments for my reimbursement?
We can send your reimbursement by direct deposit if you have submitted an ACH form or EFT form. ACH information and EFT forms can be submitted on our web portal.
I received an email saying my Explanation of Benefits can now be viewed online. What does this mean?
The Explanation of Benefits provides details for what claims have been processed; including both approved and denied claims. Your entire claims history is stored in our web portal in the form of EOBs and can be accessed at any time. You will receive full instructions for processing claims and how to contact us for prompt service for your claims.
Will Sankaty Light Benefits accept and process claims for medical services rendered outside of the United States?
Yes. As long as your company is domiciled in the United States and offers an eligible underlying health 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.