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.

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


SimplePay pharmacy coverage includes retail, specialty, and mail order benefits, just like your existing plan. The prescription benefit is included in the medical plan out-of-pocket.


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 Walgreens 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.


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.)


Good news! 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.

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.

 

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

Eden Health Virtual Primary Care


Included in medical election for employees and dependents with $0 copay.

 

Virtual Primary Care Benefits

This unique benefit is included for all medical plan members and your covered dependents, and is the easiest way to get the primary care you need while at home or on the-go, at no cost to you.


What you get:

  • Extended, unrushed doctor’s visits
  • No paperwork, no wait time
  • Expert team of providers
  • Prescriptions or medical refills any time
  • Nationwide medical assistance
  • Help with COVID-19 concerns
  • Lifestyle coaching
  • 24 / 7 virtual care

 

Scope of Care

Acute Care

  • Diagnose and treat illnesses, injuries, and infections including
  • Colds, flus, and other bacterial, fungal, & viral infections
  • Rashes, acne, and dermatological issues
  • Sprains, strains, aches, and pains
  • Fatigue, weakness, dizziness, & headaches

Preventive Care

  • Annual wellness exams
  • Travel medicine and prophylaxis coordination
  • Behavioral and sexual health screenings
  • Illness and injury prevention

Chronic Care

  • Management of ongoing issues
  • Allergies
  • Asthma
  • Diabetes
  • High and low blood pressure
  • High cholesterol
  • Gastrointestinal disorders
  • Back and muscular pain

COVID 19 Care

  • Patient questions around COVID-19
  • Virtual symptom screening
  • Medical guidance, support, and testing coordination

 

2021 Wellness Program


More information on the 2021 wellness program coming soon!

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.

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.