Professional Documents
Culture Documents
© All rights reserved. Health Plan Intermediaries Holdings, LLC, 2018 Confidential. Do not distribute. For agent use only
Product Summary
Deductible Options $500, $1,000, $2,000, $2,500, $5,000, $7,500, $10,000
Length of Coverage Available for up to 36 months of coverage depending upon state regulations.
Reapply Rules
Arizona – One reapply of 180 days or less in any 12 month period. After the insured has had two consecutive coverage
periods, there must be a 63 day break before a new policy can be issued.
Wisconsin – Coverage cannot exceed 18 consecutive months without a 63 day break.
Nevada – Total days may not exceed 185 days in any given 365 day period
In a state with a maximum policy duration of 6 months, you have the option to select:
• 6 months
• up to 36 months with Pre-Existing Waiver Rider
• up to 36 months without Pre-Existing Waiver Rider
• Prepay up to 180 days
Disclaimer: Certain states may have regulations that limit coverage options to less than 6 months. Please refer to the full state
chart for more details. Note that state specific guidelines are subject to change.
Deductible Choice of: $500, $1,000, $2,000, $2,500, $5,000, $7,500, $500, $1,000, $2,000, $2,500, $5,000, $7,500, $500, $1,000, $2,000, $2,500, $5,000, $7,500,
$10,000 $10,000 $10,000
Out-Of-Pocket Maximum Choice of: $2,000, $4,000 $2,000, $4,000 $2,000, $4,000
Coverage Period Maximum Choice of: $250,000, $500,000, $1,000,000 $250,000, $500,000, $1,000,000 $250,000, $500,000, $1,000,000
Doctor Visits After the Copayment shown above, After the Copayment shown above, Coinsurance After the Copayment shown above, Coinsurance
Coinsurance is 100% of Eligible Expenses and is 100% of Eligible Expenses and benefits are not is 100% of Eligible Expenses and benefits are not
benefits are not subject to the Plan Deductible. subject to the Plan Deductible. Any other covered subject to the Plan Deductible. Any other covered
The office visit maximum for all Doctor office services or tests performed as part of the office services or tests performed as part of the office
visits, including any other covered services or visit will be subject to the Plan Deductible and visit will be subject to the Plan Deductible and
tests performed as part of the office visit, will Coinsurance. Coinsurance.
not exceed $2,000 per Covered Person per
Coverage Period Office Visits in excess of the
maximum number of Copayments will be
subject to the Plan Deductible and Coinsurance
Unless specified otherwise, the following benefits are for Insured and each Covered Dependent subject to the plan Deductible, Coinsurance Percentage, Out-Of-Pocket Maximum and Policy Maximum chosen.
Benefits are limited to the Usual, Reasonable and Customary for each Covered Expense, in addition to any specific limits stated in the policy.
Hospital Intensive or Critical Care Benefits, including nursing services and all Subject to Deductible and Coinsurance Subject to Deductible and Coinsurance
miscellaneous medical charges are limited to
$2,000 per day.
Doctor Visits $50 per day. Benefits for all Hospital visits during Subject to Deductible and Coinsurance Subject to Deductible and Coinsurance
a Hospital stay are limited to $500 per Covered
Person per Coverage Period.
Outpatient Expenses
Outpatient Surgical Facility The benefit payable per day including all Subject to Deductible and Coinsurance Subject to Deductible and Coinsurance
miscellaneous expense, is limited to $1,500.
Outpatient Miscellaneous Hospital The benefit payable for miscellaneous Outpatient Subject to Deductible and Coinsurance Subject to Deductible and Coinsurance
Expenses Hospital expenses, excluding Outpatient Surgery.
Benefits are limited to $1,500 per Covered
Person per Coverage Period for all Eligible
Expenses combined.
Emergency Room Treatment Subject to the Emergency Room Additional Subject to the Emergency Room Additional Subject to the Emergency Room Additional
Deductible shown above, then Deductible Deductible shown above, then Deductible and Deductible shown above, then Deductible and
and Coinsurance. The Additional Deductible Coinsurance. The Additional Deductible is waived Coinsurance. The Additional Deductible is waived
is waived if admitted within 24 hours of if admitted within 24 hours of Emergency Room if admitted within 24 hours of Emergency Room
Emergency Room Treatment. Treatment. Treatment.
Surgical Facility or Ambulatory Surgery The benefit payable for each emergency room Subject to Deductible and Coinsurance Subject to Deductible and Coinsurance
Center visit, including professional and facility services,
will not exceed $250 per visit.
Surgical Services
Surgeon $5,000 per surgery, for all Eligible Expenses Subject to Deductible and Coinsurance Subject to Deductible and Coinsurance
combined, not to exceed $10,000 per Covered
Person per Coverage Period
Assistant Surgeon $1,000 per surgery, for all Eligible Expenses Subject to Deductible and Coinsurance Subject to Deductible and Coinsurance
combined, not to exceed $2,000 per Covered
Person per Coverage Period.
Administration of Anesthetics $1,000 per surgery, for all Eligible Expenses Subject to Deductible and Coinsurance Subject to Deductible and Coinsurance
combined, not to exceed $2,000 per Covered
Person per Coverage Period.
Extended Care Facility Subject to Deductible and Coinsurance up to Subject to Deductible and Coinsurance up to Subject to Deductible and Coinsurance up to
$100 per day and 30 days per Coverage Period $100 per day and 30 days per Coverage Period $100 per day and 30 days per Coverage Period
Hospice Care Subject to Deductible and Coinsurance up to Subject to Deductible and Coinsurance up to Subject to Deductible and Coinsurance up to
$5,000 per Coverage Period $5,000 per Coverage Period $5,000 per Coverage Period
Acquired Immune Deficiency Syndrome Subject to Deductible and Coinsurance up to Subject to Deductible and Coinsurance up to Subject to Deductible and Coinsurance up to
$10,000 per Coverage Period for all Covered $10,000 per Coverage Period for all Covered $10,000 per Coverage Period for all Covered
(AIDS) Expenses including Inpatient Hospital, Surgical Expenses including Inpatient Hospital, Surgical Expenses including Inpatient Hospital, Surgical
and Outpatient Miscellaneous Medical Covered and Outpatient Miscellaneous Medical and Outpatient Miscellaneous Medical
Expenses Covered Expenses Covered Expenses
Joint/Tendon Surgery Subject to Deductible and Coinsurance up to Subject to Deductible and Coinsurance up to Subject to Deductible and Coinsurance up to
$3,000 per Coverage Period for all Covered $3,000 per Coverage Period for all Covered $3,000 per Coverage Period for all Covered
Expenses including Inpatient Hospital, Surgical Expenses including Inpatient Hospital, Surgical Expenses including Inpatient Hospital, Surgical
and Outpatient Miscellaneous Medical Covered and Outpatient Miscellaneous Medical and Outpatient Miscellaneous Medical
Expenses for both left and right knees Covered Expenses for both left and right knees Covered Expenses for both left and right knees
Knee Injury or Disorder Subject to Deductible and Coinsurance $3,000 Subject to Deductible and Coinsurance $3,000 Subject to Deductible and Coinsurance $3,000
per Coverage Period for all Covered Expenses per Coverage Period for all Covered Expenses per Coverage Period for all Covered Expenses
including Inpatient Hospital, Surgical and including Inpatient Hospital, Surgical and including Inpatient Hospital, Surgical and
Outpatient Miscellaneous Medical Covered Outpatient Miscellaneous Medical Covered Outpatient Miscellaneous Medical Covered
Expenses for both left and right knees Expenses for both left and right knees Expenses for both left and right knees
Gallbladder Surgery Subject to Deductible and Coinsurance up to Subject to Deductible and Coinsurance up to Subject to Deductible and Coinsurance up to
$3,000 per Coverage Period for all Covered $3,000 per Coverage Period for all Covered $3,000 per Coverage Period for all Covered
Expenses including Inpatient Hospital, Surgical Expenses including Inpatient Hospital, Surgical Expenses including Inpatient Hospital, Surgical
and Outpatient Miscellaneous Medical Covered and Outpatient Miscellaneous Medical Covered and Outpatient Miscellaneous Medical Covered
Expenses Expenses Expenses
Appendectomy Subject to Deductible and Coinsurance up to Subject to Deductible and Coinsurance up to Subject to Deductible and Coinsurance up to
$3,000 per Coverage Period for all Covered $3,000 per Coverage Period for all Covered $3,000 per Coverage Period for all Covered
Expenses including Inpatient Hospital, Surgical Expenses including Inpatient Hospital, Surgical Expenses including Inpatient Hospital, Surgical
and Outpatient Miscellaneous Medical Covered and Outpatient Miscellaneous Medical Covered and Outpatient Miscellaneous Medical Covered
Expenses Expenses Expenses
Kidney Stones Subject to Deductible and Coinsurance $3,000 Subject to Deductible and Coinsurance $3,000 Subject to Deductible and Coinsurance $3,000
per Coverage Period for all Covered Expenses per Coverage Period for all Covered Expenses per Coverage Period for all Covered Expenses
including Inpatient Hospital, Surgical and including Inpatient Hospital, Surgical and including Inpatient Hospital, Surgical and
Outpatient Miscellaneous Medical Covered Outpatient Miscellaneous Medical Covered Outpatient Miscellaneous Medical Covered
Expenses Expenses Expenses
Temporomandibular Joint Disorder (TMJ) Subject to Deductible and Coinsurance up to Subject to Deductible and Coinsurance up to Subject to Deductible and Coinsurance up to
$3,000 per Coverage Period for all Covered $3,000 per Coverage Period for all Covered $3,000 per Coverage Period for all Covered
Expenses including Inpatient Hospital, Surgical Expenses including Inpatient Hospital, Surgical Expenses including Inpatient Hospital, Surgical
and Outpatient Miscellaneous Medical Covered and Outpatient Miscellaneous Medical Covered and Outpatient Miscellaneous Medical Covered
Expenses Expenses Expenses
Home Health Care Subject to Deductible and Coinsurance up to Subject to Deductible and Coinsurance up to $30 Subject to Deductible and Coinsurance up to $30
$30 per day and a maximum of 30 days per per day and a maximum of 30 days per Coverage per day and a maximum of 30 days per Coverage
Coverage Period Period Period
Therapy Services - Physical Therapist, Subject to Deductible and Coinsurance up to Subject to Deductible and Coinsurance up to $15 Subject to Deductible and Coinsurance up to $15
Speech Therapist and Occupational Therapist $15 per day and a maximum of 30 days per per day and a maximum of 30 days per Coverage per day and a maximum of 30 days per Coverage
Coverage Period Period Period
Ambulance, Ground or Air Subject to Deductible and Coinsurance up to Subject to Deductible and Coinsurance up to Subject to Deductible and Coinsurance up to
$500 per trip – Ground up to $1,000 per trip – $500 per trip – Ground up to $1,000 per trip – Air $500 per trip – Ground up to $1,000 per trip – Air
Air Ambulance Ambulance Ambulance
Durable Medical Equipment and Medical Subject to Deductible and Coinsurance Subject to Deductible and Coinsurance Subject to Deductible and Coinsurance
Supplies
Bone Density Testing Subject to Deductible and Coinsurance up to Subject to Deductible and Coinsurance up to Subject to Deductible and Coinsurance up to
$150 per Coverage Period $150 per Coverage Period $150 per Coverage Period
Disclaimer: Coverage is not limited to the benefits listed in this document; any eligible expenses are subject to plan limitations. Please check the product certificate or master
policy for complete details.
ACA Disclaimer: THIS COVERAGE IS NOT REQUIRED TO COMPLY WITH CERTAIN FEDERAL MARKET REQUIREMENTS FOR HEALTH INSURANCE, PRINCIPALLY THOSE
CONTAINED IN THE AFFORDABLE CARE ACT. BE SURE TO CHECK THE CERTIFICATE CAREFULLY TO MAKE SURE YOU ARE AWARE OF ANY EXCLUSIONS OR
LIMITATIONS REGARDING COVERAGE OF PRE-EXISTING CONDITIONS OR HEALTH BENEFITS (SUCH AS HOSPITALIZATION, EMERGENCY SERVICES, MATERNITY
CARE, PREVENTIVE CARE, PRESCRIPTION DRUGS, AND MENTAL HEALTH AND SUBSTANCE USE DISORDER SERVICES). YOUR COVER-AGE ALSO HAS LIFETIME
AND/OR ANNUAL DOLLAR LIMITS ON HEALTH BENEFITS. IF THIS COVERAGE EXPIRES OR YOU LOSE ELIGIBILITY FOR THIS COVERAGE, YOU MIGHT HAVE TO WAIT
UNTIL AN OPEN ENROLLMENT PERIOD TO GET OTHER HEALTH INSURANCE COVERAGE. ALSO, THIS COVERAGE IS NOT “MINIMUM ESSENTIAL COVERAGE. IF YOU
DON’T HAVE MINIMUM ESSENTIAL COVERAGE FOR ANY MONTH IN 2018, YOU MAY HAVE TO MAKE A PAYMENT WHEN YOU FILE YOUR TAX RETURN UNLESS YOU
QUALIFY FOR AN EXEMPTION FROM THE REQUIREMENT THAT YOU HAVE HEALTH COVERAGE FOR THAT MONTH.
Disclaimer Note: This is a brief description of AdvantHealth Short Term Medical plan. Please check the product certificate or master policy for complete details
on benefits, limitations, and exclusions.