Arizona Health Insurance > Assurant Health/Time Insurance Company > CoreMed & MaxPlan Plan Provisions

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Office Visit Copay

With this benefit, a copay is your only cost for an eligible network office visit. The cost of an office visit includes examination, consultation, evaluation, any development of a treatment plan and allergy shots. Any associated imaging and laboratory services, such as x-rays and blood tests, are covered subject to deductible and coinsurance, but are not eligible for benefits under the office visit copay.

After the preventive services waiting period, preventive services performed by a network provider during an office visit, such as immunizations and annual examinations, are covered by the office visit copay. Any associated imaging and laboratory services, such as mammograms and PSA tests, are covered subject to deductible and coinsurance, but are not eligible for benefits under the office visit copay.

Other services that are subject to deductible and coinsurance, but not eligible for benefits under the office visit copay, are: office visits with non-participating providers, surgical procedures, allergy tests, treatment of behavioral health or substance abuse and maternityrelated visits.

Maternity Benefit (optional feature)

The maternity deductible is separate from the plan deductible. Once the maternity deductible is met, the plan pays for covered maternity services (whether or not the plan deductible has been satisfied). Prescription drugs are covered under the plan prescription drug benefit. If conception occurs during the first 90 days of coverage, routine maternity charges will be excluded. Facility fees do not apply.

First-Dollar Preventive Services (Optional - One Deductible Plan)

Your Assurant Health HSA plan provides benefits for preventive services. Add this first-dollar benefit option and you’ll have $500 per person per calendar year for preventive services –– before your deductible is met. This benefit is available on OneDeductible HSA plans once you have been insured for 12 months. Remaining preventive services are covered subject to deductible and coinsurance up to the annual preventive services benefit maximum.

Medically Necessary Care

Treatment must be medically necessary to be covered. Medically necessary services or supplies must be:

• Appropriate and consistent with the diagnosis
• Commonly accepted as proper treatment
• Reasonably expected to result in improvement of the condition
• Provided in the least intensive setting without affecting the quality of medical care provided.

Maximum Allowable Amount

The maximum allowable amount is the most the plan pays for covered services. If you use a non-network provider, you are responsible for any balance in excess of the maximum allowable amount.

Network Services

When you use network providers, covered charges are discounted and never exceed the maximum allowable amount.

Non-Network Services

• Emergencies: Covered services are always paid at the network benefit percentage –– even if you are out of network –– subject to the maximum allowable amount.
• Non-emergencies: Covered services are subject to the non-network deductible, the maximum allowable amount provision, a 20% benefit percentage reduction, and the increased non-network coinsurance out-of-pocket maximum.
• Individual non-network deductible is the individual deductible plus $1,000.
• Family non-network deductible is two times the individual non-network deductible and is met collectively by two or more persons.
• Non-network coinsurance out-of-pocket maximum is $10,000/person – $20,000/family for all options except the $0 Deductible Package, which has $12,500/person – $25,000/family.

Utilization Review

Authorization is required before inpatient treatment and certain types of outpatient procedures. Unauthorized services will result in a penalty of 25% of the charge (up to $1,000). Unauthorized transplants are not covered.

Benefit Waiting Periods on Certain Treatment

Benefits for certain types of treatment are payable after the benefit waiting period listed here:

• Surgical treatment of tonsils/adenoids—3 months
• Surgical treatment of bunions, hemorrhoids, inguinal hernia (except strangulated or incarcerated), varicose veins—6 months
• Sterilization—12 months

Benefit waiting periods are waived when this plan is replacing other similar in-force coverage.

Pre-Existing Conditions

A pre-existing condition is an illness or injury and related complications for which, during the 12-month period immediately prior to the effective date of your health insurance coverage: 1) you sought, received or were recommended medical advice, consultation, diagnosis, care or treatment, 2) prescription drugs were prescribed, 3) symptoms were produced, or 4) diagnosis was possible. No benefits are paid for charges incurred due to a pre-existing condition until you have been continuously insured under the plan for 12 months unless the condition was fully disclosed on the application. After the 12-month period, benefits are paid for a pre-existing condition, unless the condition is specifically excluded from coverage.

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