Optimum Health Designs
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1 Designed for Individuals, Families & Employers (PCP or Specialist) Preventive Care Tests Diagnostic, Xray & Laboratory Emergency Room Surgery (Inpatient & Outpatient) Anesthesia Supplemental Accident for Hospital & Skilled Nursing Facility Pharmacy Discount Card Hearing Vision Care Alternative Care Dental Care Infertility Treatment Medical PPO DIscount through MultiPlan Network Sponsored through membership in the National Congress of Employers Association. Questions? Contact your broker Underwritten by American Financial Security Life Insurance Company
2 American Financial Benefits There is a 0 day waiting period for all benefits related to sickness. Benefit Description per Insured Benefits are Annual Silver Gold Diamond Med Max Plus Inpatient Hospital Confinement): The carrier will pay the benefit shown if you incur charges for and are confined in a hospital due to injuries received in a covered accident or due to a covered illness. Per Day Maximum Days $,000 0 Doctor Office Visits (Primary Care or Specialist): The carrier will pay the benefits shown if you incur charges for and require a doctor s visit due to injuries received in a covered accident or due to a covered illness. Per Visit $6 Preventive Care Office Visit: A Benefit payable under the Preventive Care Benefit is not payable under any other Benefit of the Policy. Per Visit $6 Preventive Care DXL Coverage for routine examination or well child care. Covered services include: medical history, physical examination, X-rays and laboratory tests including a Pap test, colorectal screening, prostate cancer screening, mammography and bone density screening received on the same day. Per Visit $6 Outpatient Diagnostic Testing, X-ray and Lab Indemnity Benefit(DXL): This Benefit applies to all diagnostic testing, X-ray and laboratory services received on the same day. This benefit does not include Preventive Care Per Day of Services Maximum Days $ Inpatient and Outpatient Surgery and Anesthesia - Surgeon Fee The carrier will pay the benefit shown if you undergo a surgical procedure due to a covered accident or illness. Reimbursements are based on the Medicare/RBVS benefit schedule. Surgery is a % of Surgery Benefit RBRVS Anesthesia 0% 70% 00% 00% National Fee Schedule used is 00 RBRVS % of Surgeons Fees 0% 0% 0% 0% The carrier will pay the benefit shown if you Page
3 American Financial Benefits Benefit Description per Insured Benefits are annual Silver Gold Diamond Med Max Plus Hospital Emergency Room Benefits: The carrier will pay the benefit shown if you incur charges for an Emergency Room visit due to injuries received in a covered accident or due to a covered illness. Per Day Supplemental Accident Medical Benefit (Hospital and Skilled Nursing Facility Confinement): The carrier will pay benefits in addition to other covered benefits if you are confined to a Hospital or Skilled Nursing Facility as a result of an accident. Per Confinement Maximum Confinements 0 $,000 $,000 $,000 MEMBER Monthly Membership $67 $ $9 $6 MEMBER & SPOUSE Monthly Membership $88 $99 $4 $8 MEMBER & CHILDREN Monthly Membership $70 $7 $4 FAMILY Monthly Membership $79 $ $76 $788 There is a 0 day waiting period for all benefits related to sickness. The waiting period does not apply to an injury. Monthly rates do not include a one-time enrollment fee, which will be quoted by your insurance agent. This insurance is not major medical coverage and is not designated as a substitute for basic health insurance or major medical coverage. The plan limitations are disclosed in the certificate of coverage provided in the fulfillment kit. The limited benefit plan has a pre-existing condition limitation. A pre-existing condition, physical or mental, regardless of cause or condition, for which medical advice, diagnosis, care or treatment was recommended or received from a physician within a month period preceding the effective date of covered person. Plans are not available in all states. Check the state availability on the website. Certain provisions of the plan vary by state. There is a 0 day free look period. Effective Dates and Premium Billing Effective dates are available either on the st or th of the month. Initial premium draft inclusive of the non-refundable one-time enrollment fee is processed the day of enrollment. Future drafts occur on the 0 th of each month (for st effective dates) and the th of each month (for th effective dates). Please make sure you have sufficient funds before you enroll. Credit cards and bank automatic draft are available. Page
4 MultiPlan Provider Network As an NCE Association member, you will enjoy the savings you will receive when you use a MultiPlan provider. If there is a benefit that is not covered under the limited medical plan, or if you have exhausted your benefits for the policy year, and you use a network provider, your claims are repriced, therefore reducing your out-of-pocket costs. All plans pay the same dollar amounts whether or not the network is utilized, and there is no reduction in benefits. Simply present the NCE Member ID card at the time of service. The provider will send the claim direct to the carrier s claims - department (payor) for re pricing and benefit payments. Over 0,000 practitioners in all 0 states! Doctors and Physicians (includes specialists) Hospitals or Surgical Centers (IN/OUT) Clinics and Specialty Centers Laboratories and Imaging Centers Look up providers online at: Eligibility Information The Limited Benefit Health Insurance Plan, underwritten by American Financial Security Life Insurance Company is a Policyholder health plan provided to eligible members of National Congress of Employers (NCE) Association who are under age 6 and not Medicare eligible. The plans designed for NCE Association effectively reduce the policyholder s healthcare expense and liability while providing members quality health coverage. Dependents can include spouses and dependent children up to age 6 if a full time student. Coverage cannot be issued to a child only (under age 8). Page 4
5 MEDICAL EXCLUSIONS There is a 0 day waiting period from the date of the effective date for all benefits related to sickness. The waiting period does not apply to services resulting from an injury. (7) 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 The Carrier 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. () 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 the patient s condition; () Pre-employment or pre-marital examinations; or routine physical examinations; () 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 be nder any Worker s Compensation Law, Occupational Disease Law or similar legislation; (4) Non-prescription drugs, vitamins, minerals and nutritional supplements; () Experimental substances and/or drugs not approved by the Food and Drug Administration, or for investigative drugs or substances labeled Caution Limited by Federal Law to investigational use ; (6) Treatment, services and supplies for Experimental or Investigational procedures, drugs or treatment methods; (7) Treatment, services and supplies for any Experimental or Investigational organ transplant procedure; (8) Treatment, services and supplies for which the Covered Person is not legally required to pay; (9) Telephone consultations, failure to keep scheduled appointments, completion of claim forms, or providing medical information necessary to determine coverage; (0) Treatment, services and supplies provided by a Close Relative (i.e. spouse, child or parent); () Enrollment in including, but not limited to, a health, athletic or similar club or weight loss, non-smoking, exercise or similar programs; () Recreational or educational therapy, or non-medical self-care or self-help training, nutritional counseling, marriage, family or goal oriented counseling; () Treatment, services and supplies provided outside the scope of the license for the institution or practitioner rendering services; (4) Education, training, custodial care 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, a personal residence; () Cosmetic Surgery; (6) (8) keratotomy or keratoplasty and hearing exams, hearing aids, or the fitting of hearing aids; (9) Illness or Injury that results from war or an act of war, riot or in the commission or attempted commission of an assault or felony. This includes an act of international armed conflict. It also includes a conflict in which the armed force of any international authority is involved; (0) To the extent that payment under the Policy is prohibited by any law of the jurisdiction in which the Covered Person resides; () Travel or transportation by anyone other than professional ground or Air Ambulance; () Treatment, services or supplies received prior to the Covered Person termination date of coverage under the Policy; () 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); (4) Pregnancy and related services; () Custodial Care; (6) Dental services; (7) Voluntary sterilization or reversal thereof; (8) Transsexual surgery and related surgery; (9) Routine foot care; (0) Amniocentesis, ultrasound or any other procedures requested solely for sex determination of the fetus, unless Medically Necessary to determine the existence of a sex linked genetic disorder; () Temporomandibular joint dysfunction; () 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); () Intentional self-inflicted Illness or Injury while sane; except that this exclusion will not apply to any self inflicted Illness or Injury that is the result of a medical condition ; (4) An Illness or Injury incurred (a) during the commission or attempted commission of a crime or felony or while engaged in an illegal act; or (b) while imprisoned; () Physical therapy, Speech therapy and Occupational therapy; Page
6 MEDICAL EXCLUSIONS (6) Phys ep ed in the Phys t, if s hown as included in the Schedule of Benefits; Contact your insurance agent today to enroll in Optimum Health Designs, Guaranteed Issue with Easy Enrollment and Instant Fulfillment. (7) Preventive Care except as specified in the Preventive Care Indemnity Benefit, if shown as included in the Schedule of Benefits; (8) Venipuncture; (9) Prescription drugs; (40) Hospice Care; (4) Home Health Care; (4) Treatment, services, 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; and (4) Treatment, services and supplies for an Illness prior to the expiration of the Waiting Period. LIMITATIONS AND EXCLUSIONS FOR PRE-EXISTING CONDITIONS Benefits shall not be payable for a Pre-Existing Condition as defined herein. This provision will cease to apply to any loss incurred in connection with a Pre-Existing Condition after months of continuous coverage. This provision does not apply to a newborn or newly adopted child or child placed for adoption under the age of 8 if such child is enrolled for coverage within days from the date of birth or the date of adoption or placement for adoption. Page 6
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