AFFORDABLE CHOICE PLAN COMPARISON Surgical and Hospitalization Benefits ELITE PLUS ELITE
CLASSIC PLUS
CLASSIC
Inpatient Hospital Confinement (per Inpatient Day)
$6,000 $7,500 $9,000 $10,500 $12,000 $3,000
$4,000 $5,000 $6,000 $7,000 $8,000 $2,000
$3,000 $3,750 $4,500 $5,250 $6,000 $1,000
$2,000 $2,500 $3,000 $3,500 $4,000 $1,000
Year 2 Year 3 Year 4 Year 5
Building Benefit Injury Reimbursement Inpatient Hospitalization Benefits increase 25% each year, years 2-5, for injury-related hospital stays. (per day) Hospital Admission Benefits (for the first Inpatient Day per calendar year)
Emergency Room (Per day/calendar year maximum) Urgent Care (Per day/calendar year maximum)
$300/2 CY
$300/2 CY
$250/1 CY
$250/1 CY
$300/4 CY
$300/4 CY
$250/2 CY
$250/2 CY
Surgery Benefit Daily surgical benefits for both inpatient and outpatient surgery. The reimbursement schedule for 1 unit is similar to what is payable under the Medicare Physician Fee Schedule for surgeries. (Maximum $50,000 benefit per calendar year) Ambulatory Surgical Benefit If outpatient surgery is performed in an Ambulatory Surgical Center or Outpatient Hospital facility, the benefits payable include the surgical and anesthesia benefits in addition to per day ambulatory/outpatient facility benefit. Daily Assistant Surgeon Benefit Daily Anesthesiologist Benefit
3 X the policy fee schedule
2.5 X the policy fee schedule
2 X the policy fee schedule
1 X the policy fee schedule
$3,000
$2,500
$2,000
$1,000
Pays 20% of the eligible surgical benefit Pays 25% of the eligible surgical benefit
$200/10 days
$175/10 days
$125/8 days
$75/6 days
Doctor’s Office Visit with Rollover (Per day/per calendar year)
Rollover provision allows five-visit carryover per policy year.
Prescription Benefit (Per Day) Outpatient Medical Benefits
$75
$50
$50
$25
Colonoscopy Pap PSA Surgical Pathology Other Laboratory Services
$600 $300 $300 $300 $50
$600 $300 $300 $300 $50
$500 $250 $250 $200 $50
$500 $250 $250 $200 $50
Preventative Services: (per service) Laboratory Services: (per day)
Therapy Services: (per day for physical, occupational, speech) Radiology Services: (per day: MRI/PET scan/ CT scan/mammogram/other radiology tests) Calendar year limit for all Outpatient Benefits Ground and Air Ambulance Limit of 2 daily benefits per calendar year for all ambulance transportation (per day*) Allergy Shots and Immunization** (child only) (per day allergy shots/immunizations) Cancer Benefit Pays for Radiation, Chemotherapy, & Immunotherapy (per day/40 days per calendar year)
$75
$75
$50
$50
$700/$700/ $700/$300/$250
$600/$600/ $600/$300/$250
$500/$500/ $500/$250/$200
$300/$300/ $300/$250/$200
$8,000
$6,000
$4,000
$4,000
$150 Ground Ambulance $1,500 Air Ambulance
$10/$25
$2,000
$2,000
$1,000
$1,000
Inpatient Hospital Confinement/ Building Benefit Injury Reimbursement
$1,000,000 calendar year limit $750 calendar year maximum $100 calendar year maximum
Prescription Benefit
Allergy Shots and Immunization
Lifetime Maximum
$5,000,000
*In MI, only one per day benefit will be paid per day, regardless of how many trips are made for that day. ** In MI, Immunization does not apply.
The plans shown above are limited benefit fixed-indemnity plans and benefits are per Covered Person. This is not a major medical insurance plan. Fixed-indemnity benefits are provided for hospital confinement and specified medical and surgical events. These benefits are paid in daily amounts for covered events without regard to the costs of services rendered. This plan does not provide expense reimbursement for charges based on your health care provider’s statement.
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