Overview
Monthly Premium | $191.96 |
Teladoc | $19.99 |
AFEUSA Association | $19.99 |
PEP Benefit (one time payment) | $15.00 |
Initial total cost | $246.94 |
Monthly Premium $191.96 |
Teladoc $19.99 |
AFEUSA Association $19.99 |
PEP Benefit (one time payment) $15.00 |
Initial total cost $246.94 |
Benefits & coverage
Plan Type | PPO - PHCS Practitioner & Ancillary Only Network |
Deductible | Individual: $500.00 |
Coinsurance | 30% after deductible |
Policy maximum benefit | $1,000,000.00 |
Policy term | 3 x 364 days |
HIPAA creditable coverage | No |
Max out of pocket | $2,500.00 |
Out-of-network coverage | Yes |
Office visit for primary doctor or urgent care | After the Deductible has been satisfied, the Company will pay the Coinsurance Percentage for all Covered Expenses. After a $25 Copayment for the first 2 visits, the Company will pay 100% of the Coinsurance Percentage for Covered Expenses and the Deductible will not apply. After the first 2 visits, Covered Expenses will be subject to Deductible and Coinsurance. Covered Expenses for any other covered services or tests performed as part of the visit will be subject to the Deductible and Coinsurance. Not to exceed $1,000 per Coverage Period, including all additional services or test performed during the Office Visit. (This maximum will not apply to any services or tests that fall under another Benefit) |
Coinsurance Maximum | Individual: $2,000.00 |
Does Out of Pocket Maximum Amount include deductible? | No |
Out of country coverage | N |
Waiting Period for Illnesses | 5 days, 30 days for Cancer, 6 months for various covered surgeries |
Plan Type PPO - PHCS Practitioner & Ancillary Only Network |
Deductible Individual: $500.00 |
Coinsurance 30% after deductible |
Policy maximum benefit $1,000,000.00 |
Policy term 3 x 364 days |
HIPAA creditable coverage No |
Max out of pocket $2,500.00 |
Out-of-network coverage Yes |
Office visit for primary doctor or urgent care After the Deductible has been satisfied, the Company will pay the Coinsurance Percentage for all Covered Expenses. After a $25 Copayment for the first 2 visits, the Company will pay 100% of the Coinsurance Percentage for Covered Expenses and the Deductible will not apply. After the first 2 visits, Covered Expenses will be subject to Deductible and Coinsurance. Covered Expenses for any other covered services or tests performed as part of the visit will be subject to the Deductible and Coinsurance. Not to exceed $1,000 per Coverage Period, including all additional services or test performed during the Office Visit. (This maximum will not apply to any services or tests that fall under another Benefit) |
Coinsurance Maximum Individual: $2,000.00 |
Does Out of Pocket Maximum Amount include deductible? No |
Out of country coverage N |
Waiting Period for Illnesses 5 days, 30 days for Cancer, 6 months for various covered surgeries |
Primary Care Physician (PCP) Required | No |
Specialist Referrals Required | No |
Network | PPO - MultiPlan PHCS Practitioner & Ancillary Only Network |
Primary Care Physician (PCP) Required No |
Specialist Referrals Required No |
Network PPO - MultiPlan PHCS Practitioner & Ancillary Only Network |
Periodic Health Exam | $50 Copayment, Coinsurance is 100% of Eligible Expenses, Deducible will not apply. This benefit is payable one time per 12 month period. |
Periodic OB-GYN Exam | Yes |
Well Baby Care | After the Deductible has been satisfied, the Company will pay the Coinsurance Percentage for all Covered Expenses. The Deductible will not apply to Immunizations. Covered Expenses for any other covered services or tests performed as part of the visit will be subject to the Deductible and Coinsurance. |
OB-GYN Exam Conditions | $50 Copayment, Coinsurance is 100% of Eligible Expenses, Deducible will not apply. This benefit is payable one time per 12 month period. |
Periodic Health Exam $50 Copayment, Coinsurance is 100% of Eligible Expenses, Deducible will not apply. This benefit is payable one time per 12 month period. |
Periodic OB-GYN Exam Yes |
Well Baby Care After the Deductible has been satisfied, the Company will pay the Coinsurance Percentage for all Covered Expenses. The Deductible will not apply to Immunizations. Covered Expenses for any other covered services or tests performed as part of the visit will be subject to the Deductible and Coinsurance. |
OB-GYN Exam Conditions $50 Copayment, Coinsurance is 100% of Eligible Expenses, Deducible will not apply. This benefit is payable one time per 12 month period. |
Generic Prescription Drugs | After the Deductible has been satisfied, the Company will pay the Coinsurance Percentage for all Covered Expenses.Inpatient: Deductible + Coinsurance Outpatient: Not Covered, discount card provided |
Brand Prescription Drugs | After the Deductible has been satisfied, the Company will pay the Coinsurance Percentage for all Covered Expenses.. Inpatient: Deductible + Coinsurance Outpatient: Not Covered, discount card provided |
Non-Formulary Prescription Drugs Coverage | After the Deductible has been satisfied, the Company will pay the Coinsurance Percentage for all Covered Expenses.. Inpatient: Deductible + Coinsurance Outpatient: Not Covered, discount card provided |
Generic Prescription Drugs After the Deductible has been satisfied, the Company will pay the Coinsurance Percentage for all Covered Expenses.Inpatient: Deductible + Coinsurance Outpatient: Not Covered, discount card provided |
Brand Prescription Drugs After the Deductible has been satisfied, the Company will pay the Coinsurance Percentage for all Covered Expenses.. Inpatient: Deductible + Coinsurance Outpatient: Not Covered, discount card provided |
Non-Formulary Prescription Drugs Coverage After the Deductible has been satisfied, the Company will pay the Coinsurance Percentage for all Covered Expenses.. Inpatient: Deductible + Coinsurance Outpatient: Not Covered, discount card provided |
Emergency Room | After the Deductible has been satisfied, the Company will pay the Coinsurance Percentage for all Covered Expenses, including the emergency room Doctor charge, 24 hour observation and all miscellaneous medical expenses incurred during the emergency room visit. Covered Expenses are subject to the Deductible and Coinsurance. Covered Expenses will not exceed a maximum benefit of $250 per visit. |
Outpatient Lab/X-Ray | Included as part of Outpatient Miscellaneous Expense Services |
Outpatient Surgery | After the Deductible has been satisfied, the Company will pay the Coinsurance Percentage for all Covered Expenses. Not to exceed $2,500 per surgery, maximum of $5,000 per Coverage Period |
Hospitalization Regular Care | After the Deductible has been satisfied, the Company will pay the Coinsurance Percentage for all Covered Expenses. Not to exceed the Average Standard Room Rate charged by the Hospital, including all Inpatient Miscellaneous Medical Expenses, maximum $1,250 per day. |
Emergency Room After the Deductible has been satisfied, the Company will pay the Coinsurance Percentage for all Covered Expenses, including the emergency room Doctor charge, 24 hour observation and all miscellaneous medical expenses incurred during the emergency room visit. Covered Expenses are subject to the Deductible and Coinsurance. Covered Expenses will not exceed a maximum benefit of $250 per visit. |
Outpatient Lab/X-Ray Included as part of Outpatient Miscellaneous Expense Services |
Outpatient Surgery After the Deductible has been satisfied, the Company will pay the Coinsurance Percentage for all Covered Expenses. Not to exceed $2,500 per surgery, maximum of $5,000 per Coverage Period |
Hospitalization Regular Care After the Deductible has been satisfied, the Company will pay the Coinsurance Percentage for all Covered Expenses. Not to exceed the Average Standard Room Rate charged by the Hospital, including all Inpatient Miscellaneous Medical Expenses, maximum $1,250 per day. |
Pre & Postnatal Office Visit | Not Covered |
Labor & Delivery Hospital Stay | Not Covered |
Pre & Postnatal Office Visit Not Covered |
Labor & Delivery Hospital Stay Not Covered |
Chiropractic Coverage | Not Covered |
Mental Health Coverage | After the Deductible has been satisfied, the Company will pay the Coinsurance Percentage for all Covered Expenses. Outpatient: Not to exceed $100 per visit, maximum of 10 visits per Coverage Period Inpatient: Not to exceed $100 per day, maximum of 30 days per Coverage Period. |
Chiropractic Coverage Not Covered |
Mental Health Coverage After the Deductible has been satisfied, the Company will pay the Coinsurance Percentage for all Covered Expenses. Outpatient: Not to exceed $100 per visit, maximum of 10 visits per Coverage Period Inpatient: Not to exceed $100 per day, maximum of 30 days per Coverage Period. |
Physician network
One of the popular aspects of short-term medical insurance plans is they do not confine you to a specific network. In other types of major medical plans if a member seeks services outside of the network they either have a higher percentage of cost shares or they have to pay the full claim themselves. The only downside to the open network allowance is that you may get balance billed. To avoid the chance of balance billing, you need to see a network provider. The plan’s network is the Multiplan PHCS network.
The plan’s network is the Multiplan PHCS network.
Please note: PHCS Network applies to outpatient physicians only.
Facility Charges (Inpatient and Outpatient) benefit amounts are payable at 150% of the Medicare Rate.
Limitations & Exclusions
We will not pay for loss or expense caused by or resulting from any of the following:
We will not provide benefits for any loss caused by, or resulting from, a Pre-Existing Condition. Pre-Existing Conditions means any medical condition or Sickness for which:
Consultation means evaluation, diagnosis, or medical advice was given with or without the necessity of a personal examination or visit. This limitation does not apply to a newborn child or newborn adopted child who is added to coverage in accordance with Eligibility provision.
This limitation does not apply to any Covered Expense payable for Pre-Existing Conditions until the Pre-Existing Allowance Maximum benefit shown in the Schedule of Benefits has been reached.
Disclaimer: Preferred STM limitations, exclusions, terms, and conditions may vary by state law. Please check the product certificate or master policy for complete details.
RTBs
Definitions
This section provides the meaning of special terms used in this Certificate. Whenever the following terms appear capitalized in this Certificate, these definitions apply.
Accident means an act or event which: (1) is unforeseen, unexpected and unanticipated and is the direct cause of a loss covered under the Policy; (2) is definite as to time and place; (3) is not a Sickness; and (4) occurs on or after the Certificate Effective Date and while insurance is in effect for a Covered Person.
Ambulatory Surgical Center means a licensed health care facility whose main purpose is the diagnosis or treatment of patients by surgery. It must (1) admit and discharge the patient within the same working day; (2) be supervised by a Doctor; (3) require a licensed anesthesiologist or licensed Certified Registered Nurse Anesthetist to administer anesthesia and remain during the surgery; (4) provide a post-anesthesia recovery room; and (5) have a written agreement with at least one Hospital for immediate acceptance of patients who develop complications.
“Ambulatory surgical center” does not include: (1) a facility whose main purpose is performing terminations of pregnancy; (2) an office maintained by a Doctor for the practice of medicine; or (3) an office maintained for the practice of dentistry.
Coinsurance Percentage means the applicable percentage amount the Company will pay for Covered Expenses incurred by the Covered Person after satisfaction of the Deductible and any Copayments have been met.
Coinsurance Maximum means the maximum amount of Covered Expenses that the Covered Person will pay before the Company will begin paying benefits at 100% of Covered Expenses for the remainder of the Coverage Period, not to exceed the Coverage Period Maximum Benefit Amount and any applicable maximum benefit amounts. The Coinsurance Maximum does not include Deductibles, Copayments, Pre-Authorization penalties, amounts in excess of the Maximum Allowable Expense and amounts in excess of the maximum benefit amounts.
Complications of Pregnancy means: (1) conditions (when pregnancy is not terminated) whose diagnoses are distinct from pregnancy but are adversely affected by or caused by pregnancy, such as acute nephritis, nephrosis, cardiac decompensation, missed abortion, hyperemesis gravidarum, preeclampsia, and similar medical and surgical conditions of comparable severity; and (2) non-elective Cesarean section, ectopic pregnancy which is terminated and spontaneous termination of pregnancy which occurs during a period of gestation in which a viable birth is not possible.
“Complications of Pregnancy” does not include false labor, occasional spotting, Doctor-prescribed rest during the period of pregnancy, morning Sickness, elective Cesarean section, and similar conditions associated with the management of a difficult pregnancy but not constituting a nosologically distinct complication of pregnancy.
Confined/Confinement means the time in which a Covered Person is a Registered Bed-Patient in a Hospital, on the order of a Doctor, for Medically Necessary medical treatment.
Copayment means the amount required to be paid by a Covered Person each time a specific service is provided, as shown in the Schedule of Benefits. Copayments are deducted before any applicable Deductible or Coinsurance Percentage is applied. Copayments do not apply toward the Coinsurance Maximum.
Covered Dependent means Eligible Dependents who have become Covered Person(s) under the Group Policy.
Covered Expenses means Expenses for treatments, services and supplies which a Doctor recommends (1) as Medically Necessary to treat a Sickness or Injury; (2) which are not in excess of the Maximum Allowable Expense; and (3) which are not otherwise excluded by this Certificate or exceed any amount payable under the terms of this Certificate. The Company reserves the right to interpret and determine coverage for Covered Expenses.
Coverage Period means the length of time coverage is in force under this Certificate, as shown in the Schedule of Benefits.
Coverage Period Maximum Benefit Amount means the total aggregate amount of benefits payable under the Certificate for all Covered Expenses which are incurred for Sickness or Injury by each Covered Person during such person's Coverage Period.
Covered Person(s) means You and Your Covered Dependents.
Deductible means the amount of Covered Expenses, up to the Maximum Allowable Expense, that each Covered Person must pay before benefits will be payable. The Deductible is shown in the Schedule of Benefits and does not include any Copayment amounts. The Deductible does not apply towards the Coinsurance Maximum.
Doctor means a licensed practitioner of the healing arts who is practicing and treating within the scope and limitations of that license. “Doctor” does not include You, a Covered Dependent, Immediate Family, or a Covered Person’s employer.
Domestic Partner means a person of the opposite or same sex with whom the Covered Person has established a Domestic Partnership. In no event, will a person's legal spouse be considered a Domestic Partner.
Domestic Partnership means a relationship between the Covered Person and one other person of the opposite or same sex. The following requirements apply to both persons:
Effective Date means the date coverage under the Group Policy begins for a Covered Person. The Covered Person’s Effective Date is shown on the Schedule of Benefits.
Emergency means the sudden onset or sudden worsening of a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent layperson, who possess an average knowledge of health and medicine, to result in: (1) placing the patient’s health in serious jeopardy; (2) serious impairment to bodily functions; or (3) serious dysfunction of any bodily organ or part.
Evidence of Insurability means an Eligible Person will satisfy the insurability requirement on the day the Company agrees in writing to accept the person as insured for that amount. To determine a person’s acceptability for coverage, the Company will require evidence of good health and may require it to be provided at the Insured Person’s expense.
Expenses means the amounts billed for treatments, services and supplies rendered to a Covered Person. An expense shall be considered to have been incurred on the date the treatment, service or supply was provided.
Experimental or Investigational means a treatment, drug, device, procedure, supply or service and related services (or any portion thereof, including the form, administration or dosage) for a particular diagnosis or condition when any one of the following exists: (1) It cannot be legally marketed without the approval of the United States Food and Drug Administration (FDA) and such approval has not been granted at the time of its proposed use; (2) It is not yet recognized as acceptable medical practice throughout the United States to treat that Illness or Injury; (3) It is the subject of either: (a) a written investigational or research protocol; or (b) a written informed consent or protocol used by the treating facility in which reference is made to it being experimental, investigative, educational, for a research study, or posing an uncertain outcome, or having an unusual risk; or (c) an ongoing phase I, or phase II clinical trial or as the experimental or research arm of a phase III clinical trial, as the phases are defined in regulations and other official actions and publications issued by the FDA and the Department of Health and Human Services (HHS); or (d) an ongoing review by an Institutional Review Board (IRB); (4) It does not have either: (a) the positive endorsement of national medical bodies or panels, such as the American Cancer Society; or (b) multiple published peer review medical literature articles, such as the Journal of the American Medical Association (J.A.M.A.), concerning Health Care Service and reflecting its recognition and reproducibility by non‑affiliated sources the Claims Administrator determines to be authoritative; or (5) It is regarded within a Doctor's profession as appropriate only when provided in a clinical research setting.
We may also determine whether a treatment, drug, device, procedure, supply or service is experimental or investigational by using the following evaluations: (1) Reports in peer review medical literature; (2) Scientific evaluations published by organizations that conduct health care research such as the Agency for Health Care Policy and Research, the National Institutes of Health, the American Medical Association, and the American College of Physicians; (3) Opinions of independent medical consultants; (4) Listings in drug correspondence, including the American Medical Association's Drug Evaluations, the American Hospital Formulary Service Drug Information, and the United States Pharmacopoeia Drug Information; (5) Use of a written informed consent addressing the experimental or investigational nature of the service or supply. This applies whether consent is used by the Covered Person's Doctor or by any other Doctor studying the same or similar service or supply; (6) Any requirement that the use of the service or supply be subject to Institutional Review Board ("IRB") approval; or (7) Written protocols used by the health care provider.
Extended Care Facility means an institution, other than a Hospital, operated and licensed pursuant to law, that provides:
Group Policy means the contract issued to the Group Policyholder providing the benefits described herein.
Home Health Care Agency means an entity licensed by state or local law operated primarily to provide skilled nursing care and therapeutic services in an individual’s home and:
Home Health Care Plan means a program for continued care and treatment of an individual established and approved in writing by the individual’s attending Doctor. As part of the plan, an attending Doctor must certify that proper treatment of the Injury or Sickness would require continued confinement in a Hospital in the absence of the services and supplies.
Hospital means an institution which is legally constituted and operated in accordance with the laws pertaining to Hospitals in the jurisdiction where it is located, which meets all of the following requirements:
“Hospital” does not mean primarily a clinic, nursing home, rest or convalescent home, extended care facility, Hospice or similar establishment nor, other than incidentally, a place providing care for persons with mental illness or nervous disorders; the aged; or those suffering from alcoholism or drug addiction.
Confinement in a special unit of a Hospital used primarily as a nursing, rest, or convalescent home shall be deemed to be Confinement in an institution other than a Hospital.
Immediate Family means: (1) the parent, spouse, brother, sister or children of a Covered Person; or (2) a resident in a Covered Person’s household.
Injury means bodily harm caused by an accident, directly and independently of Sickness or bodily infirmity, resulting in unforeseen trauma requiring immediate medical attention. The Injury must occur after the Covered Person’s Effective Date of coverage and while such person’s coverage is in force. All injuries to the same Covered Person sustained in one accident, including all related conditions and recurring symptoms of the Injuries, will be considered one injury. Bodily damage caused by chewing is not considered an Injury.
Intensive Care Unit means a section, ward or wing within a Hospital which is separated from other Hospital facilities and: (1) is operated exclusively for the purpose of providing professional care and treatment for critically ill patients; (2) has special supplies and equipment necessary for such care and treatment which are available on a standby basis for immediate use; (3) provides room and board, and constant observation by a Nurse or other specially-trained Hospital personnel; and (4) is not maintained for the purpose of providing normal postoperative recovery treatment or service.
Initial Coverage Period means the initial length of time the Covered Person elected which begins on the Effective Date shown in the Schedule of Benefits.
Maximum Allowable Expense means the maximum charge that will be considered as a Covered Expense. It will be the lesser of billed charges, the Usual and Customary Fee, the negotiated or contracted discount, the Coverage Period Maximum Benefit Amount under this coverage, or 150% of the Medicare allowable charge. The Company has discretionary authority to determine the Maximum Allowable Expense.
Medically Necessary means a Confinement, service, supply, or treatment that meets each of these requirements:
The fact that a Doctor may prescribe, authorize, or direct a service does not of itself make it Medically Necessary or covered by the Group Policy.
Mental Illness means any condition classified as neurosis, psychoneurosis, psychopathy, psychosis, or functional disorders of any type or cause appearing in the most recent edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (the "DSM").
Nurse means a licensed registered graduate professional Nurse (R.N.) or a licensed practical Nurse (L.P.N.) who is under the direction of a Doctor. Nurse does not include the Immediate Family of a Covered Person.
Policyholder means the entity that has elected to offer You coverage under the Group Policy.
Prescription Or Legend Drugs means (1) a Legend Drug; (2) injectable insulin prescribed by a Doctor; (3) a compounded drug of which at least one part is a Legend Drug; or (4) any other drug that, under state law, may only be dispensed upon the written prescription of a Doctor.
Registered Bed-Patient means an individual who, while Confined to a Hospital, is assigned to a bed in any department of the Hospital, and for whom a charge for room and board is made by the Hospital.
Rehabilitative means treatment for purposes of restring bodily function which has been lost due to a covered Sickness or Injury. Care ceases to be rehabilitative when the patient can perform the activities which are normal for someone of the same age and gender or the patient has reached maximum therapeutic benefit and further treatment cannot restore bodily function beyond the level the patient currently possess.
Routine Physical Exam means examination of the physical body by a Doctor for preventive or informative purposes only, and not for the diagnosis or treatment of any condition.
Sickness means an illness, disease, or infection which begins while coverage is in force under the Group Policy for the Covered Person. All related conditions and recurring symptoms of Sickness to the same person will be considered one Sickness. Sickness includes Complications of Pregnancy, provided conception occurred after the Covered Person’s Effective Date of coverage.
Substance Abuse means alcohol, drug (whether prescribed by a Doctor or not) or chemical abuse, overuse or dependency and the resultant physiological and/or psychological effects requiring medical treatment, procedures, services or supplies, including detoxification.
Usual, Reasonable and Customary means:
In reaching a determination as to what amount should be considered as Usual, Reasonable and Customary for services and supplies, We may use and subscribe to a standard industry reference source that collects data and makes it available to its member companies. The data base used reflects the amounts charged by providers for health care services based on geographic zip code areas generating a statistically credible charge distribution. The data is reflective of reported provider charges from the lowest to the highest for each service or supply. The data is also adjusted periodically to reflect negotiated fee schedules with providers not included in the data base.
We, Us, Our, Company means Pan-American Life Insurance Company.
You or Your (also, Certificateholder) means an Eligible Person who is properly enrolled for coverage under the Group Policy. You are the person (who is not a Dependent) on whose behalf the Group Policy is issued to the Policyholder.
*Definitions vary by state. Please refer to your Certificate or Policy for details
About the association
Association for Entrepreneurship USA (AFEUSA) strives to bring you the most current information on business, technology, and related processes to help you grow the confidence needed to succeed. Entrepreneurship takes a much different shape today than in the past. In fact, you may have a business and not even know it. You might be selling goods on eBay, repairing old cars and posting ads online, might be a grandmother who babysits kids, or an Uber or Lyft driver. Membership benefits are not associated with the insurance company.
ACI Legal and Financial Services/Childcare
Members and family members are eligible to receive legal and financial consultation for an unlimited number of issues at no cost. With ACI’s child care services, it’s never been easier to access reliable, affordable child care locally.
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