Apex Advantage Plan Paired With ManhattanLife Solution Frequently Asked Questions

Overview Questions of the Apex Advantage Plan Paired With ManhattanLife Solution

Why should the Apex Advantage Plan Paired with Manhattan Life be considered health care solution?

By selecting the Apex Advantage Plan along with one of the ManhattanLife Affordable Choice offerings an individual will see lower cost compared to standalone insurance plans called “major medical coverage".

Why do these plans work so well when paired together?

Each plan has a role. The Apex Advantage Plan would be used for Day-to-Day health care needs, with individuals paying a small co-pay for services.  The ManhattanLife Affordable Choice offerings are for unforeseen health care needs.  Services covered through ManhattanLife do not have a deductible.

What States is the Apex Advantage Plan Paired with Manhattan Life solution available in?

The Apex Advantage Plan Paired with Manhattan Life Solution is currently available in 38 states. See attached map.
The Apex Advantage Plan Paired with Manhattan Life Solution

General Questions regarding Apex Advantage Plan Paired with ManhattanLife Affordable Choice Solution

Can an employer replace a “major medical plan” with the Apex Advantage Paired with ManhattanLife Affordable Choice Solution?

If an employer has 50 or more employees they must offer a “major medical plan” to their employees.  Employees can choose to opt out and go to their own individual plan, or choose no coverage at all. 

Employers with more than 50 employees could choose to offer the Apex Advantage Plan Paired with ManhattanLife Affordable Choice Solution as an additional option, and less expensive alternative.

Why is the Apex Advantage Plan only being paired with the Manhattan Life Affordable Choice offerings?

The Apex Advantage Plan is our best-selling solution for covering day-to-day health care issues at a very reasonable cost.  By pairing the broad array of day-to-day health care services offered by the Apex Advantage Plan with the Manhattan Life Affordable Choice offerings, we are providing a viable health care option with optimal coverage.  All this is being offered at a substantially lower price than current major medical plans.

Will this Apex Advantage Plan Paired with ManhattanLife Affordable Choice Solution be ACA (Affordable care Act) compliant?

Yes.  The Apex Advantage Plan will be compliant with all applicable rules and regulations pertaining to Penalty A of the ACA.  See compliance opinion letter under the "About" tab on the website.

The Manhattan Life Affordable Choice offerings are hospital Indemnity plans?  What does that mean?

A Hospital Indemnity (HI) plan provides specific, fixed benefits regardless of actual cost that go directly to the policyholder (unless otherwise assigned).  

Is this Apex Advantage Plan Paired with ManhattanLife Affordable Choice Solution considered a major medical plan?

No, this not a major medical plan solution.  However, the combination of the Apex Advantage Plan Paired with Manhattan Life Affordable Choice Solution offers very comprehensive coverage at a reasonable price.

The Apex Advantage Plan is a self-insured plan. Apex Management Group offers, through a self-funded model, a four (4) year rate lock at a static, premium level. 

The Manhattan Life Affordable Choice Offerings are fixed benefit plans, not major medical plans.  Manhattan Life pays a flat amount listed as scheduled and there is no deductible. 

Can an employer replace a “major medical plan” with the Apex Advantage Paired with ManhattanLife Affordable Choice Solution?

If an employer has 50 or more employees they must offer a “major medical plan” to their employees.  Employees can choose to opt out and go to their own individual plan, or choose no coverage at all. 

Employers with more than 50 employees could choose to offer the Apex Advantage Plan Paired with ManhattanLife Affordable Choice Solution as a less expensive alternative.

Is the Apex Advantage Plan Paired with ManhattanLife Affordable Choice Solution available to Employer groups only?  The minimum Employer group size is four (4) employees.

Apex Management Group is currently making this solution available to Employer Groups Plans only, through a List-Billing Arrangement.

What is a List-Billing Arrangement?

List-Billing is a process that allows an employer to facilitate employees' purchase and payment of individual health insurance policies via post-tax payroll deduction. Under a list-bill arrangement, the employer is sent a single monthly bill "listing covered employees" and the amount due for each employee's personal health care coverage choices.  Employers may elect to pay all or a percentage of the employee bill through the list billing and payroll process.

Can people enroll at any time in the Apex Advantage Plan Paired with ManhattanLife Affordable Choice Solution?

Yes.  The Apex Advantage Plan Paired with ManhattanLife Affordable Choice Solution can be offered 365 days a year.

Are there medical questions to answer in order to enroll for coverage?

Yes, because the ManhattanLife portion of the solution is an underwritten product.  There are no required medical questions for the Apex Advantage Plan portion of the product.

 

Is there a waiting period?

For services covered by the Apex Advantage Plan portion of the solution everything is covered from day one.

For the ManhattanLife Affordable Choice portion of the solution, everything is covered from day one with the exception of pre-existing conditions as outlined during the underwriting.

How long is the waiting period for pre-existing conditions?

If underwriting has determined a condition to be pre-existing, coverage for that condition begins 12 months after the policy has been issued.

Is there a network I must use?

When seeking services provided with the Apex Advantage Plan you must stay within the PHCS network which is owned by MultiPlan. There are over 900,000 physicians in this network nationwide, so finding a doctor should not be a problem.   The Apex Advantage Plan does not provide coverage for out of network services.

For services with the Manhattan Life Affordable Choice portion of the plan, while also utilizing the MutiPlan network, you are not required to use it.  However, using the MultiPlan is advantageous as it will give you access to network discounts. MultiPlan hospital discounts can be as much as 40-50% and physician discounts vary between 25% and 35%.

How long does the claims process take?

Services utilizing the Apex Advantage Plan only require a small co-pay at the time of service.  Services covered through ManhattanLife Affordable Choice options have eligible claims paid within 7-10 business days if receiving all necessary documentation.  Payments from ManhattanLife Affordable Choice options are paid directly to the policyholder (unless otherwise assigned). 

Does the Apex Advantage Plan Paired with ManhattanLife Affordable Choice Solution cover retirees?

No, both plans would terminate upon reaching age 65.

What happens if a person it terminated from their job?

Since the ManhattanLife portion of the plan is truly an Individual Plan (accommodated to an employer group through a List-Billing arrangement), if an individual’s job is terminated, they can take their plan with them and continue 100% of the payments on their own.

However, since the Apex Advantage Plan portion is a true Group Employee Plan would be eligible as a COBRA benefit.

Are pre-existing conditions covered?

There is no underwriting for the Apex Advantage Plan, so all services for this portion of the solution are available from one day one. The ManhattanLife Affordable Choice portion of the solution would cover pre-existing conditions after a 12 month waiting period.

How does the Apex Advantage Plan Paired with ManhattanLife Affordable Choice Solution cover basic doctor visits?

Both plans cover basic doctor visits.  However, the Apex Advantage Plan would generally be the first choice because the patient would only have a small copay for service.

  • $20 Copay for a Primary Care office visit
  • $50 Specialist Office Visit
  • $50 Copay Urgent Care
  • $50 Diagnostic X-Ray, Lab
  • $200 Copay CT Scan or MRI

The Mahattan Life Affordable Choice options would also provide coverage for doctor visits. The payments from these plans would offset most of the co-pays in the Apex Advantage Plan, meaning, some visits would be 100% covered.

  • The Elite Plus Plan covers 4 days at $100 per day
  • The Elite Plan covers 4 days year at $75 a day
  • The Classic Plus Plan covers 3 days at $75 a day
  • The Classic Plan covers 3 days a year at $50 a day.

What about prescription drug coverage?

The Apex Advantage Plan Paired with ManhattanLife Affordable Choice Solution provides prescription drug coverage through both plans.  The Apex Advantage Plan has a 6 Tier plan with patient co-pays.

  • Tier 1 – Low Cost Generics - $1 Copay
  • Tier 2 – Generics - 10% Coinsurance
  • Tier 3 – Preferred Brand - 20% Coinsurance
  • Tier 4 – Non-Preferred Brand - 40% Coinsurance
  • Tier 5 – Specialty, Generic and Preferred - 10%  Coinsurance (Plan pays 90% up to a max of $150 per Rx);
  • Tier 6 – Non-Preferred Specialty – 20% Coinsurance (Plan pays 80% up to a max of $250 per Rx).

All ManhattanLife Affordable Choice options will pay a $25 fixed benefit per prescription with a $750 calendar year maximum.

Is there a military discount?

No. Participation in the military service of any country or international organization will not be covered under the Apex Advantage Plan Paired with ManhattanLife Affordable Choice Solution.

Does the Apex Advantage Plan Paired with ManhattanLife Affordable Choice Solution cover pregnancy?

Generally, no. The basic offerings of the ManhattanLife Plans do not cover pregnancy.  However, the basic Manhattan Life Affordable Choice options may cover complications of pregnancy.  For example, a Caesarean Section may be covered if deemed medically necessary to protect the health and safety of the mother and child.

Is there a way to provide coverage for pregnancy?

ManhattanLife has a gap coverage option called the “Out of Pocket Protection Plan” that could be selected and utilized to provide coverage toward any necessary hospital admission or other health care need. The “Out of Pocket Protection Plan” would add a reasonable additional cost to the Manhattan Life Elite Plus, Elite, Classic Plus, and Classic plans. The “Out of Pocket Protection Plan” provides selected hospital Admission coverage levels of $6,350 / $5,000 / $2,500.

 

Is the optional coverage for the ManhattanLife “Out of Pocket Protection Plan” also available in all 35 States that the ManhattanLife Affordable Choice plan is available in?

No, of the 35 available States that we can offer the Apex Advantage Plan Paired with Manhattan Life Affordable Solution, we are not able to offer the ManhattanLife “Out of Pocket Protection Plan” as an additional option in Alaska, Hawaii, Maine, Montana, Oregon, Utah, West Virginia, or Wyoming.

Does the Apex Advantage Plan Paired with ManhattanLife Affordable Choice Solution cover newborns?

Yes. The first 31 days of a newborn are covered. Within that first month, you must provide notice of birth and additional premiums for them to be covered from their date of birth.

**Some states may vary. Please see your policy for verification.

Does the Apex Advantage Plan Paired with ManhattanLife Affordable Choice Solution will cover outpatient services?

Yes, both the Apex and ManhattanLife plan portions pay for some Diagnostic X-Ray and Lab work.  Preventative services are also covered under the Apex Advantage Plan, and all ManhattanLife Affordable Choice options.

Are benefits paid to the provider or the patient?

The Apex Advantage Plan claim benefit payments are made directly to the provider.  ManhattanLife Affordable Choice benefit payments are paid directly to the policyholder, unless otherwise assigned to an entity.

Is there a surgery benefit?

Yes.  The ManhattanLife portion of the solution has surgical benefits for both inpatient and outpatient surgery with a maximum of $50,000 per calendar year.  Limit of 1 daily benefit per calendar year, daily benefits for both inpatient and outpatient surgery.  The reimbursement schedule for 1 unit is similar to what is payable under the Medicare Physician Fee Schedule for Surgeries.

The ManhattanLife Affordable Choice Surgery Benefits are:

Elite Plan Plus
3 x - the policy fee schedule

Elite Plan
2.5 x - the policy fee schedule

Classic Plan Plus
2 x - the policy fee schedule

Classic Plan
1 x - the policy fee schedule

If a person is Admitted to the emergency room and discharged within 24 hours, or the person goes in as an outpatient will the Apex Advantage Paired with ManhattanLife Affordable Choice Solution cover them.

A person must be admitted for 24 hours to receive the inpatient benefit.  Otherwise, the emergency room visit benefit would be available.

How are claims handled at the hospitalization/surgical level?

The patient would present their card at the beginning of services and assign over all benefits. The provider would then send the invoice for services to ManhattanLife who would then negotiate costs (through Karis 360). Any surplus funds from the assignment would be returned to the patient.  Also, any final amounts due would be invoiced to the patient.

If a person is admitted to the hospital, what will Apex Advantage Plan Paired with ManhattanLife Affordable Choice Solution pay towards the daily room charge?

As of October, 2019 The ManhattanLife portion of the solution will pay the following hospital admissions benefits.

 

Hospital Admissions Benefits                    Elite Plus     Elite       Classic Plus     Classic

(for the first Inpatient Day per calendar yr)    $3,000        $2,000         $1,000           $1,000  

Inpatient Hospital Confinement              Elite Plus     Elite        Classic Plus      Classic

(per Inpatient Day)                                         $5,000        $3,000         $2,000            $1,500

Calendar year Limit                                                        $1,000,000 per year.

Is there a calendar year limit on the Apex Advantage Plan Paired with ManhattanLife Affordable Choice Solution.

The Apex Advantage Plan has certain annual limits on physician visits, procedures, and certain types of prescriptions.  These can be reviewed at:  https://www.apexmanagementgroup.com/plans/manhattanlife-affordable-choice-products-paried-apex-group-products

The ManhattanLife Affordable Choice offerings have a calendar year limit of $1,000,000.

Is there a lifetime limit on the Apex Advantage Plan Paired with ManhattanLife Affordable Choice Solution.

The Apex Advantage Plan benefits are renewed annually.  There is no lifetime limit on the Apex Advantage Plan.

The ManhattanLife Affordable Choice plan options have a $5,000,000 lifetime limit on the policy.