FREQUENTLY ASKED QUESTIONS
What is GundersenOne?
GundersenOne offers options from Gundersen Health Plan for those purchasing health insurance for themselves and/or their families. Gundersen Health Plan is locally owned and operated providing insurance coverage in the Coulee Region for more than 17 years. More than 85,000 of your friends and neighbors already trust Gundersen Health Plan for their insurance. If you are self-employed, between jobs, working but with no insurance available or enjoying early retirement, GundersenOne may be the right health insurance choice for you.
- Platinum, Gold, Silver or Bronze Level plans to fit your budget and coverage needs
- A network of providers that includes the Gundersen Health System providers you know and trust, along with many regional clinics and hospitals in the Tri-State Region
If you would like to learn more about GundersenOne enrollment, please call the Gundersen Health Plan Enrollment Center at (608) 775-8092 or (855) 685-6404.
What is a subsidy?
A subsidy is a tax credit that lowers monthly premiums. Eligibility is based on income. If you enroll in a GundersenOne plan through this website, you will not be eligible for a subsidy. Many individuals and families are eligible for this help with premium costs. We encourage you to visit the Health Insurance Marketplace website to learn more. If you are eligible for a subsidy, you can purchase your GundersenOne plan through the Health Insurance Marketplace website.
What is the Open Enrollment Period?
The annual Open Enrollment Period takes place once each year. You do not need to have a qualifying event to be eligible to enroll during this time. The 2016 Open Enrollment Period ended Jan. 31, 2016.
What is a Special Enrollment Period?
A Special Enrollment Period is available throughout the year for people who experience a qualifying event such as marriage, birth of a child, adoption or involuntary loss of health coverage. This enrollment period is available for a specified amount of time after a qualifying event has occurred.
When will my coverage be effective?
Coverage effective dates are dependent on enrollment type. You will select coverage effective dates when you enroll.
What is a grace period?
A grace period is a period of time after a payment becomes due before your policy is terminated for non-payment of premium. Gundersen Health Plan has established a three-month grace period. After the initial premium has been paid, subsequent premium payments are due before the first day of each of the following months. The grace period begins on the due date (first of the month) and extends three months from that date. You must pay all outstanding premiums in full prior to the end of the grace period for your coverage to remain in force.
During the second and third months of your grace period, upon receipt of any medical or pharmacy claims, Gundersen Health Plan will pend, or hold, those claims until the appropriate premium payment is received.
Following guidance provided to Issuers from the Marketplace, during the first month of your grace period, Gundersen Health Plan will pay all claims (medical and pharmacy). However, during the second and third months of your grace period, upon receipt of medical and pharmacy claims, Gundersen Health Plan will not pay the claim upon receipt. Rather, the claim will be pended until premium payment for those months have been received. If full outstanding premium payment is not received, you will be responsible to pay any medical and pharmacy claims that were incurred during the second and third months.
What is prior authorization?
You and your physician have the sole responsibility for making medical decisions regarding your care. However, in order to monitor the frequency, intensity and the appropriateness of the services rendered to you, we require prior authorization for certain services. Services that require a prior authorization are identified in your Summary of Benefits and Coverage (SBC), Schedule of Benefits and your Policy. Failure to obtain necessary prior authorization may result in a denial of coverage, in which case, the responsibility of a payment may be yours. Please read your Policy, Summary of Benefits and Coverage (SBC) and Schedule of Benefits carefully to see what covered services require a prior authorization. It is recommended that you contact us for prior authorization requirements before you receive care.
You will be notified of the prior authorization determination no later than 10 business days after our receipt of a request. If it is determined by us the request fails to follow our procedures for filing a prior authorization, you will be notified within 5 days. The period of the initial decision may be extended up to an additional 15 calendar days if we determine it is necessary due to: 1) such matters beyond our control (including a failure to submit necessary information), and 2) we notify you to explain the circumstances regarding an extension prior to the expiration of the initial 10 business days.
What if I need a drug that isn't included in the drug formulary?
Members may request an exception to allow a non-formulary medication to be covered as a formulary drug. All standard decisions will be completed within 72 hours and expedited within 24 hours. A member and/or physician can submit the prior authorization form along with submitting documentation to support the medical necessity of the non-formulary medication. The form is available online for members and/or physicians to access - you can find the form here.
What if I receive services from out-of-network providers?
Whenever you receive services from an out-of-network provider, please be aware that you may be liable for higher out of pocket costs. You may choose to use a non-participating provider; however, you should always request a written referral from our Medical Director prior to receiving such services. When receiving services from an out-of-network provider you will pay more out-of-pocket costs. The plan’s payment for covered services is based on the allowed amount. Because out-of-network providers are not contracted with us, they may balance bill you the difference between the allowed amount and the actual charge. This amount may be significant and is your responsibility. This applies to all services with the exception of urgent or emergent services. For more information on coverage for out-of-network benefits, please refer to your Summary of Benefits and Coverage (SBC) and Schedule of Benefits. These benefits are also called Level 2 benefits.
What is an explanation of benefits (EOB)?
After you have had a healthcare service (for example: wellness visit, Urgent Care), you will receive an Explanation of Benefits (EOB) in the mail. An EOB is a statement that outlines how a member’s health insurance plan contributed to (paid for) a healthcare service (a claim) received by a member of the plan. Sometimes there may be confusion as to how to read this statement. You can view a sample Gundersen Health Plan EOB along with a description of how to read and understand the document here.
What is coordination of benefits?
Coordination of Benefits (COB) is a method of integrating benefits payable under more than one plan so that benefits from all sources do not exceed 100% of allowable expenses.
Can I submit a claim for a healthcare service if my provider fails to do so?
If you receive services from a health care provider who doesn’t file a claim on your behalf or from a non-participating provider and are required to make payment, please obtain a claim form from the provider or provide us with the following information when requesting payment from us.
- Subscriber’s name and address.
- Patient’s name and date of birth.
- Number from your ID card.
- Name and address of the provider of the service(s).
- Name and address of any ordering physician.
- A diagnosis from the physician.
- An itemized bill that includes applicable procedure codes or a description of each charge.
- The date of injury or sickness.
- If you have other coverage, please include the name of the other insurance carrier(s).
- Proof of payment.
Submit this information to the following address:
Gundersen Health Plan, Inc.
1900 South Ave., Mail Stop: NCA2-01
La Crosse, WI 54601
You must agree to provide us with any additional information regarding your claim that we may require to process the claim.
To file a pharmacy claim you may submit an itemized receipt to us. You will receive reimbursement for any covered prescription drug services outlined in Section 4 of your policy, minus the applicable copayment. Reimbursement will be at the current contracted rates and any difference between this rate and the amount that you paid, will be your responsibility. Send the itemized receipt to the address below and include the following information:
- Drug name
- NDC number
- Providers name and NPI number
- Date of service
- How many days the drug was supplied for
- Quantity filled
- Pharmacy’s NABP number
Gundersen Health Plan, Inc.
Attn: Pharmacy Dept.
1900 South Ave., Mail Stop: NCA2-01
La Crosse, WI 54601
For questions on how to file a medical or pharmacy claim, please call Customer Service at (608) 775-8092 or (855) 685-6404. For people who are deaf, hard of hearing, or speech impaired please call (800) 877-8973 or 711 or you may call through a video relay service company of your choice.
What is a retroactive denial?
In the event that Gundersen Health plan determines that a claim was paid in error, the claim payment will be reversed and you may be responsible for any charges you incurred for services you received from your provider. To prevent services being denied after you’ve received care, always pay your premium on time and call Gundersen Health Plan Customer Service prior to obtaining service to verify that the services you will be receiving are a covered benefit under your policy.
What happens if my premium bill is incorrect?
Enrollee recoupment of overpayments is the refund of a premium overpayment by the enrollee due to the over-billing by the Issuer. Gundersen Health Plan runs the premium billing process the second Wednesday of each month. If there are terminated members who have an overpayment on their account, they will be identified by the 15th of each month. Once they have been identified, they will be issued a refund in the amount of the overpayment. However, in situations where you believe you may have overpaid on your account, and your account is still active, please call our Customer Service department at (608) 775-8092 or (855) 685-6404. We will research your request and administer a refund check as appropriate.