Underwritten by Companion Life Insurance Company. HealthWINS A Small Group Limited Benefit Health Insurance Plan for Your Employees

Transcription

1 Underwritten by Companion Life Insurance Company. HealthWINS A Small Group Limited Benefit Health Insurance Plan for Your Employees

2 Small Group Limited Benefit Health Insurance Underwritten by Companion Life Insurance Company. Benefits Option 1 Option 2 Option 3 Inpatient Benefits Daily Inpatient Hospital Benefit Maximum Number of Days per Year Daily Intensive Care Unit Benefit 1 Maximum Number of Days per Year 0 30 Days $1, Days 0 30 Days $1, Days $1, Days $2, Days Surgery & Anesthesia Benefits Surgical Indemnity Benefit 2 Anesthesia Benefit 80% Schedule 20% of the surgical benefit 100% Schedule 20% of the surgical benefit 100% Schedule 20% of the surgical benefit Outpatient Benefits Physician s Office Visit Benefit Maximum Number of Visits per Year Wellness Benefit Maximum Number of Visits per Year Diagnostics/Labs/X-Ray Benefit Maximum Number of Test Days per Year Emergency Room Benefit Maximum Number of Visits per Year 3 Visits 3 Test Days 3 Visits 3 Test Days 3 Visits 3 Test Days Other Benefits Accident Benefit Generic Prescription Drugs Retail Co-Pay Maximum Benefit per Month $1,000 Greater of $15 or 50% $200 per individual 3 1 Daily Intensive Care Unit Benefit is paid in lieu of Daily Inpatient Hospital Benefit for the number of days listed in schedule. 2 Surgical indemnity schedule based on the 2009 Arizona RBRVS Facility fee schedule. 3 Maximum family limit: three times the individual amount. $2,500 Greater of $15 or 50% $200 per individual 3 $5,000 Greater of $15 or 50% $200 per individual 3 Monthly Rates Limited Benefit Health and Non-Insured Prescription Product Fees* Insurance Premium Total Monthly Cost Option 1 Individual $ $9.00 $ Individual & Spouse $ $9.00 $ Individual & Children $ $9.00 $ Individual & Family $ $9.00 $ Option 2 Individual $ $9.00 $ Individual & Spouse $ $9.00 $ Individual & Children $ $9.00 $ Individual& Family $ $9.00 $ Option 3 Individual $ $9.00 $ Individual & Spouse $ $9.00 $ Individual & Children $ $9.00 $ Individual & Family $ $9.00 $ *Includes fees for Beechstreet PPO, Consult A Doctor, Member Advocacy and Fulfillment

3 Small Group Limited Benefit Health Insurance Assumptions and Contingencies: Proposal valid for employers domiciled in the following states: DE, IL, MD, MI, OH, RI, PA and VA. Rates are updated annually on January 1st. Individual groups rates will not increase until coverage has been in effect for at least 12 months. Only one of the above options may be selected by the plan sponsor and offered to the eligible members. Rates are valid through 2012 effective dates. Proposal is contingent on employer groups having at least 2 eligible employees. Groups with fewer than 10 eligible employees require 100% participation. Groups with 10+ eligible employees require the greater 25% or 10 participants. Proposal excludes coverage for any claims resulting from occupational injury or sickness. Employees must be actively at work on the effective to be eligible for coverage. Retirees are not eligible for coverage. All active employees working at least 15 hours per week and their dependents under age 65 and who are not Medicare eligible are eligible to participate. Noncontributory plans require 100% participation. All eligible employees and dependents must be enrolled. Contributory/Voluntary plans: * 2-9 employees requires 100% participation * 10+ employees requires the greater of 10 enrollees or 25% participation Employees covered by another group health plan are not considered eligible. COBRA enrollees are not considered eligible. Monthly premiums are due the first day of each month. If there is a material difference between the enrollment and/or claims information provided to underwrite this risk and the final enrollment we reserve the right to revise the rates retroactively within 30 days of the effective date. Pre-Existing Condition means a disease, Accident, Sickness or physical condition for which a Covered Person: had treatment; incurred expense; took medication; or received a diagnosis or advice from a Physician, during the 12-month period immediately before the Effective Date of coverage. The term Pre-Existing Condition will also include conditions which are related to such disease, Accident, Sickness or physical condition. This proposal is a summary of coverage and cannot be considered a contract. Terms in the policy take precedence. The insurance Policy, master policy and state specific variations are the official documents governing the plan. The official documents are the final authority and will govern unless superseded by law. Excluded Industries: Family Businesses: Employers are not eligible if one family, living in the same household, related by blood or marriage, comprises 50% or more of the group. Commercial fishing, mining, oil & gas extraction, logging & wood product processing, taxicabs, junk & scrap dealers, car washes, sports teams, PEOs, leasing companies, farming, explosives, bombs & pyrotechnics, asbestos products, fire arms & ammunition, jewelry stores, dental offices, religious organizations, native American tribes. Collective bargaining groups, members of credit unions, MEWA s, 1099 workers, Taft Hartley groups, affinity groups, associations.

4 Exclusions No benefits will be payable for the limited benefit health insurance Policy as the result of: (a) suicide or any attempt thereat, while sane or insane. (b) any intentionally self-inflicted injury or Sickness; (c) rest care or rehabilitative care and treatment; (d) cosmetic surgery or care or treatment solely for cosmetic purposes, or complications therefrom. This exclusion does not apply to cosmetic surgery resulting from a covered Accident if initial treatment of the Covered Person is begun within 12 months of the date of the Accident; (e) immunization shots and routine examinations such as: health exams; periodic check-ups; pre-marital exams; physicals; (f) routine newborn care, including routine nursery charges; (g) voluntary abortion, except with respect to the Insured or covered Dependent spouse: (1) where such person s life would be endangered if the fetus were carried to term; or (2) where medical complications have arisen from an abortion; (h) pregnancy of a Dependent child, unless required by law; (i) the treatment of:(1) mental illness;(2) functional or organic nervous disorder, regardless of cause; (3) alcohol abuse; (4) drug use, unless such drugs were taken on the advice of a Physician and taken as prescribed, for more than 10 days in any Calendar Year, with respect to payment of the Daily In-Hospital Indemnity Benefit; (j) participation in a riot, civil commotion, civil disobedience, or unlawful assembly. This does not include a loss which occurs while acting in a lawful manner within the scope of authority; (k) committing, attempting to commit, or taking part in a felony or assault, or engaging in an illegal occupation; (l) participation in a contest of speed in power driven vehicles, parachuting, parasailing, bungee-jumping, or hang gliding; (m) air travel, except: (1) as a fare-paying passenger on a commercial airline on a regularly scheduled route; or (2) as a passenger for transportation only and not as a pilot or crew member; (n) any Accident occurring as a result of the Covered Person being intoxicated (where the blood alcohol content meets the legal presumption of intoxication under the law of the state where the Accident took place); (o) sex changes; (p) experimental treatments or surgery; (q) the reversal of tubal ligation and vasectomies; (r) artificial insemination, in vitro fertilization, and test tube fertilization, including any related testing, medications, or Physician services, unless required by law; (s) treatment of exogenous obesity or weight control; (t) an act of war, whether declared or undeclared, or while performing police duty as a member of any military or naval organization. This exclusion includes Accident sustained or Sickness contracted while in the service of any military, naval or air force of any country engaged in war. (u) accident or sickness arising out of and in the course of any occupation for compensation, wage or profit. Expenses which are payable under Occupational Disease Law or similar law, whether or not application for such benefits have been made; (v) Pre-Existing Conditions, except as described in the Schedule; (w) air or ground ambulance service; or (x) for loss incurred, care or treatment received, or hospital confinement occurring outside of the United States. In addition to the Exclusions and Limitations for all coverages, the following are not covered under the Out-Patient Physician Office Visit Indemnity Benefit and the Outpatient Diagnostic X-Ray and Laboratory Indemnity Benefit: (a) visits made, examinations given, or x-rays or laboratory tests performed as an in-patient while Confined to a Hospital; (b) routine eye examinations or fitting of glasses; (c) fitting of hearing aids; (d) dental examinations or dental care other than expenses resulting from accidental injury; and (e) benefits which are provided under any other part of the Policy. Exclusions continued next page

5 Exclusions (continued) Prescription Drug benefits are not payable for the following items: All over-the-counter products and medications unless shown under the definition of Prescription Drug. This includes, but is not limited to, electrolyte replacement, infant formulas, miscellaneous nutritional supplements and all other over-the-counter products and medications. Blood glucose meters; insulin-injecting devices. Diabetic supplies; alcohol swabs, lancets, lancets devices, test strips and tablets. Depo-Provera; condoms, contraceptive sponges, and spermicides; sexual dysfunction drugs. Biologicals (including allergy tests); blood products; growth hormones; hemophiliac factors; MS injectables; immunizations; all other injectables unless shown under the definition of Prescription Drug. All other medical supplies and durable medical equipment unless shown under the definition of Prescription Drug. Liquid nutritional supplements; pediatric Legend Drug vitamins; prescribed versions of Vitamins A, D, K, B12, Folic Acid and Niacin - used in treatment versus as a dietary supplement; all other Legend Drug vitamins and nutritional supplements. Anorexiants; Any cosmetic drugs including, but not limited to, Renova, skin pigmentation preps; Any drugs or products used for the treatment of baldness; Topical dental fluorides. Refills in excess of that specified by the prescribing Physician; or refills dispensed after one year from the original date of the prescription. Any drug labeled Caution - limited by Federal Law for Investigational Use or experimental drugs. Any drug which the Food and Drug Administration has determined to be contraindicated for the specific treatment. Drugs needed due to conditions caused, directly or indirectly, by an Insured Person taking part in a riot or other civil disorder; or the Insured Person taking part in the commission of a felony. Drugs needed due to conditions caused, directly or indirectly, by declared or undeclared war or an act of war; or drugs dispensed to an Insured Person while on active duty in any armed force. Any expenses related to the administration of any drug. Drugs or medicines taken while in or administered by a hospital or any other health care facility or office. Drugs covered under Worker s Compensation, Medicare, Medicaid or other Governmental programs. Drugs, medicines or products, which are not Medically, Necessary. Diaphragms; Erectile dysfunction Legend drugs, unless specifically listed in the definition of Prescription Drug; Infertility Legend drugs. Epi-Pen, Epi-Pen Jr., Ana-Kit, Ana-Guard; Glucagon-auto injection; Imitrex-auto injection. Smoking deterrents, Legend or over-the-counter. Vacation supplies and replacement of lost, stolen, spilled, broken or dropped Prescription Drugs. All newly marketed pharmaceuticals or currently marketed pharmaceuticals with a new FDA for a period of one year from such FDA approval for its intended indication. Prenatal vitamins.

6 Date: Request for Proposal Small Group Limited Benefit Health Insurance Sales Account Executive: Company INFORMATION Requested Effective Date: Type of Business: SIC Code: Name of Company: Company Address: City: State: Zip: If the company is domiciled at an address different from above, please provide the company s legal name & address: Group Contact: Address: Contact Number: Company Website: Group Tax ID#: ERISA Administrator: Section 125 compatibility: q Yes PLAN INFORMATION Total Number of Eligible Lives: Target Number of Employees Enrolled: q No Open Enrollment Period: q 30-Days q 60-Days q Part-Time q Full-Time q Both % PT % FT Employer Contribution: q Yes q No Employee: % or $ Dependent: % or $ benefit INFORMATION Census Attached? q Yes q No Plan Requested: q Option 1 q Option 2 q Option 3 Eligibility File: q Paper q Electronic AGent information Soliciting Agent(s)/Broker(s) Name: Commission Level: % Agency Name: Phone: Fax: Address: City: State: Zip: Address: Comments: Are Agents Currently Appointed? q Yes q No Form Completed By: Date: Please submit RFP to: MAG, Attn: Sales Support, One Enterprise Drive, Suite 210, Shelton, Ct Toll Free: Fax: salessupport@amwins.com 10.10

7 Affordable healthcare coverage is critical to protecting you and your family from unexpected illness or injury. That s why your company is offering a guaranteed health plan for its employees and their families. This brochure is not a contract of insurance. The terms and conditions of coverage will be detailed in the Policy of Insurance issued once we receive your acceptance. If there are any differences between the terms and conditions of this brochure and the policy issued to you, the Policy of Insurance will govern. The Policy of Insurance is governed by the laws of the state in which it is delivered. Certain terms or provisions may be different if required by the laws of that state. This small group limited benefit health insurance plan is underwritten by Companion Life Insurance Company. This plan is not major medical insurance and is NOT designed to replace, provide, or modify major medical insurance. Companion Life Insurance Company 10/10