Short Option. Coverage for short-term health care needs. anthem.com. MVABR4914A Rev. 12/11

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1 Short Option Coverage for short-term health care needs MVABR4914A Rev. 12/11 anthem.com

2 Short Option health coverage We realize that many Virginians, for one reason or another, are in need of health care protection for just a short period of time. Short Option offers benefits similar to those available through our traditional major medical plans, but is designed especially for those in need of temporary protection. With Anthem s Short Option program, you don t have to worry about gaps in coverage while you re between health care plans. 1

3 Summary of benefits This chart lists benefits for each person on a policy. Because this policy offers coverage for a limited period of time, past or present health conditions are not covered. All services require that you meet the deductible amount before receiving benefits. Lifetime maximum Providers Policy term $1 million Freedom to choose doctors and hospitals; however, you save more on the cost of services by visiting a participating provider. See page 3 for details. 30, 60, 90 or 180 days Benefit period deductible $1,000 Coinsurance 20% coinsurance Out-of-pocket maximum $1,000 Doctor visits/outpatient services 20% coinsurance Prescription drugs 20% coinsurance Emergency services 20% coinsurance Hospital inpatient services Psychiatric & chemical dependency care 20% coinsurance Outpatient: first 5 visits at 20% coinsurance; visits 6-20 with a 50% coinsurance. Inpatient: 25-day maximum with a 20% coinsurance. 2

4 Important terms Allowable charge The allowance Anthem determines for covered services. Participating providers accept Anthem s allowable charge as payment in full. Benefit period The length of your coverage. This is the same as your policy term. For Short Option, it is either 30, 60, 90 or 180 days. Coinsurance It s the percentage of the covered charge that you pay. Covered services A service or supply that we ll help cover (according to your policy), such as doctor s visits, diagnostic tests, hospitalization, prescription drugs and others. Deductible This is the amount you pay each benefit period for covered services before we start to share costs with you. The deductible is separate for each person. If there are three or more people on your policy, our family deductible can save you money. It is equal to two individual deductibles, so once the family amount is met, no one else on your policy has to meet a deductible for the rest of the benefit period. Effective date The date your coverage begins. Non-covered service Services we don t cover. Some examples are exercise equipment, stop-smoking programs, over-the-counter drugs, experimental treatment, whirlpool baths, private duty nursing, and transportation to and from the doctor. Out-of-pocket expense limit Once you reach this, we cover almost 100% of your costs for the rest of the benefit period. You remain responsible for certain coinsurance amounts and other items that never count toward the out-of-pocket expense limit. (Please see page 6 for a list of these exceptions.) Participating provider You get the protection and advantage of Anthem s participating providers to help you save money. These doctors agree to accept our allowable charge as payment in full for covered services. A non-participating doctor may charge more, and you are responsible for the difference. So, it s a good idea to make sure a doctor participates before you go. With nearly 16,000 doctors and over 85 hospitals, chances are your doctor already participates.* Pre-existing condition This policy never covers pre-existing conditions. A pre-existing condition is any medical condition you had in the 24 months before your policy s effective date. If you received medical advice, diagnosis, or care for a condition you had during that time, it is a pre-existing condition. A pre-existing condition is also a condition that would cause a prudent person to seek medical advice, diagnosis, care or treatment. This means that if you had symptoms that would make an ordinary person seek treatment for the condition, that condition is a pre-existing condition, regardless of whether you went to the doctor for treatment. Prescription drugs prescribed for a pre-existing condition are not covered. If you purchase two Short Option policies with no break in coverage, medical conditions existing during the first policy will not be covered under the second policy. * BCBSA Provider Data Counts

5 You should know about... Coordination of benefits Anthem Blue Cross and Blue Shield individual policies have a coordination of benefits provision. This provision says that if you are issued an Anthem Blue Cross and Blue Shield individual policy, and one of the persons covered by your Anthem policy is covered by another group health plan, the group health plan will have primary responsibility for the covered expenses of that family member. For any dependent children on your Anthem individual policy who are enrolled under another individual health plan, the primary policy is the policy of the parent whose birthday (month and day) falls earlier in the calendar year. The parent s birth year is not considered. Eligibility Short Option is available only to people who: Live in the Anthem Blue Cross and Blue Shield service area for the term of the policy. Qualify medically and meet lifestyle criteria. Are over the age of 3 months and under the age of 65. Are not pregnant, are not the child of an expectant parent, or do not have a pregnant spouse/domestic partner or dependent child who is pregnant (even if not on the policy). Are not entitled to Medicare benefits. Are not eligible for Anthem group coverage. Do not currently have individual protection that provides similar benefits, unless Short Option will replace the existing coverage. Are United States citizens or who are foreign nationals who have lived in the United States for the three consecutive months prior to purchasing this coverage. This three month requirement is waived for foreign nationals who are on a valid and approved work or student visa. The work or study program must be on a full-time basis. In addition, the foreign national may not travel outside the United States for more than 30 days during the term of the policy. Are not on active duty with any branch of the armed services. To be eligible for coverage as a domestic partner, you: Must have been living together six or more months together and plan to continue living together. Are financially interdependent. Are at least 18 years old. Are not married to anyone else and not related by blood in a way that would prohibit marriage. Eligible children must also be: Unmarried. Under age 19 (or under age 23 if a full-time student). Your spouse/domestic partner and dependent children are eligible to apply for this coverage if they meet the conditions listed above. Renewability This policy is issued for a specified term (benefit period) for which you apply and are accepted. It can t be renewed under any circumstances; however, you may purchase up to two Short Option policies in a calendar year. If you purchase two 180-day policies, you must have at least a 60-day break between the two. Premium We base premiums on factors like your age, sex, type of benefits and level of benefits, membership type, health and lifestyle. These premiums are set by class. You will not be singled out for a premium change. We will give you prior written notice of any premium change. The premium must be included with your application. You can pay by credit card. The effective date can be as early as the day you sign your completed application. Once complete, return the application with the correct premium payment (the amount for the entire coverage period). However, if you are purchasing the 180-day coverage, you may pay half of the premium to begin your coverage. You will then be billed for the remaining premium. Employer payment of premiums The policy described in this brochure is an individual health insurance policy which can t be used as an employerprovided health care benefit plan. No employer of any person covered under this policy may contribute to premiums directly or indirectly, including wage adjustments. If you run a business that s 1) wholly owned by you or by you and your spouse/domestic partner; 2) has no employees; or 3) has employees, but doesn t offer health benefits to them. Then we don t consider that business to be your employer. A church may purchase an individual policy for an employee but it can only be for that one employee. Cancelling your policy If you want to cancel your Anthem policy, you must call or notify us in writing. Any premium you ve paid beyond your cancellation date will be refunded to you within 31 days of the cancellation. Termination Termination of your policy will be effective as of 11:59 p.m. on the date of cancellation. 4

6 Exclusions and limitations In order for health care companies to cover a wide variety of services and keep the cost of health care coverage down for customers, they have to set exclusions and limitations. Exclusions are certain services or conditions that are not covered under a policy. Limitations are preset limits (or maximum amounts) for some services which are covered under a policy. If you have any questions about these, your Anthem Sales Representative is here to help. Exclusions This policy does not cover: Services and complications not listed as being covered in this policy. Services for pre-existing conditions and related complications. Pregnancy-related services except complications of pregnancy related to a pregnancy beginning after the policy s effective date. Services for artificial or surgical means of conception. Services for sickness or injury caused by war or participation in a felony, riot, or any act of civil disobedience. Services for injuries or sickness sustained while serving in any branch of the armed services. Travel or transportation, except professional ambulance services covered by the policy. All medical, surgical and psychiatric services for, or related to, cosmetic surgery or cosmetic procedures. This includes any medical, surgical and psychiatric services to correct complications of a cosmetic procedure. Body piercing and cosmetic tattooing are considered cosmetic procedures. Cosmetic surgery doesn t mean reconstructive surgery for trauma, infection or disease. We decide on our own if surgery is cosmetic or is clearly essential to the health of the patient. Services for palliative or cosmetic footcare. Services covered under federal or state programs (except Medicaid). Services performed by your immediate family or by you. Charges for telephone consultations or failure to keep scheduled appointments. Services rendered by a provider to a co-worker. Services for which a charge is not normally made. Separate charges for services by health care professionals employed by a covered facility which makes their services available. Services for any dental care not covered by the policy. Services for vision care not covered by the policy. Implantable or removable hearing aids, including exams for prescribing or fitting hearing aids regardless of the cause of the hearing loss, with the exception of cochlear implants. Services for rest cures, residential care or custodial care. Your coverage doesn t cover benefits for care from a residential treatment center or other non-skilled, sub-acute setting. But it will cover benefits if the setting qualifies as a substance abuse treatment facility. The facility has to be licensed to give a continuous, structured, 24-hours-a-day program of drug or alcohol treatment and rehabilitation. This includes 24-hour-a-day nursing care. Services for routine physical examinations, routine laboratory tests, routine X-rays, or other routine services that exceed what is specifically provided for in the policy. Services that are not medically necessary, in our sole discretion. Services for injuries or sickness resulting from any activities for wage or profit when 1) your employer makes payment to you because of your condition; 2) your employer is required by law to provide benefits to you; or 3) you could have received benefits for your condition if you had complied with the relevant law. Services we deem in our sole discretion to be experimental or investigative, except in the limited circumstances listed in the policy. Birth control devices or contraceptives. Therapy primarily for vocational rehabilitation. Services for drug, alcohol or other psychiatric conditions rendered by any skilled nursing facility or by any home health care agency. Certain drugs and therapeutic devices, including over-the-counter drugs and exercise equipment. Organ or tissue transplants that are considered experimental/investigative or not medically necessary. Outpatient services for marital counseling, coma-stimulation activities, and educational, vocational and recreational therapy. Services performed outside the United States and its territories. Manual or mechanical interventions for illnesses or injuries other than musculoskeletal illnesses or injuries and any services over the first $500 paid. Self-help, training and self-administered services, including biofeedback and related testing. 5

7 Vaccinations, immunizations, or other injections not used to treat a current illness, except as specifically provided for in the policy. Telemedicine services such as phone, or fax. Services for the following conditions (unless deemed emergency medical care): hernias, tonsil or adenoid disorders, reproductive organ disorders (excluding laparoscopy-assisted vaginal hysterectomy or vaginal hysterectomy), varicose veins and appendix disorders. Services for injuries or diseases resulting from any interscholastic sport. Services or supplies ordered by a physician whose services are not covered by the policy. Prescription drugs This policy does not cover: Prescription drugs prescribed for pre-existing conditions. Over-the-counter drugs. Contraceptive pills. Contraceptive devices (including contraceptive implants). Charges to administer prescription drugs or insulin, except as stated in the Covered Services chapter. Prescription refills that exceed the number of refills specified by the provider. A prescription that is dispensed more than one year after it s prescribed by the physician. Drugs that are consumed or administered at the place where they are dispensed, except as stated in the Covered Services chapter. Prescription drugs prescribed for weight loss or as stop-smoking aids. Prescription drugs prescribed primarily for cosmetic purposes. Prescription drugs dispensed by anyone other than a pharmacy, with the exception of a physician dispensing a one-time dosage of an oral medication either at the physician s office or in a covered outpatient setting in order to treat an acute situation. Prescription drugs not approved by the FDA. Out-of-pocket expense limit exclusions The following items never count toward your out-of-pocket expense limit: Amounts we apply to your deductible. The coinsurance amounts listed below. Amounts exceeding the allowable charge. Expenses for services not covered by this policy. Limitations This policy covers certain services up to a preset limit. For example, visits to a health care provider may be limited by the number of visits, or services may be limited by a maximum dollar amount. Once you reach the preset limit on a service, the policy will not pay benefits for that service for the rest of the benefit period. Your policy will have detailed information on the benefit limitations that are outlined below. Limitations under this policy are: Psychiatric services: 20 visits for outpatient services; 25 days for inpatient services. Up to 10 inpatient days may be exchanged for 15 partial days. (1 inpatient day = 1.5 partial days.) Manual or mechanical medical interventions, including spinal manipulation ($500 cap). Outpatient physical therapy and/or outpatient occupational therapy ($1,000 cap). Outpatient speech therapy ($250 cap). Home health care services (45 visits). Ground ambulance services ($1,500 cap). Durable medical equipment ($2,500 cap). Capped benefits are described in the policy. Please call your Anthem sales representative if you have any questions about any benefit we mention in this brochure. Coinsurance Limitations There are some coinsurance amounts you are always responsible for, even when you have met your deductible and out-of-pocket expense limit: Coinsurance for outpatient psychiatric service visits. Coinsurance for manual or mechanical medical interventions, including spinal manipulation. Coinsurance for outpatient physical therapy, outpatient speech therapy and outpatient occupational therapy. Coinsurance for durable medical equipment and home health care services. Coinsurance (which increases to 25%) for covered services received at non-participating hospitals or non-contracting substance abuse treatment facilities located in Virginia. 6

8 This is not your policy and is intended as a brief summary of services. If there is any difference between this brochure and the policy, the provisions of the policy shall control. This brochure is only one piece of your entire fulfillment kit. This brochure refers to Policy form # (PHC) 5/92, and Application # 01630VAMENABS and 01631VAMENABS. Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. Anthem Blue Cross and Blue Shield is an independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

9 Anthem Blue Cross and Blue Shield P.O. Box 14046, Roanoke, VA Short Option Application for Short-Term Major Medical Insurance Underwriting Fax # Applicant Information Last Name First Home Address (Street or Rural Route required do not use P.O. Box) City M.I. Social Security Number / / State Zip Billing Address (if different from above) City State Zip r Check here if all correspondence is to be mailed to the billing address. Address: Birthdate (mm/dd/yyyy) Sex Marital Status / / r M r F r Married r Single r Divorced Telephone Number(s): Day: ( ) Evening: ( ) Fax: ( ) 2. Family Information for persons to be covered Last Name(s) First M.I. (Attach additional sheet of paper if necessary) Spouse/Domestic Partner Child Child Child Social Security Number Birthdate ((mm/dd/yyyy) Sex / / r M r F / / r M r F / / r M r F / / r M r F Are all applicants listed on this application United States citizens? r Yes r No If NO, who? and how many months/years have they resided in the United States? years and months 3. Program Selection (a deductible and policy term must be selected) A. Deductible: r $1,000 B. Policy Term: r 30 Days r 60 days r 90 Days r 180 Days C. Desired Effective Date: If your application is approved your coverage can start on any day of the month after the date we receive your application. The requested effective date is not a guarantee that the effective date will be the requested date in the event we agree to provide coverage. Please choose the date you would like your coverage to start: / / MM/DD/YYYY 01630VAMENABS Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. An independent licensee of the Blue Cross and Blue Shield Association. Registered marks Blue Cross and Blue Shield Association. PAGE 1 OF 3

10 4. Eligibility Information 1. Is any person to be covered eligible for Medicare, or will he or she become eligible for Medicare during the term of this policy? r Yes r No If Yes, name of the eligible person(s): 2. Is any person to be covered eligible for employer sponsored group health coverage, but not enrolled? r Yes r No If Yes, name of the eligible person(s): Name of Carrier: r Anthem Blue Cross and Blue Shield r Other: (specify name of carrier) 3. Will this policy replace any current health insurance (including Anthem Blue Cross and Blue Shield)? r Yes r No If Yes, name of carrier: Date coverage ends: ID#: 4. Is any person to be covered already insured by any individual or group hospital, major medical, or medical expense insurance that will not terminate prior to the effective date of this policy? If Yes, state the name of each person: 5. Health History Questions r Yes r No When answering questions on this enrollment application the information provided for each individual should include only information about that individual, and should not include any genetic information. Genetic information includes family medical history and information related to the individual s genetic testing, genetic services, genetic counseling, or genetic diseases for which the individual may be at risk. All responses pertaining to an individual will only be considered and applied to the individual in question. 1. Is any applicant currently pregnant (includes positive pregnancy test within the last 30 days), an expectant father, or in the process of adoption or surrogate pregnancy? r Yes r No If Yes, who: 2. Has any applicant been diagnosed with or treated for AIDS or ARC? r Yes r No If Yes, provide the name of each person: 3. Has any applicant been advised by a healthcare provider to have testing, examination, evaluation, treatment, therapy, or surgery that has not yet been completed? r Yes r No If Yes, who? Specify condition(s): 4. Is any applicant a candidate for or recipient of an organ or bone marrow transplant? r Yes r No If Yes, provide the name of each person: 5. Within the last 30 days, has any applicant been admitted to an inpatient hospital or surgical facility? r Yes r No If Yes, who? Specify condition(s): 6. Within the last 12 months, has any applicant received a prescription or taken any prescribed medication except for birth control for contraception, hormone replacement therapy, Synthroid, or short term (10 days or less) antibiotics? r Yes r No If Yes, provide the name of each person: Specify medication(s) and condition(s): 7. Within the last 5 years, has any applicant been diagnosed with or received treatment for heart, lung, blood (e.g. Hemophilia, leukemia), blood vessel, kidney, liver, brain, nerve or immune system disorders, diabetes, cancer, stroke, heart attack, high blood pressure, ulcerative colitis, Crohn s Disease, or alcohol abuse or drug abuse? r Yes r No If Yes, who? Specify condition(s): PAGE 2 OF 3

11 6. Certification (must be signed and dated to avoid delays in processing) I and my agent (if applicable) certify that I have read or have had read to me this completed application. I understand that any answer or statement made within this application that is untrue and is material to the risk assumed by Anthem Blue Cross and Blue Shield may prevent the recovery of benefits under the policy. Such answer or statement may also result in the termination or voiding of the policy back to its effective date. I understand that: 1. no coverage will be in force until my application is approved by the Company, the appropriate premium is actually received by the Company, and that the effective date will be the date assigned by the Company; 2. coverage is not provided and benefits will not be paid for a health condition that exists prior to the date this policy takes effect; 3. I can purchase no more than two Short Option policies in a calendar year and if I purchase two 180 day policies, I must have at least a 60 day break between the two; 4. children under three months of age are not eligible for this coverage; primary applicants under the age of 19 are not eligible for this coverage. 5. no sales agent or broker is authorized to do any of the following: accept risks; make decisions about policy eligibility; change any policy provision; add terms to any policy; or terminate any policy. 6. my domestic partner, if applicable, is only eligible for coverage if: he or she has been my sole domestic partner for 6 months or more; he or she is mentally competent; he or she, is at least 18 years old; is not related to me in any way (including by blood or adoption) that would prohibit us from being married under state law; he or she is not married to or separated from anyone else; and he or she is financially interdependent with me. 7. benefits provided by this coverage combined with benefits payable under any other health care policy or HMO program will not exceed the allowable charge. I authorize Anthem Blue Cross and Blue Shield, or an agent, subsidiary or affiliate that has a business associate contract with Anthem Blue Cross and Blue Shield, to obtain any medical records or other health history information concerning me and any family member listed on my Application from any physicians, hospitals, pharmacies, other health care providers, pharmacy benefits managers, health benefits plans, health insurers, medical or pharmacy benefit administrators, Consumer Reporting Agencies, and/or insurance support organizations. I also authorize any physicians, hospitals, pharmacies, other health care providers, pharmacy benefits managers, health benefit plans, medical or pharmacy benefit administrators, Consumer Reporting Agencies, and/or insurance support organizations to furnish any medical records or health history information concerning me and any family member listed on my Application to Anthem Blue Cross and Blue Shield, or an agent, subsidiary or affiliate that has a business associate contract with Anthem Blue Cross and Blue Shield. This authorization is for the term of the coverage of the health insurance policy in connection with a determination of coverage regarding a claim for health insurance benefits. However, this authorization will expire 24 months from the date I sign it for purposes of determining my eligibility or continued eligibility for coverage under any health insurance or life insurance policy issued. You or an authorized representative have the right to receive a copy of this Authorization upon request. I understand that the policy that I am applying for is an individual health insurance policy. As such, I understand that the policy, if issued, shall not be used as an employer-provided health care benefit plan. I certify that no employer of any person covered under this policy may pay any premium for this coverage, directly or indirectly, including through wage adjustment. I understand that employer does not include a trade or business wholly owned by an individual, or individual and spouse/domestic partner, that has no other employees or that does not offer health benefits to any other employees. Also, as it pertains to this provision, a church may purchase an individual policy if only purchasing it for one employee. I understand that premiums not paid in accordance with this provision shall result in the discontinuance of the policy issued from this application. X Signature of Applicant or Legal Representative if applicable Date (mm/dd/yyyy) X Signature of Spouse/Domestic Partner or Legal Representative if applicable Date (mm/dd/yyyy) X Signature of Other Adult Person to be covered or Legal Representative if applicable Date (mm/dd/yyyy) X Signature of Other Adult Person to be covered or Legal Representative if applicable Date (mm/dd/yyyy) X Signature of Agent if applicable Date (mm/dd/yyyy) - ( ) Agent Number Agent Name (Please print) Telephone Number Receipt Date: Address: ( ) Fax Number PAGE 3 OF 3

12 Payment Methods for Individual Short Term Health Coverage Virginia Please complete in blue or black ink. Applicant Name (please print) Application ID Primary Applicant s Social Security Number Premium Calculation (No additional premium required for more than 3 children) $ + $ + $ + $ + $ = $ policyholder spouse/domestic partner child child child total PLEASE TELL US HOW YOU WILL PAY YOUR PREMIUM Credit/Debit Card (complete Section A) Charge full payment Charge 1/2 payment (Available on 180-day policies only) Check or Money Order attached (make payable to Anthem Blue Cross and Blue Shield) When you provide a check as payment, you authorize us either to use information from your check to make a one-time electronic fund transfer from your account or to process the payment as a check transaction. When we use this information from your check to make an electronic fund transfer, funds will be withdrawn from your account as soon as the day of approval, and you will not receive your check back from your financial institution. A. Credit/Debit Card As a convenience to me, I request and authorize Anthem Blue Cross and Blue Shield to charge the credit/ debit card indicated one time for the initial premium payment amount upon approval. I understand that if this option is selected, the credit/debit card indicated may be charged for the indicated premium payment amount as early as the date of approval. If the premium payment amount varies from the quote generated by the system or due to changes during the underwriting process, I also authorize Anthem to charge the credit/debit card indicated for the different amount. I agree that Anthem is fully protected in honoring any credit/debit card payments. I further agree that if any credit/debit card payment is dishonored, with or without cause, intentionally or inadvertently, Anthem is under no liability whatsoever, including any fees imposed by the credit/debit card company or my bank, if my credit/debit card is rejected even though such dishonor results in termination of coverage. We accept Visa and MasterCard. FOR 180 DAY POLICIES ONLY: If I choose to charge my premium, I have the option of having the first half billed to my VISA or MasterCard. Should I choose to use this option, I understand that I will pay the remaining second half of the premium with a check or money order when it becomes due. I understand that a service charge will be incurred for any withdrawal not honored. Type Of Card: Visa MasterCard Card Number: Expiration Date: Authorized Signature (as it appears on the credit/debit card) X Cardholder Name (as it appears on the credit/debit card please print) Date Cardholder Billing Address City State ZIP Code PLEASE RETAIN A COPY OF THIS AUTHORIZATION FOR YOUR RECORDS. Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia. Independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association VAMENABS Paper 10/ VAMENABS VA IND Short Term Premium Payment Paper FR 10 11