Referral

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An official notice from a qualified physician to an insurer that recommends specialist treatment for a member. Referrals from a member’s Direct Primary Care physician are required for all non-emergency services on Decent plans.

Out-of-pocket Maximum

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Out-of-pocket refers to the member’s personal cost. An out of pocket expense can refer to how much the co-payment, coinsurance, or deductible is. The out-of-pocket maximum is referring to how much the member would have to pay for the whole year out of their pocket, excluding premiums, after which the plan pays for 100% of in-network services.

Out-of-network

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These are physicians and medical establishments that are not covered under your insurance plan. Services from out-of-network providers are usually more expensive than those rendered by in-network providers. This is because out-of-network providers have not negotiated lower rates with the insurer. The member’s plan may also dictate there is no coverage for out-of-network services outside of urgent and emergent care.

In-network

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These are the physicians and medical establishments that deliver patient services covered under the insurance plan. In-network providers are the most affordable option to members. Insurers typically have negotiated lower rates with in-network providers.

Individual and family deductibles

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Each family member has an individual deductible. The family has a deductible, too. All individual deductibles funnel into the family deductible. The family deductible can be reached without any members on a family plan meeting their individual deductible. For example, a family of four on the 2021 Saver 70 plan with Decent would have an Family Deductible of $8,500, while each individual member would have an Individual Deductible of $4,250. Once the sum of all deductibles combined reaches $8,500, the deductible will have been met.

Deductible

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A deductible is how much the member pays for health care services out-of-pocket before health insurance kicks in. Once the deductible limit is met, the member may still need to pay copays and coinsurance until they’ve hit the out-of-pocket max, after which the plan pays for 100% of in-network services.

Co-payment (Copay)

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A fixed rate a member will pay for a health service. For example, the 2021 Zero 90 plan on Decent has a Specialist Visit copay of $50. The amount spent on a copay does not apply to the deductible.

Contribution

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This is the amount an employer pays toward employee health insurance premiums, which may or may not include a contribution to employee dependents’ premiums.

Coinsurance

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This is the percentage an insurer will pay for a health service. The member pays the difference. For example, the Decent 2021 Zero 60 plan has a 50% coinsurance on specialty drugs after the pharmacy deductible is met. This means a member will pay for the cost of specialty drugs until they reach their Pharmacy deductible of $5,500. After that point, their plan will pay 50% of the cost of the specialty drug.

Claim

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A claim is a request for payment sent to a health insurer, and is usually submitted by a health care provider for health services rendered to the member. How claims are paid depend on many factors. For example, the member’s plan, the provider’s network status, and any agreements in place with the provider and/or facility where the health services took place all play a role.

What do Decent plan names mean?

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Levels: 60, 70, 80, 90

These numbers indicate the actuarial value of the plan. The higher the numbers, the richer the plan is. We've built our 60 plans to correspond to the estimated value of a standard bronze plan, the 70 roughly equals a silver plan, ect.

Zero

  • "Zero" refers to a $0 Medical deductible.
  • These plans have a separate deductible for Specialty Pharmacy (Tier 4 & 5) prescriptions.
  • Specialty Pharmacy (Tier 4 & 5) drugs account for 1.9% of all prescriptions, and are used by about 2% of the US population.
  • Tier 1 (Generic), Tier 2 (Preferred) and Tier 3 (Brand Name) drugs do NOT count towards the Specialty Pharmacy Deductible.
  • You can find a complete listing of Tier 1, Tier 2 and Tier 3 drugs in our formulary.

Remote

  • "Remote" plans feature Virtual Direct Primary Care.
  • Instead of travelling to an office, with Virtual Direct Primary care a mobile app allows you to securely connect to your personal Primary Care Doctor.
  • Virtual Direct Primary Care enables the treatment and diagnosis of over 1,500 conditions, as well as writing prescriptions and creating referrals.
  • If members are on a Remote plan and their Virtual Direct Primary Care doctor thinks they need to see a primary care doctor in person, they'll need to pay the specialty copay on their plan.
  • Plans without the "Remote" designation feature in-person Direct Primary Care, where your personal Primary Care Doctor has a physical office you can visit.
  • ALL PLANS feature $0, unlimited access to your personal Primary Care Doctor.

Saver

  • "Saver" plans can be used with a Health Savings Account (HSA), and are considered High Deductible Health Plans (HDHP).
  • HSAs allow you to save pre-tax dollars to use towards qualifying medical expenses, can earn interest over time, and do not expire at the end of the year.

What happens if my employees travel outside of Decent’s Texas service area?

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Direct Primary Care & Virtual Direct Primary Care doctors can address many medical questions and issues remotely, even when you're travelling out of state. Wherever members are, if they need Urgent or Emergent care, they should go get it - it's covered.

Which plans should I pick for my employees?

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Consider what you have now:

Employees who currently have Gold-level plans may expect something similar.

Consider which 2-3 plans to offer as a set:

Consider a set of plans that have a range of benefits so that each employee can find something that fits their specific health needs.

What is the minimum premium contribution rate required to enroll in a Decent employer plan?

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Generally, the more an Employer contributes to premiums, the more likely the company will reach the participation minimum (40%).

Employee premiums:Employers must contribute between 50% and 100% to Employee-only premiums.

Dependent premiums:While Employers are not required to contribute to dependent premiums, greater contributions generally result in a higher participation rate (and higher satisfaction) by Employees.

How is Decent’s Direct Primary Care (DPC) model different from other primary care?

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All Decent plans include a subscription to a members only Direct Primary Care or Virtual Direct Primary Care Clinic. Members get the same doctor for every visit, so they can build a trusting relationship with their doctor. Direct Primary Care (DPC) is about focusing time and care on the patient instead of the traditional fee-for-service revenue model. This allows the DPC to spend more time with their patients and conduct comprehensive care management, while reducing the overhead and negative incentives associated with fee-for-service third-party-payer billing. As a Decent member, that translates to more savings and more access to their physician than the traditional primary care physician (PCP) model.

What is the difference between age-banded and composite rates?

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Age-Banded rates are simple and predictable. Blended/Composite rates are more common for companies with 5 or more employees.

Age-Banded rates:These pre-established rates are based on age and location. Employee premiums are looked up by age, the age of their dependents, and where they live.

Blended/Composite rates:Blended/Composite rates include four rate tiers: Employee Only, Employee and Spouse, Employee and Children, and Employee and Family. These rates are calculated using the total of the Age-Banded rates for the company's employees and dependents.

What are Decent’s expansion plans?

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Decent expanded from Austin city limits in 2019 to a Texas statewide offering in 2020. We accept remote employees in all states onto our plans so long as over 50% of the total employees at a prospective company are located in Texas at the time the policy is written and renewed.

We’re currently evaluating several states to potentially expand to in the near future - just let us know if you have one in mind where you’d like to write our policies and we’ll see what we can do!

What drugs, at what rates, are in Decent’s formulary?

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Decent’s Formulary can be found here. Specific rates are contingent on the plan selected. Please consult our SBCs for full details on pricing per plan type.

If my client buys a virtual DPC plan from Decent, what happens if they want to see an in-person primary care doctor?

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The process is similar to seeing a specialist. Members should seek a referral from their virtual Primary Care Provider to see an in-person primary care doctor. Copay or Coinsurance costs for seeing the in-person primary care doctor would apply.

Do Decent plans offer emergency or standard coverage outside of Texas?

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Urgent and Emergent care out of your area will be covered as in-network. For example, if your client was on vacation in Florida and got stung by a jellyfish scuba diving and had to go to urgent care - we have your client covered. In terms of standard coverage, our network is currently confined to areas within Texas’s state lines. We’ll be expanding soon, but we’re not a good fit for anyone who lives out of state for the time being.

How do I get a quote for a client?

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For a business, please submit their employee census inside of our broker portal along with your client's preferred contribution structure and start date.

How does Decent track and pay commissions for its appointed brokers?

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That’s such a good question we made a whole handout for it. Please check out Decent’s guide to broker commissions to see how your commissions will be tracked and paid.

How do I get added as a Broker of Record (BOR) to an existing policy?

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Please have the group’s business administrator complete the Small Group BOR letter and email it to brokers@decent.com.

What are the participation and contribution requirements for small business plans?

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On our small group plans we have a minimum participation requirement of 40% of eligible employees.

We also have a minimum employer contribution threshold of 50% of employee premiums.

How do I know if my clients are eligible to enroll?

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Decent is the exclusive TPA for a Multiple Employer Welfare Arrangement and as such, we do have a “commonality of industry requirement” for which companies can enroll. Ours is fairly broad (technology companies and the companies that primarily support them).

Outside of that, your company just needs one non-founder employee.

If you’re curious if your client qualifies, we recommend you chat with our Customer Service Ambassadors who can clear that up for you with a few quick questions.

How do I update my agency and general agency affiliation?

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Email your update to brokers@decent.com with the following information:

  • Your NPN
  • Current agency name
  • Requested new agency name
  • Effective date of change

How do I access my Broker account and what can I do from there?

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Once your appointment process is complete, you’ll receive an invitation to log into Decent’s broker portal. From there you’ll be able to:

  • Access all of Decent’s forms
  • Request age banded and composite rate group quotes for your clients
  • Note: Decent is currently working on a system to allow brokers to generate age banded quotes in real time. Before that goes live, please allow for two business days between employee census submission and the returning of a formalized quote.
  • Submit employer applications
  • Submit employee enrollment requests
  • Monitor the status of employer applications and associated employee enrollments
  • Submit change orders
  • Get real time billing and commission updates from your submitted accounts

How can I get appointed to sell Decent’s plans?

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Complete our appointment flow which you can find here. Once you’ve submitted all required information and documents, your personal point of contact will reach out within two business days with a digital copy of our agent agreement for you to sign.

Review our Reimbursement Policies

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Review our Reimbursement Policies for more information on the following topics:

  • Bundled Services
  • Drug Testing
  • Non-Reimbursable Services
  • Transfer
  • Evaluation and Management Service
  • Radiology
  • Physician-Administered Drugs
  • Durable Medical Equipment
  • Intraoperative Neuromonitoring
  • In-Office Laboratory Testing & Procedures
  • Obstetrical Care Bundling
  • Assistant Surgeon
  • Co-Surgeons / Team Surgeons
  • Anesthesia
  • Hospital Based Clinics
  • Bilateral Procedures
  • Multiple Procedures
  • Unlisted and Unspecified Procedures
  • Medically Unlikely, Mutually Exclusive, and Component Procedures
  • Services Incidental to Admission
  • Observation Stays
  • Surgical Supplies
  • Emergent Admissions
  • Readmissions
  • Mid-level Providers
  • Never Events
  • Surgical Techniques
  • Add-on Codes
  • Incident-to services

Review Decent’s > Provider Manual

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Review Decent’s Provider Manual  to learn more about:

  • Referral & Pre-approval requirements
  • Claim processing
  • Appeals
  • And other important topics

Submitting claims

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Electronic Submission

Decent highly recommends that providers submit claims electronically via your billing software and clearinghouse of choice using Decent’s Electronic Payer ID: DECENT

If you are having any issues setting up the ability to submit claims electronically, please contact your billing vendor to ensure they have Decent’s Payer ID in their system. Our clearinghouse is Healthcare IP.

Paper Claim Submission

If a claim cannot be submitted electronically, a paper UB-04 or CMS-1500 should be submitted to:

Decent
P.O. Box 4366
Seattle, WA 98194-0366

Decent supports the following EDI Transactions

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Type (Ansi v5010) Description 270/271 Eligibility Request and Response 276/277 Claim Status Inquiry and Response 835 Remittance Advice 837 Health Care Claim

How to Credential / Contract with Decent

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We are excited that you want to join Decent’s network. In 2019, we are building our network in Texas, and will expand to other states soon, please reach out if you’re interested in joining us.

Here is how to join our network:

  1. Request a provider agreement at support@decent.com.
  2. Once you receive the contracting packet
  • Review and sign the Contract
  • Complete the enclosed W-9 and Profile documents
  • Fill out the 835 Enrollment form to receive Electronic Remittance Advice
  • Fill out the EFT form to get reimbursed faster
  • If you are an individual provider or provider group, please complete the enclosed Group information for billing purposes.
  1. You may submit your completed documents through any of the following methods:
  • Email to: support@decent.com
  • Mail to: Decent, P.O. Box 4366, Seattle, WA 98194-0366(Please retain a copy for your records)
  1. Remember that we’re here to help - if you ever have any questions, feel free to either reach us by chat on our website, by email at support@decent.com, or by phone at:

866-HEART-US (866-432-7887)

If I buy a virtual DPC plan from Decent, what happens if I want to see an in-person primary care doctor?

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The process is similar to seeing a specialist. You should seek a referral from you virtual Primary Care Provider to see an in-person primary care doctor. Copay or Coinsurance costs for seeing the in-person primary care doctor would apply.

Note: Since primary physician is your VDPC, you'll still need to consult them for confirmation on any referrals recommended by the in person primary care physician that you see in a one off capacity.

What happens if I get sick or hurt while traveling? Will Decent still cover me?

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If you are traveling and have an emergency Decent will cover you. We will work to get you the best price possible.

How does Decent offer low rates and let me join mid-year?

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We’re able to offer more affordable premiums because we’ve built everything from scratch. We don’t have the massive legacy processes and departments of a traditional health insurance company. We’re allowed to offer year round sign-up, and we think it’s a great thing for our members.

Do the DPCs also treat kids?

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Yes (with the exception of Dr. Ikbal who sees patients 13 years old and up) and we have many pediatricians in our network.

Does Decent offer other types of insurance like dental, vision, life?

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At this time Decent does not offer dental, vision, or life although we do have partners who offer policies that we can get your company set up on. Please ask either your broker or your Decent representative for options.

Are vaccines and flu shots covered?

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Yes, all of these are covered 100% and can be taken care of at your DPC provider's office. We encourage you to get your flu shot or any vaccinations, and we will work directly with your doctor to have them paid for.

Where can I go to pick up a prescription?

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You can go to any of our 64,000 in-network pharmacies to pick up a prescription.

What type of plans are these? HMO, PPO, or something else?

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All of the plans that Decent administers are categorized as POS (Point of Service). This is a hybrid of sorts between an HMO (Health Maintenance Organization), which generally has a small network and no out of network benefits, and a PPO (Preferred Provider Organization) which offers more flexibility on which providers you can see but generally comes with higher premiums. We’ve designed our POS plans to have the best of both - low premiums with a provider network you’ll love.

If I have a pre-existing condition will my rate be higher?

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No, we do not determine prices on pre-existing conditions.

Why do I have to be a technology company to sign up for Decent? Are other industries or individuals eligible for your plans?

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Decent is administering a health insurance plan for the Texas Freelance Association. In order to qualify for health benefits, members must demonstrate that they are indeed a technology company (or one that derives a majority of it's revenue from technology companies). At this time individuals and companies from other verticals are not eligible for the plans but we're working on ways to expand access currently.

What hospitals can I go to with a Decent plan?

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We are proud to have St. David’s Healthcare, Seton, and Baylor in our provider network. Our members can receive services at all of these organizations' facilities, including their hospitals, emergency care, rehab centers, and outpatient surgery centers.

If a doctor is not on the list of in network providers what does that mean? Can my doctor be added to Decent’s network?

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If your specialist is not covered and you see them, the service would be covered under out of network benefits (less coverage). However, we are happy to reach out to add them to our provider network! Feel free to your doctors information with us (support@decent.com), and we’ll have our contracting team reach out to them.

Where are Decent’s plans available?

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We are currently administering plans throughout the state of Texas. We plan to expand to more states in 2022.

Where can I see Decent’s network of providers?

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You can find our full provider directory here.

When can I sign up to get coverage with Decent?

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You can sign up any time! Yes, any time. Follow the link here to get your personalized quote and enroll in the plan of your choice!

How do I activate my account with my virtual DPC?

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If you’re enrolled in one of Decent’s virtual plans, then unlimited access to your virtual primary care doctor is included and comes at no additional cost to you! It’s critical that you download and activate your account in the MedLion Clinic phone app as this is the only way to interact with your assigned physician. On your first date of coverage, you’ll receive a welcome email from MedLion Clinic with instructions. Follow this guide for additional assistance and let us know if you have any questions--our friendly Customer Service Ambassadors are standing by to help.

Seeing a Participating Provider gets me the highest level of coverage. How do I make sure I stay in-network?

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Start by working with your selected Direct Primary Care (DPC) doctor. For lab-work: your physician will send the referral to Clinical Pathology Laboratories (CPL). For high-tech radiology, diagnostic testing, or a specialist visit: they will FAX the referral to 512-729-7178 or securely email it to support@decent.com. From there, our friendly Customer Service Ambassadors will notify you of an in-network option near your address and submit the referral documentation to the provider for scheduling. Please note that while all specialist visits require a referral from your DPC, Urgent Care and Emergency Room visits do not require a referral, nor do routine visits to an in-network gynecologist or pediatrician. Specialists may also refer you for testing or to another provider. Please ensure you are referred in-network to reduce your out of pocket liability. We’re here to help if you’re ever unsure of what to do.

When can I sign up my company to get coverage with Decent

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You can sign up any time! Yes, any time. Follow the link here to get your personalized quote and enroll in the plan of your choice!

Seeing a Participating Provider gets me the highest level of coverage. How do I make sure I stay in-network?

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Start by working with your selected Direct Primary Care (DPC) doctor. For lab-work: your physician will send the referral to Clinical Pathology Laboratories (CPL). For high-tech radiology, diagnostic testing, or a specialist visit: they will FAX the referral to 512-729-7178 or securely email it to support@decent.com. From there, our friendly Customer Service Ambassadors will notify you of an in-network option near your address and submit the referral documentation to the provider for scheduling. Please note that while all specialist visits require a referral from your DPC, Urgent Care and Emergency Room visits do not require a referral, nor do routine visits to an in-network gynecologist or pediatrician. Specialists may also refer you for testing or to another provider. Please ensure you are referred in-network to reduce your out of pocket liability. We’re here to help if you’re ever unsure of what to do.

I need to get tested for COVID-19. How much will it cost?

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The cost of COVID-19 testing is fully covered by your plan. Medically necessary treatment for COVID-19 is covered under the standard benefits of your plan.

I need to get tested for COVID-19. What should I do?

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If you are experiencing any COVID-19 symptoms or if you know that you may have been exposed to someone who has tested positive for COVID-19, please consult with your selected Direct Primary Care (DPC) doctor by phone or text, or visit a CareNow urgent care location. Many test locations require a physician referral or prior authorization due to the volume of cases, so we recommend calling ahead for an appointment for the smoothest experience. You can utilize this resource to find a convenient test location.