Limited Indemnity Benefit Plan
ATA ASSOCIATION HEALTH PLANS
A Group Hospital Indemnity Benefit Plan
Plus Premier
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500 | 1000 | ||
| Base Plan Benefits | Benefit per Day in-patient | $500 | $1,000 | |
| Maximum daily inpatient days per confinement | 30 days | 30 days | ||
| Optional Benefits | ||||
| Outpatient Physician Office | Benefit per visit per member per calender year | $50.00 | $70.00 | |
| Calender year maximum per insured | 6 | 6 | ||
| Outpatient Diagnostic X-Ray | Benefit per tests daily for tests performed | $50.00 | $50.00 | |
| Lab Indemnity Benefit | Calender year max per insured for outpatient tests only | 4 | 4 | |
| Surgical & Anesthesia | Per benefit amount shown in the Surgical Schedule, based on indemnity benefit level | $1000 | $1000 | |
| chosen for type of surgery performed | ||||
| Additional benefit for anesthesia administration | 20% | 20% | ||
| In-Hospital Additional | Benefit per admission per confinement | $500 | $1000 | |
| Maximum additional benefit confinement per year | 2 | 2 | ||
| Intensive Care Indemnity | Per day of confinement in an intensive care room | $500 | $1000 | |
| Maximum days per calender year | 30 | 30 | ||
| Off The Job Accidental | Pays actual charges per covered accident up to the amount. | $500 | $500 | |
| Maximum benefit of 5 accidents per calender year per member. | ||||
| Wellness Indemnity | Benefit per visit for physical exams or certain diagonostic benefits | $50 | $100 | |
| Maximum visits per insured per year | 1 | 1 | ||
| Well-child visits – 4 per calender year for | ||||
| children 0-12 months, 2 per calender year | ||||
| for children 13-24 months | ||||
| Emergency Room | Benefit per visit for sickness or illness (2 max per year per member) | $50 | $50 | |
| Critical Illness Benefit | Benefit per initial diagnosis of a covered critical illness | |||
| and an additional lump sum benefit of the same | ||||
| amount for Member | N/A | $5000 | ||
| subsequent and seperate covered critical illness | ||||
| for Spouse/Child | N/A | $2500 | ||
| Daily in-patient drug & alcohol | Benefit per day of confinement if insured is confined | $300 | $300 | |
| benefit | as inpatient in a rehabilitation facility for substance | |||
| abuse | ||||
| Calender year max $10,000 Lifetime max $30,000 | ||||
| Daily in-patient mental & | Benefit per day of confinement if an insured is | $300 | $300 | |
| nervous benefit | confined as an inpatient in a rehabilitation facility | |||
| for mental and nervous conditions | ||||
| Calender year max $10,000 Lifetime max $30,000 | ||||
| Additional Coverage | ||||
| Group Term Life Insurance | Member $5000 Spouse/Child $2500 | |||
| with AD&D Rider | Note: AD&D Coverage is not available on Children | |||
| RX Benefits – Express Scripts | 50% co-payment for name or generic brand medication up to the | $500 | $1000 | |
| medication up to the maximum per member per | ||||
| year benefit. Express Scripts discount card will be | Annual | Annual | ||
| mailed to member after benefits are maxed out for | Max | Max | ||
| year. All plans have a negotiated wholesale rate less | ||||
| discount. 50/50 Co-Pay | ||||
| Accident Medical Plan | Additional accident benefit over health plan benefits | Included | Included | |
| $1000 deductible and up to $25,000 benefit per accident | ||||
| (See Policy for complete details) |
