Renew/Terminate Coverage
Terminations
If it becomes necessary for you to terminate your Inclusive Health Policy, you are responsible for notifying to notify us promptly.
According to your Inclusive Health Policy, your policy will terminate:
- On the date You are no longer a Resident of North Carolina;
- On the date You request termination of this Policy in writing, or if later, the date such notice is received by Us;
- On the date of Your death;
- On the date that North Carolina law requires cancellation of this Risk Pool Policy;
- On the date that the Lifetime Maximum Benefit is reached;
- 30 days after We make an inquiry concerning Your eligibility or Residence to which You do not reply;
- On the premium due date if premium is not paid when due, subject to the Grace Period provision;
- On the date there is fraud or material misrepresentation made by or with the knowledge of the Covered Person in applying for this coverage or filing a claim for benefits, subject to the Time Limit on Certain Defenses provision;
- At the end of the month for which Risk Pool premium has been paid, following the date that You cease to meet the eligibility requirements of the Risk Pool, as described in the Loss of Eligibility provision;
- On the date that We cease to offer this particular type of policy in North Carolina, as allowed by state law and subject to Our provision of 90 days advance written notice of such termination to You and the beneficiary. In such case You will have the opportunity at the time of termination to purchase any other policy We offer in North Carolina; or
- On the date that We cease to do business in the individual insurance market in North Carolina, as allowed by state law and subject to our provision of 180 days advance written notice of such termination to You and the beneficiary.
We will provide you with a certification of Creditable Coverage at the time You cease to be covered under this Policy. A certification of Creditable Coverage is a written certification of the period of Creditable Coverage under a health plan and any waiting period and affiliation period imposed with respect to the individual for any coverage under that plan. You may also request a certification of Creditable Coverage from Us within 24 months after the date of termination.
To notify us you should:
1. Fill out an IH Member Change form. A Member Change Form is available at:
An on-line Change Form is also available at:
2. Fax the Inclusive Health Member Change for to: (586) 226-3112.
Renewals
When you enroll in the Inclusive Health plan, your policy and the rates are in effect for one year unless you request to terminate the coverage. Renewals occur once a year and this is the time when a member can change plans, deductible amounts, etc. Your rate is guaranteed for one year from the effective date of the policy and cannot be changed or altered throughout the year.
An Open Enrollment period will occur each year 45 days prior to the new effective date of the policy. Your Inclusive Health Policy states the following:
Changes to Your Premium
Premium is subject to change annually at the time of renewal.
We will provide written notice at least 45 days prior to the Effective Date of any premium change.
To makes a change to your policy during the Open Enrollment Period, please:
1. Fill out an Inclusive Health Member Change form.
A Member Change Form is available at:
An on-line Change Form is also available at:
2. Fax the Inclusive Health Member Change for to: (586) 226-3112.
Please Note: The deductibles under all of the Plans are CALENDAR YEAR deductibles and will reset each January and begin accumulating again with services received after January 1st of each year.
Out of the Area Services
If you are enrolled in one of the Inclusive Health PPO plans (PPO 1000, PPO 2500 or PPO 3500), then you are aware that these are Preferred Provider Plans. What this means is that if you go to a provider in the network the out of pocket expenses are less than if you go outside the network.
If you are out of North Carolina and need care, please be advised that you may also be responsible for balanced billing from providers. What this means is that providers are not required to accept the North Carolina Inclusive Health reimbursement as payment in full and they can charge you the difference in the allowed amount and their charge.
According to your policy, benefits will be paid as follows:
How Benefits are Paid
We will determine if a service received by a Covered Person qualifies as a Covered Health Service. After determining that the service is a Covered Health Service, We will pay benefits as follows:
- We will determine the total amount of eligible Covered Expenses incurred related to a particular Covered Health Service;
- We will then review the eligible Covered Expenses incurred against any Policy or benefit maximums which may apply to a particular Covered Health Service;
- If You are required to pay a Copayment, We will subtract the amount of Your Copayment from the eligible Covered Expense amount;
- If You have not met Your Deductible, We will subtract any amounts You are required to pay as part of Your Deductible;
- We will then review Your Out-of-Pocket Limit. If You have not yet incurred enough Coinsurance expenses to equal the amount of the Out-of-Pocket Limit, We will subtract any Coinsurance amounts You must pay from the eligible Covered Expenses incurred;
- We will make payment for the remaining eligible Covered Expenses incurred to You or the provider of the service; or
- You will not be billed for any amount in excess of the negotiated rate for that service pursuant to the agreement between the provider and Us, unless services are received outside North Carolina. Covered Services received outside of North Carolina will be reimbursed at the applicable Medicare reimbursement rate. You will be subject to costs in excess of Our covered payment.
We will provide you with a certification of Creditable Coverage at the time You cease to be covered under this Policy. A certification of Creditable Coverage is a written certification of the period of Creditable Coverage under a health plan and any waiting period and affiliation period imposed with respect to the individual for any coverage under that plan. You may also request a certification of Creditable Coverage from Us within 24 months after the date of termination.
To notify us you should:
1. Fill out an IH Member Change form. A Member Change Form is available at:
An on-line Change Form is also available at:
2. Fax the Inclusive Health Member Change for to: (586) 226-3112.
Renewals
When you enroll in the Inclusive Health plan, your policy and the rates are in effect for one year unless you request to terminate the coverage. Renewals occur once a year and this is the time when a member can change plans, deductible amounts, etc. Your rate is guaranteed for one year from the effective date of the policy and cannot be changed or altered throughout the year.
An Open Enrollment period will occur each year 45 days prior to the new effective date of the policy. Your Inclusive Health Policy states the following:
Changes to Your Premium
Premium is subject to change annually at the time of renewal.
We will provide written notice at least 45 days prior to the Effective Date of any premium change.
To makes a change to your policy during the Open Enrollment Period, please:
1. Fill out an Inclusive Health Member Change form.
A Member Change Form is available at:
An on-line Change Form is also available at:
2. Fax the Inclusive Health Member Change for to: (586) 226-3112.
Please Note: The deductibles under all of the Plans are CALENDAR YEAR deductibles and will reset each January and begin accumulating again with services received after January 1st of each year.
Out of the Area Services
If you are enrolled in one of the Inclusive Health PPO plans (PPO 1000, PPO 2500 or PPO 3500), then you are aware that these are Preferred Provider Plans. What this means is that if you go to a provider in the network the out of pocket expenses are less than if you go outside the network.
If you are out of North Carolina and need care, please be advised that you may also be responsible for balanced billing from providers. What this means is that providers are not required to accept the North Carolina Inclusive Health reimbursement as payment in full and they can charge you the difference in the allowed amount and their charge.
According to your policy, benefits will be paid as follows:
How Benefits are Paid
We will determine if a service received by a Covered Person qualifies as a Covered Health Service. After determining that the service is a Covered Health Service, We will pay benefits as follows:
- We will determine the total amount of eligible Covered Expenses incurred related to a particular Covered Health Service;
- We will then review the eligible Covered Expenses incurred against any Policy or benefit maximums which may apply to a particular Covered Health Service;
- If You are required to pay a Copayment, We will subtract the amount of Your Copayment from the eligible Covered Expense amount;
- If You have not met Your Deductible, We will subtract any amounts You are required to pay as part of Your Deductible;
- We will then review Your Out-of-Pocket Limit. If You have not yet incurred enough Coinsurance expenses to equal the amount of the Out-of-Pocket Limit, We will subtract any Coinsurance amounts You must pay from the eligible Covered Expenses incurred;
- We will make payment for the remaining eligible Covered Expenses incurred to You or the provider of the service; or
- You will not be billed for any amount in excess of the negotiated rate for that service pursuant to the agreement between the provider and Us, unless services are received outside North Carolina. Covered Services received outside of North Carolina will be reimbursed at the applicable Medicare reimbursement rate. You will be subject to costs in excess of Our covered payment.