Everest 5000/20/7000/250000 - OR Short Term Health Plan from Everest - Healthpocket

Short Term Plans Found

 

Everest 5000/20/7000/250000

$36.66/mo

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Zip Code97229
Applicant12/10/1983 Male
Coverage Start12/11/2018
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Benefits & Coverage

Insurance TypeShort Term Medical Insurance
Insurance ProviderEverest
Plan Type
Deductible$5,000
Coinsurance20% after deductible
Coverage Max$250,000
Application Fee$0

Plan TypeShort Term Medical Insurance
Office Visit for Primary Doctor$30 Copay per visit or consultation per Covered Not to exceed a maximum of 3 Doctor's Office or Urgent Care Center Visits Copays per Covered Person. Coinsurance is 30% of Eligible Expenses and benefits are not subject to the Plan Deductible. Doctor's office or urgent care visits or doctor consultations in excess of the maximum number of Doctor's Office or Urgent Care Center Visits' Copays will be subject to the Plan Deductible and Coinsurance.
Office Visit for Specialist$30 Copayment per visit per Covered Person not to exceed a maximum of 3 Copayments per Covered Person. Eligible Expenses and benefits are not subject to the Plan Deductible or Coinsurance. Office Visits in excess of the maximum number of Copayments will be subject to the Plan Deductible and Coinsurance.
Coinsurance20% after deductible
Annual DeductibleIndividual: $5,000.00
Family: $15,000.00
Separate Prescription Drugs DeductibleN/A
Prescription DrugsGeneric: Not covered except those administered by a Doctor in an Inpatient or Outpatient setting covered under this Policy as an Eligible Expense.
Brand Name: Not covered except those administered by a Doctor in an Inpatient or Outpatient setting covered under this Policy as an Eligible Expense.
Non-formulary: Not covered except those administered by a Doctor in an Inpatient or Outpatient setting covered under this Policy as an Eligible Expense.
Annual Out-of-Pocket LimitIndividual: $7,000.00
Family: $21,000.00
Does Out-of-Pocket Limit include deductible?No
Lifetime Maximum$250,000.00
Out-of-Network CoverageNo

Physicians

Primary Care Physician (PCP) RequiredNo
Specialist Referrals RequiredNo

Preventive Care Coverage

Periodic Health ExamNo
Periodic OB-GYN ExamNo
OB-GYN Exam ConditionsNot Covered
Well Baby CareNo

Prescription Drug Coverage

Generic Prescription DrugsNot covered except those administered by a Doctor in an Inpatient or Outpatient setting covered under this Policy as an Eligible Expense.
Brand Prescription DrugsNot covered except those administered by a Doctor in an Inpatient or Outpatient setting covered under this Policy as an Eligible Expense.
Non-Formulary Prescription Drugs CoverageNot covered except those administered by a Doctor in an Inpatient or Outpatient setting covered under this Policy as an Eligible Expense.
Separate Prescription Drugs DeductibleN/A

Hospital Services Coverage

Emergency RoomEmergency Room (This includes the emergency room physician charge, 24 hours surveillance and all miscellaneous medical charges) The benefit payable for each emergency room visit, including professional and facility services, will not exceed $250 per visit.
Outpatient Lab/X-Ray
Outpatient SurgeryFacility charges up to a max of $1,250 per day; $5,000 Surgeon and $1,000 Assistant Surgeon\nlimitations apply
HospitalizationAverage Standard Room Rate: $1,000 per day. Hospital ICU: $1,250 per day

Maternity Coverage

Pre & Postnatal Office VisitNot Covered
Labor & Delivery Hospital StayNot Covered

Additional Coverage

Chiropractic CoverageNot Covered
Mental Health CoverageInpatient: $100 per day, 31 day maximum per Covered Person per Coverage Period. Outpatient: $50 per visit, 10 visits per Covered Person per Coverage Period

Everest STM membership offers the following health insurance benefits, underwritten by Everest Reinsurance Company. Everest STM plans are not available in all states. State options and benefits may vary.

Why Short-Term Medical (STM)?

Short-term medical pays benefits like a major medical insurance plan, but for a predetermined length of time. Members can select from a wide range of deductible and coinsurance options to tailor a plan to fit their lifestyle needs and budget.

How do members figure out what coverage they need and enroll?

Consider the benefit period and choose payment method:

  • Single Payment
    This option is ideal if it is known exactly how many days the coverage is needed. The minimum number of days that members may apply for coverage is 30 days; the maximum is 180 days. Payment via Visa, MasterCard, or bank draft is accepted.
  • Monthly Pay
    This plan gives members the flexibility to continue coverage for as long as it is needed and allows them to discontinue the plan once their temporary need ends. Payment via Visa, MasterCard, or bank draft is accepted.

Consider lifestyle needs and budget and choose one from each of the following:

  • Deductible: $1,000, $2,500, or $5,000
    The selected deductible must be paid by each Covered Person before Coinsurance benefits are payable. After 3 individuals meet their deductible, the deductible is deemed satisfied for any remaining covered individuals.
  • Coinsurance Percentage 80/20
    The selection of a Coinsurance Percentage represents the percent of covered eligible expenses that we pay and that members pay after the deductible has been satisfied up to the Out of Pocket Maximum.
  • Out of Pocket Maximum: $2,000, $3,000 or $4,000
    Once members reach their Out of Pocket Maximum Amount selected, we pay 100%* up to the Coverage Period Maximum Benefit.

*Subject to Maximum Allowable Expense

What medical expenses are covered?

The following benefits are for the Insured and each Covered Dependent subject to the plan Deductible, Coinsurance Percentage, Out of Pocket Maximum, and Coverage Period Maximum Benefit. Benefits are limited to Maximum Allowable Expense for each Covered Eligible Expense, in addition to any specific limits stated in the policy.

  • Preventive / Wellness Care
  • $30 Copayment per visit per Covered Person not to exceed a maximum of 3 Copayments per Covered Person. Eligible Expenses and benefits are not subject to the Plan Deductible or Coinsurance. Office Visits in excess of the maximum number of Copayments will be subject to the Plan Deductible and Coinsurance.
  • $50 Copayment for one annual Routine Physical Exam. Coinsurance is 100% and benefits are not subject to the Plan Deductible.
  • Outpatient and Inpatient Treatment for Mental and Nervous Disorders
  • Outpatient and Inpatient Treatment for Substance Abuse
  • Organ and Tissue transplants
  • Inpatient prescription drugs
  • Physical, Occupational and Speech Therapy $50 per day and 20 visits combined
  • Ambulance Transportation maximum benefit $250
  • Outpatient Hospital or Emergency Room Care
  • Inpatient Room & Board, including Intensive Care
  • Outpatient Miscellaneous Medical Services, doctors medical care and treatment performed in a hospital
  • Home Health Care benefit $50 per visit for a maximum of 1 visit per day and 30 Home Health Care visits.
  • Extended Care Facility up to $150 per day for a maximum of 30 days
  • Outpatient Surgical Facility
  • Surgeon services in the hospital or outpatient surgical facility

Note: This is a brief description of the plan benefits, which may vary by state. Benefits for this plan may be limited. See policy documents for full terms and limitations of coverage.

Loss caused by, contributed to or resulting from the following is excluded or otherwise limited as specified:

  1. Pre-existing Conditions:
    1. Charges resulting directly or indirectly from a condition for which a Covered Person received medical treatment, diagnosis, care or advice, including diagnostic tests or medications, within the 60-month period immediately preceding such person’s Certificate Effective Date are excluded for the first 12 months of coverage hereunder.
    2. Pre-existing Conditions includes conditions that produced any symptoms which would have caused a reasonable prudent person to seek diagnosis, care or treatment within the 60 month period immediately prior to the Covered Person’s Certificate Effective Date of coverage under the Policy.

    This exclusion does not apply to a newborn child or newborn adopted child who is added to coverage in accordance with PART II – ELIGIBILITY AND EFFECTIVE DATE OF INSURANCE.

  2. Waiting Period:
    1. Covered Persons will only be entitled to receive benefits for Sicknesses that begin, by occurrence of symptoms and/or receipt of treatment, more than 5 days following the Covered Person’s Certificate Effective Date of coverage under the Policy.
    2. Covered Persons will only be entitled to receive benefits for Cancer that begins, by occurrence of symptoms or receipt of treatment more than 30 days following the Covered Person’s Certificate Effective Date of coverage under the Policy.
  3. Charges during the first 6 months after the Certificate Effective Date of coverage for a Covered Person for the following:
    1. Total or partial hysterectomy, unless it is Medically Necessary due to a diagnosis of carcinoma;
    2. Tonsillectomy;
    3. Adenoidectomy;
    4. Repair of deviated nasal septum or any type of surgery involving the sinus;
    5. Myringotomy;
    6. Tympanotomy;
    7. Herniorraphy; or
    8. Cholecystectomy.

    However, if such condition is a Pre-Existing Condition, any benefit consideration will be in accordance with the Pre-Existing Conditions limitation.

  4. The benefits payable for the following conditions or procedures are limited to the specified amounts shown in the Schedule of Benefits:
    1. Kidney stone
    2. Appendectom
    3. Joint or tendon Surgery
    4. Knee Injury or disorder
    5. Acquired Immune Deficiency Syndrome (AIDS)/ Human Immuno-deficiency Virus (HIV)
    6. Gallbladder Surgery
  5. Charges which are not incurred by a Covered Person during his/her Coverage Period.
  6. Charges which exceed any limits or limitations specified in this Certificate, including the Schedule of Benefits.
  7. Charges for services of supplies in excess of the Maximum Allowable Expense.
  8. Charges for services or supplies which are not administered by or under the supervision of a Doctor.
  9. Mental, emotional or nervous disorders or counseling of any type, except as specifically covered as an Eligible Expense.
  10. Marital counseling or social counseling.
  11. Treatment for Substance Abuse, unless specifically covered under the Policy as an Eligible Expense.
  12. Prescription Drugs, except those administered by a Doctor in an Inpatient or Outpatient setting covered under this Policy as an Eligible Expense.
  13. Medications, vitamins, and mineral or food supplements including pre-natal vitamins, or any over-the-counter medicines, whether or not ordered by a Doctor.
  14. Any drug, treatment or procedure that either promotes or prevents conception including but not limited to: artificial insemination, treatment for infertility or impotency, sterilization or reversal of sterilization.
  15. Any drug, treatment or procedure that corrects impotency or non-organic sexual dysfunction.
  16. Modifications of the physical body in order to improve the psychological, mental or emotional well-being of the Covered Person, such as sex-change surgery.
  17. Cosmetic Treatment, except for reconstructive surgery where expressly covered under the Policy.
  18. Weight modification or surgical treatment of obesity.
  19. Eye surgery, including LASIK, when the primary purpose is to correct nearsightedness, farsightedness or astigmatism.
  20. Dental Expenses, except as necessary to restore or replace sound and natural teeth lost or damaged as a result of an Injury. The Injury must be severe enough that the contact with the Doctor occurs within seventy-two (72) hours of the Accident, unless extenuating circumstances exist due to the severity of the Injury that prevent you from contacting the Doctor.
  21. Expenses incurred in the treatment by any method for jaw joint problems including temporomandibular joint dysfunction (TMJ), TMJ pain syndromes, craniomandibular disorders, myofacial pain dysfunction or other conditions of the joint linking the jaw bone and skull and the complex of muscles, nerves and other tissues related to the joint, unless specifically covered under the Policy as an Eligible Expense.
  22. Routine pre-natal care, Pregnancy, child birth, and post-natal care. (This exclusion does not apply to “Complications of Pregnancy” as defined.)
  23. Charges for a Covered Dependent who is a newborn child not yet discharged from the Hospital, unless the charges are Medically Necessary to treat premature birth, congenital Injury or Sickness, or Sickness or Injury sustained during or after birth.
  24. Sclerotherapy for veins of the extremities.
  25. Abortions, except in connection with covered Complications of Pregnancy or if the life of the expectant mother would be at risk.
  26. Joint replacement or other treatment of joints, spine, bones or connective tissue including tendons, ligaments and cartilage, unless related to a covered Injury.
  1. Surgeries, treatments, services or supplies which are deemed to be Experimental Treatment.
  2. Chronic fatigue or pain disorders.
  3. Kidney or end stage renal disease.
  4. Treatment or diagnosis of allergies, except for emergency treatment of allergic reactions.
  5. Treatment for cataracts.
  6. Treatment of sleep disorders.
  7. Treatment required as a result of complications or consequences of a treatment or condition not covered under this Certificate.
  8. Treatment incurred as a result of exposure to non-medical nuclear radiation and/or radioactive material(s).
  9. Treatment for acne, moles, skin tags, diseases of sebaceous glands, seborrhea, sebaceous cyst, unspecified disease of sebaceous glands, hypertrophic and atrophic conditions of skin, nevus.
  10. Treatment for or related to any Congenital Condition, except as it relates to a newborn child or newborn adopted child added as a Covered Person pursuant to the terms of this Certificate.
  11. Treatment, medication or hormones to stimulate growth, or treatment of learning disorders, disabilities, developmental delays or deficiencies, including therapy.
  12. Spinal manipulation or adjustment.
  13. Biofeedback, acupuncture, recreational, sleep or MIST Therapy®, holistic care of any nature, massage and kinestherapy, excepted as provided for under Home Health Care.
  14. Hypnotherapy when used to treat conditions that are not recognized as Mental Disorders by the American Psychiatric Association, and non-medical self-care or self-help programs.
  15. Eyeglasses, contact lenses, hearing aids, hearing implants, eye refraction, visual therapy, orthoptics, visual eye training and any examination or fitting related to these devices, and all vision and hearing tests and examinations.
  16. Care, treatment or supplies for the feet, orthopedic shoes, orthopedic prescription devices to be attached to or placed in shoes, treatment of weak, strained, flat, unstable or unbalanced feet, metatarsalgia or bunions and treatment of corns, calluses or toenails.
  17. Care and treatment for hair loss including wigs, hair transplants or any drug that promises hair growth, whether or not prescribed by a Doctor.
  18. Exercise programs, whether or not prescribed or recommended by a Doctor.
  19. Telephone or Internet consultations and/or treatment or failure to keep a scheduled appointment.
  20. Charges for travel or accommodations, except as expressly provided for local ambulance.
  21. All charges incurred while confined primarily to receive Custodial or Convalescent Care.
  22. Services received or supplies purchased outside the United States, its territories or possessions, or Canada unless specifically covered under the Policy as an Eligible Expense
  23. Any services or supplies in connection with cigarette smoking cessation.
  24. Any services performed or supplies provided by a member of a Covered Person’s Immediate Family.
  25. Services received for any condition caused by a Covered Person’s commission of or attempt to commit an assault, battery, or felony, whether charged or not, or to which a contributing cause was the Covered Person being engaged in an illegal occupation.
  26. Services or supplies which are not included as Eligible Expenses as described herein.
  27. Participating in hazardous occupations or other activity including participating, instructing, demonstrating, guiding or accompanying others in the following: operation of a flight in an aircraft other than a regularly scheduled flight by a commercial airline, professional or semi-professional sports, extreme sports, parachute jumping, hot-air ballooning, hang-gliding, base jumping, mountain climbing, bungee jumping, scuba diving, sail gliding, parasailing, parakiting, rock or mountain climbing, cave exploration, parkour, racing including stunt show or speed test of any motorized or non-motorized vehicle, rodeo activities, or similar hazardous activities. Also excluded is Injury received while practicing, exercising, undergoing conditional or physical preparation for such activity.
  28. Injuries or Sicknesses resulting from participation in interscholastic, intercollegiate or organized competitive sports. This does not include dependent children participating in local community sports activities
  29. Injury resulting from being under the influence of or due wholly or partly to the effects of alcohol or drugs, other than drugs taken in accordance with treatment prescribed by a Doctor.
  30. Intentionally self-inflicted Injury or Sickness (whether the Covered Person is sane or insane).
  31. Charges resulting from a declared or undeclared war, or from voluntary participation in a riot or insurrection.
  32. Charges incurred by a Covered Person while on active duty in the armed forces. Upon written notice to Us of entry into such active duty, the unused premium will be returned to the Covered Person on a pro-rated basis.
  33. Costs for Routine Physical Exams or other services not needed for medical treatment, unless specifically covered under the Policy as an Eligible Expense.
  34. Charges You or Your Covered Dependent are not required to pay, or which would not have been billed, if no insurance existed.
  35. Charges to the extent that they are paid or payable under other valid or collectible group insurance or medical prepayment plan.
  36. Charges that are eligible for payment by Medicare or any other government program except Medicaid. Costs for care in government institutions unless You or Your Covered Dependent are obligated to pay for such care.
  37. Charges related to Injury or Sickness arising out of or in the course of any occupation for compensation, wage or profit, if the Covered Person is insured, or is required to be insured, by occupational disease or workers’ compensation insurance pursuant to applicable state or federal law, whether or not application for such benefits have been made.
  38. Medical expenses which are payable under any automobile insurance policy without regard to fault (does not apply in any state where prohibited).

This is a brief description of the plan limitations and exclusions, which may vary by state.

Everest STM Underwritten By: Everest

Disclaimer: THIS IS A SHORT-TERM LIMITED DURATION HEALTH INSURANCE POLICY THAT IS NOT INTENDED TO AND DOES NOT QUALIFY AS THE MINIMUM ESSENTIAL COVERAGE REQUIRED BY THE AFFORDABLE CARE ACT (ACA). UNLESS YOU PURCHASE A POLICY THAT PROVIDES MINIMUM ESSENTIAL COVERAGE IN ACCORDANCE WITH THE ACA, YOU MAY BE SUBJECT TO A FEDERAL TAX PENALTY. ALSO, THE TERMINATION OR LOSS OF THIS POLICY DOES NOT ENTITLE YOU TO A SPECIAL ENROLLMENT PERIOD TO PURCHASE A HEALTH INSURANCE POLICY THAT QUALIFIES AS MINIMUM ESSENTIAL COVERAGE OUTSIDE OF AN OPEN ENROLLMENT PERIOD.THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES. This is a brief summary of Everest Short-Term Medical Insurance underwritten by Everest Reinsurance Company provided by Policy Form Series EAH 00 524 08 15. Availability and terms may vary by state.

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  • Phone Number
    (503) 629-0237
  • Office Locations
    14223 Nw Spruceridge Ln
    Portland, OR 97229
14223 Nw Spruceridge Ln Portland OR, 97229

Does the plan require Pre-Certification?

All Inpatient hospitalizations and procedures done at an Outpatient Surgery Facility must be pre-certified. Everest Reinsurance Company's professional review organization must be contacted as soon as possible before the expense is to be incurred. If the Covered Person does not comply with the Pre-certification requirements as stated in the insurance certificate, the Eligible Medical Expenses will be reduced by 50%.

How does Usual and Customary Fees affect my benefits?

The Policy defines Usual and Customary Fees as the usual, fair and reasonable fee for medical treatment provided to a Covered Person (or any other form of medical care, procedure, drug or supply).

In determining a Usual and Customary Fee, the Company at its discretion, consults:

  1. one (1) or more standard industry sources to calculate services of comparable severity and nature in the same geographical area, the cost of the goods and services reasonably required to produce and deliver such treatment and/or the charge most commonly paid for such treatment. The standard industry sources utilize cost-based formula methodology and/or pricing data (updated semi-annually) to produce replicable and consistent cost and/or pricing parameters;
  2. the cost to the health care provider of performing or providing the medical treatment, including reasonable allowance for overhead and profit;
  3. fee schedules used by third parties such as Medicare or Medicaid, including Medicare allowable charge data for Medicare Part B;
  4. hospital cost data as submitted to Medicare, including Medicare allowable charge data for Medicare Part A; and
  5. prevailing negotiated fee schedules for same or similar services performed in the same geographical area.

All benefits are limited to Usual and Customary Fees. Usual and Customary Fee definition may vary by state.

What if members change their minds after the purchase of STM coverage?

If not 100% satisfied with coverage and members have not already used any of the insurance benefits, they may return the certification to us within 10 days of receipt. Coverage will be cancelled as of the effective date and the plan cost will be returned. No questions asked!

What is the Pre-Existing Conditions Limitation?

Charges resulting directly or indirectly from a condition for which a Covered Person received medical treatment, diagnosis, care or advice within the 60* month period immediately preceding such person's Certificate Effective Date. A Pre-Existing condition includes conditions that produced any symptoms which would have caused a reasonable prudent person to seek diagnosis, care or treatment within the 60* month period.

*varies by state

Who is eligible to apply for this insurance?

Everest STM is available to members and their spouses, who are between 18 and 64 years old and their dependent unmarried children under 26 years old; and can answer "No" to all of the questions in the application for insurance. Child-only coverage is available for ages 2-25.

When does the STM coverage terminate?

Coverage under the Policy will cease at 12:01 a.m. for a Covered Person, based on the time zone in the place where the Insured resides, on the earliest of the following:

  1. The date premiums are not paid in accordance with the terms of the Policy, subject to the Grace Period;
  2. On the next premium due date after the Company receives a written request from the Insured to terminate coverage, or any later date stated in the request;
  3. The date an Insured performs an act or practice that constitutes fraud, or is found to have made an intentional misrepresentation of material fact, relating in any way to the Policy, including claims for benefits under the Policy;
  4. The date of the Insured's death or the termination date of the Insured's coverage, if the Insured's spouse is not covered under the Policy;
  5. The date the Insured obtains other insurance, excluding Medicare;
  6. The Certificate termination date stated on the Schedule of Benefits.
  7. The date that members enter full-time active duty in the armed forces of any country or international organization other than for reserve duty of 30 days or less;
  8. The date other major medical insurance coverage becomes effective for a Covered Person;
  9. The date that insurance under the Policy is discontinued; or
  10. The first day of any policy month We elect to terminate the Policy by giving the Group Policyholder at least 30 advance written notice.
PremiumPlan NameDeductible

HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, Medicaid or an individual health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan.

HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, Medicaid or an individual health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan.