|Applicant||2/17/1984 Male |
|Insurance Type||Short Term Medical Insurance|
|Coinsurance||0% after deductible|
|Plan Type||Short Term Medical Insurance|
|Office Visit for Primary Doctor||$40 Copayment per visit per Covered Person. Benefit not subject to Coinsurance or Plan Deductible.|
|Office Visit for Specialist||$40 Copayment per visit per Covered Person. Benefit not subject to Coinsurance or Plan Deductible.|
|Coinsurance||0% 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: $5,000.00Family: $15,000.00|
|Does Out-of-Pocket Limit include deductible?||Yes|
|Out of Country Coverage||No|
|Primary Care Physician (PCP) Required||No|
|Specialist Referrals Required||No|
Preventive Care Coverage
|Periodic Health Exam||Yes|
|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||$500 additional deductible per visit for use of emergency room in the event of Sickness or Injury. The Deductible is waived if the Covered Person is directly admitted as an Inpatient for further treatment after which the Plan Deductible and Coinsurance will apply.|
|Outpatient Lab/X-Ray||Not Covered|
|Outpatient Surgery||$500 additional deductible per surgery for Out-Patient Surgery after which Plan Deductible and Coinsurance will apply. Maximum of 3 Deductibles per Covered Person. Surgeries in excess of the maximum number of outpatient surgery deductibles will be subject to the Plan Deductible and Coinsurance|
|Hospitalization||Average Standard Room Rate: Average Standard Room Rate.|
|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|
This Section explains how benefits are paid under the Policy. The section entitled ELIGIBLE EXPENSES lists the types of medical care that We cover and to what extent. In order for Us to pay benefits, You or the Covered Person must meet the following conditions:
Copayment Amounts Defined:
Coverage Period Maximum Benefit
This is the maximum amount We will pay under the Policy per Covered Person, per Coverage Period.
What medical expense are covered?
The Policy covers the Eligible Expenses listed below. We apply these Eligible Expenses separately for each Covered Person.
An expense is “incurred” on the date a provider or facility performs the service or furnishes the supplies.
The following are Eligible Expenses under the Policy:
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 or newly adopted child who is added to coverage in accordance with the policy’s eligibility and effective date of insurance.
How do my benefits work?
Benefits are payable under the Policy after a Covered Person incurs charges for Eligible Expenses in excess of any applicable Additional Deductible, and then the Plan Deductible or Copayment, unless otherwise specified. Benefits will be paid at the Coinsurance amount shown in the Schedule of Benefits. Once the Out of Pocket Maximum amount is reached, the Coinsurance amount for the remainder of the Coverage Period is 100%. All benefits payable are subject to the Coverage Period Maximum Benefit. Your Schedule of Benefits shows Your Plan Deductible, Additional Deductibles, Copayment, Coinsurance amount, Out of Pocket Maximum amount and Coverage Period Maximum Benefit. Reimbursement is also subject to any benefit limitations shown in the Schedule of Benefits.
What is a Plan Deductible?
The Plan Deductible is the amount of Eligible Expenses a Covered Person must incur during a Coverage Period before We pay benefits.
What is a Family Deductible Maximum?
Once 3 family members have met their respective Plan Deductible in a Coverage Period, no further Plan Deductible will be required for the remainder of the Coverage Period. The Family Deductible Maximum does not apply to any additional Deductibles.
Type of Deductibles included in this plan:
Outpatient Surgery Deductible – An additional deductible that must be satisfied for Charges incurred for surgery performed in an Outpatient Surgical Facility. There is a maximum of 3 Deductibles per Covered Person per Coverage Period. Surgeries in excess of the maximum number of outpatient surgery deductibles will be subject to the Plan Deductible and Coinsurance.
Emergency Room Deductible – An additional deductible must be paid for Charges incurred for use of an emergency room in the event of Sickness or Injury. The Deductible is waived if the Covered Person is directly admitted as an Inpatient for further treatment after which the Plan Deductible and Coinsurance will apply.
Advanced Diagnostic Studies Deductible – An additional deductible must be satisfied for each day Charges are incurred in a non-Hospital setting for Advanced Diagnostic Studies, including PET, MRI and CAT scans after which the Plan Deductible and Coinsurance will apply.
Does the plan require Pre-Certification?
All Inpatient hospitalizations and procedures done at an Outpatient Surgery Facility must be pre-certified. LifeShield National Insurance Co.'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 LifeShield Advantage 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
What is an Out-Of-Pocket Maximum?
It means an amount of allowable expenses that is the responsibility of each Covered Person to meet before the Company will begin paying the expenses at 100%. It does not include Deductibles, Copayments, penalty coinsurance for failure to pre-certify required services or charges in excess of the Usual and Customary Charge. Once the Out of Pocket Maximum is met, the Policy will begin paying 100% of allowable Usual and Customary costs for the remainder of the Coverage Period, not to exceed Coverage Period Maximum Benefit and any applicable benefit limits.
Who is eligible to apply for this insurance?
LifeShield Advantage 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 LifeShield Advantage 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:
AdvantHealth Plan 1 5000/20/9000/500000
AdvantHealth Plan 1 5000/20/7000/500000
AdvantHealth Plan 3 5000/20/9000/1000000
Standard Life Select STM Plan 2 5000/30/250K Extended
AdvantHealth Plan 2 5000/20/9000/1000000
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