Medical

Jim Ellis is pleased to offer a healthcare plan called SimplePay Health. The goal with SimplePay is to simplify the healthcare experience while getting you and your dependents to the best doctors available.

You can contact SimplePay today to find out specific physician and cost information: 800-606-3564 or healthpro@simplepayhealth.com.

Healthcare is complex.  One of the problems with healthcare is that most of the time, we don’t know what we will owe in advance of a service or procedure.  Another problem is that there is a tremendous variation in quality between doctors within the network, and we can’t easily identify the best doctors to ensure we get the best quality care while avoiding unnecessary procedures. SimplePay Health solves both of these challenges.

 

Important Documents

COVID Testing


SimplePay Health Plan participants have access to $0 cost COVID-19 testing as long as the tests are submitted through insurance. Both Rapid and PCR tests are covered at 100%. In-network testing facilities include LabCorp, Quest Diagnostics, CVS, and Walgreens - as well as in-network doctor's offices. For more information, contact your SimplePay Health Pro by calling 1-800-606-3564 or emailing healthpro@simplepayhealth.com.

Over-the-Counter COVID Test


Starting January 15, per guidance from the “Agencies” (Department of Labor, Health and Human Services, and Treasury), at-home over-the-counter (OTC) COVID-19 tests authorized by the U.S. Food and Drug Administration (FDA) can be processed either free of charge through your MedOne prescription benefit or submitted for reimbursement. You will not need a prescription or a note from your provider for coverage under this new guidance.

How do I get a free at-home over-the-counter (OTC) COVID-19 test?
We encourage you to firstly order your free at-home tests from directly via https://www.covidtests.gov/. These test kits will not run through your MedOne prescription plan. Effective for purchase dates on or after January 15, 2022, at-home over-the-counter COVID-19 tests authorized by the
U.S. Food and Drug Administration (FDA), can be processed either free of charge through your MedOne prescription benefit or submitted for reimbursement. You will not need a prescription or a note from your provider for coverage under this new guidance. The expiration of this guidance to cover at-home over-the-counter (OTC) COVID-19 tests under the prescription benefit is unknown at this time.

Your prescription plan offers up to 8 free at-home over-the-counter COVID-19 tests authorized by the U.S. Food and Drug Administration (FDA) per covered plan member per calendar month.

How much will I pay for a test kit processed at the pharmacy counter?
Please utilize a pharmacy in the MedOne network for processing of your test kit at point of sale (at the pharmacy counter). The MedOne pharmacy network is the same network you utilize today for your prescription needs. If you have the test kit ran through the MedOne pharmacy benefit at point of sale (at the pharmacy counter), your cost share will be $0.

How much will I be reimbursed for an at-home COVID-19 test if I purchase the test upfront and then submit a claim for reimbursement to MedOne (vs. it being ran through the MedOne pharmacy benefit at the pharmacy counter)?
Be sure to keep your receipt and product packaging if you need to submit a claim to MedOne for reimbursement. MedOne will process your test kit claim at a rate of up to $12 per individual test (or the cost of the test, if less than $12). Please see the attached OTC COVID-19 Test Claim form. This form is located on the resources page, under the medical section. 

Who can I call if I have more questions?
If you have questions about processing of at-home over-the-counter COVID-19 tests through your MedOne prescription benefit, please call MedOne at the phone number on your member ID card.

 

For additional details, please see the OTC COVID Test Member communications, located on the resources page, under the medical section. 

Healthcare Process


 

Medical - Copay Plan


No deductible, no coinsurance, only copays.  Once you meet the Out-of-Pocket Maximum, the plan pays 100%.  With this plan option, you will pay less at the time of service for your medical care.  You could pay significantly less at the time of service if you use Tier 1 providers (described below), because copays for these providers are lowest.   

 

Sample ID Card

Three Simple Steps for Healthcare


Copays Based on Quality of the Physicians


Data shows that within the same health plan networks, all doctors are not the same in terms of quality.  Some physicians have better outcomes and lower readmission and complication rates than others.  With SimplePay, the copays are based on the quality of the physicians, and you pay a lower copay for better quality providers.  SimplePay’s tools make it easy for you to make informed healthcare decisions and identify the level of quality for individual doctors. 

 

Know What You Owe Up Front


SimplePay’s mobile app includes a user-friendly doctor search tool with a map that displays doctors within your search parameters and the corresponding member copays.  You’ll also have a dedicated HealthPro, available by telephone and app messaging.  The HealthPro is your resource for all aspects of your health plan, including doctor recommendations.

 

 

Large National Open Access Network


The SimplePay Health plan includes in-network coverage only. You must access a participating provider for coverage to apply.  However, the network is extensive.  The SimplePay Health plan uses the national Aetna Open Choice PPO network.  Access aetna.com/individuals-families/find-a-doctor.html, then select Plan from an employer, and choose Open Choice PPO under Aetna Standard Plans.

 

The plan is “open access.”  You’re not required to select a Primary Care Physician, and you may go directly to a specialist within the network without a referral.  We do however, encourage you to use the search tools to access the best providers that have the lowest copays.  

Preventive Care and Unlimited Coverage


In compliance with the Affordable Care Act, preventive care is covered at 100% with no member cost share.  Simply use the app search tool or contact your HealthPro for assistance.   There are no pre-existing limitations, and the plan includes unlimited coverage for covered services.

No Payment at Time of Service


You pay nothing at the time of service at the physician’s office or the pharmacy.  You will receive one consolidated monthly SimplePay statement.  For Copay plan members, it will include your member copays.  For HDHP members, the statement will include your deductible expenses until you meet your deductible.  No more Explanations of Benefits (EOBs), and no more multiple bills from doctors and hospitals.  The SimplePay health plan pays the providers in full.

 

Convenient Financing Available

Another great feature of the new SimplePay Health plan is built-in zero-interest member financing available. If you can’t pay your monthly copay statement by the due date, you can take advantage of a zero interest payment plan through convenient payroll deduction.

Medical Plan Summary


Prescription Drug Coverage


The SimplePay Health Plan includes retail and mail order prescription drugs benefits. The prescription drug benefit is included in the medical plan out-of-pocket. 

 

The Health plan does not include coverage for specialty medications. Specialty medications are high cost oral and injectable drugs that treat complex chronic conditions. For a list of specialty medications please see the 2022 medical section on the Resources page


Did you know certain pharmacies are more expensive than others and cost the health plan more money for same exact medication? For example, the same prescription you fill at CVS could cost twice as much as a prescription filled at your local grocery store. Just like the health plan, you’ll pay less when accessing certain pharmacies for your prescriptions. SimplePay has a user-friendly prescription drug search tool that allows you to select your pharmacy based on cost. Effective 1/1/2022, Walgreens is an excluded pharmacy.


MedOne is the name of your prescription drug vendor, and the MedOne Rx logo is included on your health plan ID Card. (There is a single ID card for both medical and pharmacy.)


Your SimplePay Health Pro is your single-point-of-contact for your medical and pharmacy service needs.

 

 

Please note: The SimplePay Health plan requires pharmacies to dispense generics when available unless the physician specifically prescribes preferred brand or non-preferred brand and indicates “Dispense as Written.”  Should a member choose a preferred or non-preferred brand when the physician allowed the generic to be dispensed, the member will pay the difference between the generic and the preferred or non-preferred brand.   The cost difference is not covered by the plan and does not accumulate towards the out-of-pocket maximum.

Pharmacy Benefit Program Enhancement


We are excited to announce an enhancement to the pharmacy benefit included in the Jim Ellis medical plan. Effective August 1, 2022, your pharmacy benefit will incorporate over 20 discount card networks, including GoodRx.  As a result, you will no longer need to present any discount cards to your pharmacy.  Simply present the new Meritain medical ID card that you will be receiving in the mail, to receive the lowest price possible for your medications. 

 

Important information and action items:

  • Effective August 1, 2022, your current medical insurance card will no longer be active. You will need to provide your new medical insurance ID card (once received) to your pharmacy, ASAP. Not doing so will result in a possible claim denial on your prescriptions.  The new ID card includes an updated RxBin 022832.
  • Please do not use an automatic voice system for prescription refills until AFTER you have presented your new medical insurance ID card to your pharmacy. When ordering refills for the first time (post 8/1) you will need to speak with a member of pharmacy personnel first, to make sure your insurance coverage information has been updated.
  • Please also ensure that your insurance information has been updated for any of your current mail order prescriptions. Not updating this information could lead to a rejected claim and a delayed processing time.
  • Notify any dependents you cover under your Jim Ellis health plan that they also need to use the new medical insurance ID card (once received) at the pharmacy to avoid prescription denials and delays. 

 

Questions?  Contact the Jim Ellis Benefits Service Center by calling 770-295-1100 or emailing benefits@jimellisbenefits.com.

 

If you have questions or issues at the pharmacy when attempting to fill a script, contact the SimplePay Health Pros at 1-800-606-3564, MedOne Advocates at 855-210-6985, or the Benefits Service Center. 

International Pharmacy Programs


You may qualify for free prescription medications with one of the International Rx Programs!  All employees, spouses, and dependent children who are enrolled in a Jim Ellis medical plan are eligible. All members may receive eligible prescription medications at zero cost ($0 copay), simply by enrolling to receive these medications through international mail order. If your medications are included on the list of eligible drugs, you’ll receive an Enrollment Package automatically that will include an enrollment form and program information. Members taking eligible Brand medications will be contacted by CanaRx. Members taking eligible Diabetic medications will be contacted by ElectRx. 

CanaRx (Brand Rx)

• Phone: 866-893-6337

• Email: info@canarx.com

ElectRx (Specialty and Diabetic Rx)

• Phone: 855-353-2879

• Email: info@electrx.com

SimplePay Health Monthly Statement


Instead of receiving Explanations of Benefits and bills from the doctor or hospital, you receive one medical statement at the end of the month summarizing the copays or deductibles you owe from the past 30 days. The copays on your statement match the copay amounts provided through the search tool or your Health Pro. There is a possibility the physician or pharmacy could bill less than the copay, in which case the lower billed amount would display on your statement. If you pay your statement in full by the due date, you’ll receive 1.5% credit on future statements.

 

  1. In the event you have a $0 balance, you will not get a statement in the mail.  You can still go online to see any posted transactions. 
  2. Statements include medical and pharmacy expenses.
  3. The balance is due by the end of the month of the statement date.
  4. You must pay the minimum due by the due date to not enter the autopay program the following month.  Once you are in the autopay program, you stay in that program until the balance is paid in full.  To get out of the autopay program, you can go into the system and make a payment above and beyond the minimum that pays off the full balance.

 

MyPHA


Did you know that you have a Personal Health Assistant?

That's right, someone to help you understand your health issues, how to log in and use your benefits, find the right resources and doctors, pay less for prescriptions, provide support and coaching, answer your questions, and more! Best of all, this service is free and completely confidential.

 

Tenisha DeWindt

972-893-4005

tenisha.dewindt@mypha.com

SimplePay Health Clinical Solutions


SimplePay Member Portal


This informative video (password: Simple2021!) contains information on accessing the online member portal, such as:

  • Registering/Activating your account
  • Navigating the portal at a high level
  • How to search for a provider
  • How to search for a pharmacy and prescription costs
  • Accessing SimplePay claims and statements
  • How to access ID cards

How Copay Tiers Are Determined


Tiering Methodology

SimplePay Health uses one of the country’s largest healthcare databases consisting of 30+ billion Medicare and Commercial claims. SimplePay uses this data to accurately determine the quality of providers in your network. Below are the 4 Primary components that SimplePay Health uses to assign provider tiers:

 

Quality of Care – Quality is studied first and is the primary driver in assessing a provider’s tier. A few of the determining factors for quality include:

  • Outcomes
  • Board Certifications
  • History of Malpractice
  • Hospitalization Rates
  • Timely and Effective Care
  • Readmission Rates

 

Relationships It is important that providers are referring to other high-quality physicians and operating within high quality facilities to ensure you are receiving the best care possible.

 

Experience – Physician years of experience plays a factor in assigning the tier of the provider. Additionally, past member experiences play a roll. There is value in having positive experiences with a health care provider throughout your episode of care.

 

Cost – Providers must demonstrate they provide cost efficient care.

 

If you have additional questions relating to the quality of your current provider or provider you are considering using, please do not hesitate to reach out to your Simplepay Health Pro at 800-606-3564 or HealthPro@simplepayhealth.com.

Livongo - Diabetes Management


Your enrollment in the SimplePay medical plan includes a diabetes management program called Livongo.  Livongo (Diabetes and Cardiovascular Disease Management) helps make it easier to live with diabetes and high blood pressure.  Livongo is available to you, your spouse, or your dependent(s) enrolled in the SimplePay Health medical plan who have been diagnosed with diabetes and/or hypertension.  The program includes the benefits below: 

  • Connected devices – A blood glucose meter and blood pressure monitor that upload readings to secure online account; you can also get valuable guidance.
  • Support from Coaches – Communicate with coaches about diabetes and ask questions on nutrition or making lifestyle changes.
  • Unlimited strips at no cost – Livongo ships supplies right to your door when you are running low.

 

To sign up, simply visit join.livongo.com/SIMPLEPAY/register.  Attached is additional information on the program, and we encourage you to take advantage of this free benefit to help manage your health.

 

Please contact your SimplePay Health Pro at 800-606-3564 or via email at HealthPro@simplepayhealth.com with any questions.

Edison Healthcare


As part of our commitment to transforming healthcare, we continually pursue new benefits that support our employees and their families by providing the highest quality healthcare available.  Edison Healthcare is part of the medical plan for 2022.

Distance and cost should never get in the way of you receiving the best possible medical care. Our employees who are enrolled in medical will have full access to Edison’s Smart Care Network.  All possible barriers have been removed for the best care and all travel expenses will be covered for you and a companion. All employees, spouses, and dependent children who are enrolled in the medical plan are eligible.  This is ZERO COST HEALTHCARE at AMERICA’S BEST MEDICAL CENTERS for the below diagnosis types.

 

Edison specializes in delivering excellent and appropriate care to individuals facing spine, joint & orthopedic, heart/valve, and cancer surgeries for adult and pediatric patients.

 

Second Opinions

A thorough medical review is provided before travelling to an Edison’s Smart Care Center.

 

Travel with Ease

Edison will coordinate all of your travel, cover all costs, and provide you a prepaid card for your food and incidentals. Traveling for care has never been this easy!

 

Why are Edison’s medical centers considered the best of the best?

  • Medical centers that are recognized as the top in the world based on risk-adjusted quality outcomes.
  • Multi-disciplinary teams who deliver a fully vetted diagnosis, the best possible treatment, and extraordinary surgical outcomes.
  • Team-based diagnosis / treatment plan for all and doctors who are paid a salary rather than procedure based compensation.

 

Get to know Edison
We encourage you to reach out and learn how Edison can help you and your family today. We understand how frightening a new diagnosis can be, which is why we have partnered with Edison to give you the best resources and care possible!

Phone: (866) 982-7988
Email: ehc@edisonhealthcare.com

Patient Process: https://edisonhealthcare.com/patientprocessvideo

Transparency in Coverage - Machine-Readable Files (MRF's)


The Transparency in Coverage final rule, released on October 29, 2020, requires health plans and issuers to publicly disclose pricing information via machine-readable files (MRFs) that include:

  • Negotiated rates for in-network providers,
  • Billed charges and allowed amounts paid for out-of-network providers

In compliance with this ruling, you can find the latest version of the MRF, at the weblink, below. Please note that the files contained at this weblink, will be refreshed on a monthly basis. The machine-readable files are formatted to allow researchers, regulators, and application developers to access and analyze data more easily.

 

https://Health1.Meritain.com/app/public/#/one/insurerCode=MERITAIN_I&brandCode=MERITAINOVER/machine-readable-transparency-in-coverage?searchTerm=17753&lock=true

Separations


For employment separations, the medical plan coverage end date is the date of separation.  In certain cases, medical plan premiums may be paid by employees through the end of the pay period, but the medical plan coverage end date could be prior to the end of the pay period. 

American Exchange


Free Health Insurance Enrollment Available Through American Exchange.

 

American Exchange has partnered with Jim Ellis Atlanta as an option to provide employees with a free insurance enrollment and advisory service for Individual Marketplace plans. By calling 888-995-1674, you will be directed to a local Licensed Agent who can help you understand your health insurance options. The call is 100% free and individual rates may be cheaper for your spouse and dependents.

 

You can also click here to set an appointment online: American Exchange.