The following is a more detailed summary of the Tri-Share Limited Benefit Group Healthcare Plan. This is a brief description and does not replace or modify the comprehensive description of all benefits, limitations and exclusions contained in the policy/certificate and riders that are subject to the laws of the state insurance department having jurisdiction. Benefits, limitations, exclusions and rates may vary by state: not available in all states.
Regardless of the combination of Limited Medical benefits selected, the maximum payable per person per calendar year is $100,000 (this maximum is not applicable for Rx or life benefits).
Required Benefits
Daily In-Hospital Indemnity Benefit
The Daily-Hospital Indemnity Benefit is $1,000. The individual must be confined in a hospital receiving treatment or surgery for an accident or illness. This benefit requires a 24-hour hospital stay, however, benefits are payable from the first day of confinement. The indemnity benefit pays a daily amount as selected above for hospital confinements with no specific calendar year or per confinement limit.
In-Hospital Intensive Care Unit Indemnity Benefit
The In-Hospital Intensive Care Unit Indemnity Benefit is $1,000.
The indemnity benefit is payable for 10 days of Intensive Care confinement per covered person per calendar year. A 24-hour hospital stay is required.
The In-Hospital Intensive Care Benefit is payable in addition to the Daily In-Hospital Indemnity Benefit. This benefit pays in addition to the Daily In-Hospital Indemnity Benefit for a total of $2,000 per day.
Surgery and Anesthesia Indemnity Benefit
The Surgery and Anesthesia Indemnity Benefit is $1,500 maximum per person per calendar year.
The Surgery Benefit will pay for both inpatient and outpatient surgical procedures according to the amount shown in the Surgical Schedule or comparable amounts for surgeries not listed subject to the maximum benefit plan selected. If multiple procedures are performed at the same time through the same incision, the amount payable is based on the primary procedure.
The Anesthesia Benefit pays 20% of the Surgery Benefit paid which is $300 maximum per person per calendar year.
Outpatient Physician Office Visit Indemnity Benefit
The Outpatient Physician Office Visit Indemnity Benefit is $50. It is payable for treatment for injury or sickness in a physician’s office.
The indemnity benefit is payable per visit up to 6 visits per person per calendar year.
Outpatient Diagnostic X-ray and Laboratory Indemnity Benefit
The Outpatient Diagnostic X-ray and Laboratory Indemnity Benefit is $100. The benefit is payable per testing day per covered person for medically necessary outpatient x-rays, lab exams, tests and procedures ordered by an attending physician.
The per person per calendar year maximum is $200.
Outpatient Prescription Drug Benefit
The Prescription Drug Benefit is:
- $15 Co-pay for Generic Formulary Drugs
- Up to 40% Discount for non-formulary and Brand name drugs
- $15 Co-pay for oral formulary contraceptives
- Benefit maximum - $750 per calendar year per covered person
Covered drugs must be prescribed by a physician for treatment of a covered accident or sickness. Please note that the Discount for non-formulary and Brand name drugs is a non-insurance benefit.
Employee Group Term Life with AD&D Benefits
Employee Group Term Life with AD&D is $5,000.
If the covered employee leaves the group, he or she can convert their group term coverage to an individual life insurance policy, without disability or other supplementary benefits, subject to satisfying certain requirements. The terms of conversion are given in the life insurance rider attached to the insurance policy.
KeyCare Guide and Wellness Services Benefit
The KeyCare Guide and Wellness Services provides services for Vision Care, Nurse Hotline and Counseling Services as well as Health Tools and Self Care Resources for personal health assessment and education. It is not insurance.
The Vision Care network (Coast to Coast) has direct contracts with more than 10,000 participating eye care locations nationwide. As a member you can save on eyeglasses, contacts, prescription sunglasses, eye exams and surgical procedures.
The Nurse Hotline (IntelliCare) allows telephone access to experienced registered nurses 24 hours a day, 7 days a week, 365 days a year. They are an immediate source of health information about general health concerns, medication and usage, etc. Spanish speaking nurses are on staff.
The Counseling Services (APS) allows employees to speak with a counselor 24 hours a day, 7 days a week, 365 day a year regarding any personal problems they may be facing. In addition, if the employee is referred to one of the 27,000 counseling providers nationwide, he/she will receive discounts of 25% to 30% off the normal billing charges from those providers.
KeyCare Guide provides the Health Tools and Self Care Resources. This product provides individuals with “personal wellness programs” designed around each member’s particular health characteristics. Ultimately the program helps achieve the individual’s personal health goals while helping the employer organization reduce healthcare costs, improve morale, reduce absenteeism and increase productivity.
A Personal Health Assessment (PHA) is completed on-line and will lead each individual through a series of questions that help determine his or her individual health risks.
A Healthy Living Educational Program is provided as a follow-up to the completed Health Assessment. The program includes self-care guides featuring health tips and tracking/reporting mechanisms that can be tied to company sponsored incentive and reward programs.
All health education lessons in The PHD Network™ are written and developed by experts at Duke University Medical Center.
Hospital Admission Indemnity Benefit
The Hospital Admission Indemnity Benefit is $1,000. It is payable one time per calendar year per covered person and is paid in addition to any other benefit provided. A 24-hour stay is required.
Hospital Emergency Room Indemnity Benefit
The Hospital Emergency Room Indemnity Benefit is $300. The benefit is paid per visit per accident or injury. Emergency treatment for accident or injury must be performed within 72 hours.
Outpatient Physician Office Visit – Wellness Indemnity Benefit
The Wellness Indemnity Benefit is $50 per visit. This benefit assists with expenses associated with physical exams, pap smears, and blood screening tests, mammograms, immunizations and prostate-specific tests.
The maximum paid is $150 per covered person per calendar year.
Ambulance Indemnity Benefit
The Ambulance Indemnity Benefit is $150. The benefit is payable up to a maximum of three occurrences per covered person per calendar year, with a lifetime maximum of five times the benefit amount.
Benefits are payable for professional transportation furnished by a licensed ambulance service to the nearest facility for treatment of an injury or sickness. Air transportation to the nearest facility is payable only for medically necessary treatment.
Mental & Nervous In-Hospital Confinement Indemnity Benefit
The Mental & Nervous In-Hospital Confinement Indemnity Benefit is $600 per day.
The benefit amount is 60% of the Daily In-Hospital amount of $1,000. It is limited to a maximum of $5,000 per person per calendar year and $30,000 per person lifetime maximum. A 24-hour hospital stay is required, and benefits are payable from the first day of confinement.
Substance Abuse In-Hospital Confinement Indemnity Benefit
The Substance Abuse Daily In-Hospital Confinement Indemnity Benefit is $600.
The benefit amount is 60% of the Daily In-Hospital amount of $1,000. It is limited to 30 days per person per calendar year. A 24-hour hospital stay is required, and benefits are payable from the first day of confinement.
PPO Network
The PPO network used for the Tri-Share plan is (NPPN) National Preferred Provider Network. It is managed by Plan Vista Solutions, and has over 4,400 acute care facilities, 700,000 physician locations, and 100,000 ancillary care providers.
If utilized, covered individuals will receive a discount off of billed charges when seeing an in-network medical physician or receiving services at an in-network medical facility. Employees can choose to visit any provider, but will only receive discounts from in-network providers. To see a listing of network providers, visit the National Preferred Provider Network website at www.nppn.com.