Limited Benefit Health Insurance Proposal

Limited Benefit Health Insurance Proposal

Prepared For :

Date Prepared :

Presented By : Standard Life and AccidentAgent Name

Valued Client

S T A N D A R D L I F E A N D A C C I D E N T I N S U R A N C E C O M P A N Y - G a l v e s t o n , T X - 8 8 8 . 2 9 0 .1 0 8 5

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The Ultissential Care Advantage…………...………………………………3

Inpatient Benefit Description All Plans……………………………………4

Outpatient Benefit Description All Plans………………………………… 5

Prescription Drug Plan………………………………………………………6

MultiPlan PPO Network……………………………………………………7

Critical Illness Benefit……………………………………………… 8

Accidental Death and Dismemberment Benefit……………………. 9

Frequently Asked Questions……………………………………………… 10

Table of Contents

Monthly Rates Voluntary………………………………………………… 11

Monthly Rates Employer Contribution……………………………………12

Exclusions and Limitations…………………………………………………13-14

2S T A N D A R D L I F E A N D A C C I D E N T I N S U R A N C E C O M P A N Y

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- Available to companies with a minimum of two (2) lives- Can be used as a tool for recruiting and promoting employee retention- Multiple plan choices- Plans can be placed under Section 125/Cafeteria Plan- Optional maternity benefit

Employer Advantage:

Foremost in the minds of most employees is health insurance. In fact, the concern for health insurance is ranked higher than for retirement plans.* Consequently, foremost in the minds of most employers is how to provide health benefits that are affordable to both the employee and the company.

Ultissential Care from Standard Life and Accident Insurance Company (Standard Life) can be your answer. Ultissential Care is affordable, Limited Benefit Health Insurance. The plans pay a fixed amount to help cover common inpatient and outpatient medical expenses such as costs associated with hospitalization, surgery, doctor visits, x-rays, lab tests and more, including wellness benefits and a critical illness benefit not always provided by other insurance. Ultissential Care also provides a valuable prescription drug plan**.

- Straight forward benefits- Premiums are paid through payroll deduction, simplifying the process for employees- No deductibles- No copayments, except on prescription drug benefits**- No coordination of benefits, plans pay regardless of coverage under other insurance plans- Optional provider network may lower employee out-of-pocket costs***- Underwritten by Standard Life and Accident Insurance Company

S T A N D A R D L I F E A N D A C C I D E N T I N S U R A N C E C O M P A N Y 3

Employee Advantage:

*Reuters, Entrepreneurial, Grow your own, “Want to keep your employees? Try better benefits.” 14 Jan. 2011. Web 5 May 2011, http://blogs.reuters.com/small-business/2011/01/14/want-to-keep-your-employees-try-better-benefits/

**The prescription drug plan is a separate benefit offered by and underwritten by Fidelity Security Life Insurance Company. Each company is responsible only for its own products and services.

***PPO provider services are provided by MultiPlan. Each company is responsible only for its own products and services.

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Hospital Confinement:* 365 Days

$500 / day30 day CYM



$350 / day

25%


90% RBRVS

30 day CYM

$1,000

$2,000 / day30 day Maximum

30 day CYM


25%

$350 / day

60% RBRVS

$1,400 / day30 day Maximum

75% RBRVS

25%

$250/ day30 day CYM


$1,000 / day 30 day Maximum

Surgical Schedule**

Anesthesia

Continuous Care: 30 Days

Substance Abuse: 30 Days

Mental Illness: 30 Days

365 days

INPATIENT

Hospital Admission* N/A

PLAN BENEFIT DESCRIPTION

$1,000 / day

Plan 700

$500 / day $700 / day

Plan 500 Plan 1000

$700

365 days

Intensive Care

365 days

** Resource Based Relative Value System (RBRVS) means the methods used by the Federal Government to determine relative benefit values. Surgical benefit in North Carolina is a schedule of benefits not to exceed $10,000.

* “Hospital” does not include any institution or part thereof used as a Rehabilitation Unit or Rehabilitation Facility; a Hospice unit, including any bed designated as a Hospice or a swing bed; a convalescent home; a rest or nursing facility; an extended-care facility; a Skilled Nursing Facility; or a facility primarily affording custodial or educational care, care or treatment for persons suffering from mental disease or disorders, care for the aged, or care for persons addicted to drugs or alcohol.

Benefits provided depend upon the plan selected and the premium will vary with the amount of the benefits selected.


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$100 / Trip1 trip / perl d

$100 / Trip1 trip / perl d

per calendar year4 test days

$250 / surgery

calendar year

N/A

$80 / visit3 visits per

$250 per test day

N/AN/A


calendar year

calendar year

$100 / visit 3 visits per

$175 / surgery

N/AN/A

N/A

N/A

N/AN/A

N/AN/AN/A

$250 per test day4 test days

per calendar year

N/A

N/AN/AN/A

N/AN/A

3 visits percalendar year

N/A


calendar year


calendar year

$100 / visit

5 visits percalendar year

$150 / visit1 visit per

calendar year

Ambulatory Surgical Center

Ambulance Services Ground

Outpatient Diagnostic, X-Ray and Lab Benefit

Emergency Room: Accident

Wellness Benefit

Emergency Room: Sickness

OUTPATIENT

Physician Office Visit $50 / visit

PLAN BENEFIT DESCRIPTION Plan 500 Plan 700 Plan 1000

*Prescription drug plan is a separate benefit offered by and underwritten by Fidelity Security Life Insurance Company.**Optional provider network may lower employee out-of-pocket costs. Each company is responsible only for its own products and services

PPO Medical Network** MultiPlan

S T A N D A R D L I F E A N D A C C I D E N T I N S U R A N C E C O M P A N Y

$5,000

MultiPlanMultiPlan

$2,400

1 trip / per

calendar yearcalendar year

calendar year

$10,000$20,000

$100 / TripN/A

$10,000

$10 Copay$30 CopayDiscount

Yes

$20,000

$5,000


$10,000$20,000

$5,000

$100 / Trip1 trip / per

$2,400

calendar year


YesYes$2,400

N/A

N/AN/A

Accidental DeathCommon Carrier

Critical Illness

- Mail OrderAnnual Max per Member

Insured Prescription Drug Benefit* - Generic - Preferred Name Brand - Non-preferred Brand Name

Ambulance Services Air

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You may purchase up to a 31-day supply of most prescription medications

What you need to know about using your Prescription Drug Plan

Please remember, your copayment applies only to medications on the BMR Insured Rx Formulary included in your Welcome Kit. Any medications not included, such as non-formulary drugs, you will receive the BMR Insured Rx discounted cost, but you are responsible for 100% of the cost of the medication at time of purchase. Please refer to the BMR Insured Rx Formulary included in your plan information or visit our web site, www.bmr-inc.com, to confirm if your medication is brand or generic and the cost.

If you do not have the ability to access our web site through the Internet, you may also contact our team of highly skilled Member Service Representatives (866 718 2375) who will assist in answering your questions

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Your plan provides you with prescription drugs through RESTAT’s national network of more than 64,000pharmacies.

Some of the participating pharmacies include; CVS, Walgreens, Wal-Mart, Rite Aid, Target, K-Mart and most independent pharmacies. Select a convenient pharmacy using the pharmacy locator on our website. Present your ID card, pay the copayment and you’re done. If you do not have access to the internet call BMR Member Services at 866.718.2375.

S T A N D A R D L I F E A N D A C C I D E N T I N S U R A N C E C O M P A N Y6

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Ultissential Care partners with MultiPlan to provide its Limited Benefit Plan participants access to thousands of hospitals, practitioners and ancillary facilities who have agreed to significant discounts on their medical services. MultiPlan is the nation’s oldest, largest and most comprehensive provider of independent medical cost management solutions, including PPO Networks.

To locate a MultiPlan Provider visit www.multiplan.com - Search for a Provider - Locate the logo shown below on the “other logos” tab.

With a network of more than half a million healthcare professionals, over 4,700 Hospitals and over 96,000 ancillary care facilities, plan participants will have access to a wide range of quality healthcare providers across the county.

Ultissential Care plan participants can access and choose their Providers in order to take advantage of discounted prices through facilities and providers that are part of the MultiPlan network.

E l f M lti l PPO S i

*This illustration is an example of average discounts based on all claims processed in a 12 month period.Effective discounts will vary from state to state. PPO Provider services are provided by MultiPlan, Inc.www.multiplan.com

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Hospitals and Facilities 101,000 16%-33%

Physicians 744,000 39.2%

Example of Multiplan PPO SavingsDescription Effective Discount*Total Number

Phycisians/Facilities


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c. Multiple Myeloma.

A lump sum benefit in the amount listed will be paid upon diagnosis of a covered illness that first occurs not less than 30 days after your effective date of coverage.

a. leukemia;

b. lymphoma; or

The following are not “Invasive Cancer”:

c. early prostate cancer diagnosed as T1N0M0 or equivalent staging;

The benefit is payable for a single-incident of a covered illness while the coverage is in force.

The following illnesses are covered when diagnosed by a physician:

1. Invasive Cancer: means a malignant neoplasm, which is characterized by the uncontrolled growth and spread of malignant cells and the invasion of tissue through the basement membrane or capsule. “Invasive Cancer” includes, but is not be limited to any form of:

b. benign tumors or polyps;

a. pre-malignant lesions;

3. Heart Attack: means an acute myocardial infarction resulting in:

d. cancer in situ; or

e. any skin cancer (other than invasive malignant melanoma or skin malignancies that have become metastatic).

b. resulting in the loss of the normal function of the heart.

a. the death of a portion of the heart muscle (myocardium) due to a blockage of one or more coronary arteries; and


2. Stroke: means any acute cerebrovascular accident producing neurological impairment resulting in paralysis. Transient ischemic attack (mini-stroke), head injury, chronic cerebrovascular insufficiency and reversible ischemic neurological deficits are excluded.

An established (old) myocardial infarction or heart attack occurring during any surgical procedure is excluded.

4. End-Stage Renal Failure: means the chronic and irreversible failure of both kidneys, which requires the Covered Person to undergo periodic and ongoing dialysis.

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This benefit is not payable if the Common Carrier Benefit is eligible to be paid.

Common Carrier Benefit

A lump sum benefit in the amount listed will be paid when an injury, caused by an accident, results in the death of the Covered Person within 90 days of the accident date.

Accidental Death Benefit

Accidental Dismemberment benefits will be paid when an injury that results in a dismemberment that is specified in the Certificate Schedule of Benefits, occurs within 90 days of the date of the accident.

Common Carrier benefits listed will be paid if a Covered Person dies from an injury resulting from an accident while riding in or on a Common Carrier, i.e. airplane, bus, train. This benefit is paid in lieu of the Accidental Death Benefit.

The benefit will also apply if the accident occurs while entering or exiting, getting in or out of, or on or off of, the Common Carrier. A taxi is not considered a Common Carrier.

Accidental Dismemberment Benefits

The benefit will be paid upon proof of death.

If a Covered Person suffers one or more losses from the same accident for which benefits are payable under more than one category, the amount payable will be limited to only one of the covered losses, the largest to which the Covered Person is entitled.


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1.

2.

3.

4.

5.

Yes. Benefits will be paid for covered services by any licensed physician or accredited hospital. However, PPO negotiated discounts may not apply to physicians or facilities outside of the

and is not major medical coverage.No. Ultissential Care is a fixed indemnity plan. This policy is not designed to cover all medical expenses

Yes. Ultissential Care does not coordinate benefits. The plan pays even if benefits are paid for the same

If elected by the employer, pregnancy will be covered if the participant's effective date of coverage is

illness under a different plan

Can Ultissential Care be used if the participant has separate health insurance?

prior to the date of conception.

Does Ultissential Care cover maternity?*

Yes. Spouses of employees and children under age 26 may apply under the employee’s policy.

Will Ultissential Care pay benefits if I go outside of the network?

MultiPlan network. Participants should verify benefits before any services are applied.

Can dependents be insured?

Is this Major Medical coverage?

6.

7.

**May vary by state

*The Maternity Benefit is mandatory in Montana

illness under a different plan.

Who receives the benefit payment?**Benefits can be assigned to the participant’s healthcare provider, unless the participant elects


to receive the benefit payment directly.

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Is Ultissential Care COBRA eligible?Yes, Ultissential Care is COBRA eligible for employers with over 20 employees.

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$239.22 $495.43Plan 1000

$615.65

$713.65

Plan 700 $204.22 $419.43

Spouse Child(ren)

$268.43Plan 500 $130.22

Member + Member +

Plan 500

$225.22

$146.22

With Maternity

Member

Plan 1000 $270.22 $539.43 $760.65

$219.41

$450.43 $382.41 $648.65

$292.43 $241.41

Plan 700

Child(ren)Family

$442.41

Without Maternity*

Member Family

$354.41

$402.41

Member + Member +

$385.65

$410.65

Spouse

*The Maternity Benefit is mandatory in Montana.

Rates are guaranteed for 90 days from date of proposal. If proposal is accepted after 90 days, then plans must be re-quoted or confirmed.

This policy is renewable at the option of the Company. The Company may change premiums from time to timebased on class, composition or by age.

Proposal is based on information provided and subject to underwriting and Home Office approval.


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$351.41

$195.41

Plan 700

$116.22

$179.22

Member +

$620.65Plan 1000 $208.22 $430.43

Plan 500

$334.41

Plan 1000 $660.65$385.41

Without Maternity*

Member Member +

Plan 700 $196.22 $392.43

$235.22 $468.43

$366.43 $310.41

FamilySpouse Child(ren)

$341.65

$537.65

$237.43

$565.65

$129.22 $258.43 $214.41

Child(ren)Family

Plan 500

Member +

$363.65

With Maternity

MemberSpouse

Member +

*The Maternity Benefit is mandatory in Montana.

time based on class, composition or by age.This policy is renewable at the option of the Company. The Company may change premiums from time to Proposal is based on information provided and subject to underwriting and Home Office approval.


Rates are guaranteed for 90 days from date of proposal. If proposal is accepted after 90 days, then plans must be re-quoted or confirmed. For rate determination, any case which has 50% or greater employer contribution and participation levels of at least 85% of the eligible employees will qualify for the above rates.

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Waiting Period Limitation:Loss caused by or relating to sickness will not be covered for the first 30 days after the Certificate EffectiveDate of each Covered Person.

Pre-existing Condition Limitation:Loss caused by or relating to a Pre-existing Condition is not covered for the first 12 months* after the CertificateEffective Date of each Covered Person.

Exclusions:No coverage shall be provided and no benefits will be paid for any loss resulting in whole or in part fromor contributed to, or as a natural and probable consequence of any of the following

1. Suicide or any attempt at suicide or intentionally self-inflicted injury or any attempt atintentionally self-inflicted injury or any act of auto-eroticism, while sane or insane

2. Travel or flight in or on (including getting in or out of, or on or off of) any vehicle used for aerialnavigation, if the Covered Person is:

a. riding as a passenger in any aircraft not intended or licensed for the transportation of passengers

b. performing, learning to perform or instructing others to perform as a pilot or crew member of any aircraft; or

c. riding as a passenger in an aircraft owned, leased or operated by the Covered Person’s employer

3. War (whether declared or not) or any act of war, while serving in the military service or any auxiliaryunit attached thereto;

4. Full-time active duty in the armed forces, National Guard or organized reserve corps of any countryor international authority. (Unearned premium for any period for which the Covered Person is notcovered due to his/her active duty status will be refunded. Loss caused while on short-term NationalGuard or reserve duty for regularly scheduled training purposes is not excluded.)

5. The Covered Person’s being intoxicated (defined as blood alcohol concentration equal to or in exces of .08 gms/dl blood alcohol). This applies whether or not the Covered Person is charged with anyviolation in connection with a loss and there is no need to prove a loss was caused, contributed to,or resulted from the excessive blood alcohol concentration

6. The Covered Person’s: a) voluntary use of illegal drugs; b) the intentional taking of over the countermedication not in accordance with recommended dosage and warning instructions; and c) intentionalmisuse of prescription drugs;

7. The Covered Person’s commission of or attempt to commit a felony

8. The Covered Person being engaged in an illegal occupation;

9. Services and supplies which are not Medically Necessary to treat a covered loss (other than asstated in the Wellness and Preventive Care Benefit);

10. Services and supplies which are received without charge or legal obligation to pay or would notnormally be paid in the absence of insurance;

11. Services and supplies which are received outside of the United States of America, it’s possessionsand territories;

12. Dental care or treatment unless due to an injury to a sound and natural tooth;

*May vary by state


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13. Cosmetic surgery or reconstructive surgery, including breast reduction and surgery to repair, replace, or remove breast implants; however, this Exception does not apply when surgery is required:

a. To repair a birth defect of a child born to the Employee and continuously covered under the Policy

b. For reconstructive surgery following a covered mastectomy;

14. Any covered loss that is covered under any state or federal Worker’s Compensation, Employer’Liability law or similar law;

15. Any procedure for refractive correction, eye refraction or the purchase or fitting of vision or hearingaids, Cochlear Implants and related devices.

16. Participating in hazardous occupations or other activity including participating, instructing, demonstrating, guiding or accompanying others in the following: professional or semi-professionasports, extreme sports, organized body contact sports, parachute jumping, hot-air ballooning, hanggliding, base jumping, mountain climbing, bungee jumping, scuba diving, sail gliding, parasailingparakiting, rock or mountain climbing, cave exploration, parkour, racing including stunt show or speedtest of any motorized or non-motorized vehicle, rodeo activities, or similar hazardous activities. Alsoexcluded is injury received while practicing, exercising, undergoing conditional or physical preparationfor such activity;

17. A custodial institution, domiciliary care or rest cures;

18. Weight reduction or treatment of obesity, including exogenous, endogenous or morbid obesity; o

19. Diagnosis or treatment (including surgery) of sexual dysfunctional disorders or inadequacy, org ( g g y) y q y,transsexual surgery.


The Company may deny coverage of a person who does not meet the Company’s underwriting requirements at the time of enrollment. The Policy is cancellable at the option of the company and we have a right to increase premiums.

THIS POLICY PROVIDES LIMITED BENEFITS. Policy form SL-VERSEP/SL-VERSEC is not available in all states and benefits and premium may vary. This plan contains terms of renewability, exclusions and limitations. This is a lead for solicitation of insurance and an agent will contact you. For a complete description of the terms of coverage, pricing information, and exclusions and limitations, please contact the company or your insurance professional.

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Limited Benefit Health Insurance Proposal

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