Aspen

Short-Term Medical Insurance Plans

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Why Choose Aspen Short-Term Medical Insurance Plans?

Life is unpredictable so you should always have health insurance to protect your financial wellbeing. For those times you find yourself without employer health insurance coverage, an Aspen Short-term Health Insurance plan is an affordable solution. Purchase an Aspen plan until permanent insurance becomes available for you.

Aspen Short-term Health Insurance plans offer many attractive benefits for its members:

  • $40 Copayment to visit the doctor's office and/or urgent care clinic.
  • Access to the PHCS nationwide network of providers.
  • Annual routine physical is included for each covered person with a $50 Copayment.

It is ideal for those who are:

  • Between jobs or have been laid off
  • Waiting for employer benefits
  • Part-time or temporary employee
  • Recently graduated
  • Without adequate health insurance

Aspen STM Feature Highlights

  • Coverage Period Maximums of $1,500,000
  • Deductible options of $1,000, $2,500, $5,000 or $7,500
  • Access to the nationwide PHCS Network
  • Coinsurance options: 70/30, 80/20
  • Maximum out-of-pocket options: $2,000, $5,000, or $10,000
  • Purchase in full or make monthly payments

Get a free quote to see all the details

Benefits 101



Benefits Plan 1 Plan 2 Plan 3
Plan Deductible Options $1,000, $2,500, $5,000, $7,500$1,000, $2,500, $5,000, $7,500$1,000, $2,500, $5,000, $7,500, $10,000
Coinsurance Options 70%, 80%, or 100%70%, 80%, or 100%70%, 80%, or 100%
Out of Pocket Maximum Options $2,000, $5,000$2,000, $5,000$2,000, $5,000, $10,000
Coverage Period Maximum Benefit Options $250,000, $750,000, $1,000,000$100,000, $250,000, $750,000, $1,000,000, $1,500,000$100,000, $250,000, $750,000, $1,000,000, $1,500,000
Additional Deductibles
Outpatient Surgery Additional DeductibleNo Additional DeductiblesNo Additional Deductibles$500 per surgery after which Plan Deductible and Coinsurance will apply. Maximum 3
Emergency Room Additional DeductibleNo Additional DeductiblesNo Additional Deductibles$500 per visit after which Plan Deductible and Coinsurance will apply. Deductible is waived if admitted to hospital
Advanced Diagnostic Studies Additional DeductibleNo Additional DeductiblesNo Additional Deductibles$500 per occurrence after which Plan Deductible and Coinsurance will apply.
Copayments
Doctor's Office Visit / Urgent Care Center$40 Copayment per visit, not to exceed a maximum of 3. Coinsurance is 100% of Eligible Expenses and benefits are not subject to the Plan Deductible. Office Visits in excess of the maximum number of Copayments will be subject to the Plan Deductible and Coinsurance. Any other covered services or tests performed as part of the office visit will be subject to the Plan Deductible and Coinsurance. The office visit maximum for all Doctor office visits, including any other covered services or tests performed as part of the office visit, will not exceed $2,000 per Covered Person per Coverage Period.$25 Copayment per visit per Covered Person. Coinsurance is 100% of Eligible Expenses and benefits are not subject to the Plan Deductible.$40 Copayment per visit per Covered Person. Coinsurance is 100% of Eligible Expenses and benefits are not subject to the Plan Deductible.
Wellness Benefit$50 Copayment for one annual Routine Physical Exam. Coinsurance is 100% and benefits are not subject to the Plan Deductible.$50 Copayment for one annual Routine Physical Exam. Coinsurance is 100% and benefits are not subject to the Plan Deductible.$50 Copayment for one annual Routine Physical Exam. Coinsurance is 100% and benefits are not subject to the Plan Deductible.
Advanced Diagnostic Studies CopaymentSubject to Deductible and Coinsurance.$500 Copayment per occurrence for Advanced Diagnostic Studies in an Outpatient setting, including PET, MRI, CAT scans not to exceed a maximum of 3 Copayments per Covered Person. Coinsurance is 100% of Eligible Expenses and benefits are not subject to the Plan Deductible. Occurrences in excess of the maximum number of Copayments will be subject to the Plan Deductible and Coinsurance.Subject to Deductible and Coinsurance.
Inpatient Hospital
Standard Room RateAverage Standard room rate. Benefits, including nursing services and all miscellaneous medical charges are limited to $1,000 per day.Average Standard room rate. Benefits, including nursing services and all miscellaneous medical charges are limited to $4,000 per day.Average Standard room rate.
Intensive Care or Critical Care UnitThe benefit payable for each day of confinement in an Intensive Care or Critical Care Unit. Benefits, including nursing services and all miscellaneous expenses, are limited to $1,250 per day.The benefit payable for each day of confinement in an Intensive Care or Critical Care Unit. Benefits, including nursing services and all miscellaneous expenses, are limited to $4,000 per day.The benefit payable for each day of confinement in an Intensive Care or Critical Care Unit.
Inpatient Doctor Visits$50 per day. Benefits for all Hospital visits during a Hospital stay are limited to $500 per Covered Person per Coverage Period.$50 per day. Benefits for all Hospital visits during a Hospital stay are limited to $500 per Covered Person per Coverage Period.Subject to Deductible and Coinsurance.
Emergency RoomThe benefit payable for each emergency room visit, including professional and facility services, will not exceed $250 per visit. (This includes the emergency room physician charge, 24 hours surveillance and all miscellaneous medical charges).The benefit payable for each emergency room visit, including professional and facility services, will not exceed $500 per visit. (This includes the emergency room physician charge, 24 hours surveillance and all miscellaneous medical charges).Subject to Additional Deductible shown above, then subject to Deductible and Coinsurance.
Outpatient Hospital Services
Outpatient Surgical FacilityThe benefit payable per day including all miscellaneous expense, is limited to $1,250.The benefit payable per day including all miscellaneous expense, is limited to $2,500.Subject to Additional Deductible shown above, then subject to Deductible and Coinsurance.
Outpatient Miscellaneous Hospital ExpensesThe benefit payable for miscellaneous Outpatient Hospital expenses, excluding Outpatient Surgery. Benefits are limited to $1,250 per Covered Person per Coverage Period for all Eligible Expenses combined.The benefit payable for miscellaneous Outpatient Hospital expenses, excluding Outpatient Surgery. Benefits are limited to $2,500 per Covered Person per Coverage Period for all Eligible Expenses combined.The benefit payable for miscellaneous Outpatient Hospital expenses, excluding Outpatient Surgery.
Other Covered Services
Surgeon$5,000 per surgery, for all Eligible Expenses combined, not to exceed $10,000 per Covered Person per Coverage Period.$10,000 per surgery, for all Eligible Expenses combined, not to exceed $20,000 per Covered Person per Coverage Period.Subject to Deductible and Coinsurance.
Assistant Surgeon and Surgical Assistant$1,000 per surgery, for all Eligible Expenses combined, not to exceed $2,000 per Covered Person per Coverage Period.$2,000 per surgery, for all Eligible Expenses combined, not to exceed $4,000 per Covered Person per Coverage Period.Subject to Deductible and Coinsurance.
Administration of Anesthetics$1,000 per surgery, for all Eligible Expenses combined, not to exceed $2,000 per Covered Person per Coverage Period.$2,000 per surgery, for all Eligible Expenses combined, not to exceed $4,000 per Covered Person per Coverage Period.Subject to Deductible and Coinsurance.
Extended Care Facility$150 per day not to exceed a maximum of 30 days per Covered Person per Coverage Period.$150 per day not to exceed a maximum of 30 days per Covered Person per Coverage Period.$150 per day not to exceed a maximum of 30 days per Covered Person per Coverage Period.
Home Health Care$50 per visit. There is a limit of 1 visit per day not to exceed a maximum of 30 visits per Covered Person per Coverage Period.$50 per visit. There is a limit of 1 visit per day not to exceed a maximum of 30 visits per Covered Person per Coverage Period.$50 per visit. There is a limit of 1 visit per day not to exceed a maximum of 30 visits per Covered Person per Coverage Period.
Hospice Care$2,500 per Covered Person per Coverage Period.$2,500 per Covered Person per Coverage Period.$2,500 per Covered Person per Coverage Period.
Ambulance
Injury$250 per transport$500 per transport$500 per transport
Sickness$250 per transport$500 per transport$500 per transport
Physical, Occupational and Speech Therapy$50 per day and 20 visits combined per Covered Person per Coverage Period.$50 per day and 20 visits combined per Covered Person per Coverage Period.$50 per day and 20 visits combined per Covered Person per Coverage Period.
Organ or Tissue Transplants$50,000 per Covered Person per Coverage Period$50,000 per Covered Person per Coverage Period$50,000 per Covered Person per Coverage Period
AIDS$10,000 per Covered Person per Coverage Period$10,000 per Covered Person per Coverage Period$10,000 per Covered Person per Coverage Period
TMJ$3,500 per Covered Person per Coverage Period$3,500 per Covered Person per Coverage Period$3,500 per Covered Person per Coverage Period
Kidney Stones$1,500 per Covered Person per Coverage Period$1,500 per Covered Person per Coverage Period$1,500 per Covered Person per Coverage Period
Appendectomy$2,500 per Covered Person per Coverage Period$2,500 per Covered Person per Coverage Period$2,500 per Covered Person per Coverage Period
Joint or Tendon Surgery$2,500 per Covered Person per Coverage Period$2,500 per Covered Person per Coverage Period$2,500 per Covered Person per Coverage Period
Knee Injury or Disorders$2,500 per Covered Person per Coverage Period for both left knee and right knee$2,500 per Covered Person per Coverage Period for both left knee and right knee$2,500 per Covered Person per Coverage Period for both left knee and right knee
Gallbladder Surgery$2,500 per Covered Person per Coverage Period$2,500 per Covered Person per Coverage Period$2,500 per Covered Person per Coverage Period
Mental Disorders
Inpatient$100 per day, 31 day maximum per Covered Person per Coverage Period.$100 per day, 31 day maximum per Covered Person per Coverage Period.$100 per day, 31 day maximum per Covered Person per Coverage Period.
Outpatient$50 per visit, 10 visits per Covered Person per Coverage Period$50 per visit, 10 visits per Covered Person per Coverage Period$50 per visit, 10 visits per Covered Person per Coverage Period
Substance Abuse
Inpatient$100 per day, 31 day maximum per Covered Person per Coverage Period.$100 per day, 31 day maximum per Covered Person per Coverage Period.$100 per day, 31 day maximum per Covered Person per Coverage Period.
Outpatient$50 per visit, 10 visits per Covered Person per Coverage Period$50 per visit, 10 visits per Covered Person per Coverage Period$50 per visit, 10 visits per Covered Person per Coverage Period
Option of Waiver of Pre-Existing Conditions RiderYesYesYes

Aspen American 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

  1. Pre-Existing Conditions:

    1. Charges resulting directly or indirectly from a condition for which a Covered Person received medical treatment, diagnosis, care or advice, including diagnostic tests or medications, within the 24 month period immediately preceding such person’s Certificate Effective Date of coverage under the Policy.
    2. Pre-Existing Conditions includes conditions that produced any symptoms which would have caused a reasonably prudent person to seek diagnosis, care or treatment within the 24 month period immediately prior to the Covered Person’s Certificate Effective Date of coverage under the Policy.

    This exclusion does not apply to any Eligible Expense payable for Pre-Existing Conditions until the Allowance Benefit maximum shown in the Schedule of Benefits has been reached. This exclusion does not apply to a newborn child or newborn adopted child who is added to coverage in accordance with PART II – ELIGIBILITY AND EFFECTIVE DATE OF INSURANCE.

  2. Waiting Period:

    1. Covered Persons will only be entitled to receive benefits for Sicknesses that begin, by occurrence of symptoms and/or receipt of treatment, more than five (5) days following the Covered Person’s Certificate Effective Date of coverage under the Policy.
    2. Covered Persons will only be entitled to receive benefits for Cancer that begins, by occurrence of symptoms or receipt of treatment more than 30 days following the Covered Person’s Certificate Effective Date of coverage under the Policy.
  3. Charges during the first 6 months after the Certificate Effective Date of coverage for a Covered Person for the following:

    1. Total or partial hysterectomy, unless it is Medically Necessary due to a diagnosis of carcinoma;
    2. Tonsillectomy;
    3. Adenoidectomy;
    4. Repair of deviated nasal septum or any type of surgery involving the sinus;
    5. Myringotomy;
    6. Tympanotomy;
    7. Herniorrhaphy; or
    8. Cholecystectomy (Gallbladder). However, if such a condition is a Pre-Existing Condition, any benefit consideration will be in accordance with the Pre-Existing Conditions limitation.
  4. The benefits payable for the following conditions or procedures are limited to the specified amounts shown in the Schedule of Benefits:

    1. Kidney stones
    2. Appendectomy
    3. Joint or tendon surgery
    4. Knee Injury or disorder
    5. Acquired Immune Deficiency Syndrome (AIDS)/ Human Immuno-deficiency Virus (HIV)
    6. Gallbladder surgery
  5. Charges which are not incurred by a Covered Person during his/her Coverage Period.
  6. Charges which exceed any limits or limitations specified in this Certificate, including the Schedule of Benefits.
  7. Charges for services of supplies in excess of the Maximum Allowable Expense.
  8. Charges for services or supplies which are not administered by or under the supervision of a Doctor.
  9. Mental, emotional or nervous disorders or counseling of any type, unless specifically covered as an Eligible Expense.
  10. Marital counseling or social counseling.
  11. Treatment for Substance Abuse, unless specifically covered as an Eligible Expense.
  12. Outpatient Prescription Drugs, unless specifically covered as an Eligible Expense. This does not include those administered by a Doctor in an Inpatient or Outpatient setting covered as an Eligible Expense.
  13. Medications, vitamins, and minerals or food supplements including prenatal vitamins, or any over-the-counter medicines, whether or not ordered by a Doctor.
  14. Any drug, treatment or procedure that either promotes or prevents conception including but not limited to: artificial insemination, treatment for infertility or impotency, sterilization or reversal of sterilization.
  15. Any drug, treatment or procedure that corrects impotency or non-organic sexual dysfunction.
  16. Modifications of the physical body in order to improve the psychological, mental or emotional well-being of the Covered Person, such as sex-change surgery.
  17. Cosmetic Treatment, except for reconstructive surgery where expressly covered as an Eligible Expense.
  18. Weight modification or surgical treatment of obesity.
  19. Eye surgery, including LASIK, when the primary purpose is to correct nearsightedness, farsightedness or astigmatism.
  20. Dental Expenses, except as necessary to restore or replace sound and natural teeth lost or damaged as a result of an Injury. The Injury must be severe enough that the contact with the Doctor occurs within seventy-two (72) hours of the Accident, unless extenuating circumstances exist due to the severity of the Injury that prevent you from contacting the Doctor.
  21. Expenses incurred in the treatment by any method for jaw joint problems including temporomandibular joint dysfunction (TMJ), TMJ pain syndromes, craniomandibular disorders, myofascial pain dysfunction or other conditions of the joint linking the jaw bone and skull and the complex of muscles, nerves and other tissues related to the joint, unless specifically covered as an Eligible Expense.
  22. Routine prenatal care, Pregnancy, childbirth, and post-natal care. (This exclusion does not apply to “Complications of Pregnancy” as defined.)
  23. Sclerotherapy for veins of the extremities.
  24. Abortions, except in connection with covered Complications of Pregnancy or if the life of the expectant mother would be at risk.
  25. Joint replacement or other treatment of joints, spine, bones or connective tissue including tendons, ligaments and cartilage. This exclusion does not apply if these treatments are related to a covered Injury.
  26. Surgeries, treatments, services or supplies which are deemed to be Experimental Treatment.
  27. Chronic fatigue or pain disorders.
  28. Kidney or end stage renal disease.
  29. Treatment or diagnosis of allergies, except for emergency treatment of allergic reactions.
  30. Treatment for cataracts.
  31. Treatment of sleep disorders.
  32. Treatment required as a result of complications or consequences of a treatment or condition not covered under this Certificate.
  33. Treatment incurred as a result of exposure to non-medical nuclear radiation and/or radioactive material(s).
  34. Treatment for acne, moles, skin tags, diseases of sebaceous glands, seborrhea, sebaceous cyst, unspecified disease of sebaceous glands, hypertrophic and atrophic conditions of skin, nevus.
  35. Treatment for or related to any Congenital Condition, except as it relates to a newborn child or newborn adopted child added as a Covered Person pursuant to the terms of this Certificate.
  36. Treatment, medication or hormones to stimulate growth, or treatment of learning disorders, disabilities, developmental delays or deficiencies, including therapy.
  37. Spinal manipulation or adjustment.
  38. Biofeedback, acupuncture, recreational, sleep or MIST Therapy®, holistic care of any nature, massage and kinesiotherapy, unless specifically covered as an Eligible Expense.
  39. Hypnotherapy when used to treat conditions that are not recognized as Mental Disorders by the American Psychiatric Association, and non-medical self-care or self-help programs.
  40. Eyeglasses, contact lenses, hearing aids, hearing implants, eye refraction, visual therapy, orthoptics, visual eye training and any examination or fitting related to these devices, and all vision and hearing tests and examinations.
  41. Care, treatment or supplies for the feet, and orthopedic prescription devices to be attached to or placed in shoes.
  42. Treatment of weak, strained, flat, unstable or unbalanced feet, metatarsalgia or bunions; treatment of corns, calluses or toenails; and orthopedic shoes.
  43. Care and treatment for hair loss including wigs, hair transplants or any drug that promises hair growth, whether or not prescribed by a Doctor.
  44. Exercise programs, whether or not prescribed or recommended by a Doctor.
  45. Telephone or Internet consultations and/or treatment or failure to keep a scheduled appointment.
  46. Charges for travel or accommodations, except as expressly provided for local ambulance.
  47. All charges incurred while confined primarily to receive Custodial or Convalescent Care.
  48. Services received or supplies purchased outside the United States, its territories or possessions, or Canada unless specifically covered as an Eligible Expense.
  49. Any services or supplies in connection with cigarette smoking cessation.
  50. Any services performed or supplies provided by a member of a Covered Person’s Immediate Family.
  51. Services received for any condition caused by a Covered Person’s commission of or attempt to commit an assault, battery, or felony, whether charged or not, or to which a contributing cause was the Covered Person being engaged in an illegal occupation.
  52. Services or supplies which are not included as Eligible Expenses as described herein.
  53. Participating in hazardous occupations or other activity including participating, instructing, demonstrating, guiding or accompanying others in the following operation of a flight in an aircraft other than a regularly scheduled flight by a commercial airline

    • professional or semi-professional sports
    • extreme sports
    • parachute jumping
    • hot-air ballooning
    • Hang-gliding
    • base jumping
    • mountain climbing
    • bungee jumping
    • scuba diving
    • sail gliding
    • Parasailing
    • para kiting
    • rock or mountain climbing
    • cave exploration
    • Parkour
    • racing including stunt show or speed test of any motorized or non-motorized vehicle
    • rodeo activities
    • or similar hazardous activities.

    Also excluded is Injury received while practicing, exercising, undergoing conditional or physical preparation for such activity.

  54. Injuries or Sicknesses resulting from participation in interscholastic, intercollegiate or organized competitive sports. This does not include dependent children participating in local community sports activities.
  55. Injury resulting from being under the influence of or due wholly or partly to the effects of alcohol or drugs, other than drugs taken in accordance with treatment prescribed by a Doctor.
  56. Intentionally self-inflicted Injury or Sickness (whether the Covered Person is sane or insane).
  57. Charges resulting from a declared or undeclared war, or from voluntary participation in a riot or insurrection.
  58. Charges incurred by 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 the Covered Person on a prorated basis.
  59. Costs for Routine Physical Exams or other services not needed for medical treatment, unless specifically covered as an Eligible Expense.
  60. Charges You or Your Covered Dependent are not required to pay, or which would not have been billed, if no insurance existed.
  61. Charges to the extent that they are paid or payable under other valid or collectible group insurance or medical prepayment plan.
  62. Charges that are eligible for payment by Medicare or any other government program except Medicaid. Costs for care in government institutions unless You or Your Covered Dependent are obligated to pay for such care.
  63. Charges related to Injury or Sickness arising out of or in the course of any occupation for compensation, wage or profit, if the Covered Person is insured, or is required to be insured, by occupational disease or workers’ compensation insurance pursuant to applicable state or federal law, whether or not application for such benefits have been made.
  64. Medical expenses which are payable under any automobile insurance policy without regard to fault (does not apply in any state where prohibited).


Disclaimer: THIS IS A BRIEF DESCRIPTION OF ASPEN STM SHORT TERM MEDICAL PLAN LIMITATIONS AND EXCLUSIONS, TERMS AND CONDITIONS MAY BE DIFFERENT WHERE REQUIRED BY STATE LAW. PLEASE CHECK THE PRODUCT CERTIFICATE OR MASTER POLICY FOR COMPLETE DETAILS ON BENEFITS, LIMITATIONS, AND EXCLUSIONS.


Frequently Asked Questions

What do I do about a payment error?

You can update your payment information on the member portal @ www.AgileHealthInsurance.com/customers but if you need to process a payment you do have to call Agile at (877) 353-0962 to process the payment.

How do I cancel my policy?

You can cancel your policy on the customer portal @ www.AgileHealthInsurance.com/customers

How does my policy work?

Please go to our benefit page that will walk you through the various aspects that you, the member, need to understand. It is not impossible to learn but there are a few things you need to understand. Once you understand those elements, understanding your policy is much easier.

How do I verify that my doctor accepts my insurance policy?

Please go to our provider network page that will connect you with the provider search tool that will tell you if your doctor is in the network. Also, please know that a unique aspect of short-term medical is that many plans will let you go to any doctor you want; you file for reimbursement yourself. However, in those cases there is a possibility that you will be balance billed (definition: the difference between what your health insurance reimburses and what the doctor chooses to charge).

How do I get a refund?

If the policy is within the “free-look period” which is 10 days in most states, this can be done in the member portal @ www.AgileHealthInsurance.com/customers. Other requests will have to be escalated and refunds will be granted on a case by case basis in accordance with each individual insurance company’s policy. Please call (877) 353-0962 for other requests.

How do I replace ID cards?

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

Will I receive a tax penalty?

For those who are considering short term health for three months or longer, you may be subject to the tax penalty. The penalty is prorated based on the number of months a consumer goes without coverage that is compliant with the Affordable Care Act.

How do I change my information in the system?

Simple changes should be made thru the member portal @ www.AgileHealthInsurance.com/customers. If the changes cannot be made in the portal, members should call (877) 353-0962.

Where do I send my claim?

The back of the member ID card has an address to send the claim and a Payor ID to reference.

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

All Medical Claims:

Insurance Benefit System Administrators ℅ Zelis
P.O. Box 247
Alpheratta, GA 30009-0247
EDI Payor ID: 07689

All Other Claims Information:

Insurance Benefit System Administrators

P.O. Box 2917

Shawnee Mission, KS 66201-1317

Benefits, Claim Services:

1(800)650-3199

Pre-Notification:

1(800)650-6497

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 @ www.AgileHealthInsurance.com/customers

For other payment errors where you need to process a payment, you need to call Agile 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.

AGILE SERVICE PLEDGE

We pledge to be:

  • Responsive
  • Experts Knowledgeable in Short-Term Medical Insurance
  • Accountable
  • Transparent

Cancellation

Please call (877)353-0962

ID Cards

You can print replacement ID cards from the member portal @ 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