Frequently Asked Questions

EHBA is a third-party administrator (TPA) that provides employers and health benefit plan members with services to help them get the most from their benefit plan.

A TPA is a company that your employer hires to handle the many tasks associated with managing your health benefit plan. For example, EHBA handles general enrollment tasks when new plan members sign up to receive health benefits.

We also process your health claims, making sure they are handled quickly and accurately. EHBA even has medical professionals available who can help coordinate your care if you are in hospital or dealing with a chronic health condition.

With a level-funded plan, an employer pays a health carrier the same monthly amount to cover the estimated cost of expected claims, the premium for stop-loss insurance that covers healthcare costs over a set dollar amount, and plan administration costs. If total claims costs are higher or lower than expected, the carrier makes adjustments at the end of the plan year — a refund to the employer for lower claims, or a premium increase on the stop-loss renewal for higher claims.

Stop-loss coverage is an essential part of this arrangement, because it limits an employer's financial responsibility for claims over a certain amount, either per employee or for the entire covered population.

At EHBA we work and contract with many different PPO networks. A PPO is a network of healthcare providers who have agreed to discount what they charge for services when treating members of a benefit plan.

When you choose to see an in-network PPO provider, you will pay less for their services than if you had chosen an out-of-network provider. You have the option to see non-PPO providers, but you will pay more for their services.

EHBA will provide you with prompt, personalised service. As a plan member served by us, you have a customer service team of helpful people available to assist you and answer questions about your health benefits. We are always just a phone call away, and you will be able to speak to someone who can help you get the answers you need.

You may also receive other services, depending on your health plan's features, to help you and your covered family members use the healthcare system and receive appropriate care at a reasonable cost.

Please refer to your plan documents, or give us a call at 1-855-826-3422.

To request a replacement ID card, email member.services@exemplarhba.com or give us a call at 1-855-826-3422.

Contact our customer service team at 1-855-826-3422.

Please contact our customer service team at 1-855-826-3422.

The policy is published as a PDF. Contact member services if you need a copy.

Annual wellness visits are intended to check your overall health and are considered preventive care. Your provider will record your height, weight and vital signs, review your medical history including any changes and perform a general exam. Your provider may discuss any health risks and preventative measures that would be recommended for you. Making a personal health plan with your provider is important to maintaining your health.

The insurance plan pays for wellness care but may not cover all that is recommended. The following services are not part of your annual exam and may be billed separately:

• A problem is discussed, and a plan is developed to address it.
• Chronic conditions are addressed, and/or medication is prescribed.
• Diagnostic tests/services are ordered or performed.

These services will not be covered as part of your annual exam.

Please contact Exemplar Health Benefits Administrator at 1-855-826-3422 if you have questions or concerns related to annual preventive or wellness care.

Visit our formulary look up tool at https://www.prorxsolutions.com/formularyLookupTool.html