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 all major credit cards or bank draft is accepted.

• Monthly Payment

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. Members can select coverage periods of up to 36 months. Payment via all major credit cards or bank draft is accepted.

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

Deductible Options: $500, $1,000, $2,000, $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: 80% (80/20)

The 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: Choice of $2,000 or $4,000

Once members reach their Out of Pocket Maximum Amount selected, we pay 100% of up to the Coverage Period Maximum Benefit.

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, Additional Deductibles, 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
• Doctor’s office consultation/Urgent Care visits
• Organ and Tissue transplants
• Inpatient prescription drugs
• Physical, Occupational and Speech Therapy
• Ambulance Transportation
• 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
• Extended Care Facility
• Outpatient Surgical Facility
• Surgeon services in the hospital or outpatient surgical facility

Pre-Existing Waiver Rider:

Pre-Existing Waiver Rider option will waive any conditions that were covered during the prior coverage period which means consumers will not have to re-qualify for another term to begin. Terms of coverage and limitations may vary by state.

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

How will consecutive policy terms work?

When a customer applies for consecutive policy terms in one enrollment, they will be issued their initial term of coverage, and subsequent terms will be pending. Customers will not have to reapply for additional terms. The waiting period on all subsequent terms will be waived. When subsequent terms of coverage are set to begin, the customer will receive an email stating the plan has continued into the next term. The email will provide them with their new monthly rate (if applicable), and they will have the opportunity to opt out at this time.

How does Usual and Customary Fees affect my benefits?

Usual, Reasonable and Customary Amount – means the lesser of:

1. The actual charge; or
2. What the provider would accept for the same service or supply in the absence of insurance; or
3. The amount based on one or more factors such as:
   1. The amount of resources expended to deliver the service or supply; or
   2. The amount charged for the same or comparable service or supply in a community similar to where the service or supply is furnished; or
   3. The costs incurred by providers in a community similar to where the service or supply is furnished and the amount by which the service or supply is commonly marked up by providers; or
   4. Charging protocols and billing practices generally accepted by the medical community or specialty groups, including charging protocols and billing practices related to Medicare; or
   5. Inflation trends by geographic region; or
4. The negotiated rate; or
5. For facility based charges, 150% of the Centers for Medicare and Medicaid Services Prospective Payment System amount unadjusted for geographic locality.

 All benefits are limited to Usual, Reasonable and Customary Fees.
Usual, Reasonable 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?

Pre-Existing Condition – means a condition:

1. For which medical advice, diagnosis, care, or treatment (includes receiving services and supplies, Consultations, diagnostic tests or prescription medicines) was recommended or received from a Physician within the 36* months immediately preceding the Covered Person’s Effective Date; or
2. That had manifested itself in such a manner that would have caused an ordinarily prudent person to seek medical advice, diagnosis, care, or treatment (includes receiving services and supplies, Consultations, diagnostic tests or prescription medicines) within the 36* months immediately preceding such person’s Effective Date.

*varies by state

Who is eligible to apply for this insurance?

AdvantHealth STM is available to members and their spouses, who are between 18 and 64 years old and their dependent unmarried children under 25 years old; and can answer “No” to all of the questions in the application for insurance. Child-only coverage is available for ages 2-17.

When does the coverage terminate?

A Member’s coverage under the Policy will terminate on the earliest of the following dates:

1. The last day for which Your premium has been paid;
2. The date You become a full-time member of the Armed Forces of any country if the period of active duty is to exceed 31 days;
3. The date the Policy terminates;
4. The date You reach age 65 or become effective under Medicare;
5. The date You cease to be a Member of the Policyholder;
6. The end of the Coverage Period;
7. The date You die;
8. The date You reach the Coverage Period Maximum Benefit Amount;
9. Your Effective Date in the event of any fraud or intentional misrepresentation of material fact on Your part in obtaining coverage under the Policy; or
10. The next premium due date in the event of any fraud or intentional misrepresentation of material fact on Your part or the part of Your representative in filing a claim.

At the death of the Member, all rights and privileges as a Member under the Policy will transfer to the surviving Dependent Spouse. The Dependent Spouse will then be considered the Member instead of a Dependent. In the event the Dependent Spouse remarries, coverage under the Policy for the Dependent Spouse and Dependent Child(ren), if any, will end on the first day of the month following the date of that marriage. If there is no surviving Dependent Spouse, or at the death of a surviving Dependent Spouse, all rights and privileges as a Member under the Policy will transfer to each Dependent child, if any, and he or she will be considered the Member instead of a Dependent.

Dependents

Insurance on a Dependent will terminate on the date such Dependent ceases to qualify as a Dependent. Except as Provided in the Continuation of Coverage provision, Your Dependent insurance will automatically terminate on the Earliest of the following dates:

1. The date Your insurance terminates;
2. The last day for which Your Dependent premium has been paid;
3. In the case of Your Dependent child, the date he or she no longer qualifies as a Dependent by attaining the limiting age (see definition of “Dependent”).
4. In the case of Your Dependent child, the first day following the Dependent’s marriage;
5. The date Your Dependent enters active duty with the armed services of any country if the period of active duty is to exceed 31 days;
6. In the case of a Dependent Spouse, the first day following the date of the final decree of dissolution of marriage; or
7. The date a Covered Person reaches the Coverage Period Maximum Benefit Amount.

Limitations and Exclusions

We will not provide a Benefit for any of the items listed in this section regardless of Medical Necessity or recommendation of a health care provider.

1. Treatment, services and supplies which are not related to a specific diagnosis, acute symptoms or course of treatment; medical care or surgery which is not Medically Necessary; and any maintenance type therapy not reasonably expected to improve a Covered Person’s condition.
2. Pre-employment or pre-marital examinations; or routine physical examinations.
3. Treatment, services and supplies for Experimental or Investigational procedures, including Experimental or Investigational organ transplant procedures, drugs or treatment methods.
4. Treatment, services and supplies for which the Covered Person is not legally required to pay.
5. Telephone consultations, failure to keep scheduled appointments, completion of claim forms, or providing medical information necessary to determine coverage.
6. Treatment, services and supplies provided by a Close Relative.
7. Treatment, services and supplies provided outside the scope of the license for the institution or practitioner rendering services.
8. Education, training, or bed and board while confined to an institution which is primarily a school or other institution for training, a place of rest or a place for the aged, or a personal residence.
9. Treatment, services or supplies received prior to the Covered Person’s Effective Date, or after the end of the Coverage Period.
10. Inpatient Hospital admission occurring on a Friday or Saturday in conjunction with a surgical procedure scheduled to be performed during the following week. A Sunday admission will be eligible only for the procedure scheduled to be performed early Monday morning. (This limitation will not apply to necessary medical admissions requiring immediate attention or to Emergency surgical admissions).
11. Amounts in excess of the Usual, Reasonable and Customary charges made for Covered Expenses.
12. Surgery for a Covered Person for a total or partial hysterectomy, unless it is Medically Necessary due to a diagnosis of carcinoma (subject to all other coverage provisions, including but not limited to the Pre-Existing Condition exclusion); tonsillectomy, adenoidectomy, repair of deviated nasal septum or any type of surgery involving the sinus, myringotomy, tympanotomy, or herniorrhaphy.
13. Outpatient Prescription Drugs, contraceptive drugs and devices, non-prescription drugs, vitamins, minerals and nutritional supplements.
14. Cosmetic Surgery.
15. Infertility and impregnation procedures, such as but not limited to, artificial insemination, in-vitro fertilization, embryo and fetal implantation and G.I.F.T. (gamete intrafallopian transfer).
16. Pregnancy and related services; except for Complications of Pregnancy.
17. Voluntary termination of pregnancy.
18. Voluntary sterilization or reversal thereof.
19. Custodial Care.
20. Dental services.
21. Routine foot care.
22. Speech Therapy.
23. Mental or Nervous Disorders.
24. Substance Use Disorders.
25. Treatment, services, or supplies for obesity, extreme obesity, morbid obesity or weight reduction, including, but not limited to, wiring of the teeth and all forms of surgery including, but not limited to, bariatric surgery, intestinal bypass surgery and complications resulting from any such surgery.
26. Programs, treatment or procedures for tobacco use cessation.
27. Treatment of acne or varicose veins.
28. Diagnosis or treatment of a sleeping disorder.
29. Allergy testing and allergy injections.
30. Diabetic Equipment, Supplies and Self-Management training.
31. Autism Spectrum Disorder.
32. Therapy or treatment for learning disorders or disabilities or developmental delays.
33. Participation in Clinical Trials.
34. Prosthetic and Orthotic Devices; except as specifically covered in Section 4 – Benefits.
35. Homeopathy.
36. Orthopedic Manipulation.
37. Private duty nursing services.
38. Acupuncture and Acupressure.
39. Genetic testing or counseling including, but not limited to, amniocentesis and chorionic villi testing.
40. Sex transformation; treatment of sexual function, dysfunction or inadequacy; or treatment to enhance sexual performance or desire.
41. Treatment to stimulate growth and growth hormones for any purpose.
42. Eye examinations, eyeglasses, or contact lenses to correct refractive errors and related services including surgery performed to eliminate the need for eyeglasses, for refractive errors such as radial keratotomy or keratoplasty.
43. Hearing exams, hearing aids, or the fitting of hearing aids.
44. Treatment for cataracts.
45. Orthoptics and visual eye training.
46. Treatment, services and supplies for a Covered Dependent who is a newborn child not yet discharged from the Hospital. This does not apply to charges that are Medically Necessary to treat premature birth, congenital Injury or Illness, or Illness or Injury sustained during or after birth.
47. Personal comfort or convenience items, including homemaker services or supportive services focusing on activities of daily life that do not require the skills of qualified technical or professional personnel, including but not limited to bathing, dressing, feeding, routine skin care, bladder care and administration of oral medications or eye drops.
48. The purchase of a noninvasive osteogenesis stimulator (bone stimulator).
49. Services or supplies of a common household use, such as exercise cycles, air or water purifies, air conditioners, allergenic mattresses, and blood pressure kits.
50. Enrollment in health, athletic or similar clubs.
51. Weight loss, non-smoking, exercise or similar programs.
52. Recreational or educational therapy, or non-medical self-care or self-help training, nutritional counseling, marriage, family or goal oriented counseling.
53. Travel or transportation rendered by any person or entity other than professional ground or Air Ambulance.
54. Care in government institutions unless a Covered Person is obligated to pay for such care.
55. Treatment, services and supplies rendered to 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 You on a pro rata basis.
56. Treatment, services and supplies received outside of the United States or its possessions except as specifically covered in Section 4 – Benefits.
57. Treatment, services and supplies for an Injury caused by an accident that arises out of or in the course of employment or for which the Covered Person is entitled to benefits under any Worker’s Compensation Law, Occupational Disease Law or similar legislation.
58. Illness or Injury that results from war or an act of war, (whether declared or undeclared) while serving in the military or an auxiliary unit attached to the military.
59. Illness or Injury that results from participation in a riot or insurrection.
60. Illness or Injury that results from commission or attempted commission of a felony or to which a contributing cause was the Covered Person being engaged in an illegal occupation.
61. Complications resulting from treatment of conditions which are not covered under the Policy.
62. Suicide or attempted suicide or intentionally self-inflicted Injury, whether while sane or insane.
63. Injuries from participating in organized competitive sports.
64. Treatment, services and supplies resulting from participation in skydiving, scuba diving, hand or ultra light gliding, ballooning, bungee jumping, parakiting, riding an all-terrain vehicle such as a dirt bike, snowmobile or go-cart, racing with a motorcycle, motor vehicle, boat or any form of aircraft, any participation in sports for pay or profit, or participation in rodeo contests.

Treatment or services required due to Accidental Injury sustained while operating a motor vehicle where the Covered Person’s blood alcohol level, as defined by law, exceeds that level permitted by law or otherwise violates legal standards for a person operating a motor vehicle in the state where the Injury occurred.