American
Health Shield Plan Highlights - Fairmont
Specialty Group (FSG)
How
benefits are covered?
The benefit options for covered expenses for
injury or sickness per insured person per
benefit period.
American
Health Shield STM pays benefits for each covered
person in the following manner: First, you meet
your deductible. Choose from five options: $250,
$500, $1,000, $2,500 or $5,000
Then
American Health Shield STM pays 80% or 50% of
the next $5,000 of covered expenses
After
this, 100% of the covered expenses up to your
coverage period maximum of $1 million
Plan
Highlights
What
is Short Term Health Insurance?
According
to a 08/2005 U.S. Department of Commerce
report*, 45.8 million Americans are without
health insurance coverage. Don't risk
being a statistic - without health
insurance coverage, an unexpected illness or
injury could be financially devastating!
*
U.S. Census Bureau / U.S. Department of Commerce
/ Economics and Statistics Administration
The American
Health Shield - Short Term
Medical is a quality, affordable plan
of temporary medical insurance designed
specifically for healthy people who are
temporarily without health insurance.
This plan offers coverage from 30-days to
180-days or up to 12-months in most states that
can become effective as early as tomorrow and be
paid for in one single payment or easy monthly
installments.
Ideal
protection for persons:
- Between
jobs, laid off, on strike
- Attending
school or recently graduated
- Employed
part-time or temporarily
- Waiting
for permanent health insurance to begin
- Temporarily
without health insurance for most any reason
American
Health Shield - Short Term Medical is not an HMO
or PPO plan. In the event of an illness or
injury, and you may receive treatment from
any licensed healthcare provider or facility
anywhere in the U.S.
Eligibility
Requirements
Who
is eligible to apply for the American Health
Shield - Short Term Medical:
-
You
and your spouse, age 18 to 64 and 11
months, and your unmarried dependent
children age 15 days through 18 (24, if
a full-time student) that live with you.
To
be considered for coverage, persons listed on
the application form must:
- Be
a US citizen (or permanent resident for the
past 12 months) and have a Social Security
Number;
- Not
be traveling outside the U.S.;
- Live
in a state where this plan of insurance is
available;
- Not
be covered by major medical, group health,
hospital, governmental, or other medical
insurance coverage that will not terminate
prior to the Effective Date of this plan;
- Not
be pregnant or the expectant father of an
unborn child;
- Not
have been declined for health insurance
within the past 12 months and/or received
consultation or treatment (within the past 5
years) for any condition identified on the
application form;
- Not
participate in hazardous activities or
sports.
Child
only coverage is available for your eligible,
unmarried dependent child (age 2 through 18)
that live with you. Enter the oldest child
as the applicant, and all other child(ren) as
dependents. Child(ren) only applications
must be signed by a parent or legal
guardian, then mail or fax all pages of the
completed application to:
Short
Term Medical Department
PO Box 20594
Tampa, FL 33622-0594
1-727-799-9093 (Facsimile)
Covered
Medical Expense Highlights
The
American Health Shield - Short Term
Medical provides benefits for Covered
Medical Expenses related to covered Injury or
Sickness, which are: 1) not in excess of
Usual and Customary Charges; 2) not in excess of
a maximum benefit amount; 3) made for services
and supplies which are a Medical Necessity and
listed as Covered Medical Expenses in the Policy
or Certificate issued by Fairmont Specialty
Group.
- Hospital
Charges:
average semi-private room rate, medical care
and treatment
- Surgery
in a Hospital or Ambulatory Surgical Center
- Physician
Services
for diagnosis, treatment and surgery
- Intensive
Care:
up to three times the average semi-private
room rate
- Skilled
Nursing Facility:
up to $30 per day for 30 days
- Ray
Exams, Laboratory
tests and analyses
- X-Ray
and Radioactive
isotope therapy, anesthesia, oxygen, casts,
splints, crutches, braces, surgical
dressings, artificial limbs or eyes, rental
of medical supplies
- Blood
or blood plasma
and their administration
- Ambulance
Services:
$250 per emergency
- Organ
Transplants:
$50,000 lifetime maximum
- Acquired
Immune Deficiency Syndrome
(AIDS): $10,000 lifetime maximum
- Home
Health Care:
up to 40 visits
- Hospice
Care:
up to $5,000
- Spinal
Manipulation/Adjustment:
up to $1,000
- Mammography,
pap smear and screens
- Gallbladder
Surgery:
up to a $2,500 lifetime maximum
- Knee
injury or disorder:
up to a $2,500 lifetime maximum for both
left and right knees
Usual
and Customary Charges
means the lesser of: 1) the actual charge; 2)
what the provider would accept for the same
service or supply in the absence of insurance;
or 3) the reasonable charge as determined by
Fairmont Specialty Group, based on factors such
as: a) the most common charge for the same or
comparable service or supply in a community
similar to where the service or supply is
furnished; b) the amount of resources expended
to deliver the treatment rendered; c) charging
protocols and billing practices generally
accepted by the medical community or specialty
groups; or d) inflation trends by geographic
region.
Pre-Admission
Certification:
This plan requires a Pre-Admission Certification
by a Professional
Review Organization prior to in-patient
Hospitalization or surgery.
A Covered
Person or their Attending Physician must
call the Professional
Review Organization: 1. For elective or
non-emergency Hospitalization or surgery, at
least 10-days prior to the date of proposed
Hospitalization; 2. Within 48-hours of an
emergency admission; or 3. Within 48-hours of
delivery for complicated childbirth.
Non-compliance with the Pre-Admission
Certification procedure will result in a reduction
in benefits of 50%, unless the Covered
Person is incapacitated and unable to
contact the Professional Review Organization. In
such cases, the Covered
Person must contact us as soon as
possible.
Covered
Medical Expenses and Benefits vary by state.
Detailed information about these and additional
Covered Medical Expenses is listed in the Policy
or Certificate issued by Fairmont Specialty
Group to approved applicants.
Payment
Options & Methods
American
Health Shield - Short Term Medical
let's you choose the payment option (single or
monthly payment) and payment method (automatic
bank draft, credit card, or personal check)
that's most convenient for you.
Additionally, once coverage commences, premium
rates are guaranteed for the length of the
Coverage Period issued! Note - If
you prefer to make payment(s) by personal check
or money order, you must mail your completed
application form and initial payment to Fairmont
Specialty Group.
Payment
Options
-
Single
Payment - If you know the exact
length of time you'll need this coverage and
prefer to make one single payment for the
entire Coverage Period, this payment option
is ideal. Simply select the exact total
number of days you need coverage (30-day
minimum / 180-day maximum) and pay for that
Coverage Period.
-
Monthly
Payments - If you are unsure how
long you'll need this coverage or prefer the
convenience of making monthly installment
payments, this option is ideal. Each
monthly payment is for 30-days or 1-month of
coverage, up to the 180-day or 12-month
maximum Coverage Period. If your need
for this coverage ceases before your
Coverage Period expires, simply stop making
monthly payments and your coverage will
terminate at the end of the period you last
made payment for.
Payment
Methods
-
Personal
Check: You will receive
payment coupons with your Policy or
Certificate. The 1st
payment coupon will reflect a credit equal
to your initial payment. Subsequent
monthly payments, must be received by
Fairmont Specialty Group on or before the
payment due dates shown on payment coupons.
-
Automatic
Bank Draft or Credit Card:
Your initial payment and subsequent monthly
payments will be automatically debited (on
or immediately following the payment due
dates) from your bank account or your
MasterCard / VISA that is identified on the
Electronic Payment Authorization form. If
you wish to discontinue coverage before your
Coverage Period expires, simply mail or fax
your written request for termination to
Fairmont Specially Group and we will
discontinue future automated electronic
debits. Note - 5 days advance written
and signed notice from the Primary Insured
is required to ensure future credit card
debits are discontinued.
If
you submit the application form and initial
payment via:
Internet
or facsimile, the earliest date that
coverage can begin (if approved by Fairmont
Specially Group) is 12:01 a.m. on the day after
Fairmont Specially Group receives the completed
application form and valid electronic payment
information. A later effective date may be
requested, but no more than 30 days following
the application date. Note - payment
must be made by automatic bank draft or
MasterCard / VISA.
U.S.
Mail, the earliest date that coverage
can begin (if approved by Fairmont Specially
Group) is 12:01 a.m. on the day after the
postmark date stamped by the U.S.P.S. on the
envelope in which Fairmont Specially Group
receives the completed application form and
payment for the total amount due. If the
U.S.P.S. postmark date is not legible or
present, the earliest date that coverage can
begin is the day after the completed application
form and payment for the correct plan cost are
received by Fairmont Specially Group. A
later effective date may be requested, but no
more than 30 days following the application
date.
IMPORTANT
- The coverage Effective Date is determined by
Fairmont Specially Group and will be shown in
the Policy or Certificate that is issued. No
agent or agency has the authority to bind,
modify or issue coverage. Issuance of
coverage is subject to Fairmont Specially
Group’s acceptance of the submitted
application form and your initial payment for
the American Health Shield - Short Term Medical.
Coverage
Termination Date
Coverage
will terminate on the earliest of the following
dates:
The
last day of the period through which the premium
is paid; The date the Covered Person ceases to
be eligible; or the Coverage Period expiration
date.
Extension
of Benefits After Termination
If
a Covered Person is receiving benefits for a Hospital
Confinement
on the date the Coverage Period, Policy or
Certificate terminates, benefits will continue
in accordance with the terms of the Policy or
Certificate for as long as that Confinement
remains continuous and the Covered Person
is Totally Disabled
by reason of such Injury
or Sickness. However, in no event will
coverage continue beyond the end of the 90-days
following the date Coverage Period, Policy or
Certificate terminates.
Note
- Benefit payments for such condition both
before and after the Termination Date are
subject to all applicable benefit maximum
limits. Once the "Extension of
Benefits After Termination" provision has
been exhausted, all benefits cease to exist, and
under no circumstances will further payments be
made.
Renewability
The
American Health Shield - Short Term
Medical is not renewable nor intended
to be permanent coverage. Coverage will
terminate upon expiration of your Coverage
Period. However, you may be eligible to
apply for another Coverage Period following the
expiration of your previous Benefit Period.
If a new Coverage Period is applied for and
issued by Fairmont Specially Group, there
is no continuous coverage between any previous
and current Benefit Period. Any
condition or symptom, which occurred under a
previous Coverage Period, may be treated as a
pre-existing condition under a subsequent
Coverage Period. Note - In no event
will Fairmont Specially Group issue successive
Coverage Periods totaling more than 365 days.
Immediately
following Fairmont Specially Group’s receipt
and approval of your submitted application form,
a Policy or Certificate will be issued and
mailed to your residence/home address.
Please read the Policy or Certificate carefully.
It is important to us that you understand and
are satisfied with the American Health Shield
- Short Term Medical insurance plan.
If you are not satisfied that this coverage will
meet your insurance needs, simply return the
Policy or Certificate with your written and
signed request for cancellation within 10
days after you receive it. Coverage
will be canceled as of the effective date and
you will receive a full refund of your initial
payment - no questions asked!
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