AWA Limited Benefit Health Insurance

Transcription

1 AWA Limited Benefit Health Insurance Sponsored by: Administered by: Homeland HealthCare 2435 North Central Expressway, Suite 100 Richardson, Texas Call Toll-free Visit us at This brochure is intended to summarize the benefits of the American Worker s Association (AWA) Plans. As a summary, it may not include every benefit or benefit limitation, or exclusion of the group contract. Only the Master Group Policy determines the complete terms of the group insurance coverage with regard to the accident and health benefits of this plan. The provisions of this summary apply to residents of most states. State laws vary and the laws of your state may affect the benefit plan. The Value-Added Benefits portion of this plan is provided through the AWA. Insurance Coverage Underwritten by: NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, Pa. This is not basic health insurance or major medical coverage and is not designed as a substitute for basic health insurance or major medical coverage. Benefits may vary from state to state. AWA Standard

2 $1 Million Dollars Lifetime Maximum AWA Limited Benefit Health Insurance No Annual Maximum BENEFITS AND COVERAGES HEALTH SCREENING BENEFIT-Pays a Per Test Amount when an Insured Person undergoes specified routine examinations or other preventive testing. ROUTINE WELL-CHILD BENEFIT-Pays a Per Physician s Visit amount when an Insured Dependent Child visits a Physician and undergoes physical examination and/or appropriate immunizations during the first 12 months following birth. HOSPITAL BENEFITS Hospital Admission Benefit: Pays a lump sum Hospital Admission Benefit if an Insured Person is admitted as an inpatient to a Hospital for treatment of Sickness or Injury. Hospital Confinement Benefit: Pays a Daily Hospital Confinement Benefit for each day that an Insured Person is charged for a room as an Inpatient when that Insured Person becomes confined as an Inpatient to a Hospital for treatment of Sickness Injury. Intensive Care Unit Benefit: If benefits have become payable for an Insured Person under the Hospital Confinement Benefit, and such Insured Person becomes confined in an Intensive Care Unit, pays an additional Daily Intensive Care Unit Benefit for each day and Insured Person is confined in and charged for an Intensive Care Unit. SURGICAL/ANESTHESIA BENEFITS Pays a scheduled Surgical Benefit when an Insured Person undergoes a surgical procedure for treatment of Sickness of Injury. Anesthesia: Pays an Anesthesia Benefit for the administration of anesthesia for which a charge is incurred during a covered surgical procedure. EMERGENCY ROOM ACCIDENT TREATMENT BENEFITS - Pays a Per Accident Benefit shown when an Insured Person suffers an injury that, within 72 hours of the accident that caused the injury, requires him or her to receive Emergency Treatment in the Emergency room of a Hospital. EMERGENCY ROOM SICKNESS TREATMENT BENEFIT Pays a Per Visit Benefit when an Insured Person visits the emergency room of a Hospital for Emergency Treatment of Sickness. PHYSICIAN'S OFFICE VISITS BENEFIT Pays a Per Visit benefit if an Insured Person visits a Physician s office for treatment of Sickness or Injury. OUTPATIENT DIAGNOSTIC X-RAY AND LABORATORY BENEFIT Pays an Outpatient Diagnostic X-Ray and Laboratory Benefit when an Insured Person visits a Physician s office or other outpatient setting except an emergency room, and undergoes diagnostic x-ray and laboratory tests for treatment of Sickness or Injury. AMBULATORY SURGICAL CENTER BENFIT Pays a lump sum benefit if an Insured Person visits an Ambulatory Surgical Center for treatment of Sickness or Injury. ACCIDENTAL DEATH BENEFIT Pays a lump sum benefit if an Insured Person suffers an injury that results in death. CRITICAL ILLNESS RIDER Pays a lump sum benefit upon diagnosis of a specified Critical Illness after a 30 day waiting period. The Insured Person must survive for 30 days after the diagnosis. PHYSICIAN & HOSPITAL DISCOUNTS We offer the Discount Provider Network from Medical Resource LLC to complement the benefits provided by AWA. Discounted rates are available at premier physicians, hospitals, and medical centers around the country. THIS IS LIMITED INDEMNITY COVERAGE. This is not basic health insurance or major medical coverage and is not designed as a substitute for basic health insurance or major medical coverage. Benefits may vary from state to state. Please see Exclusions & Limitations included in this document. Insurance coverage underwritten by National Union Fire Insurance Company of Pittsburgh, Pa.

3 Limited Benefit Health Insurance AWA Bronze AWA Silver AWA Gold AWA Platinum Preventive Benefits Physician's Office (per visit 3 pp/py - 6 family) $50 $50 $75 $75 Health Screening (per treatment-3/year) $25 $25 $50 $75 Routine Well Child (per visit-6/year) $30 $40 $50 $60 Oklahoma Only: Immunization Benefit $20 $20 $20 $20 DXL (per test 6 pp/py) - $50 $100 $125 Emergency Room (per visit 4/year pp) $50 $100 $150 $250 Hospital Benefits Hospital Admission $250 $500 $750 $1,000 Hospital Confinement Benefit - First 30 Days $250 $500 $750 $1,000 Intensive Care Unit (per day) $250 $500 $750 $1,000 Surgery Benefits Surgical Schedule (% of scheduled amount) - 100% 100% 100% Anesthesia (% of surgical scheduled amount) - 25% 25% 25% Ambulatory Surgery Center (per day) - $100 $150 $250 Other Benefits Critical Illness (1st diagnosis) - $2,500 $5,000 $10,000 Critical Illness Waiting Period (days) Invasive Cancer Benefit % - 100% 100% 100% - InSitu Cancer Benefit % - 25% 25% 25% - Heart Attack Benefit % - 100% 100% 100% - Stroke Benefit % - 100% 100% 100% - Renal Failure Benefit % - 100% 100% 100% - Coronary By-Pass Surgery Benefit % - 100% 100% 100% - ADL Deficit Benefit % - 100% 100% 100% Accidental Death Benefits Accidental Death Benefit $10,000 $20,000 $30,000 $40,000 Common Carrier Benefit $2,500 $5,000 $7,500 $10,000 Dismemberment Benefits Loss of Both Hands OR Both Feet $10,000 $10,000 $15,000 $20,000 Loss of Sight in Both Eyes $10,000 $10,000 $15,000 $20,000 Loss of One Hand AND One Foot $10,000 $10,000 $15,000 $20,000 Loss of One Hand AND Sight in One Eye $10,000 $10,000 $15,000 $20,000 Loss of One Hand OR One Foot $10,000 $10,000 $15,000 $20,000 Loss of Speech AND Hearing in Both Ears $10,000 $10,000 $15,000 $20,000 Loss of Hearing in One Ear $10,000 $10,000 $15,000 $20,000 Loss of Thumb AND Index Finger of Same Hand $10,000 $10,000 $15,000 $20,000 Loss of One or More Fingers OR Toes $2,500 $2,500 $2,500 $2,500 Loss of Sight of One Eye $10,000 $10,000 $15,000 $20,000 Dislocations & Fracture Benefits Dislocation Benefits (all) $1,000 $1,000 $1,250 $1,500 Concussion $100 $100 $125 $150 Fractures Rib $500 $500 $500 $500 Fractures Other * $1,000 $1,000 $1,250 $1,500 * Covered fractures include Pelvis, Skull, Neck, Thigh, Upper Arm, Ankle, Lower Leg, Elbow, Heel, Shoulder Blade, Lower Jaw, Collarbone, Forearm, Wrist, Vertebrae, Sternum, Kneecap, Cheekbone, Hand, Foot, and Coccyx Homeland HealthCare Value Benefits* 3 Tier Prescription Discount Benefit Included Included Included Included $10 Generic Only Drug Benefit Optional Optional Optional Optional CAREington International Dental Discount Included Included Included Included COLE Vision Discount Program Included Included Included Included Homeland Lab & Imaging Included Included Included Included TeleDoc 24/7/365 Physician Access Included Included Included Included Accidental Medical Benefit (per occurrence, no limit) $2,000 $2,000 $2,000 $2,000 *Homeland Health Care Value Added Benefits Program is not underwritten by the National Union Fire Insurance Company of Pittsburgh, Pa.

4 VALUE-ADDED ADDED BENEFITS* *These Benefits are not provided by the National Union Fire Insurance Company of Pittsburgh, Pa. Option 1: 3-Tier Discount Prescription Card Members save on prescription medication at over 53,000 participating pharmacies nationwide. Tier 1 Preferred brand and generic drugs for $10 or less for scheduled quantity/dose Tier 2 Preferred brand and generic drugs for $20 or less for scheduled quantity/dose Tier 3 Preferred brand and generic drugs for $40 or less for scheduled quantity/dose Options 2: $10 Co-Pay Generic Prescriptions Card PRESCRIPTION DRUG BENEFIT This insured drug benefit covers most of the commonly prescribed generic drugs at a low member co-pay of $10. In addition, this benefit allows members to purchase brand name drugs and non co-pay generics at a discounted rates through a pharmacy network with over 48,000 locations nationwide including all major chains, and most independent pharmacies. LAB BENEFIT: Homeland Direct Lab & Diagnostic Services Homeland's lab benefit is supported by 9,000 fully accredited patient service centers nationally. Members can access testing results on-line within 72 hours. Members have unrestricted access to 1,700 tests. Confirmation summaries are provided to members via , fax, or telephone within 60 minutes of ordering or registering. These summaries illustrate ordering activity, patient service center location, date of service, and procedural information. Reporting processes are HIPPA compliant. The member has a choice of modality to receive results: fax, , or regular mail. DENTAL BENEFIT: CAREINGTON International Save 20-60% on most dental procedures at over 29,0000 providers nationwide. Save on specialty care such as orthodontics and cosmetic dentistry. Discounts on complete dentures. Discounts on complete dentures. VISION BENEFIT: COLE Managed Vision Pay only $20 for eye exams (limit: one per person per year.) U.S. Laser Network LASIK or PRK surgery discounted 15% from retail price, and 5% off promotional price. Members save 15% on conventional contacts, and 40% on frames and lenses. TelaDoc TelaDoc is a network of licensed primary care physicians who diagnose routine, non-emergency, medical problems via the telephone. TelaDoc physicians recommend treatment and prescribe medication (when appropriate) over the telephone 24 hours a day, 365 days a year. Simply make a phone call and, in most cases, speak to a doctor in less than an hour. *Disclosures: 1. Please note that THESE ITEMS ARE NOT INSURANCE. 2. The plan provides discounts at certain health care providers for medical services. 3. The plan does not make payments directly to the providers of medical services. 4. Plan members are obligated to pay for all health care services but will receive a discount from those healthcare providers who have contracted with the discount medical plan organization. 5. Discount Medical Plan Organization and administrator: CAREINGTON International Corporation, 7400 Gaylord Parkway, Frisco, TX 75034; phone The program and its administrators have no liability for providing or guaranteeing service or the quality of service rendered. Note to Utah residents: This contract is not protected by the Utah Life and Health Guaranty Association.

5 LIMITED BENEFIT HEALTH INSURANCE EXCLUSIONS & LIMITATIONS No coverage shall be provided and no benefits will be paid for any loss resulting in whole or in part from, or contributed to by, or as a natural and probable consequence of any of the following excluded risks. 1. suicide or any attempt at suicide or intentionally self-inflicted Injury or any attempt at intentionally self-inflicted Injury or any act of auto-eroticism. 2. travel or flight in or on (including getting in or out of, or on or off of) any vehicle used for aerial navigation, if the Insured Person is: a. riding as a passenger in any aircraft not intended or licensed for the transportation of passengers; b. performing, learning to perform or instructing others to perform as a pilot or crew member of any aircraft; or c. riding as a passenger in an aircraft owned, leased or operated by the Insured Person's employer. 3. declared or undeclared war, or any act of declared or undeclared war. 4. full-time active duty in the armed forces, National Guard or organized reserve corps of any country or international authority. (Unearned premium for any period for which the Insured Person is not covered due to his or her active duty status will be refunded.) (Loss caused while on short-term National Guard or reserve duty for regularly scheduled training purposes is not excluded.). 5. the Insured Person s being under the influence of intoxicants while operating any vehicle or means of transportation or conveyance. 6. the Insured Person s being under the influence of drugs unless taken under the advice of and as specified by a Physician. 7. the Insured Person s commission of or attempt to commit a felony. 8. services and supplies which are not prescribed by a Physician as necessary to treat an Injury or Sickness; are received without charge or legal obligation to pay; would not normally be paid in the absence of insurance; are received outside of the United States; or are received while incarcerated by legal authorities of any state or country for any reason. 9. dental treatment unless due to an Injury. 10. cosmetic care, except for reconstructive plastic surgery required as a result of Injury; to restore a normal bodily function; to improve functional impairment by anatomic alteration made as necessary as a result of a congenital birth defect; or for breast reconstruction following mastectomy. 11. any Injury or Sickness covered under any state or federal Worker s Compensation, Employer s Liability law or similar law. 12. services and supplies which are not due to an Injury or Sickness except as specifically provided. 13. mental or nervous disorders or substance abuse. 14. participating in any sport or sporting activity for wage, compensation, or profit, including officiating or coaching; or racing any type vehicle in an organized event. 15. driving any taxi for wage, compensation, or profit. 16. mountaineering using ropes and/or other equipment; parachuting; or hang gliding. 17. custodial care or rest.

6 Monthly Rates* - Standard States Standard States Include: AL, AZ, AR, DE, FL, IL, IA, KY, ME, MI, MO, MS, ND, NE, NV, NH, NM, OH, OR, PA, SC, SD, TN, TX, UT, VA, WI, WY. The AWA Limited Benefit Health Insurance Plan is Underwritten by National Union Fire Insurance Company of Pittsburgh, Pa. The Value Added Benefit Program is provided by Homeland HealthCare. Administered by: BRONZE Plan GOLD Plan Member Plus Spouse Plus Child(ren) Family Member Plus Spouse Plus Child(ren) Family < 25 $ $ $ $ < 25 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ SILVER Plan PLATINUM Plan Member Plus Spouse Plus Child(ren) Family Member Plus Spouse Plus Child(ren) Family < 25 $ $ $ $ < 25 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ For the $10 Generic Only Drug Card Option: Please add $13 to the Individual, $26 to the Plus Spouse and Plus Child(ren), $36 to the Monthly Family rates. Plan currently NOT Available in: AK,CT,DC,GA,HI,ID,IN,KS,LA,MA,MN,MT,NC,OK,PR,RI,VT,WA *Different Rates Apply in: CA, CO, MD & WV. The premium rates above include a charge for the Value Added Benefits and administrative services provided by the AWA and Homeland HealthCare. The additional premium is 17% of the monthly cost. AWA Stand.

7 AWA Limited Benefit Health Insurance from the Domestic Accident & Health Division of the AIG Companies Individual Enrollment Form for Group Accident & Sickness Indemnity Insurance Underwritten by Please Print NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA. Executive Offices: 70 Pine Street, New York, NY (Herein called the Company) Group Policyholder: AMERICAN WORKERS ASSOCIATION Requested Effective Date: Enrollee Name: Enrollee Address: City: State: Zip: Social Security Number: Daytime Phone Number: Gender: Male Female Date of Birth: Address: Coverage: Enrollee Only Enrollee and Spouse Enrollee and Child(ren) Family Plan Selection: Bronze Silver Gold Platinum Prescription Option: 3 Tier $10 Co-pay (Write spouse s name below if you are applying for Enrollee and Spouse or Enrollee and Family coverage; if no spouse or if spouse is not to be covered, put N/A or None in space below.) Spouse s Name: Date of Birth: / / SSNumber: Beneficiary* (Please print full name): Relationship: *The enrollee will be the beneficiary for his or her spouse and/or dependent children if dependent coverage is selected unless designated otherwise. Dependent Information Name Date of Birth SS# Gender (M/F) Dependent: Dependent: Dependent: By signing below, I and the individuals named herein are eligible for insurance. I understand that this is not basic health insurance or major medical coverage and it is not intended as a substitute for basic health insurance or major medical coverage and that the coverage will not begin until the effective date shown in the coverage document. I further understand that the coverage will not pay benefits during the Plan Period described below for pre-existing condition I/we currently have or have had in the past. Beginning on the Effective Date, benefits will not be paid for any pre-existing condi-tion until the end of 12-consecutive months. I authorize Homeland HealthCare to collect any and all premiums due for this coverage. Fraud Warning: Any person who knowingly and with intent, defrauds or deceives any insurance company by submitting an application or filling a claim that contains any false or incomplete information, or conceals information for the purpose of misleading, is guilty of insurance fraud, which is a felony and subject to criminal and/or civil penalties. Enrollee s Signature AWA - 11/06 Standard Date Automatic Bank Draft (drafted on the 25th of each month) Bank Name Routing Number Bank Account Number Applicant Signature Date Agent Signature Agent # Agent Name (Print) Agent Number Monthly Plan Cost (from chart) One-Time Enrollment Fee Vision Option $1500 Dental Option TOTAL First Month s Payment = $ $

8 Here are just some of the benefits provided to members of The American Worker s Association. For a complete list please visit 24-HOUR EMERGENCY ROADSIDE ASSISTANCE Members can gain peace of mind on the road by registering for Emergency Roadside assistance. Once registered, members will receive emergency roadside assistance membership materials including membership cards that will enable the member and their family to get assistance from a participating service provider whenever car troubles arise. Members will be covered for the first $50 per occurrence for each covered emergency expense, including towing, flat tire assistance, battery service, and lock-out service. CAR RENTAL DISCOUNTS The car rental discount will allow members to receive discounts on selected car rental companies including Avis, Alamo, Hertz, or National. You will be quoted a special, member discount rate. Rates are based on the type of car you want and the area where you rent. Discounts apply to weekly, daily, promotional and holiday rates, as well as some weekend rates. In an effort to assist our members in becoming more informed about their healthcare, the Association is pleased to offer a telephone service that allows members to ask questions and receive information about their health, illnesses, and medications. Members have unlimited access to registered nurses via a toll-free number 24 hours a day, 365 days a year. These nurses are specially trained to offer prompt, confidential medical counseling to help members make informed decisions about their health and the medical care they receive. GATEWAY MEDICARD In an emergency, getting vital health information to medical personnel quickly could be critical. Your Gateway Medicard keeps your personal medical profile handy at all times. When you send in your Gateway Medicard Data Form, it is photographed on microfilm and laminated in a durable plastic card. You'll feel more secure knowing emergency medical personnel will have access to data needed to administer appropriate care. American Worker Dental PREFERRED SCHEDULED Available in addition to the AWA Health Plan, the American Workers Association provides this scheduled indemnity benefits dental program with a rich, annual maximum of $1,500! A $50 deductible is waived for preventative services. -See the dentist of your choice. -Set reimbursements for procedures no surprises. -Cash paid directly to you or your provider. -Twelve month wait on major, no waiting period on other services. Reimbursement 0150 Comprehensive Oral Evaluation $ X-Ray Bitewing (4 films) $ Routine Prophylaxisadult (every 6 months) $ Resin Filling-2 surfaces, anterior $ Crown-porcelain fused to high noble metal* $ Root Canal-Molar* $ Periodontal Scaling and Root Planning-per quadrant* $ Single Tooth (extraction) $ 40 Sample only. See member certificate for all codes, exclusions and limitations. *Depending on your provider s billing practice. Underwritten by Standard Life and Accident Insurance Company, Galveston, TX. Monthly Rates: Member $ 29.50, Plus 1 $59.50, Family $87.00