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The Max Benefit-National Choice Plan
PLAN HIGHLIGHTS, SUMMARY OF BENEFITS, ENROLLMENT FORM / APPLICATION AND BANKING
AUTHORIZATION COVER MESSAGE
OPEN ENROLLMENT FIXED LOW MONTHLY RATES ARE AS FOLLOWS:
Individuals: $399.00
Member + 1: $699.00
Families: $899.00
Included you will find plan highlights, a summary of benefits. Please review these benefits and contact your
representative at 888.933.9449 to take an application by phone or receive an application to complete and fax back to us at 888.814.9977 or email to your representative listed on this page.
Plan Highlights
• LIFETIME MAXIMUM BENEFIT: $1,000,000.00 PER MEMBER
• CALENDAR YEAR MAXIMUM: $250,000.00 PER MEMBER
• Guaranteed Issue to individuals & Families
• Physicians Office Visit $25 Co-Pay
• Low Deductible 80/20 coverage
• Multi Plan PPO and PHCS PPO Network
• Stable & Locked Rates Guaranteed for 1 year
• Available in most states
• HIPAA Compliant
• Fully insured
• No participation requirements for groups
(Combined maximum in-network and out-of-network benefits)
IMPORTANT: These rates can only be guaranteed through Friday. We must have your information entered into the
system by the close of business in order to honor the rates quotes above. Please contact a representative to be
enrolled. Your effective date will be 1 st or the 15th of the next month for this plan.
Best Regards,
My Health USA
Phone 888.933.9449
www.myhealthusa.com
My HEALTH USA
The Max Benefit-National Choice Plan
TYPE OF EXPENSE:
Calendar year deductible PPO Provider Non-PPO Provider
Annual Deductible $500 (2x Mem +1-3x family) $5,000 (2x Mem +1-3x family)
Calendar Year Out-of Pocket PPO Provider Non PPO Provider
Maximum
Individual $2,500.00 $7,500.00
Family $7,500.00 $15,000.00
CALENDAR YEAR DEDUCTIBLES APPLY TO EVERY EXPENSE LISTED BELOW EXCEPT WHERE NOTED
(Co-payments are not applied to Calendar Year Deductibles)
Eligible Medical Expenses PPO Provider Non-PPO Provider
Hospital Inpatient Benefits
· Limit per day $1,250.00
Hospital Pre-Admission Co-pay Subject to Annual Subject to Annual
Deductible Deductible
Physician Services 80% of allowable 60% of allowable
Charges after annual charges after annual
Deductible deductible
Inpatient 80% of allowable 60% of allowable
Charges after annual Charges after annual
Deductible Deductible
Maternity Care Inpatient 80% of allowable 60% of allowable
Charges after annual Charges after annual
Deductible Deductible
Hospital In-Patient Surgery 80% after annual deductible 60% after annual deductible
Emergency Room 80% after $150 co-pay 60% after $250 co pay
Up to $1,250.00 up to $1,250.00
Per occurrence per occurrence
Surgery Outpatient 80% after outpatient 60% after outpatient
Co-pay of $500.00 co-pay of $1,500.00
Per occurrence per occurrence
Eligible Medical Expenses PPO Provider Non-PPO Provider
Physician Services
Primary Care Office Visit 100% after $25.00 co-pay 60% of allowable charges
· Maximum benefit $100.00 per visit up to 7 visits per member after annual deductible
Per year up to 7 visits per member per year
Specialist Office Visit 100% after $50.00 co-pay 60% of allowable charges
· Maximum benefit of $200 per visit up to 7 visits per member after annual deductible
Per year up to 7 visits per member Per year
Prenatal Maternity Care in patient 80% of allowable charges 60% of allowable charges
(Member or spouse only) after annual deductible after annual deductible
Urgent Care Facility 100% after $50 co-pay 80% after $150 co-pay
· Maximum benefit of $300 per visit per visit up to a maximum per visit up to a maximum
Of 7 visits per member per year of 7 visits per member per year
Other Facility Services PPO Provider Non-PPO Provider
80% Subject to annual deductible 60% Subject to annual deductible
Chiropractic care 100% after $25 co-pay per visit 80% after $25 co-pay per visit
· Maximum benefit per visit $100.00 visit
· Maximum annual benefit $500.00
· Per member
My HEALTH USA
The Max Benefit-National Choice Plan
Preventative Care $25.00 co-pay 100% No Benefits
· Maximum of $300 benefit per up to maximum benefit
Calendar year per member
Includes Physician Visit
Pap Smear, PSA, GYN exams, blood
Work and mammograms for female
Over age 40 or as required by Physician
Routine Well Child Care $25.00 co-pay 100% up to No Benefits
· Up to age 7 maximum annual benefits
· Maximum of $300 annual benefit
· Benefit per member per year
Diagnostic Lab & X-Ray, Outpatient 80% after annual deductible 60% after annual deductible
· (Non routine) services up to $1,500.00 per member per year
Mental Health/Substance Abuse
· Inpatient/Outpatient.
Number of annual visits is a combined
Maximum for both mental health and
Substance abuse care.
Outpatient Care visits maximum of 50% after annual deductible 50% after annual deductible
· 10 visits per member per year with a Maximum benefit of $100 per visit
Inpatient Care maximum of 10 days 50% after annual deductible 50% after annual deductible
· Per member per year.
Maximum daily benefit of $400
· Substance Abuse care both in and out
Patient is limited to $2,000 per member
Per calendar year
· $5,000 per year maximum for both
Mental Health and Substance Abuse
$30,000 Lifetime maximum benefit
Durable Medical Equipment 80% after annual deductible 60% after annual deductible
· $1,500 per year maximum per member
· Anything over $100 requires Pre-certification to be covered expense
Home Health Care/Hospice Care 80% after annual deductible 60% after annual deductible
· $5,000 maximum lifetime benefit per member
· Requires Pre-certification
Other Eligible Medical Expense 80% after annual deductible 60% after annual deductible
Medical Supplies PPO Providers Non-PPO Providers
· Syringes and related supplies for 80% after annual deductible 60% after annual deductible
Conditions such as diabetes, dressings
For conditions such as cancer or burns,
Catheters, Ostomy bags and related
Supplies, test tape, surgical trays and
Renal dialysis supplies
· Maximum annual benefit of $5,000 Per member
Ambulance – Up to $300.00 80% after annual deductible 60% after annual deductible
· Maximum Benefit per occurrence
Skilled Nursing Care 80% after annual deductible 60% after annual deductible
· Rehabilitation Center, Skilled Nursing Facility, Private Duty Nursing
· $200 per day maximum with a Maximum of 15 days per member Per year
MyHEALTH USA
The Max Benefit-National Choice Plan
Therapy, Outpatient 80% after annual deductible 60% after annual deductible
· Physical, Speech, Cardiac, Pulmonary, Occupational
· Maximum benefit of $1,000 Per member per year
Transplant Related Expenses PPO Provider Non-PPO Provider
· Pre-approval must be obtained. No benefit paid without prior Approval being given by the Insurance Company.
· Prescription drugs are not applied towards
The Transplant Lifetime Maximum Lifetime Maximum No Benefits
· Kidney (single/Double) $60,000.00
· Pancreas $100,000.00
· Heart $100,000.00
· Lung (single/double) $100,000.00
· Liver $100,000.00
· Pancreas Only $80,000.00
· Heart and Lung (single/double) $100,000.00
· Bone Marrow $100,000.00
Prescription Drug Benefits PPO Provider Non-PPO Provider
· Express Scripts is the provider for medication
Outpatient Prescription Medications
· $1,500 per year calendar maximum per member
Generic only $20.00 co-pay No benefit
100% after co-pay
Contraceptives $20.00 co-pay No Benefit
100% after co-pay
Brand Name 50% co-pay No Benefit
Maintenance Medications 90 day supply with No Benefit
3 prescriptions
Co-pays
ALL CONDITIONS ARE SUBJECT TO A 12/12 PRE-EXISTING EXCLUSION PERIOD UNLESS MEMBER PROVIDES PROOF OF PRIOR CREDITIBLE COVERAGE. Month for month credit will be given up to the full 12 month period if proof of prior creditable coverage is provided with no more than a 63 day gap from the time prior coverage termed and new covered begins.
Our medical plans are low-cost alternative, providing medical insurance at fixed amounts, and these Insured Benefits are paired with medical savings to designated providers in our PPO networks. The Insured Benefit Medical Plans offered thru My Health USA is a group insurance program. The group insurance benefits vary depending in the plan selected. This insurance is guaranteed issue major medical coverage with limitations; it is not designated as major medical coverage. The plan limitations are disclosed in the certificate of coverage provided in the fulfillment kit which will mailed to you in a timely manner once your payment is processed. For costs and complete details of the coverage, call your representative at 888 933 9449.
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