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Zip Code	79936 (edit)
Applicant	5/26/1984 Male (edit)
Coverage Start	5/27/2019 (edit)

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Insurance Type	Short Term Medical Insurance
Insurance Provider	Standard Life
Plan Type	PPO
Deductible	$5,000
Coinsurance	30% after deductible
Coverage Max	$1,000,000
Application Fee	$20.00 (one-time, non-refundable)

Plan Type	Short Term Medical Insurance
Office Visit for Primary Doctor	During your coverage period, you can make an unlimited number of Doctor Office and Urgent Care visits for a predictable $50 dollar copay per visit, not subject to deductible or coinsurance, up to a maximum benefit of $2000 per coverage period.
Office Visit for Specialist	During your coverage period, you can make an unlimited number of Doctor Office and Urgent Care visits for a predictable $50 dollar copay per visit, not subject to deductible or coinsurance, up to a maximum benefit of $2000 per coverage period.
Coinsurance	30% after deductible
Annual Deductible	Individual: $5,000.00 Family: $15,000.00
Separate Prescription Drugs Deductible
Prescription Drugs	Generic: Inpatient: Coinsurance + Deductible Outpatient: Not Covered, discount card provided Brand Name: Inpatient: Coinsurance + Deductible Outpatient: Not Covered, discount card provided Non-formulary: Inpatient: Coinsurance + Deductible Outpatient: Not Covered, discount card provided
Annual Out-of-Pocket Limit	Individual: $11,000.00 Family: $33,000.00
Does Out-of-Pocket Limit include deductible?	Yes
Lifetime Maximum	$1,000,000.00
Out-of-Network Coverage	Yes
Out of Country Coverage	None
Physicians
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	N/A
Well Baby Care	No
Prescription Drug Coverage
Generic Prescription Drugs	Inpatient: Coinsurance + Deductible Outpatient: Not Covered, discount card provided
Brand Prescription Drugs	Inpatient: Coinsurance + Deductible Outpatient: Not Covered, discount card provided
Non-Formulary Prescription Drugs Coverage	Inpatient: Coinsurance + Deductible Outpatient: Not Covered, discount card provided
Separate Prescription Drugs Deductible
Hospital Services Coverage
Emergency Room	30% Coinsurance after deductible
Outpatient Lab/X-Ray	30% Coinsurance after deductible
Outpatient Surgery	30% Coinsurance after deductible
Hospitalization	30% Coinsurance after deductible
Maternity Coverage
Pre & Postnatal Office Visit	Not Covered
Labor & Delivery Hospital Stay	Not Covered
Additional Coverage
Chiropractic Coverage	Covered except: spinal manipulation or adjustment
Mental Health Coverage	Inpatient: $100 maximum per day, 31 day maximum per Coverage Period; Outpatient: $50 maximum per visit, 10 visit maximum per Coverage Period.

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What medical expenses are covered?

The following benefits are for the Insured and each Covered Dependent subject to the plan Deductible, Additional Deductibles, Coinsurance Percentage, Stop Loss Amount and Maximum Limit per Coverage Period. Benefits are limited to the Reasonable and Customary charge for each Covered Eligible Expense, in addition to any specific limits stated in the policy.

Preventive / Wellness Care (This benefit is not subject to the Plan Deductible or Coinsurance Percentage)
Organ and Tissue transplants
Outpatient and Inpatient Treatment for Mental and Nervous Disorders
Physical Therapy maximum benefit $50 per visit per day for a maximum of 20 visits
Ambulance Transportation maximum benefit $250
Inpatient prescription drugs
Doctor's office consultation in excess of a $50 co-pay. This benefit is not subject to the Plan Deductible or Coinsurance Percentage
Outpatient Hospital or Emergency Room Care

Inpatient Room & Board, including Intensive Care
Miscellaneous Medical Services, doctors medical care and treatment performed in a hospital
Home Health Care benefit $40 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
Assistant Surgeon services up to 20% of surgeons benefit

Note: This is a brief description of the plan benefits, which may vary by state.

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

Pre-existing conditions:
1. Charges resulting directly or indirectly from a condition for which a Covered Person received medical treatment, diagnosis, care or advice within the sixty-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 sixty-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 or newly adopted child who is added to coverage in accordance with PART II – ELIGIBILITY AND EFFECTIVE DATE OF INSURANCE.
If the applicant requests a Certificate Effective Date that is within 3 days of the date of the Enrollment Form, then Covered Persons will only be entitled to receive benefits for:
1. Cancer that begins, by occurrence of symptoms and/or receipt of treatment, at least 30 days following the Covered Person’s Certificate Effective Date of coverage; and
2. All other Sicknesses that begin, by occurrence of symptoms and/or receipt of treatment, at least 72 hours following the Covered Person’s Effective Date of Coverage.
Expenses 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. Gallbladder Removal.
However, if such condition is a pre-existing condition any benefit consideration will be in accordance with the pre-existing conditions limitation.
The benefits for the following conditions or procedures, per Covered Person per Coverage Period, are payable up to the following:
1. Kidney Stones: $1,500
2. Appendectom: $2,500
3. Joint or Tendon Surgery for Injury only: $2,500
4. Acquired Immune Deficiency Syndrome (AIDS)/Human Immuno-deficiency Virus (HIV): $10,000
5. Gallbladder Removal: $2,500
The benefits for Mental Disorders are payable up to the following:
1. Inpatient treatment: $100 maximum per day, 31 day maximum per Coverage Period.
2. Outpatient treatment: $50 maximum per visit, 10 visit maximum per Coverage Period.
Outpatient Prescription Drugs, medications, vitamins, and mineral or food supplements including pre-natal vitamins, or any over-the-counter medicines, whether or not ordered by a Doctor.
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.
Any drug, treatment or procedure that corrects impotency or sexual dysfunction.
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.
Surgeries, treatments, services or supplies for cosmetic or aesthetic reasons, except for reconstructive surgery which is expressly covered under the Policy.
Weight modification or surgical treatment of obesity.
Eye surgery, such as LASIK, when the primary purpose is to correct nearsightedness, farsightedness or astigmatism.
Dental treatment and dental surgery except as necessary to restore or replace sound and natural teeth lost or damaged as a result of a covered Injury.
Routine pre-natal care, Pregnancy, child birth, and post-natal care. (This exclusion does not apply to “Complications of Pregnancy” as defined.)
Sclerotherapy for veins of the extremities.
Abortions, except in connection with covered Complications of Pregnancy or if the life of the expectant mother would be at risk.
Joint replacement or other treatment of joints, spine, bones or connective tissue including tendons, ligaments and cartilage, unless related to a covered Injury.
Surgeries, treatments, services or supplies which are deemed to be Experimental Treatment.
Alcoholism and Substance Abuse.
Chronic fatigue or pain disorders.
Arthritis (if non-infective), including, but not limited to, osteoarthritis, rheumatoid arthritis and rheumatism.
Venereal disease, including all sexually transmitted diseases and conditions.
Treatment or diagnosis of allergies, except for emergency treatment of allergic reactions.

Treatment for cataracts.
Treatment of sleep disorders.
Treatment required as a result of complications or consequences of a non-covered treatment or condition.
Treatment incurred as a result of exposure to non-medical nuclear radiation and/or radioactive material(s).
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.
Treatment for or related to any Congenital Condition, except as it relates to a newborn or adopted child added as a Covered Person.
Treatment, medication or hormones to stimulate growth, or treatment of learning disorders, disabilities, developmental delays or deficiencies, including therapy.
Spinal manipulation or adjustment.
Speech, vocational, occupational, biofeedback, acupuncture, recreational, sleep or music therapy, holistic care of any nature, massage and kinestherapy, excepted as provided for Home Health Care.
Hypnotherapy when used to treat conditions that are not recognized as Mental Disorders by the American Psychiatric Association, and biofeedback and non-medical self-care or self-help programs.
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.
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.
Care and treatment for hair loss including wigs, hair transplants or any drug that promises hair growth, whether or not prescribed by a Doctor.
Exercise programs, whether or not prescribed or recommended by a Doctor.
Telephone or Internet consultations and/or treatment or failure to keep a scheduled appointment.
Charges for travel or accommodations, except as expressly provided for local ambulance.
All charges incurred while confined primarily to receive Custodial or Convalescence Care.
Services received or supplies purchased outside the United States, its territories or possessions, or Canada, except as expressly described under the Policy.
Any services or supplies in connection with cigarette smoking cessation.
Any services performed or supplies provided by a member of the Insured’s Immediate Family.
Services received for any condition caused by a Covered Person’s commission of or attempt to commit a felony or to which a contributing cause was the Covered Person being engaged in an illegal occupation.
Services or supplies which are not included as Eligible Expenses as described herein.
Participating in hazardous occupations or other activity including participating, instructing, demonstrating, guiding or accompanying others in the following: professional or semi-professional sports, extreme sports, organized body contact 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.
Injuries or Sicknesses resulting from participation in interscholastic, intercollegiate or organized competitive sports.
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, but not for the treatment of Substance Abuse.
Willfully self-inflicted Injury or Sickness.
Expenses resulting from a declared or undeclared war, or from voluntary participation in a riot or insurrection. This Exception does not apply to an act of terrorism.
Expenses 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.
Charges that are eligible for payment by Medicare or any other government program except Medicaid.
Amounts in excess of the Usual and Customary charges made for covered services or supplies.
Expenses to the extent that they are paid or payable under other valid or collectible group insurance or medical prepayment plan;
Expenses for which benefits are paid or payable under workers’ compensation or similar laws.
Medical expenses which are payable under any automobile insurance policy without regard to fault (does not apply in any state where prohibited).
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.
Expenses incurred in the treatment by any method for jaw joint problems including temporomandibular joint dysfunction (TMJ), TMJ pain syndromes, craniomandibular disorders, myofascial 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, except as specifically covered.
Charges incurred for complications resulting from non-covered services under the Policy.

Last Name

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Olmer, Brooker

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Esperanza Medical And Wellness

Delia, Gomez

Violeta, Orozco

John, Fajardo

Kelly, Lambeth

Olmer Brooker, M.D.

Phone Number
(915) 855-7900
Office Locations
1418 George Dieter Dr
El Paso, TX 79936

Why Short-Term Medical (STM)?

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

How do I figure out what I need and where do I start?

First, Select Your Benefit Period and Payment Method

Single Payment
This option is ideal if you know the exact number of days you need coverage. The minimum number of days you may apply for coverage is 30 days. Pay now for the number of days you will need STM coverage. We accept payment by Visa, MasterCard, or Bank Draft.
Monthly Pay
You can select coverage up to 3 months. This plan is "pay as you go" which gives you the flexibility to continue coverage for as long as it is needed, or you can stop payments to discontinue the plan once your temporary need ends. We accept automatic monthly payments by Visa, MasterCard, or Bank Draft.

Then, based on your lifestyle needs and budget, select one from each of the following:

Deductible: $500, $1,000, $2,500, $5,000, $7,500, $10,000
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: In-Network plan 80/20, 70/30 (Out-of-Network is 20% less)
Your selection of a Coinsurance Percentage represents the percent of covered eligible expenses that we pay and that you pay, after the deductible has been satisfied up to the Stop Loss Amount
Stop Loss Amount: $10,000 or $20,000
Once you've reached your Stop Loss Amount selected, we pay 100%* up to the Maximum Limit per Coverage Period. For example, if your coinsurance is 80/20, you pay 20% of the next $10,000 in covered charges ($2,000 out-of-pocket plus deductible). Then we pay at 100% up to the Maximum Limit per Coverage Period.

*Subject to Reasonable and Customary Charges.

What medical expenses are covered?

Preventive / Wellness Care (This benefit is not subject to the Plan Deductible or Coinsurance Percentage)
Organ and Tissue transplants
Outpatient and Inpatient Treatment for Mental and Nervous Disorders
Physical Therapy maximum benefit $50 per visit per day for a maximum of 20 visits
Ambulance Transportation maximum benefit $250
Inpatient prescription drugs
Doctor's office consultation in excess of a $40 or $50 co-pay. This benefit is not subject to the Plan Deductible or Coinsurance Percentage
Outpatient Hospital or Emergency Room Care
Inpatient Room & Board, including Intensive Care
Miscellaneous Medical Services, doctors medical care and treatment performed in a hospital
Home Health Care benefit $40 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
Assistant Surgeon services up to 20% of surgeons benefit

Note: This is a brief description of the plan benefits, which 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. Standard Life and Accident'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 Reasonable and Customary affect my benefits?

We may use and subscribe to a standard industry reference source that collects data and makes it available to its member companies in order to determine the amount that should be considered as Reasonable and Customary for services and supplies.

The policy defines Reasonable and Customary charges as the lesser of the following:

A usual fee is defined as the charge made for a given service by a Doctor to the majority of his or her patients; and
A customary fee is one that is charged by the majority of Doctors within a community for the same services. ;or
The negotiated rate in effect with a PPO on the date it provides a covered service.

All benefits are limited to Reasonable and Customary charges.

What if I change my mind after I purchase the STM Coverage?

If you are not 100% satisfied with your coverage, and you have not already used any of your insurance benefits, return the certification to us within 10 days of receipt. Coverage will be cancelled as of the effective date and your 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

Additionally, if you request a Certificate Effective Date that is within 3 days of the date of enrollment, then you will only be entitled to receive benefits for:

Cancer that begins, by occurrence of symptoms and/or receipt of treatment, at least 30 days following the effective date
All other Sicknesses that begin, by occurrence of symptoms and/or receipt of treatment, at least 72 hours following the effective date of coverage.
Coverage under this plan is provided on a short term basis and is not renewable. Although the plan may be rewritten for a new separate coverage period (as long as you meet eligibility criteria), the coverage does not continue from one certificate to another. A new enrollment form must be submitted with a new effective date and new pre-existing condition exclusion period. Any medical condition which occurred or existed under the previous certificate will be treated as a pre-existing condition under the new one.

Who is eligible to apply for this insurance?

Select 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 0-25 (adult rates apply to anyone 18 or older).

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:

The date premiums are not paid in accordance with the terms of the Policy, subject to the Grace Period;
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;
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;
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;
The date the Insured obtains other insurance, excluding Medicare;
The Certificate termination date stated on Your Schedule of Benefits.

Premium	Plan Name	Deductible
from $58	AdvantHealth Plan 1 5000/20/9000/500000	$5,000.00	Select
from $60	AdvantHealth Plan 1 5000/20/7000/500000	$5,000.00	Select
from $125	AdvantHealth Plan 3 5000/20/9000/1000000	$5,000.00	Select
from $126	Standard Life Select STM Plan 2 5000/30/250K Extended	$5,000.00	Select
from $130	Standard Life Select STM Plan 2 5000/30/1M Extended	$5,000.00	Select

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, Inc. is a wholly owned subsidiary of Health Plan Intermediaries Holdings LLC (NASDAQ: HIIQ)

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Standard Life Select STM Plan 2 5000/30/1M

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