North River Epic FAQs: Answers on Epic Base, Epic PPO and Epic 20% Plans
These North River Epic FAQs cover the Epic Base, Epic PPO and Epic 20% short-term plans. Licensed Vivna agents wrote each answer in plain English. Because rules change by state, every answer shows where it applies. Call 888-730-6001 anytime for free help.
Vivna Insurance is an independent, licensed agency offering North River Insurance Company products. We are not North River Insurance Company or its affiliates. Short-term plans are not ACA coverage and may not cover pre-existing conditions. Plans and availability vary by state.
Epic Plan Basics and Eligibility
Start here to learn what Epic plans are and who can buy one. Then see how to pick a version.
β What is an Epic short-term medical plan?
Epic is temporary health insurance underwritten by The North River Insurance Company.
It helps pay medical bills during a gap in coverage, such as a job change. However, it is not comprehensive health coverage.
π Where this applies: Every state where Epic plans are sold
β Who is the insurance company behind Epic short-term plans?
The North River Insurance Company underwrites every Epic plan.
It is part of the Crum & Forster group of companies. In addition, AM Best rates that group A+ (Superior).
π Where this applies: Every state where Epic plans are sold
β What Epic short-term plan options are there?
The main Epic designs are Epic Base, Epic PPO and the Epic 20% plan.
Epic Base lets you use any provider, while Epic PPO uses the Cigna PPO network. In addition, Iowa has its own Epic PPO and Epic Base versions. Pennsylvania also has its own Epic Base version.
π Where this applies: Every state where Epic plans are sold
β Is an Epic short-term plan the same as an ACA or Obamacare plan?
No, Epic plans do not have to follow most ACA rules or cover all essential health benefits.
As a result, they have fewer benefits and federal protections than Marketplace plans.
π Where this applies: Every state where Epic plans are sold
β Does an Epic short-term plan count as minimum essential coverage?
No, the brochures state the coverage is not minimum essential coverage under the Affordable Care Act.
π Where this applies: Every state where Epic plans are sold
β Who is an Epic short-term plan designed for?
Epic is designed for temporary gaps, such as a time of transition or when you need coverage fast.
It works best for people without preexisting conditions, because those are generally excluded.
π Where this applies: Every state where Epic plans are sold
β Can an Epic short-term plan turn me down because of my health?
Yes, you must be able to answer "No" to all the health questions on the application.
Unlike ACA plans, a short-term plan can decline you based on your health.
π Where this applies: Every state where Epic plans are sold
β Do Epic short-term plans have dollar limits on benefits?
Yes, each Epic plan has a total coverage maximum, and some services have their own limits.
For example, there are therapy visit caps, a transplant maximum and prescription drug maximums.
π Where this applies: Every state where Epic plans are sold
β What happens if my Epic short-term coverage ends and I need more coverage?
Losing short-term coverage may not let you enroll in an ACA plan right away.
Instead, you might have to wait for the next open enrollment period. A licensed agent can help you plan ahead.
π Where this applies: Every state where Epic plans are sold
β What is the difference between Epic Base and Epic PPO?
Epic Base has no network, so you can use any provider at one benefit level.
By contrast, Epic PPO uses the Cigna PPO network, with lower costs in-network and higher costs out-of-network. Epic PPO also requires pre-authorization for many services.
π Where this applies: Every Epic state except Iowa and Pennsylvania
β What is the Epic 20% short-term plan?
The Epic 20% plan lets you see any provider and pay 20% coinsurance after the deductible.
Your coinsurance stops at a $10,000 out-of-pocket maximum. It has office visit copays. However, it does not cover prescription drugs.
π Where this applies: Every state with the Epic 20% plan
β Which Epic short-term plans cover mental health care?
Epic PPO covers mental illness and substance use disorder care.
However, the national Epic Base, Pennsylvania Base and Epic 20% plans exclude it. The Iowa Base plan lists a limited benefit instead.
π Where this applies: Every state where Epic plans are sold
β What total coverage maximums can I choose on an Epic short-term plan?
Epic Base offers a $250,000, $500,000 or $1,000,000 total coverage maximum.
For Epic PPO, the options are $500,000 or $1,000,000 in-network, and $375,000 or $750,000 out-of-network. Similarly, the Epic 20% plan offers $500,000 or $1,000,000.
π Where this applies: Every Epic state except Iowa and Pennsylvania
β What is the Epic short-term coverage maximum in Indiana?
In Indiana, the coverage period maximum benefit option is $2,000,000 on Epic PPO and Epic 20% plans.
This is due to Indiana regulations.
π Where this applies: Indiana
β Does an Epic short-term plan offer a supplemental accident benefit?
Yes, Epic Base and Epic PPO offer a supplemental accident benefit as an option.
It adds $5,000 or $10,000 per person. The benefit then pays 100% of medical expenses from an accidental injury, up to that amount.
π Where this applies: Every Epic state except Iowa and Pennsylvania
β Who is eligible for an Epic short-term plan?
Applicants, spouses and dependent children ages 6 months through 64 and 11 months can apply.
Also, everyone must answer "No" to all application health questions.
π Where this applies: Every state where Epic plans are sold
β Can I add my spouse and children to an Epic short-term plan?
Yes, an Epic short-term plan can cover your spouse and dependent children.
A child's coverage ends at 26 or marriage, and a spouse's ends after divorce.
π Where this applies: Every state where Epic plans are sold
β Can I keep my Epic short-term plan after I turn 65?
No, coverage ends the first day of the month you or your spouse turn 65 or become Medicare-eligible.
π Where this applies: Every state where Epic plans are sold
β Can a full-time student stay on an Iowa Epic plan?
Yes, Iowa rules let an unmarried full-time college student stay covered as a dependent.
In some cases, a dependent with a disability can also stay covered past 26.
π Where this applies: Iowa
β Can married children stay on an Epic plan in Indiana or Nevada?
Yes, Indiana and Nevada rules do not require dependent children under 26 to be unmarried.
π Where this applies: Indiana and Nevada
β Can I cover a grandchild on an Epic plan in Texas?
Yes, in Texas you can cover a grandchild who is your dependent at application.
The grandchild must be your dependent for federal income tax purposes.
π Where this applies: Texas
β Can I cover a domestic partner on an Epic plan in Louisiana?
Yes, Louisiana rules allow a domestic partner to be covered as a dependent.
π Where this applies: Louisiana
β Is a newborn of my covered child covered on an Epic plan in Florida?
Yes, in Florida, a covered dependent's newborn is covered automatically from birth.
The plan also covers newborn transport to a specialized facility, up to $1,000.
π Where this applies: Florida
Copays, Deductibles and Coinsurance
These answers explain what you pay at the doctor and the hospital. As a result, you can compare Epic versions by cost.
β What deductibles does the Epic Base short-term plan offer?
The Base brochure lists deductibles of $2,500, $5,000, $10,000, $15,000 or $20,000 per person.
However, the PPO brochure's Base column lists $5,000 to $20,000, so options may vary. Check what your quote shows.
π Where this applies: Every Epic Base state (Iowa and Pennsylvania have their own versions)
β How does coinsurance work on Epic Base?
The Base brochure shows 0% coinsurance on Epic Base.
Once you meet the deductible, covered expenses have no further coinsurance. The PPO brochure also lists a 20% Base option with a $10,000 coinsurance limit.
π Where this applies: Every Epic Base state (Iowa and Pennsylvania have their own versions)
β What are the deductibles on the Epic PPO short-term plan?
Epic PPO in-network deductibles are $5,000, $8,000 or $10,000.
Each one also has a matching out-of-network deductible of $6,600, $10,600 or $13,300.
π Where this applies: Iowa and every Epic PPO state
β What coinsurance do I pay on Epic PPO?
You pay 0% coinsurance in the Cigna PPO network once you meet the deductible.
Out-of-network, however, you pay 25% coinsurance.
π Where this applies: Iowa and every Epic PPO state
β Is there an out-of-pocket maximum for out-of-network care on Epic PPO?
No, the national Epic PPO plan lists no out-of-network out-of-pocket maximum.
In-network, however, meeting the deductible satisfies your out-of-pocket.
π Where this applies: Every Epic PPO state (Iowa has its own version)
β What are the deductibles and coinsurance on the Epic 20% plan?
The Epic 20% plan offers deductibles of $2,500, $5,000 or $10,000.
After that, you pay 20% coinsurance up to a $10,000 out-of-pocket maximum. For families, the coinsurance limit is 3 times the individual amount.
π Where this applies: Every state with the Epic 20% plan
β How does the family deductible work on an Epic short-term plan?
The family deductible maximum is 2 times the individual deductible.
On Epic PPO, the out-of-network family maximum is also 2 times the out-of-network deductible.
π Where this applies: Every state where Epic plans are sold
β What is the doctor visit copay on Epic Base?
Epic Base lists a $30 copay per coverage period for a general practitioner visit.
However, extra services during the visit, like tests, go toward the deductible and coinsurance.
π Where this applies: Every Epic Base state except Pennsylvania, plus Epic 20% states
β What is the specialist and urgent care copay on Epic Base?
Epic Base lists a $60 copay per coverage period for a specialist or urgent care visit.
However, additional services during that visit are subject to the deductible and coinsurance.
π Where this applies: Every Epic Base state except Pennsylvania, plus Epic 20% states
β Does the Epic PPO plan have office visit copays?
No, the Epic PPO plan does not have office visit copays.
Instead, the plan covers in-network doctor, specialist and urgent care visits at no charge after the deductible. Out-of-network visits are subject to the out-of-network deductible and coinsurance.
π Where this applies: Iowa and every Epic PPO state
β How much is an emergency room visit on Epic short-term plans?
Every Epic plan has a $250 copay for an emergency room visit.
On Epic Base, you then pay nothing after the deductible. Epic PPO waives the copay if you are admitted. Meanwhile, the 20% plan adds 20% coinsurance.
π Where this applies: Every state where Epic plans are sold
β Does Epic Base cover hospital stays?
Yes, the 0% Base plan covers inpatient hospital care at no charge after the deductible.
That includes room and board, ICU, surgeons, anesthesia and supplies given in the hospital.
π Where this applies: Every Epic Base state
β Does the Epic 20% plan cover hospital stays and surgery?
Yes, you pay 20% after the deductible for inpatient hospital and outpatient surgical facility charges.
Your coinsurance then stops once you reach the $10,000 out-of-pocket maximum.
π Where this applies: Every state with the Epic 20% plan
β Does an Epic short-term plan cover outpatient surgery?
Yes, Epic plans cover outpatient surgical facility charges after the deductible.
On Base and in-network PPO, you pay nothing for them after the deductible. However, out-of-network PPO and the 20% plan add coinsurance.
π Where this applies: Every state where Epic plans are sold
β Does an Epic short-term plan cover urgent care?
Yes, Epic plans cover urgent care center treatment and facility charges.
Epic Base lists a $60 urgent care copay. By contrast, Epic PPO covers it at no charge after the in-network deductible.
π Where this applies: Every state where Epic plans are sold
β Does the Pennsylvania Epic Base plan have office visit copays?
No, the Pennsylvania Epic Base plan does not have office visit copays.
Instead, it covers primary and specialist visits at no charge once you meet the deductible.
π Where this applies: Pennsylvania
Covered Services, Preventive Care and Drugs
Epic plans pay for many services in set ways. Here you can see what each benefit covers.
β Does an Epic short-term plan cover a preventive checkup?
Yes, Epic plans cover one preventive exam per coverage period after the waiting period.
Most versions pay 100% up to $100 per visit, with no deductible.
π Where this applies: Every state where Epic plans are sold
β Is there a waiting period for the preventive exam on Epic plans?
Yes, Epic plans do not cover the preventive exam during your first month of coverage.
In Pennsylvania, however, the waiting period is 30 days.
π Where this applies: Every state where Epic plans are sold
β Does Epic PPO cover preventive exams out-of-network?
Yes, Epic PPO pays 75% of eligible expenses out-of-network for one visit per coverage period.
The national PPO caps it at $100 per visit. Also, the exam is not subject to the deductible.
π Where this applies: Iowa and every Epic PPO state
β How does the preventive exam work on the Iowa Epic PPO plan?
After a one-month waiting period, the Iowa Epic PPO plan covers one visit per coverage period.
In-network pays 100%, while out-of-network pays 75%. Also, the exam is not subject to the deductible.
π Where this applies: Iowa
β Do Epic short-term plans cover well-child visits?
Yes, children's preventive care covers kids from birth through age 18.
It includes exams, developmental checks, immunizations, lab tests and routine screening tests.
π Where this applies: Every state where Epic plans are sold
β What do I pay for my child's preventive care on an Epic plan?
You pay 0% for your child's preventive care on Epic Base and in-network PPO.
By contrast, you pay 25% out-of-network on PPO and 20% on the Epic 20% plan. Also, immunizations are not subject to deductible or coinsurance.
π Where this applies: Every state where Epic plans are sold
β Are kids' vaccines covered on an Epic short-term plan?
Yes, Epic plans pay child immunizations at 100%.
They are also exempt from copays, coinsurance, deductibles and dollar limits.
π Where this applies: Every state where Epic plans are sold
β Are adult vaccines covered on an Epic short-term plan?
The brochures only describe immunizations under children's preventive care.
Also, the prescription benefit excludes immunization agents unless the certificate provides them. So confirm adult vaccine coverage before you enroll.
π Where this applies: Every state where Epic plans are sold
β Do Epic short-term plans cover mammograms?
Yes, Epic plans cover screening mammograms and breast ultrasound, including evaluation of dense breasts.
In addition, no deductible applies to screening or breast ultrasound.
π Where this applies: Every state where Epic plans are sold
β Do Epic short-term plans cover prostate cancer screening?
Yes, Epic plans cover prostate cancer screening for men age 40 and older.
Coverage follows National Comprehensive Cancer Network guidelines. Also, prostate cancer screening is not subject to the deductible.
π Where this applies: Every state where Epic plans are sold
β Do Epic short-term plans cover colon cancer screening?
Yes, Epic plans cover colon cancer screening for people 50 or older with no symptoms.
People under 50 at high risk are also covered, following accepted guidelines.
π Where this applies: Every state where Epic plans are sold
β Is an annual OB-GYN exam covered on Epic plans?
Yes, Epic plans list a routine annual obstetrical/gynecological exam under preventive health.
π Where this applies: Every state where Epic plans are sold
β Do Epic plans cover ovarian cancer screening?
Yes, Epic plans cover surveillance tests for women age 35 and older at risk for ovarian cancer.
π Where this applies: Every state where Epic plans are sold
β Are other cancer screenings covered on Epic short-term plans?
Epic plans cover only the cancer screenings listed in the certificate.
The plans exclude any cancer screening not expressly provided. They also exclude blood lead level screening.
π Where this applies: Every state where Epic plans are sold
β Does an Epic short-term plan cover ambulance rides?
Yes, Epic plans cover local ground or air ambulance for an emergency medical condition.
However, most brochures call it a limited benefit.
π Where this applies: Every state where Epic plans are sold
β Do Epic plans cover lab work, X-rays and MRIs?
Yes, Epic plans cover diagnostic radiology, ultrasound and lab services, including MRI, CT and PET scans.
However, psychometric, intelligence, behavioral and educational testing are not included.
π Where this applies: Every state where Epic plans are sold
β How many physical therapy visits do Epic short-term plans cover?
Epic plans cover up to 20 visits for physical, occupational and speech therapy for rehabilitation.
On national Base, PPO and 20% plans, it is one visit per day at $50.
π Where this applies: Every state where Epic plans are sold
β Does an Epic plan cover home health care?
Yes, Epic plans cover up to 40 visits from a home health care agency.
Up to four hours in a 24-hour period counts as one visit.
π Where this applies: Every state where Epic plans are sold
β Does an Epic short-term plan cover skilled nursing care?
Yes, Epic plans cover skilled nursing care when it replaces a hospital stay.
The plans also cover it within 14 days after a hospital stay of at least 3 days. However, they do not cover custodial or convalescent care.
π Where this applies: Every state where Epic plans are sold
β Do Epic plans cover medical equipment like crutches or wheelchairs?
Yes, Epic plans cover durable medical equipment as a limited benefit.
The plan may pay rental instead of purchase. However, customization, repair, replacement and maintenance are not covered.
π Where this applies: Every state where Epic plans are sold
β Does an Epic short-term plan cover chemotherapy and radiation?
Yes, Epic plans cover therapeutic treatment of benign and malignant conditions, including chemotherapy drugs and radiation.
However, note the 30-day cancer waiting period.
π Where this applies: Every state where Epic plans are sold
β Do Epic plans cover organ transplants?
Yes, Epic plans cover transplants for heart, lung, kidney, nonalcoholic liver, combined organs and marrow support.
However, national Base, PPO and 20% plans apply charges to a $10,000 maximum transplant benefit.
π Where this applies: Every state where Epic plans are sold
β Are there extra transplant rules on the Iowa Epic PPO plan?
Yes, the transplant candidate must have abstained from alcohol for one year right before the transplant.
Also, the Iowa PPO brochure does not list a $10,000 transplant cap.
π Where this applies: Iowa
β Do Epic short-term plans cover hospice?
Yes, Epic plans cover hospice care for a terminally ill person.
The person must have a life expectancy of 6 months or less.
π Where this applies: Every state where Epic plans are sold
β Does an Epic plan cover telemedicine visits?
Yes, Epic plans cover telemedicine when it replaces a covered office visit.
However, voicemail, fax, text messages, email and webinars do not count.
π Where this applies: Every state where Epic plans are sold
β Do Epic plans cover back, neck or joint problems?
Yes, Epic plans cover outpatient treatment of joints, neck, spine and connective tissue.
However, spinal manipulation and other non-surgical spine treatment are not covered. A 3-month waiting period also applies.
π Where this applies: Every state where Epic plans are sold
β Does an Epic short-term plan cover dental work after an accident?
Yes, Epic plans cover dental treatment and surgery after an injury.
The care must restore or replace sound natural teeth damaged by the injury. However, the plans exclude other dental care.
π Where this applies: Every state where Epic plans are sold
β Do Epic plans cover autism treatment?
Yes, Epic plans cover autism spectrum disorder treatment, including applied behavior analysis and therapy.
On national Base and PPO plans, however, ABA is limited to $50,000 a year and children under 18.
π Where this applies: Every state where Epic plans are sold
β Do Epic short-term plans cover diabetes supplies?
Yes, most Epic versions list diabetes supplies along with other diabetes care.
The list includes self-management training, equipment, supplies, medications and nutrition therapy. However, the national Base-only brochure does not list this benefit.
π Where this applies: Epic PPO and Epic 20% states, plus Iowa and Pennsylvania
β Does the Pennsylvania Epic Base plan cover anesthesia for dental work?
Yes, the plan covers general anesthesia for dental procedures in certain cases.
Coverage applies to children under 8 and to people with serious conditions. Also, the treating provider must certify it is needed.
π Where this applies: Pennsylvania
β Are sports injuries covered on Epic short-term plans?
Epic plans cover injuries from school and intramural sports.
However, injuries from professional, semi-professional, extreme or hazardous sports are not covered.
π Where this applies: Every state where Epic plans are sold
β Does an Epic plan cover emergencies outside the U.S.?
Only the Iowa Epic PPO plan covers foreign emergency care, at out-of-network benefits.
Other Epic plans exclude care outside the 50 states and D.C.
π Where this applies: Every state where Epic plans are sold
β What mental health benefit does the Iowa Epic Base plan have?
The Iowa Base plan lists 31 inpatient days and 10 outpatient visits per coverage period.
However, its exclusion list also names mental illness, so confirm with your certificate.
π Where this applies: Iowa
β How does Epic PPO cover mental health and substance use care?
Epic PPO covers in-network mental health and substance use care at no charge after the deductible.
Out-of-network care, however, is subject to the out-of-network deductible and coinsurance.
π Where this applies: Iowa and every Epic PPO state
β Does the Epic Base short-term plan cover prescriptions?
Epic Base covers prescriptions only with the optional prescription benefit.
Copays are $5 generic, $35 preferred and $70 non-preferred. In addition, the drug maximum is $1,000 for terms of 6 months or less. For longer terms, it is $2,000.
π Where this applies: Every Epic Base state except Iowa
β How does prescription coverage work on Epic PPO?
Prescription coverage on Epic PPO is an optional benefit with $5, $35 and $70 copays.
The out-of-network column shows 25%. In addition, the drug maximum is $1,000 for terms of 6 months or less. For longer terms, it is $2,000.
π Where this applies: Every Epic PPO state (Iowa has its own version)
β How does prescription coverage work on Iowa Epic plans?
Both Iowa Epic plans list a $500 drug deductible.
Then you pay $5 generic, $35 preferred brand and $75 non-preferred brand. However, specialty drugs are not covered.
π Where this applies: Iowa
β Does the Epic 20% plan cover prescriptions?
No, the Epic 20% plan's benefit table lists prescription drugs as not covered.
π Where this applies: Every state with the Epic 20% plan
β Are specialty drugs covered on Epic short-term plans?
No, the outpatient prescription benefit does not include self-injectables and specialty drugs.
π Where this applies: Every state where Epic plans are sold
β What drugs are excluded from Epic prescription coverage?
Exclusions include over-the-counter drugs, fertility and sexual dysfunction drugs, vitamins and hair loss drugs.
Weight-control drugs, experimental drugs and drugs bought abroad are also excluded.
π Where this applies: Every state where Epic plans are sold
β Are acne medications covered on Epic plans?
Epic plans do not cover acne medications for adults over 30.
The plans exclude medications for complexion or acne if the covered person is over age 30.
π Where this applies: Every state where Epic plans are sold
β Is there a prescription discount card with Epic plans?
Yes, Epic plans include a prescription drug discount card as a non-insurance benefit.
North River does not provide the card and is not affiliated with it.
π Where this applies: Every state where Epic plans are sold
Networks, Claims and Member Perks
Staying in-network keeps costs down. In addition, these answers explain claims, pre-approval and perks.
β Can I see any doctor on the Epic Base short-term plan?
Yes, Epic Base gives you all provider access with no network requirements.
Plus, there is one benefit level for every provider. That differs from a PPO with in-network and out-of-network tiers.
π Where this applies: Every Epic Base and Epic 20% state
β What is reference-based pricing on Epic Base?
With reference-based pricing, Epic Base pays providers based on Medicare allowable amounts.
The plan pays facilities up to 150% of Medicare. For professional services and supplies, it pays up to 125% of Medicare.
π Where this applies: Every Epic Base and Epic 20% state
β What if a provider balance bills me on Epic Base?
The claim administrator is authorized to resolve unexpected balance bills for covered benefits on your behalf.
However, you must notify the claim administrator when you get one.
π Where this applies: Every Epic Base and Epic 20% state
β Does balance bill protection apply to the Epic PPO plan?
No, the no-balance-bill feature applies only to Epic Base policies.
Instead, out-of-network charges on Epic PPO are subject to the deductible and coinsurance.
π Where this applies: Every Epic PPO state (Iowa has its own version)
β What network does the Epic PPO short-term plan use?
Epic PPO uses the Cigna PPO network for Shared Administration.
Cigna is not affiliated with The North River Insurance Company.
π Where this applies: Iowa and every Epic PPO state
β How do I find a Cigna PPO doctor for my Epic PPO plan?
Use Cigna's online provider directory and enter an address, city or ZIP code.
Under "Medical Plans," pick the "PPO/Choice Fund PPO" network. For more help, contact the carrier.
π Where this applies: Iowa and every Epic PPO state
β How big is the Cigna PPO network on Epic PPO?
The Cigna PPO network has more than 1 million national providers and 6,360 in-network hospitals, per Cigna's analysis.
Cigna also reports an average 49.8% discount versus out-of-network costs. However, results vary by area.
π Where this applies: Iowa and every Epic PPO state
β Do Epic PPO members get online tools?
Yes, Epic PPO members get personalized information through myCigna.
They also get a provider finder, plus health resources and videos. In addition, Iowa PPO pharmacy members get a price-a-prescription tool.
π Where this applies: Iowa and every Epic PPO state
β What happens if I go out-of-network on Epic PPO?
You pay higher out-of-network deductibles and 25% coinsurance.
The out-of-network coverage maximum is also lower. Plus, preventive exams pay 75% instead of 100%.
π Where this applies: Iowa and every Epic PPO state
β Do I need pre-authorization on the Epic PPO plan?
Yes, Epic PPO requires pre-authorization for several types of care.
These include hospital stays, surgeries, therapies, equipment, infusions, transplants and certain drugs. Otherwise, the plan reduces eligible expenses by $1,000 for care that is not pre-authorized.
π Where this applies: Iowa and every Epic PPO state
β Do I need to pre-notify for care on Epic Base?
Epic Base requests pre-notification for inpatient stays, surgeries and several other services.
The list also includes home health, therapies, equipment, infusions, transplants and certain drugs. However, the Base brochures do not list a penalty.
π Where this applies: Every Epic Base and Epic 20% state
β How soon must I report an emergency hospital admission on an Epic plan?
Report it within 48 hours or by the next regular working day after admission.
However, some states allow 72 hours.
π Where this applies: Every state where Epic plans are sold
β Do Epic short-term plans include free telemedicine?
Yes, Epic plans include free, unlimited 24/7 telemedicine doctor consults as a non-insurance benefit.
Asynchronous visits by smart medical questionnaire are included as well.
π Where this applies: Every state where Epic plans are sold
β What non-insurance perks come with an Epic plan?
You get 24/7 telemedicine, questionnaire-based visits, hearing and audiology discounts and a prescription discount card.
However, these perks are not insurance, and North River does not provide them.
π Where this applies: Every state where Epic plans are sold
β What is Communicating for America and why is it tied to my Epic plan?
It is an association promoting health and welfare, especially for self-employed rural workers and small business owners.
In many states, Epic plans are available to its members.
π Where this applies: Every Epic state except Kansas, Missouri, Montana, Oklahoma and Pennsylvania
β Do I have to join an association to get an Epic plan?
In most states, the plan is offered to Communicating for America members.
However, membership is not required in all states. Kansas, Missouri, Montana, Oklahoma and Pennsylvania plans are individual plans.
π Where this applies: Every state where Epic plans are sold
β Does the association charge fees for an Epic plan in Kentucky?
Yes, in Kentucky the association charges membership fees separately from your premium.
So the premium in your schedule does not include that fee.
π Where this applies: Kentucky
β How are claims paid on an Epic Base plan?
The provider submits the claim to the claim administrator.
Then the administrator pays based on a percentage of Medicare allowable amounts.
π Where this applies: Every Epic Base and Epic 20% state
β Do I file Epic PPO claims myself?
The brochures do not explain how to file claims on Epic PPO.
Your certificate of insurance has the full claim steps. Also, a licensed agent can help if a claim stalls.
π Where this applies: Iowa and every Epic PPO state
β How fast must Epic claims be paid in my state?
The deadline to pay Epic claims varies by state.
For example, Kentucky requires payment within 30 days and South Carolina within 60 days. Tennessee requires clean claims in 21 days.
π Where this applies: Kentucky, South Carolina and Tennessee
β Do I get interest if my Epic claim is paid late?
In some states, yes, you get interest on late Epic claim payments.
For example, Alabama adds 1.5% per month on overdue claims. Kansas adds 1% per month on claims unpaid after 30 days.
π Where this applies: Alabama and Kansas
β Is there an appeal process for Epic claims?
Several states add their own appeal process for Epic claims.
For instance, Kentucky adds internal appeal and external review, and Ohio adds external review. Missouri, Nebraska and Wisconsin add grievance procedures.
π Where this applies: Kentucky, Ohio, Missouri, Nebraska and Wisconsin
β How long do I have to submit an Epic claim notice?
The deadline for an Epic claim notice depends on the state where you live.
For example, Mississippi requires notice of claim within 30 days. By contrast, Montana allows 6 months.
π Where this applies: Mississippi and Montana
Pre-Existing Conditions, Exclusions and Waiting Periods
Short-term plans have limits that ACA plans do not. For that reason, check these answers before you buy.
β Does an Epic short-term plan cover pregnancy and childbirth?
No, Epic plans exclude routine prenatal care, pregnancy, childbirth and postnatal care.
However, the plans do not exclude complications of pregnancy, as defined in the certificate.
π Where this applies: Every state where Epic plans are sold
β Do Epic plans cover infertility treatment?
No, Epic plans exclude treatment that promotes conception, including artificial insemination and infertility care.
They also exclude sterilization and its reversal.
π Where this applies: Every state where Epic plans are sold
β Is birth control covered on an Epic short-term plan?
Yes, Epic plans cover birth control through the prescription benefit when you have it.
However, some versions exclude procedures to insert or remove implants and IUDs.
π Where this applies: Every state where Epic plans are sold
β Do Epic plans cover weight-loss treatment or surgery?
No, Epic plans exclude weight modification and obesity surgery.
The prescription benefit also excludes weight-control drugs.
π Where this applies: Every state where Epic plans are sold
β Do Epic short-term plans cover vision or hearing care?
No, Epic plans exclude eyeglasses, contacts, hearing aids, implants and routine vision or hearing exams.
They also exclude LASIK and cataract treatment.
π Where this applies: Every state where Epic plans are sold
β Does an Epic plan cover chiropractic care?
Generally no, Epic plans do not cover chiropractic care.
They exclude spinal manipulation, muscle stimulation and other non-surgical spine treatment. However, some states require coverage, so check your state's rules.
π Where this applies: Every state where Epic plans are sold
β Are joint replacements covered on Epic short-term plans?
Epic plans cover joint replacements only when they relate to an injury.
The plans exclude joint replacement for wear and tear or other non-injury reasons.
π Where this applies: Every state where Epic plans are sold
β Are TMJ disorders covered on Epic short-term plans?
Generally no, Epic plans do not cover TMJ disorders.
They exclude treatment of jaw, face, neck or head joint disorders, including TMJ. However, several states require some TMJ coverage.
π Where this applies: Every state where Epic plans are sold
β What other conditions do Epic short-term plans exclude?
Exclusions include sleep disorders, chronic fatigue or pain disorders and end stage renal disease.
ADHD, cosmetic treatment, foot care and hair loss are also excluded.
π Where this applies: Every state where Epic plans are sold
β Are cell and gene therapies covered on Epic plans?
No, Epic plans exclude cell therapy and gene therapy.
The exclusion also includes related drugs and pre- and post-treatment care.
π Where this applies: Every state where Epic plans are sold
β Do Epic plans cover injuries from risky hobbies?
No, Epic plans exclude injuries from risky activities like skydiving and scuba diving.
Other examples include rock climbing, bungee jumping, rodeo and racing. Private aircraft flights are excluded as well.
π Where this applies: Every state where Epic plans are sold
β Are injuries from drinking or drug use covered on Epic plans?
No, Epic plans exclude injuries while intoxicated or under the influence of drugs not prescribed.
Intoxication follows the legal blood-alcohol limit where the injury happened.
π Where this applies: Every state where Epic plans are sold
β Are congenital conditions covered on Epic short-term plans?
Generally no, Epic plans do not cover congenital conditions, with one exception.
The exception is a newborn, newborn adopted child or child placed for adoption added to coverage.
π Where this applies: Every state where Epic plans are sold
β Does an Epic plan pay if I have other coverage like Medicare or workers' comp?
No, Epic plans exclude expenses payable by Medicare or other government programs, except Medicaid.
They also exclude work-related injuries covered by workers' compensation. In addition, they exclude expenses paid by other insurance.
π Where this applies: Every state where Epic plans are sold
β Are there waiting periods on Epic short-term plans?
Yes, Epic plans do not cover sickness that starts in the first 3 days.
Similarly, cancer that starts in the first 30 days is not covered.
π Where this applies: Every state where Epic plans are sold
β Which surgeries have a 3-month waiting period on Epic plans?
Examples include appendectomy, gallbladder removal, hernia repair, tonsil and adenoid removal and sinus surgery.
Hysterectomy and joint, neck and spine disorders are also included. However, emergencies are exempt.
π Where this applies: Every Epic state except Pennsylvania
β Which procedures have a 3-month waiting period on the Pennsylvania Epic Base plan?
The Pennsylvania plan lists cataract, strabismus, tonsil, adenoid, hernia, arthrotomy, hemorrhoid, laminectomy and varicose vein procedures.
However, the waiting period does not apply to emergencies.
π Where this applies: Pennsylvania
β Does the 3-month waiting period on Epic plans apply in an emergency?
No, the 3-month waiting period does not apply to treatment provided on an emergency basis.
After 3 months, normal terms apply, including the preexisting condition exclusion.
π Where this applies: Every state where Epic plans are sold
β Do Epic short-term plans cover preexisting conditions?
Generally no, Epic plans exclude preexisting conditions under the policy.
However, some versions allow limited payment up to a Partial Benefit Allowance shown on your Schedule of Benefits.
π Where this applies: Every state where Epic plans are sold
β How does Epic define a preexisting condition?
It is a condition a doctor treated, diagnosed or advised on in the 24 months before coverage starts.
The definition also includes symptoms that would have led a reasonable person to seek care.
π Where this applies: Every state where Epic plans are sold
β What is the symptom look-back on the Epic Base plan?
The national Base brochure uses a 4-month look-back for symptoms.
However, treatment, diagnosis or advice from a doctor still has a 24-month look-back.
π Where this applies: Every Epic Base state (Iowa and Pennsylvania have their own versions)
β What is the Partial Benefit Allowance on an Epic plan?
The preexisting exclusion does not apply to eligible expenses until a Partial Benefit Allowance is reached.
You'll find the amount on your Schedule of Benefits, not in the brochure.
π Where this applies: Every Epic state except Pennsylvania
β Is an adopted child's preexisting condition covered on an Epic plan?
Yes, the preexisting exclusion does not apply to a child placed for adoption who is added to coverage.
π Where this applies: Every state where Epic plans are sold
β How long is the preexisting look-back for Epic plans in Mississippi?
Mississippi uses a 6-month look-back for both treatment and symptoms.
π Where this applies: Mississippi
β How long is the preexisting look-back for Epic plans in North Carolina?
North Carolina uses a 12-month look-back for advice, diagnosis, care or treatment, including prescriptions.
Children placed in foster homes are also exempt.
π Where this applies: North Carolina
β How long is the preexisting look-back for Epic plans in Texas?
Texas uses a 12-month look-back for preexisting conditions.
It counts conditions for which you received medical advice or treatment from a doctor.
π Where this applies: Texas
β How is a preexisting condition defined for Epic plans in Montana?
Montana counts medical advice or treatment within 24 months before coverage starts.
However, symptoms alone do not count.
π Where this applies: Montana
β How is a preexisting condition defined for Epic plans in Pennsylvania?
The Pennsylvania Base brochure uses a 24-month look-back for treatment and symptoms.
However, an older state chart lists treatment or advice only, so confirm with your policy.
π Where this applies: Pennsylvania
β Does routine breast cancer follow-up count as a preexisting condition in Florida?
No, in Florida, routine follow-up for returning breast cancer does not count as medical advice or treatment.
However, the exception ends if follow-up finds cancer.
π Where this applies: Florida
Enrollment, Plan Length and Cancellation
These answers cover start dates, how long coverage lasts and how to cancel. Also, see what happens when a plan ends.
β How fast can an Epic short-term plan start?
Epic plans offer effective dates as soon as the next day.
However, waiting periods still apply to certain services.
π Where this applies: Every state where Epic plans are sold
β How long can I keep an Epic short-term plan?
It depends on your state and the term you choose.
Coverage ends automatically at the end of your coverage period. Also, an older carrier chart says terms are no more than 364 days.
π Where this applies: Every state where Epic plans are sold
β Is there an application fee for an Epic short-term plan?
A fee may apply, because the free look provision mentions refunding your premium and application fee.
Ask your licensed agent for the exact amount.
π Where this applies: Every state where Epic plans are sold
β How long can I have an Epic short-term plan in Michigan?
Michigan limits short-term coverage to 185 days in any 365-day period.
After that, you need a 180-day break before applying for another North River short-term plan.
π Where this applies: Michigan
β How long can I have an Epic short-term plan in Wisconsin?
Wisconsin allows up to 364 days per coverage period and 18 months of consecutive periods.
You need a 63-day break before reapplying.
π Where this applies: Wisconsin
β How long can I have an Epic short-term plan in Montana?
In Montana, the plan must expire less than 12 months after it starts.
Also, total duration cannot exceed 36 months, including renewals or extensions.
π Where this applies: Montana
β Can I cancel an Epic short-term plan and get a refund?
Yes, you can cancel within the 10-day free look period and get a refund.
Send a written cancellation request to North River within 10 days of receiving your plan. North River then returns your premium and application fee.
π Where this applies: Every state where Epic plans are sold
β How long is the free look period for an Epic plan in Louisiana?
Louisiana extends the free look period on the certificate cover page to 30 days.
π Where this applies: Louisiana
β Can I return my Pennsylvania Epic policy to my agent?
Yes, in Pennsylvania you can return the policy within 10 days to North River or the selling agent.
All premiums are then refunded.
π Where this applies: Pennsylvania
β Can I cancel my Epic plan in the middle of the term?
Yes, coverage ends on the date you ask North River in writing to end it.
In Kansas, the unearned premium is refunded on a pro rata basis.
π Where this applies: Every state where Epic plans are sold
β When does Epic short-term coverage end?
Epic coverage ends at the earliest of several events.
Examples are the end of your coverage period, unpaid premium after the grace period, or turning 65. Reaching the maximum benefit also ends it.
π Where this applies: Every state where Epic plans are sold
β What happens to my Epic plan if I go on active military duty?
Coverage ends when you enter the armed forces, except reserve duty under 30 days.
With written notice, you get a pro rata refund of unused premium.
π Where this applies: Every state where Epic plans are sold
β How much notice do I get before an Epic rate increase?
The notice period for an Epic rate increase depends on the state.
For example, Louisiana requires 45 days for increases of 20% or more. Mississippi and Texas require 60 days.
π Where this applies: Louisiana, Mississippi and Texas
Epic Rules by State
Each state sets its own short-term rules and Epic versions. So check the answers for the state where you live.
β What does the Epic plan add for children in Florida?
In Florida, Epic plans add routine child care and cleft lip and palate care.
The plan covers routine child care from birth to 18 without the deductible. It also covers cleft lip and palate care for children under 18.
π Where this applies: Florida
β Does an Epic plan cover TMJ in Florida?
Yes, Florida rules do not allow Epic plans to exclude TMJ.
In fact, the plan covers jaw and facial bone or joint treatment for deformity, disease or injury.
π Where this applies: Florida
β What happens if I am disabled when my Epic plan ends in Florida?
Florida extends Epic benefits for a person who is totally disabled when the plan ends.
The extension then lasts until the disability ends, 90 days pass, or you reach the maximum.
π Where this applies: Florida
β What mammogram schedule does an Epic plan follow in Florida?
Epic plans in Florida follow a set mammogram schedule based on age.
First, you get one baseline at 35-39. Then screening comes every two years at 40-49 and yearly at 50 and up. Also, no copay or deductible applies to screening mammograms.
π Where this applies: Florida
β Are breast reconstruction and osteoporosis covered on Epic plans in Florida?
Yes, Epic plans in Florida cover breast reconstruction and osteoporosis care.
Reconstruction after mastectomy includes the other breast for symmetry. The plan also covers osteoporosis care for certain at-risk people.
π Where this applies: Florida
β What does an Epic plan add in Georgia?
In Georgia, Epic plans add non-surgical TMJ treatment and annual Pap smear coverage.
Georgia also removes the musculoskeletal exclusion. In addition, the plan covers Pap smears annually, up to $50 per exam.
π Where this applies: Georgia
β What Iowa rules change the Epic plans?
Iowa removes the mental health exclusion and adds out-of-pocket maximums to Epic plans.
In addition, Iowa requires a coverage maximum of at least $500,000.
π Where this applies: Iowa
β What does an Epic plan change in Indiana?
Indiana changes Epic application questions and removes the intoxication exclusion.
For example, applications can ask only about diagnoses or test results, not symptoms.
π Where this applies: Indiana
β Does an Epic plan cover chiropractic care in Kansas?
Yes, Kansas adds an orthopedic manipulation benefit to Epic plans.
The benefit is at least $500 per benefit period. Kansas also removes the manipulative services exclusion.
π Where this applies: Kansas
β Do the Epic waiting periods apply in Kansas?
No, Kansas rules removed the Epic 3-day sickness and 30-day cancer waiting periods.
Also, newborns have coverage from birth for injury or sickness.
π Where this applies: Kansas
β What does an Epic plan add in Kentucky?
Kentucky adds AIDS and HIV treatment, TMJ coverage and home health visits to Epic plans.
AIDS and HIV treatment has no coverage period limit. Also, the plan must include at least 60 home health visits.
π Where this applies: Kentucky
β Does an Epic plan cover chiropractic care in Louisiana?
Louisiana deleted the manipulative services exclusion from Epic plans.
In addition, Louisiana Rx coverage includes topical eye prescriptions.
π Where this applies: Louisiana
β What does an Epic plan add in Mississippi?
Mississippi adds TMJ coverage and yearly low-dose mammograms to Epic plans.
TMJ coverage pays up to $5,000 per coverage period. The yearly low-dose mammograms start at 35. Also, Mississippi removes the manipulative and musculoskeletal exclusions.
π Where this applies: Mississippi
β Does an Epic plan cover biomarker testing in Mississippi?
Yes, for Epic coverage issued or renewed after the Mississippi rule took effect.
However, medical evidence must support the testing, and plan limits still apply.
π Where this applies: Mississippi
β How is mental health covered on Epic plans in Missouri?
Missouri Epic PPO plans cover mental health like any other illness.
By contrast, Base plans cover set amounts, such as 90 inpatient mental health days per year.
π Where this applies: Missouri
β What else does an Epic plan add in Missouri?
Missouri adds cancer clinical trials, eating disorders and second opinions for new cancer diagnoses.
It also covers lead testing for children under 6.
π Where this applies: Missouri
β Does an Epic plan cover pregnancy in Montana?
Yes, Montana requires Epic plans to cover pregnancy like any other sickness.
Montana also adds a minimum hospital stay for maternity care.
π Where this applies: Montana
β Do Epic waiting periods apply in Montana?
No, Montana removed all waiting periods on Epic plans.
Rates also cannot change for 12 months, with 45 days' notice before a change.
π Where this applies: Montana
β Does an Epic plan cover alcoholism treatment in Nebraska?
Yes, Nebraska adds alcoholism treatment on Epic Base plans.
The benefit includes 31 days of inpatient and 60 days of outpatient alcoholism treatment.
π Where this applies: Nebraska
β What does an Epic plan add in Nevada?
Nevada adds TMJ, contraceptives, HPV vaccine and clinical trials to Epic plans.
Also, colorectal screening starts at 45. In addition, ABA therapy has a $72,000 annual limit.
π Where this applies: Nevada
β What does an Epic plan add in North Carolina?
North Carolina adds AIDS coverage without limits and non-surgical TMJ coverage up to $3,500.
The state also removes the contraceptive exclusion. In addition, the plan allows diabetic foot care.
π Where this applies: North Carolina
β Does an Epic plan cover alcoholism treatment in Ohio?
Yes, Ohio Epic plans cover alcoholism treatment when the plan excludes substance use disorder.
However, Ohio's alcoholism benefit tops out at $550 per coverage period.
π Where this applies: Ohio
β Does Ohio limit autism therapy on Epic plans?
No, Ohio removed the $50,000 limit on applied behavior analysis for Epic plans.
However, the plan requires pre-authorization.
π Where this applies: Ohio
β What changes on Epic plans in Oklahoma?
In Oklahoma, Epic plans drop the hazardous occupations exclusion.
Also, Oklahoma's 3-month waiting list covers hernia repair, varicose veins, reproductive organ disorders and hysterectomy.
π Where this applies: Oklahoma
β Does step therapy apply to Stage 4 cancer on the Pennsylvania Epic plan?
No, step therapy does not apply to Stage 4 advanced metastatic cancer in Pennsylvania.
π Where this applies: Pennsylvania
β What does an Epic plan add in Tennessee?
Tennessee adds chiropractic and spinal manipulation, clinical trials and PKU treatment to Epic plans.
Also, children under 18 get hearing aids up to $1,000 each every 3 years.
π Where this applies: Tennessee
β How long are Epic waiting periods in Tennessee?
Tennessee limits Epic benefit waiting periods to 30 days.
Also, preeclampsia counts as a complication of pregnancy.
π Where this applies: Tennessee
β Does an Epic plan cover mental health in Texas?
Yes, in part: Texas adds coverage for serious mental illness and chemical dependency treatment.
π Where this applies: Texas
β What else does an Epic plan add in Texas?
Texas adds diabetes supplies, TMJ, hearing aids and complications of pregnancy to Epic plans.
The hearing aid benefit applies to kids 18 and under. Also, Texas sets home health at 60 visits.
π Where this applies: Texas
β What does an Epic plan add in West Virginia?
West Virginia adds chronic pain care, including chiropractic, to Epic plans.
It also adds long-term antibiotics for Lyme disease. In addition, the plan covers annual kidney disease screening.
π Where this applies: West Virginia
β Are there special Epic plan rules in Arkansas or Arizona?
No, the state summary lists no special Epic requirements for Arkansas or Arizona.
π Where this applies: Arkansas and Arizona
β Does an Epic plan in Virginia exclude auto no-fault expenses?
No, Virginia removed the exclusion for expenses covered by automobile no-fault insurance.
π Where this applies: Virginia
π More Short-Term Coverage Guides
These answers cover each Epic plan in short form. When you want more depth, these guides from our licensed agents explain how short-term coverage works. Then, if a question comes up, call 888-730-6001 anytime.
π Short-Term Coverage Guides
𧩠More Short-Term FAQ Libraries
π Questions About North River Epic Plans?
These answers cover the most common Epic questions, but every situation is different. Therefore, our licensed agents compare Epic, other short-term and ACA plans for free.
Best of all, our help costs you nothing. Request a free quote online, or call 888-730-6001 to speak with an agent today. You can also reach us through our contact page.
- π 888-730-6001
- βοΈ memberservices@vivna.net
- π Deerfield Beach, Florida
Official resources: the Crum & Forster website, HealthCare.gov, and the National Association of Insurance Commissioners.
Vivna Insurance is an independent, licensed agency offering North River Insurance Company products. We are not North River Insurance Company or its affiliates. Short-term plans are not ACA coverage and may not cover pre-existing conditions. Plans and availability vary by state.