|Applicant||12/17/1983 Male |
|Insurance Type||Short Term Medical Insurance|
|Coinsurance||20% after deductible|
|Plan Type||Short 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.|
|Coinsurance||20% after deductible|
|Annual Deductible||Individual: $5,000.00Family: $15,000.00|
|Separate Prescription Drugs Deductible||N/A|
|Prescription Drugs||Generic: 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 Limit||Individual: $9,000.00Family: $27,000.00|
|Does Out-of-Pocket Limit include deductible?||No|
|Primary Care Physician (PCP) Required||No|
|Specialist Referrals Required||No|
Preventive Care Coverage
|Periodic Health Exam||No|
|Periodic OB-GYN Exam||No|
|OB-GYN Exam Conditions||Not Covered|
|Well Baby Care||No|
Prescription Drug Coverage
|Generic Prescription Drugs||Not covered except those administered by a Doctor in an Inpatient or Outpatient setting covered under this Policy as an Eligible Expense.|
|Brand Prescription Drugs||Not 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 Coverage||Not covered except those administered by a Doctor in an Inpatient or Outpatient setting covered under this Policy as an Eligible Expense.|
|Separate Prescription Drugs Deductible||N/A|
Hospital Services Coverage
|Emergency Room||Emergency 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 Surgery||Facility charges up to a max of $1,250 per day; $5,000 Surgeon and $1,000 Assistant Surgeon\nlimitations apply|
|Hospitalization||Average Standard Room Rate: $1,000 per day. Hospital ICU: $1,250 per day|
|Pre & Postnatal Office Visit||Not Covered|
|Labor & Delivery Hospital Stay||Not Covered|
|Chiropractic Coverage||Not Covered|
|Mental Health Coverage||Inpatient: $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.
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.
Consider the benefit period and choose payment method:
Consider lifestyle needs and budget and choose one from each of the following:
*Subject to Maximum Allowable Expense
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.
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:
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.
However, if such condition is a Pre-Existing Condition, any benefit consideration will be in accordance with the Pre-Existing Conditions limitation.
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.
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:
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:
Everest 5000/20/9000/250000 Extended
Everest 5000/20/8000/250000 Extended
Everest 5000/20/7000/250000 Extended
Everest 5000/20/9000/1000000 Extended
Everest 5000/20/8000/1000000 Extended