AdvantHealth

Short-Term Medical Insurance Plans

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Why Choose AdvantHealth Short-Term Medical Insurance Plans?

There may be periods in life that can leave you and your family temporarily uninsured. AdvantHealth short-term health insurance plans can help protect you from potentially high medical costs associated with unexpected sickness or injury. American Financial Security Life Insurance understands your needs, and offers affordable health insurance plans to protect you and your family. AdvantHealth plans are short-term health insurance available for 30 days to up to thirty-six months (varies by state), and provides coverage for unexpected medical expenses.

It is ideal for those who are:

  • In between jobs or have been laid off
  • Waiting for employer health benefits to start
  • Bridging the open enrollment gap
  • Recent graduates
  • Part-time or temporary employees
  • Without adequate affordable health insurance

AdvantHealth Health Insurance Feature Highlights

  • Coverage Period Maximums of $500,000 or $1,000,000
  • Deductible options of $1,000, $2,500 or $5,000
  • Access to the PHCS Network
  • Coinsurance options: 80/20
  • Purchase in full or make monthly payments

Get a free quote to see all the details

Benefits 101



  ADVANTHEALTH PLAN 2 ADVANTHEALTH PLAN 3
Coinsurance 80/2080/20
Deductible $1,000, $2,500, $5,000$1,000, $2,500, $5,000
Out-Of-Pocket Maximum $2,000 , $4,000$2,000 , $4,000
Coverage Period Maximum $1,000,000$1,000,000

Unless specified otherwise, the following benefits are for Insured and each Covered Dependent subject to the plan Deductible, Coinsurance Percentage, Out-Of-Pocket Maximum and Policy Maximum chosen. Benefits are limited to the Maximum Allowable Expense or each Covered Expense, in addition to any specific limits stated in the policy.

Doctor Office Consultation
Copay - General Practitioner$15, unlimited$25, maximum 2
Copay – Specialist $25, unlimited$40, maximum 2
Copay – Wellness$50, maximum 1$50, maximum 1
Urgent Care Additional Deductible$100N/A
Inpatient Hospital Services
Average Standard Room RateSubject to Deductible and CoinsuranceSubject to Deductible and Coinsurance
Hospital Intensive or Critical CareSubject to Deductible and CoinsuranceSubject to Deductible and Coinsurance
Doctor VisitsSubject to Deductible and CoinsuranceSubject to Coinsurance and Deductible
Surgical Covered Expenses
Surgical Facility or Ambulatory Surgery CenterSubject to Deductible and CoinsuranceSubject to Deductible and Coinsurance
Surgical ServicesSubject to Deductible and Coinsurance Subject to Deductible and Coinsurance
Assistant Surgeon Subject to Deductible and Coinsurance Subject to Deductible and Coinsurance
Other Covered Expenses   
Organ, Tissue, Bone Marrow  TransplantsSubject to Deductible and Coinsurance up to $100,000 per Coverage Period for all Covered Expenses including Inpatient Hospital, Surgical and Outpatient Miscellaneous Medical Covered ExpensesSubject to Deductible and Coinsurance up to $100,000  per Coverage Period for all Covered Expenses including Inpatient Hospital, Surgical and Outpatient Miscellaneous Medical Covered Expenses
Skilled Nursing FacilitySubject to Deductible and Coinsurance up to $100,000 per Coverage PeriodSubject to Deductible and Coinsurance up to $100,000 per Coverage Period
Emergency Room Additional DeductibleN/AN/A
Emergency Room TreatmentSubject to the Emergency Room Additional Deductible shown above, then Deductible and Coinsurance. The Additional Deductible is waived if admitted within 24 hours of Emergency Room Treatment.Subject to the Emergency Room Additional Deductible shown above, then Deductible and Coinsurance. The Additional Deductible is waived if admitted within 24 hours of Emergency Room Treatment.
Hospice CareSubject to Deductible and Coinsurance up to $5,000 per Coverage PeriodSubject to Deductible and Coinsurance up to $5,000 per Coverage Period
Acquired Immune Deficiency Syndrom (AIDS)Subject to Deductible and Coinsurance up to $10,000 per Coverage Period for all Covered Expenses including Inpatient Hospital, Surgical and Outpatient Miscellaneous Medical Covered ExpensesSubject to Deductible and Coinsurance up to $10,000 per Coverage Period for all Covered Expenses including Inpatient Hospital, Surgical and Outpatient Miscellaneous Medical Covered Expenses
      ADVANTHEALTH PLAN 2   ADVANTHEALTH PLAN 3
Joint/Tendon SurgerySubject to Deductible and Coinsurance up to $3,000 per Coverage Period for all Covered Expenses including Inpatient Hospital, Surgical and Outpatient Miscellaneous Medical Covered ExpensesSubject to Deductible and Coinsurance up to $3,000 per Coverage Period for all Covered Expenses including Inpatient Hospital, Surgical and Outpatient Miscellaneous Medical Covered Expenses
Knee Injury or DisorderSubject to Deductible and Coinsurance up to $3,000 per Coverage Period for all Covered Expenses including Inpatient Hospital, Surgical and Outpatient Miscellaneous Medical Covered Expenses for both left and right kneesSubject to Deductible and Coinsurance up to $3,000 per Coverage Period for all Covered Expenses including Inpatient Hospital, Surgical and Outpatient Miscellaneous Medical Covered Expenses for both left and right knees
Gallbladder SurgerySubject to Deductible and Coinsurance up to $3,000 per Coverage Period for all Covered Expenses including Inpatient Hospital, Surgical and Outpatient Miscellaneous Medical Covered ExpensesSubject to Deductible and Coinsurance up to $3,000 per Coverage Period for all Covered Expenses including Inpatient Hospital, Surgical and Outpatient Miscellaneous Medical Covered Expenses
AppendectomySubject to Deductible and Coinsurance up to $3,000 per Coverage Period for all Covered Expenses including Inpatient Hospital, Surgical and Outpatient Miscellaneous Medical Covered ExpensesSubject to Deductible and Coinsurance up to $3,000 per Coverage Period for all Covered Expenses including Inpatient Hospital, Surgical and Outpatient Miscellaneous Medical Covered Expenses
  Kidney StonesSubject to Deductible and Coinsurance up to $3,000 per Coverage Period for all Covered Expenses including Inpatient Hospital, Surgical and Outpatient Miscellaneous Medical Covered ExpensesSubject to Deductible and Coinsurance up to $3,000 per Coverage Period for all Covered Expenses including Inpatient Hospital, Surgical and Outpatient Miscellaneous Medical Covered Expenses
Temporomandibular Joint Disorder (TMJ)Subject to Deductible and Coinsurance up to $3,000 per Coverage Period for all Covered Expenses including Inpatient Hospital, Surgical and Outpatient Miscellaneous Medical Covered ExpensesSubject to Deductible and Coinsurance up to $3,000 per Coverage Period for all Covered Expenses including Inpatient Hospital, Surgical and Outpatient Miscellaneous Medical Covered Expenses
Home Health CareSubject to Deductible and Coinsurance up to $30 per day and a maximum of 30 days per Coverage PeriodSubject to Deductible and Coinsurance up to $30 per day and a maximum of 30 days per Coverage Period
Therapy Services - Physical Therapist, Speech Therapist and Occupational TherapistSubject to Deductible and Coinsurance up to $15 per day and a maximum of 30 days per Coverage PeriodSubject to Deductible and Coinsurance up to $15 per day and a maximum of 30 days per Coverage Period
Ambulance, Ground or AirSubject to Deductible and Coinsurance up to $500 per trip – Ground up to $1,000 per trip – Air AmbulanceSubject to Deductible and Coinsurance up to $500 per trip – Ground up to $1,000 per trip – Air Ambulance
Durable Medical Equipment and Medical SuppliesSubject to Deductible and CoinsuranceSubject to Deductible and Coinsurance
Bone Density TestingSubject to Deductible and Coinsurance up to $150 per Coverage PeriodSubject to Deductible and Coinsurance up to $150 per Coverage Period
Other Outpatient Miscellaneous Medical ServicesSubject to Deductible and CoinsuranceSubject to Deductible and Coinsurance

Disclaimer: Coverage is not limited to the benefits listed in this document; any eligible expenses are subject to plan limitations. Please check the product certificate or master policy for complete details.

Covered Medical Expenses

The following benefits are for the Insured and each Covered Dependent subject to the plan Deductible, Coinsurance Percentage, Out Of Pocket Maximum, Additional Deductibles, and Coverage Period Maximum Benefit. Benefits are limited to the Maximum Allowable Expense for each Covered Eligible Expense, in addition to any specific limits stated in the policy.

  • Preventive / Wellness Care
  • Doctor’s office consultation in excess of a $15 or $25 copay; this benefit is not subject to the Plan Deductible or Coinsurance Percentage
  • Outpatient and Inpatient Treatment for Substance Abuse
  • Organ, Tissue and Bone Marrow transplants
  • Inpatient prescription drugs
  • Physical, Occupational, and Speech Therapy $15 per day and 30 days combined
  • Ambulance Transportation maximum benefit $500 per trip, subject to deductible and coinsurance
  • Outpatient Hospital or Emergency Room Care
  • Inpatient Room & Board, including Intensive Care
  • Outpatient Miscellaneous Medical Services, doctors medical care and treatment performed in a hospital
  • Home Health Care benefit $30 per day for a maximum of 30 Home Health Care visits.
  • Extended Care Facility up to $150 per day for a maximum of 30 days
  • Outpatient Surgical Facility
  • Surgeon services in the hospital or outpatient surgical facility

American Financial Security Life Insurance Company materials

How does a Short Term Health Plan Work?

A person with a short-term health insurance plan gets in a serious accident Costing $110,000 in medical claims. Their health plan has the following cost-shares:

Example of how much the insurance policy pays

All together, the person will pay $10,000 and the insurance Company will pay $100,000 to cover the medical claims from this accident.

Provider Network

AdventHealth uses the PHCS Multiplan network. You can find a network provider by visiting www.Multiplan.com or by calling (800) 922-4362.

Exclusions

Pre-existing condition: Pre-existing condition – means a condition:

1. For which medical advice, diagnosis, care, or treatment (includes receiving services and supplies, consultations, diagnostic tests or prescription medicines) was recommended or received from a physician within the 36 months immediately preceding the covered person’s effective date; or 2. That had manifested itself in such a manner that would have caused an ordinarily prudent person to seek medical advice, diagnosis, care, or treatment (includes receiving services and supplies, consultations, diagnostic tests or prescription medicines) within the 36 months immediately preceding such person’s effective date.

Limitations & Exclusions

We 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.

  1. 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 a covered person’s condition.
  2. Pre-employment or pre-marital examinations; or routine physical examinations.
  3. Treatment, services and supplies for experimental or investigational procedures, including experimental or investigational organ transplant procedures, drugs or treatment methods.
  4. Treatment, services and supplies for which the covered person is not legally required to pay.
  5. Telephone consultations, failure to keep scheduled appointments, completion of claim forms, or providing medical information necessary to determine coverage.
  6. Treatment, services and supplies provided by a close relative.
  7. Treatment, services and supplies provided outside the scope of the license for the institution or practitioner rendering services.
  8. Education, training, 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, or a personal residence.
  9. Treatment, services or supplies received prior to the covered person’s effective date, or after the end of the coverage period.
  10. 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).
  11. Amounts in excess of the usual, reasonable and customary charges made for covered expenses.
  12. Surgery for a covered person for a total or partial hysterectomy, unless it is medically necessary due to a diagnosis of carcinoma (subject to all other coverage provisions, including but not limited to the pre-existing condition exclusion); tonsillectomy, adenoidectomy, repair of deviated nasal septum or any type of surgery involving the sinus, myringotomy, tympanotomy, or herniorrhaphy.
  13. Outpatient prescription drugs, contraceptive drugs and devices, non-prescription drugs, vitamins, minerals and nutritional supplements.
  14. Cosmetic surgery.
  15. 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).
  16. Pregnancy and related services; except for complications of pregnancy.
  17. Voluntary termination of pregnancy.
  18. Voluntary sterilization or reversal thereof.
  19. Custodial care.
  20. Dental services.
  21. Routine foot care.
  22. Speech therapy.
  23. Mental or nervous disorders.
  24. Substance use disorders.
  25. Treatment, services, or 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.
  26. Programs, treatment or procedures for tobacco use cessation.
  27. Treatment of acne or varicose veins.
  28. Diagnosis or treatment of a sleeping disorder.
  29. Allergy testing and allergy injections.
  30. Diabetic equipment, supplies and self-management training.
  31. Autism spectrum disorder.
  32. Therapy or treatment for learning disorders or disabilities or developmental delays.
  33. Participation in clinical trials.
  34. Prosthetic and orthotic devices; except as specifically covered in Section 4 - Benefits.
  35. Homeopathy.
  36. Orthopedic manipulation.
  37. Private duty nursing services.
  38. Acupuncture and acupressure.
  39. Genetic testing or counseling including, but not limited to, amniocentesis and chorionic villi testing.
  40. Sex transformation; treatment of sexual function, dysfunction or inadequacy; or treatment to enhance sexual performance or desire.
  41. Treatment to stimulate growth and growth hormones for any purpose.
  42. 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 keratotomy or keratoplasty.
  43. Hearing exams, hearing aids, or the fitting of hearing aids.
  44. Treatment for cataracts.
  45. Orthoptics and visual eye training.
  46. Treatment, services and supplies for a covered dependent who is a newborn child not yet discharged from the hospital. This does not apply to charges that are medically necessary to treat premature birth, congenital injury or Illness, or Illness or injury sustained during or after birth.
  47. Personal comfort or convenience items, including homemaker services or supportive services focusing on activities of daily life that do not require the skills of qualified technical or professional personnel, including but not limited to bathing, dressing, feeding, routine skin care, bladder care and administration of oral medications or eye drops.
  48. The purchase of a noninvasive osteogenesis stimulator (bone stimulator).
  49. Services or supplies of a common household use, such as exercise cycles, air or water purifies, air conditioners, allergenic mattresses, and blood pressure kits.
  50. Enrollment in health, athletic or similar clubs.
  51. Weight loss, non-smoking, exercise or similar programs.
  52. Recreational or educational therapy, or non-medical self-care or self-help training, nutritional counseling, marriage, family or goal oriented counseling.
  53. Travel or transportation rendered by any person or entity other than professional ground or air ambulance.
  54. Care in government institutions unless a covered person is obligated to pay for such care.
  55. Treatment, services and supplies rendered to a Covered Person while on active duty in the armed forces. Upon written notice to us of entry into such active duty, the unused premium will be returned to you on a pro rata basis.
  56. Treatment, services and supplies received outside of the United States or its possessions except as specifically covered in Section 4 - Benefits.
  57. 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 benefits under any worker’s compensation law, occupational disease law or similar legislation.
  58. Illness or injury that results from war or an act of war, (whether declared or undeclared) while serving in the military or an auxiliary unit attached to the military.
  59. Illness or injury that results from participation in a riot or insurrection.
  60. Illness or injury that results from commission or attempted commission of a felony or to which a contributing cause was the covered person being engaged in an illegal occupation.
  61. Complications resulting from treatment of conditions which are not covered under the policy.
  62. Suicide or attempted suicide or intentionally self inflicted injury, whether while sane or insane.
  63. Injuries from participating in organized competitive sports.
  64. Treatment, services and supplies resulting from participation in skydiving, scuba diving, hand or ultra light gliding, ballooning, bungee jumping, parakiting, riding an all-terrain vehicle such as a dirt bike, snowmobile or go-cart, racing with a motorcycle, motor vehicle, boat or any form of aircraft, any participation in sports for pay or profit, or participation in rodeo contests.
  65. Treatment or services required due to accidental injury sustained while operating a motor vehicle where the covered person’s blood alcohol level, as defined by law, exceeds that level permitted by law or otherwise violates legal standards for a person operating a motor vehicle in the state where the injury occurred.

Frequently Asked Questions

Why Short-Term Medical (STM)?

Short-Term Medical pays benefits like a major medical insurance plan, but for a predetermined length of time. You can select from a wide range of deductible and coinsurance options to tailor a plan to fit their lifestyle needs and budget.

How do members figure out what coverage they need and enroll?

Consider the benefit period and choose payment method:

  • Single Payment

    This option is ideal if it is known exactly how many days the coverage is needed. The minimum number of days that members may apply for coverage is 30 days; the maximum is 180 days. Payment via all major credit cards or bank draft is accepted.

  • Monthly Payment

    This plan gives members the flexibility to continue coverage for as long as it is needed and allows them to discontinue the plan once their temporary need ends. Members can select coverage periods of up to 36 months. Payment via all major credit cards or bank draft is accepted.

Consider lifestyle needs and budget and choose one from each of the following:

  • Deductible:$1,000, $2,500, $5,000

    The selected deductible must be paid by each Covered Person before Coinsurance benefits are payable. After 3 individuals meet their deductible, the deductible is deemed satisfied for any remaining covered individuals.

  • Coinsurance Percentage: 80/20

    The Coinsurance Percentage represents the percent of covered eligible expenses that we pay and that members pay after the deductible has been satisfied up to the Out Of Pocket Maximum.

  • Out of Pocket Maximum: $2,000 or $4,000

    Once members reach their Out of Pocket Maximum Amount selected, we pay 100% of up to the Coverage Period Maximum Benefit.

What medical expenses are covered?

The following benefits are for the Insured and each Covered Dependent subject to the plan Deductible, Coinsurance Percentage, Out Of Pocket Maximum, Additional Deductibles, and Coverage Period Maximum Benefit. Benefits are limited to Maximum Allowable Expense for each Covered Eligible Expense, in addition to any specific limits stated in the policy.

  • Preventive / Wellness Care
  • Doctor's office consultation/Urgent Care visits
  • Organ and Tissue transplants
  • Inpatient prescription drugs
  • Physical, Occupational and Speech Therapy
  • Ambulance Transportation
  • Outpatient Hospital or Emergency Room Care
  • Inpatient Room & Board, including Intensive Care
  • Outpatient Miscellaneous Medical Services, doctors medical care and treatment performed in a hospital
  • Home Health Care
  • Extended Care Facility
  • Outpatient Surgical Facility
  • Surgeon services in the hospital or outpatient surgical facility

How does Usual, Reasonable and Customary Fees affect my benefits?

Usual, Reasonable and Customary Amount - means the lesser of:

  1. The actual charge; or
  2. What the provider would accept for the same service or supply in the absence of insurance; or
  3. The amount based on one or more factors such as:
    1. The amount of resources expended to deliver the service or supply; or
    2. The amount charged for the same or comparable service or supply in a community similar to where the service or supply is furnished; or
    3. The costs incurred by providers in a community similar to where the service or supply is furnished and the amount by which the service or supply is commonly marked up by providers; or
    4. Charging protocols and billing practices generally accepted by the medical community or specialty groups, including charging protocols and billing practices related to Medicare; or
    5. Inflation trends by geographic region; or
  4. The negotiated rate; or
  5. For facility based charges, 150% of the Centers for Medicare and Medicaid Services Prospective Payment System amount unadjusted for geographic locality.

All benefits are limited to Usual, Reasonable and Customary Fees.

Usual, Reasonable and Customary Fee definition may vary by state.

What if members change their minds after the purchase of STM coverage?

If not 100% satisfied with coverage and members have not already used any of the insurance benefits, they may return the certification to us within 10 days of receipt. Coverage will be cancelled as of the effective date and the plan cost will be returned. No questions asked!

What is the Pre-Existing Conditions Limitation?

Pre-Existing Condition - means a condition:

  1. For which medical advice, diagnosis, care, or treatment (includes receiving services and supplies, Consultations, diagnostic tests or prescription medicines) was recommended or received from a Physician within the 36* months immediately preceding the Covered Person's Effective Date; or
  2. That had manifested itself in such a manner that would have caused an ordinarily prudent person to seek medical advice, diagnosis, care, or treatment (includes receiving services and supplies, Consultations, diagnostic tests or prescription medicines) within the 36* months immediately preceding such person's Effective Date.

*varies by state

Who is eligible to apply for this insurance?

AdvantHealth STM is available to members and their spouses, who are between 18 and 64 years old and their dependent unmarried children under 26 years old; and can answer "No" to all of the questions in the application for insurance. Child-only coverage is available for ages 2-17.

When does the coverage terminate?

A Member's coverage under the Policy will terminate on the earliest of the following dates:

  1. The last day for which Your premium has been paid;
  2. The date You become a full-time member of the Armed Forces of any country if the period of active duty is to exceed 31 days;
  3. The date the Policy terminates;
  4. The date You reach age 65 or become effective under Medicare;
  5. The date You cease to be a Member of the Policyholder;
  6. The end of the Coverage Period;
  7. The date You die;
  8. The date You reach the Coverage Period Maximum Benefit Amount;
  9. Your Effective Date in the event of any fraud or intentional misrepresentation of material fact on Your part in obtaining coverage under the Policy; or
  10. The next premium due date in the event of any fraud or intentional misrepresentation of material fact on Your part or the part of Your representative in filing a claim.

At the death of the Member, all rights and privileges as a Member under the Policy will transfer to the surviving Dependent Spouse. The Dependent Spouse will then be considered the Member instead of a Dependent. In the event the Dependent Spouse remarries, coverage under the Policy for the Dependent Spouse and Dependent Child(ren), if any, will end on the first day of the month following the date of that marriage. If there is no surviving Dependent Spouse, or at the death of a surviving Dependent Spouse, all rights and privileges as a Member under the Policy will transfer to each Dependent child, if any, and he or she will be considered the Member instead of a Dependent.

Dependents

Insurance on a Dependent will terminate on the date such Dependent ceases to qualify as a Dependent. Except as Provided in the Continuation of Coverage provision, Your Dependent insurance will automatically terminate on the Earliest of the following dates:

  1. The date Your insurance terminates;
  2. The last day for which Your Dependent premium has been paid;
  3. In the case of Your Dependent child, the date he or she no longer qualifies as a Dependent by attaining the limiting age (see definition of “Dependent”).
  4. In the case of Your Dependent child, the first day following the Dependent's marriage;
  5. The date Your Dependent enters active duty with the armed services of any country if the period of active duty is to exceed 31 days;
  6. In the case of a Dependent Spouse, the first day following the date of the final decree of dissolution of marriage; or
  7. The date a Covered Person reaches the Coverage Period Maximum Benefit Amount.

Glossary

You should also refer to your specific policy’s definitions to ensure you have the precise meaning for your needs):

Accident:

A sudden, unforeseeable event that causes injury to one or more people covered under the policy.

Allowed Amount:

The maximum amount a plan will pay for a covered health care service. May also be called “eligible expense,” “payment allowance,” or “negotiated rate.” If your provider charges more than the plan’s allowed amount, you may have to pay the difference (also known as Balance Billing).

Association Fee:

Some short-term medical plans are filed as an association group plan in various states and require monthly fees.

Balance Billing:

When a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider (one in your network) may not balance bill you for covered services.

Benefits:

The health care items or services covered under a health insurance plan. Covered benefits and excluded services are defined in the health insurance plan's contract or certificate.

Claim:

A request for payment that you or your health care provider submits to your health insurer when you get items or services you think are covered.

Coinsurance:

An enrollee begins to pay for coinsurance after their deductible has been met. A coinsurance fee refers to a percentage of a healthcare cost that they will be charged. For instance, an in-network doctor’s visit may have a 30% coinsurance rate. If the visit costs $100 total, the consumer will be responsible for paying $30, and the insurance company pays the remaining $70. Generally, the lower the member’s coinsurance percentage, the higher the premium the member must pay.

Congenital Condition:

A disease or other anomaly existing at or before birth, whether acquired during development or by heredity.

Copayment:

A copayment is similar to coinsurance, but instead of being figured as a percentage of a service’s cost, it is calculated as a flat fee for a medical service. For instance, your plan may charge a $33 copay for visiting an in-network specialist. As with coinsurance, in many cases copayments will not begin until the consumer has met their deductible. Generally, the more copays that are not after deductible (a.k.a. “first dollar”), the higher the premium the member will pay.

Cost Sharing:

The share of costs covered by your insurance that you pay out of your own pocket. This term generally includes deductibles, coinsurance, and copayments, or similar charges, but it doesn't include premiums, balance billing amounts for non-network providers, or the cost of non-covered services.

Coverage Period:

The length of time which the Insured selected in the Insured’s application and approved by the insurance company.

Covered Person:

An Insured and his/her eligible dependents for whom coverage is in effect under a policy.

Creditable Coverage:

Under HIPAA, Continuous Coverage applies when a person is transitioning from an existing health insurance plan to an employer-sponsored group health plan. With Continuous Coverage, conditions treated under the prior plan will continue to be treated under the employer plan without the being subject to a waiting period. Policy holders can contact their insurance carrier to request a Certificate of Creditable Coverage for use when transitioning from Short-Term to an employer-sponsored group health plan. For more information, see the FAQ or visit the Help Center.

Deductible:

A deductible is the amount an enrollee must pay for covered medical services before an insurance plan will start covering costs. Generally, the lower the deductible, the higher the premium the member must pay.

Dental Coverage:

Benefits that help pay for the cost of visits to a dentist for basic or preventive services, like teeth cleaning, X-rays, and fillings. Short-term medical plans generally do not have regular dental coverage but do cover restoration and replacement of natural teeth lost or damaged because of an Injury covered under the policy. Stand-alone dental plans are available on AgileHealthInsurance.com.

Dependent:

The lawful spouse or a child for whom the subscriber or insured is paying for or providing access to health insurance benefits.

Durable Medical Equipment (DME):

Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, or crutches.

Effective Date:

The date the insured’s (and eligible dependents’ if applicable) coverage under a policy is effective.

Emergency Room Care:

Emergency services you get in an emergency room.

Excluded Services:

Health care services that your health insurance or plan doesn’t pay for or cover.

Essential Health Benefits:

A set of 10 categories of services health insurance plans must cover under the Affordable Care Act. These include doctors’ services, inpatient and outpatient hospital care, prescription drug coverage, pregnancy and childbirth, mental health services, and more. Plans must offer dental coverage for children. Dental benefits for adults are optional. Short-term medical plans do not cover all 10 of the essential health benefits.

Exclusions:

Health care services that your health insurance or plan doesn’t pay for or cover.

Exemption:

Most people must have qualifying health insurance or pay a fee. But people who qualify for a health coverage exemption don’t have to pay the fee. Exemptions are granted based on certain hardships and life events, health coverage or financial status, membership in some groups, and other circumstances.

Experimental Treatment:

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 that is not clinically approved. Most health insurance policies do not cover experimental treatment. The fact that a procedure, service, supply, treatment, drug, or device may be the only hope for survival will not change the fact that it is otherwise experimental in nature.

Formulary (or Drug List):

A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Most short-term medical plans do not include prescription drug coverage.

Grace Period:

The amount of time a member is allowed to be delinquent with their monthly premium payment after the first payment is made. It is general 31 days.

Guaranteed Issue:

A requirement that ACA health plans must permit you to enroll regardless of health status, age, gender, or other factors that might predict the use of health services. Most short-term medical plans are not guaranteed issue.

Guaranteed Renewal:

A requirement that an ACA health insurance issuer must offer to renew a policy as long as the member continues to pay premiums. Short-term medical plans are not guaranteed renewable.

Health Coverage:

Legal entitlement to payment or reimbursement for your health care costs, generally under the contract with a health insurance company.

Health Insurance:

A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.

Health Status:

Refers to your medical conditions (both physical and mental health), claims experience, receipt of health care, medical history, genetic information, evidence of insurability, and disability.

Home Health Care:

Health care services a person receives at home.

Home Health Care Plan:

A program for continued care and treatment of an individual established and approved in writing by the individual’s attending doctor.

Hospice Services:

Services to provide comfort and support for persons in the last stages of a terminal illness and their families. This is generally not covered in a short-term medical plan.

Hospital:

An institution operated by law for the care and treatment of injured or sick persons; has organized facilities for diagnosis and surgery or has a contract with another hospital for these services; and has 24-hour nursing service.

Hospitalization:

Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.

Hospital Outpatient Care:

Care in a hospital that usually doesn’t require an overnight stay.

Individual Health Insurance Policy:

Policies for people that aren't connected to job-based coverage. Individual health insurance policies are regulated under state law.

Inpatient Care:

Health care that you get when you're admitted as an inpatient to a health care facility, like a hospital or skilled nursing facility.

Long-Term Care:

Services that include medical and non-medical care provided to people who are unable to perform basic activities of daily living such as dressing or bathing. Long-term supports and services can be provided at home, in the community, in assisted living or in nursing homes. Individuals may need long-term supports and services at any age. Most health insurance plans don’t pay for long-term care.

Medicaid:

Insurance program that provides free or low-cost health coverage to some low-income people, families and children, pregnant women, the elderly, and people with disabilities. Many states have expanded their Medicaid programs to cover all people below certain income levels. Whether you qualify for Medicaid coverage depends partly on whether your state has expanded its program. Medicaid benefits, and program names, vary somewhat between states. You can apply anytime. If you qualify, your coverage can begin immediately, any time of year.

Medicare:

A federal health insurance program for people 65 and older and certain younger people with disabilities. It also covers people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).

Medically Necessary:

Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.

Medical Underwriting:

A process used by insurance companies to try to figure out your health status when you're applying for health insurance coverage to determine whether to offer you coverage, at what price, and with what exclusions or limits. Most short-term medical plans are subject to medical underwriting.

Mental and Nervous Disorder:

A “biologically-based” mental disorder, including Schizophrenia, Schizoaffective disorder, Major depressive disorder, Bipolar disorder, Paranoia and other psychotic disorders, Obsessive-compulsive disorder, Panic disorder, Delirium and dementia, Affective disorders, and any other "biologically-based" mental disorders appearing in the most recent edition of the Diagnostic and Statistical Manual of the American Psychiatric Association.

Minimum Essential Coverage (MEC):

Any insurance plan that meets the Affordable Care Act requirement for having health coverage. To avoid the penalty for not having insurance you must be enrolled in a plan that qualifies as minimum essential coverage (sometimes called “qualifying health coverage”). Short-term medical plans do not qualify as minimum essential coverage.

Network:

The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services. It is annotated on your insurance card.

Out-of-Pocket Costs:

Your expenses for medical care that aren't reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that aren't covered.

Out-Of-Pocket Maximum (Or Limit):

Your out-of-pocket limit is the maximum amount you pay for deductibles, coinsurance, and copayments within your coverage period. After this amount is reached, the plan pays 100% of covered medical services delivered in-network for the remainder of the policy term. Costs that do not have to be counted towards your out-of-pocket maximum include: premiums, out-of-network costs, and uncovered medical services. Generally, the lower the out-of-pocket maximum, the higher the premium the member must pay.

Outpatient:

A person who incurs medical expenses at Doctor’s offices and freestanding clinics, and at hospitals when not admitted as an inpatient.

Penalty:

A payment (“fee,” “fine,” “individual mandate”) you make if you don’t have health insurance that counts as qualifying health coverage. The penalty in 2016 and 2017 for not having health coverage is $695 for each person on your tax return who isn’t covered ($347.50 per child), or 2.5% of your household income, whichever is more. You owe a fee for any month you, your spouse, or your tax dependents don’t have qualifying health coverage. You’ll pay the fee when you file your federal income tax return. If you’re uncovered just some months of the year, you pay 1/12 of the penalty for each month you’re uninsured. If you’re uncovered for only 1 or 2 consecutive months, you don’t have to pay the fee at all. People with very low incomes and others with special circumstances may be eligible for exemptions from the requirement to have health insurance. If you qualify for an exemption, you won’t have to pay the fee.

Policy Maximum Benefit:

The maximum dollar amount for medical services that the member’s insurance company will pay during the term of the policy. Traditionally, $1,000,000 has been the standard. However, a lower policy maximum will drive lower premiums.

Policy Term:

Policy term is the maximum duration of the initial coverage period offered by the plan. You can purchase a plan for one month up to the maximum duration and you can cancel your policy at any time. We suggest purchasing the maximum duration available. Short-term plans are not guaranteed renewable, but we can help you reapply or find a new plan.

Pre-Existing Condition:

A health problem you had before the date that new health coverage starts.

Premium:

The amount of money that the member must pay for their insurance policy. Generally, the more benefits provided will mean a higher premium for the member.

Prescription Drugs:

Drugs and medications that, by law, require a prescription.

Prevention:

Activities to prevent illness such as routine check-ups, immunizations, patient counseling, and screenings.

Primary Care:

Health services that cover a range of prevention, wellness, and treatment for common illnesses. Primary care providers include doctors, nurses, nurse practitioners, and physician assistants. They often maintain long-term relationships with you and advise and treat you on a range of health-related issues. They may also coordinate your care with specialists.

Prior Authorization (Preauthorization):

Approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan.

Qualifying Health Insurance (or Coverage):

Coverage that is compliant with the Affordable Care Act so that policyholders are not liable to the shared responsibility tax.

Qualified Health Plan:

An insurance plan that’s certified by the Health Insurance Marketplace, provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements under the Affordable Care Act. All qualified health plans meet the Affordable Care Act requirement for having health coverage, known as “minimum essential coverage.” Short-term medical is not a qualified health plan.

Rate Review:

A process that allows state insurance departments to review rate increases before insurance companies can apply them to you. Short-term medical plans are term insurance so a member will not receive a rate increase during the term of their policy.

Rescission:

The retroactive cancellation of a health insurance policy. Insurance companies will sometimes retroactively cancel your entire policy if you made a mistake on your initial application when you buy an individual market insurance policy. Under the Affordable Care Act, rescission is illegal except in cases of fraud or intentional misrepresentation of material fact as prohibited by the terms of the plan or coverage.

Rehabilitative/Rehabilitation Services:

Health care services that help you keep, get back, or improve skills and functioning for daily living that have been lost or impaired because you were sick, hurt, or disabled. These services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.

Subscriber:

The person who is the primary insured or the policyholder.

Subsidized Coverage:

Health coverage available at reduced or no cost for people with incomes below certain levels. Examples of subsidized coverage include Medicaid and the Children’s Health Insurance Program (CHIP). Marketplace insurance plans with premium tax credits are sometimes known as subsidized coverage too. Short-term medical plans do not have subsidized coverage.

Substance Abuse:

The overindulgence in and dependence on a psychoactive leading to effects that are detrimental to the individual's physical health or mental health, or the welfare of others.

Skilled Nursing Care:

Also known as custodial or convalescence care services from licensed nurses in your own home or in a nursing home. Skilled care services are from technicians and therapists in your own home or in a nursing home.

Specialist:

A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.

Surgery or Surgical Procedure:

An invasive diagnostic procedure; or the treatment of injury or sickness by manual or instrumental operations performed by a doctor while the patient is under general or local anesthesia.

UCR (Usual, Customary, and Reasonable):

The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.

Urgent Care Center:

A medical facility separate from a hospital emergency department where ambulatory patients can be treated on a walk-in basis without an appointment and receive immediate, non-routine urgent care for an Injury or Sickness presented on an episodic basis.

Vision Coverage:

A health benefit that at least partially covers vision care, like eye exams and glasses. Generally, short-term medical plans do not include a vision benefit. A “stand-alone” plan is available for purchase when someone buys a short-term medical plan.

Wellness Programs:

A program intended to improve and promote health and fitness. Coverage in a short-term medical plan varies plan to plan. Some have no wellness benefits while other plans have varying benefits.

Explanation of benefits

Explanation of benefits (commonly referred to as an EOB form) is a statement the health insurance company sends to members explaining what medical treatments and/or services were paid for on their behalf.

Example health insurance explaination of benefits document

It is most famous as that “waste” of mail that comes to people after accessing medical services announcing that it is “not a bill.” So why bother? The explanation of benefits is important for a few reasons:

  1. It explains what the cost of the medical service actually was (the allowed amount not billed amount) which is applied to a person’s maximum benefit counter.
  2. It informs the member if they have any responsibility for payment so the member knows if a bill will be coming.
  3. Many EOBs will tell the member how much of their deductible is satisfied.

Claims

Mail

International Benefits Administrators, LLC
PO BOX 3080
Farmington Hills, MI 48333

Electronic

www.changehealthcare.com

EDI Payor ID: 11329

Benefits and Claims Services:

1-844-398-9752

https://ibatpa.com/providers/

Preauthorization

American Health Holdings

1-866-790-4177

Customer Service

Billing

For simple transactions such as a payment error where your payment information needs to be updated or if you want a refund inside the “free-look period” which is 10 days in most states, this can be done in the member portal at www.AgileHealthInsurance.com/customersFor other payment errors where you need to process a payment, you need to call AgileHealthInsurance at (877) 353-0962 to process the payment.
Other refund requests will have to be escalated, please call (877) 353-0962 for other requests and they will be addressed on a case by case basis in accordance with each individual insurance company’s policy.
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Cancellation

Please call (877) 353-0962

ID Cards

You can print replacement ID cards from the member portal at www.AgileHealthInsurance.com/customers

Creditable Coverage

If you need to prove that you had creditable coverage to a new health plan, please contact the following number to receive a certificate of creditable coverage: (877) 353-0962

Reapply for Coverage with AgileHealthInsurance

Your current insurance policy is short term health insurance. This is a major medical insurance with an expiration date. There is no renewal of coverage. However, in many cases a member can reapply for another term policy. There are a couple of ways to reapply for a new term policy:

Telephonic: 45 days from policy expiration, an Agile team member will reach out to members to see if they can help them reapply for new coverage.

Self-service: At any time a member can return to www.AgileHealthInsurance.com to reapply for coverage. When doing so, be mindful of dates as one cannot enroll in a new plan that has an overlapping date with current coverage.

Your reapply application will be reviewed for underwriting and can be denied based on pre-existing conditions or other factors.

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Short-Term Medical Insurance Plans