Key Definitions
Understanding the terminology used in the Star Group Health Insurance policy helps members and HR administrators interpret benefits correctly. Below are the most frequently cited terms:
| Term | Definition |
|---|---|
| Insured Person (Member) | The employee or eligible dependent listed on the policy who receives coverage. |
| Subscriber | The primary employee who purchases the policy and is responsible for premium payments. |
| Dependent | Spouse, children (biological, adopted, or stepchildren) and, where applicable, domestic partners covered under the subscribers plan. |
| Eligibility Date | The first day the member is entitled to benefits, usually the first day of the month following enrollment. |
| Benefit Year | 12month period starting on the policy anniversary date; most limits reset annually. |
| Network Provider | A hospital, clinic, physician or other healthcare professional that has contracted with Star Group for discounted rates. |
| OutofNetwork (OON) | Any provider not in the contracted network; coverage is usually lower and may require higher costsharing. |
| Deductible | The amount the member must pay outofpocket before the insurer begins to pay its share of covered expenses. |
| Coinsurance | The percentage of a covered expense the member pays after the deductible has been satisfied. |
| OutofPocket Maximum (OOP Max) | The ceiling on the total amount a member pays in a benefit year for covered services. Once reached, the insurer pays 100% of additional covered costs. |
| PreExisting Condition | A medical condition that existed before the effective date of coverage. Specific waiting periods may apply. |
| Prior Authorization | Approval required from Star Group before certain services are rendered to guarantee coverage. |
| Grace Period | Time allowed (typically 30 days) after a missed premium before coverage is terminated. |
Coverage Overview
Star Group Health Insurance provides comprehensive medical protection for eligible employees and their dependents. Coverage is divided into three main categories: InNetwork Services, OutofNetwork Services, and Additional Benefits.
1. InNetwork Services
- Hospitalization: Room & board, surgery, anesthesia, intensive care, and related physician fees.
- Outpatient Care: Visits to primary care physicians (PCPs), specialists, diagnostic tests, and minor procedures performed at a network facility.
- Emergency Services: ER visits, ambulance transport (ground and air), and urgent care when the member is unable to reach a network facility within a reasonable time.
- Preventive Care: Immunizations, annual physicals, screenings, and counseling services at no cost when performed by a network provider.
- Maternity & Newborn Care: Prenatal visits, delivery (vaginal or Csection), postnatal care, and newborn hospital stay.
2. OutofNetwork Services
Coverage is offered, but members are responsible for a larger share of costs. The deductible, coinsurance and OOP maximums for OON services are separate from innetwork amounts. Certain highcost procedures may be denied unless a prior authorization is obtained.
3. Additional Benefits
- Prescription Drug Coverage: Tiered formulary with generic, preferred brand, nonpreferred brand, and specialty drugs.
- Vision & Dental: Optional riders providing routine eye exams, glasses/contact lenses, and basic dental services.
- Telehealth: Virtual consultations with network physicians at no cost for eligible conditions.
- Wellness Programs: Access to healthrisk assessments, coaching, and discounted gym memberships.
Benefit Limits & CostSharing
Deductibles
Deductibles are applied per individual and per family. The 2025 plan options are:
| Plan Type | Individual Deductible | Family Deductible |
|---|---|---|
| Bronze | $2,500 | $5,000 |
| Silver | $1,500 | $3,000 |
| Gold | $500 | $1,000 |
| Platinum | $0 | $0 |
Coinsurance Rates
After the deductible, the member pays the following percentages for covered innetwork services:
- Bronze 30% member / 70% insurer
- Silver 20% member / 80% insurer
- Gold 10% member / 90% insurer
- Platinum 0% member / 100% insurer (subject to OOP max)
OutofPocket Maximums (OOP Max)
Once the members total costsharing reaches the OOP Max, the plan pays 100% of further covered expenses for the remainder of the benefit year.
| Plan Type | Individual OOP Max | Family OOP Max |
|---|---|---|
| Bronze | $7,500 | $15,000 |
| Silver | $5,000 | $10,000 |
| Gold | $3,000 | $6,000 |
| Platinum | $1,500 | $3,000 |
Exclusions & Limitations
Star Group Health Insurance does not cover the following categories unless specifically added through supplemental riders:
- Cosmetic surgery performed for aesthetic purposes.
- Experimental or investigational treatments not recognized by major medical bodies.
- Elective procedures without medical necessity documentation.
- Dental orthodontics, most prosthetic devices, and routine dental cleanings (unless a dental rider is purchased).
- Alternative therapies such as acupuncture, chiropractic, or naturopathy unless a complementary health rider is in place.
- Services rendered outside the United States, except for emergency care covered under the travel exclusion clause.
- Any cost incurred prior to the eligibility date or during a preexisting condition waiting period.
Every claim is evaluated against the policys medical necessity criteria and applicable state regulations. If a service is denied, the member will receive an explanation of benefits (EOB) outlining the reason.
Claims Process
Submitting a claim is straightforward when members follow these steps:
- Obtain a Claim Form: Download from the member portal or request a paper copy.
- Gather Supporting Documents: Provider invoice, itemized bill, medical records, and a copy of the members insurance card.
- Complete the Form: Fill in personal information, diagnosis codes (ICD10), procedure codes (CPT), and the date of service.
- Submit: Upload electronically via the portal or mail to the address listed on the back of the member card. Claims must be filed within 90 days of service.
- FollowUp: Watch for the EOB within 1530 days. If additional information is required, the insurer will contact the provider or member.
For urgent or emergency services, providers typically submit claims directly to Star Group. Members should still review the EOB to ensure accuracy.
Appeals
If a claim is denied, members have the right to appeal:
- Internal Review: Submit a written request with supporting medical documentation within 30 days of the denial.
- External Review: If the internal appeal is unsuccessful, an independent thirdparty reviewer can be requested, as mandated by the Affordable Care Act.
