Aspen STM Insurance

Aspen STM Insurance

Carrier and Underwriter

Association

Billing and Customer Service

All rights reserved. Health Plan Intermediaries Holdings, LLC, ? 2019

Product Summary

Deductible Options Coinsurance Options Out of Pocket Maximum Amount Maximum Benefit Length of Coverage Network

Coverage Effective Date

Eligibility

Waiting Period

$1,000, $2,500, $5,000, $7,500, $10,000 70%, 80%, or 100%

$2,000, $5,000, or $10,000

$100,000, $250,000, $750,000, $1,000,000, $1,500,00

Available for up to 36 months of coverage depending upon state regulations

? PHCS network giving members access to in-network negotiated rate ? Facility charge: Plan pays up to 150% of Medicare allowable charges

Next day coverage; later effective date available, but not to exceed 60 days from date of transmission 18-64 applicant and spouse, dependent unmarried children under 26 Child-only coverage is available for ages 2-17 5 days for sickness 30 days for cancer 6 months for various covered surgeries

Who is this plan good for?

? Between jobs or have been laid off ? Waiting for employer benefits ? Part-time or temporary employee

? Recently graduated ? Without adequate health insurance

Pre-Existing Conditions Allowance Benefit:

Pre-Existing Conditions Allowance Benefit means, any eligible expenses related to Pre-Existing Conditions will be paid up to and no more than 50% of the Plan's Deductible, per Coverage Period. Deductibles and Coinsurance Payments of any eligible plan benefits are applicable to this benefit. However, payment of this benefit does not in any way affect or waive any of the Exclusions or Limitations. Once the plan has paid the amount of up to 50% of the Plan's Deductible the consumer is responsible for all claims related to the pre-existing conditions.

How will consecutive policy terms work?

When a customer applies for consecutive policy terms in one enrollment, they will be issued their initial term of coverage, and subsequent terms will be pending. Customers will not have to reaply for additional terms. The waiting period on all subsequent terms will be waived. When subsequent terms of coverage are set to begin, the customer will receive an email stating their plan has continued into the next term. The email will provide them with their new monthly rate (if applicable), and they will have the opportunity to opt out at this time.

How does the Waiver of Pre-existing Conditions Rider work?

Waiver of Pre-Existing Conditions Rider option will allow charges resulting from a condition for which a covered person received medical treatment, diagnosis, care or advice, including diagnostic tests or medications, within the initial policy. This includes symptoms that manifested while the person was covered under the initial policy. The Waiver of Pre-Existing Conditions Rider does not become effective until the end of the Covered Person's first initial policy, no later than the day after the termination date of the initial policy.

Disclaimer:

THIS COVERAGE IS NOT REQUIRED TO COMPLY WITH CERTAIN FEDERAL MARKET REQUIREMENTS FOR HEALTH INSURANCE, PRINCIPALLY THOSE CONTAINED IN THE AFFORDABLE CARE ACT. BE SURE TO CHECK THE CERTIFICATE CAREFULLY TO MAKE SURE YOU ARE AWARE OF ANY EXCLUSIONS OR LIMITATIONS REGARDING COVERAGE OF PRE-EXISTING CONDITIONS OR HEALTH BENEFITS (SUCH AS HOSPITALIZATION, EMERGENCY SERVICES, MATERNITY CARE, PREVENTIVE CARE, PRESCRIPTION DRUGS, AND MENTAL HEALTH AND SUBSTANCE USE DISORDER SERVICES). THE INSURED'S COVERAGE ALSO HAS LIFETIME AND/OR ANNUAL DOLLAR LIMITS ON HEALTH BENEFITS. IF THIS COVERAGE EXPIRES OR THE INSURED LOSES ELIGIBILITY FOR THIS COVERAGE, YOU MIGHT HAVE TO WAIT UNTIL AN OPEN ENROLLMENT PERIOD TO GET OTHER HEALTH INSURANCE COVERAGE. THIS INFORMATION IS A BRIEF DESCRIPTION OF THE IMPORTANT FEATURES OF THIS INSURANCE PLAN. COVERAGE MAY NOT BE AVAILABLE IN ALL STATES OR CERTAIN TERMS MAY BE DIFFERENT WHERE REQUIRED BY STATE LAW. PRE-EXISTING CONDITIONS ARE NOT COVERED, AND BENEFITS ARE SUBJECT TO THE POLICY LIMITATIONS AND EXCLUSIONS. REFER TO THE POLICY, CERTIFICATE AND RIDERS FOR COMPLETE DETAILS.

Benefits

Plan Deductible Options

Plan 1

$1,000, $2,500, $5,000, $7,500

Coinsurance Options Out of Pocket Maximum Options Coverage Period Maximum Benefit Options

70%, 80%, or 100% $2,000, $5,000 $250,000, $750,000, $1,000,000

Additional Deductibles Outpatient Surgery Additional Deductible

No Additional Deductibles

Plan 2

$1,000, $2,500, $5,000, $7,500

70%, 80%, or 100% $2,000, $5,000 $100,000, $250,000, $750,000, $1,000,000, $1,500,000

No Additional Deductibles

Emergency Room Additional Deductible

No Additional Deductibles

No Additional Deductibles

Plan 3

$1,000, $2,500, $5,000, $7,500, $10,000 70%, 80%, or 100% $2,000, $5,000, $10,000 $100,000, $250,000, $750,000, $1,000,000, $1,500,000

$500 per surgery after which Plan Deductible and Coinsurance will apply. Maximum 3 $500 per visit after which Plan Deductible and Coinsurance will apply. Deductible is waived if admitted to hospital

Advanced Diagnostic Studies Additional Deductible Copayments Doctor's Office Visit / Urgent Care Center

Wellness Benefit

No Additional Deductibles

No Additional Deductibles

$500 per occurrence after which Plan Deductible and Coinsurance will apply.

$40 Copayment per visit, not to exceed a maximum of 3. Coinsurance is 100% of Eligible Expenses and benefits are not subject to the Plan Deductible. Office Visits in excess of the maximum number of Copayments will be subject to the Plan Deductible and Coinsurance. Any other covered services or tests performed as part of the office visit will be subject to the Plan Deductible and Coinsurance. The office visit maximum for all Doctor office visits, including any other covered services or tests performed as part of the office visit, will not exceed $2,000 per Covered Person per Coverage Period.

$50 Copayment for one annual Routine Physical Exam. Coinsurance is 100% and benefits are not subject to the Plan Deductible.

$25 Copayment per visit per Covered Person. Coinsurance is 100% of Eligible Expenses and benefits are not subject to the Plan Deductible.

$50 Copayment for one annual Routine Physical Exam. Coinsurance is 100% and benefits are not subject to the Plan Deductible.

$40 Copayment per visit per Covered Person. Coinsurance is 100% of Eligible Expenses and benefits are not subject to the Plan Deductible.

$50 Copayment for one annual Routine Physical Exam. Coinsurance is 100% and benefits are not subject to the Plan Deductible.

Advanced Diagnostic Studies Copayment

Subject to Deductible and Coinsurance.

$500 Copayment per occurrence for Advanced Diagnostic Studies in an Outpatient setting, including PET, MRI, CAT scans not to exceed a maximum of 3 Copayments per Covered Person. Coinsurance is 100% of Eligible Expenses and benefits are not subject to the Plan Deductible. Occurrences in excess of the maximum number of Copayments will be subject to the Plan Deductible and Coinsurance.

Subject to Deductible and Coinsurance.

Disclaimer: All benefits are limited to Usual and Customary Fees. Usual and Customary Fees definition may vary by state. Coverage is not limited to the benefits listed; any eligible expenses are subject to plan limitations. Please check the product certificate or master policy for complete details.

Below benefits are subject to Deductible and Coinsurance.

Benefits

Plan 1

Plan 2

Plan 3

Inpatient Hospital

Standard Room Rate

Average Standard room rate. Benefits, including nursing services and all miscellaneous medical charges are limited to $1,000 per day.

Average Standard room rate. Benefits, including nursing services and all miscellaneous medical charges are limited to $4,000 per day.

Average Standard room rate.

Intensive Care or Critical Care Unit

The benefit payable for each day of confinement in an Intensive Care or Critical Care Unit. Benefits, including nursing services and all miscellaneous expenses, are limited to $1,250 per day.

The benefit payable for each day of confinement in an Intensive Care or Critical Care Unit. Benefits, including nursing services and all miscellaneous expenses, are limited to $4,000 per day.

The benefit payable for each day of confinement in an Intensive Care or Critical Care Unit.

Inpatient Doctor Visits

$50 per day. Benefits for all Hospital visits during a Hospital stay are limited to $500 per Covered Person per Coverage Period.

$50 per day. Benefits for all Hospital visits during a Hospital stay are limited to $500 per Covered Person per Coverage Period.

Subject to Deductible and Coinsurance.

Emergency Room

The benefit payable for each emergency room visit, including professional and facility services, will not exceed $250 per visit. (This includes the emergency room physician charge, 24 hours surveillance and all miscellaneous medical charges).

The benefit payable for each emergency room visit, including professional and facility services, will not exceed $500 per visit. (This includes the emergency room physician charge, 24 hours surveillance and all miscellaneous medical charges).

Subject to Additional Deductible shown above, then subject to Deductible and Coinsurance.

Outpatient Hospital Services

Outpatient Surgical Facility

The benefit payable per day including all miscellaneous expense, is limited to $1,250.

The benefit payable per day including all miscellaneous expense, is limited to $2,500.

Subject to Additional Deductible shown above, then subject to Deductible and Coinsurance.

Outpatient Miscellaneous Hospital Expenses

The benefit payable for miscellaneous Outpatient Hospital expenses, excluding Outpatient Surgery. Benefits are limited to $1,250 per Covered Person per Coverage Period for all Eligible Expenses combined.

The benefit payable for miscellaneous Outpatient Hospital expenses, excluding Outpatient Surgery. Benefits are limited to $2,500 per Covered Person per Coverage Period for all Eligible Expenses combined.

The benefit payable for miscellaneous Outpatient Hospital expenses, excluding Outpatient Surgery.

Other Covered Services

Surgeon

$5,000 per surgery, for all Eligible Expenses combined, not to exceed $10,000 per Covered Person per Coverage Period.

$10,000 per surgery, for all Eligible Expenses combined, not to exceed $20,000 per Covered Person per Coverage Period.

Subject to Deductible and Coinsurance.

Assistant Surgeon and Surgical Assistant

$1,000 per surgery, for all Eligible Ex-

$2,000 per surgery, for all Eligible Ex- Subject to Deductible and Coinsurance.

penses combined, not to exceed $2,000 penses combined, not to exceed $4,000

per Covered Person per Coverage Period. per Covered Person per Coverage Period.

Administration of Anesthetics

$1,000 per surgery, for all Eligible Ex-

$2,000 per surgery, for all Eligible Ex- Subject to Deductible and Coinsurance.

penses combined, not to exceed $2,000 penses combined, not to exceed $4,000

per Covered Person per Coverage Period. per Covered Person per Coverage Period.

Extended Care Facility

$150 per day not to exceed a maximum of 30 days per Covered Person per Coverage Period.

$150 per day not to exceed a maximum of 30 days per Covered Person per Coverage Period.

$150 per day not to exceed a maximum of 30 days per Covered Person per Coverage Period.

Home Health Care

$50 per visit. There is a limit of 1 visit per day not to exceed a maximum of 30 visits per Covered Person per Coverage Period.

$50 per visit. There is a limit of 1 visit per day not to exceed a maximum of 30 visits per Covered Person per Coverage Period.

$50 per visit. There is a limit of 1 visit per day not to exceed a maximum of 30 visits per Covered Person per Coverage Period.

Hospice Care

$2,500 per Covered Person per Cover- $2,500 per Covered Person per Cover- $2,500 per Covered Person per Cover-

age Period.

age Period.

age Period.

Disclaimer: All benefits are limited to Usual and Customary Fees. Usual and Customary Fees definition may vary by state. Coverage is not limited to the benefits listed; any eligible expenses are subject to plan limitations. Please check the product certificate or master policy for complete details.

Ambulance Injury

Benefits

Plan 1

$250 per transport

Plan 2

$500 per transport

Plan 3

$500 per transport

Sickness

$250 per transport

$500 per transport

$500 per transport

Physical, Occupational and Speech Therapy $50 per day and 20 visits combined per $50 per day and 20 visits combined per $50 per day and 20 visits combined per Covered Person per Coverage Period. Covered Person per Coverage Period. Covered Person per Coverage Period.

Organ or Tissue Transplants

$50,000 per Covered Person per Cov- $50,000 per Covered Person per Cov- $50,000 per Covered Person per Cov-

erage Period

erage Period

erage Period

AIDS

$10,000 per Covered Person per Cov- $10,000 per Covered Person per Cov- $10,000 per Covered Person per Cov-

erage Period

erage Period

erage Period

TMJ

$3,500 per Covered Person per Cover- $3,500 per Covered Person per Cover- $3,500 per Covered Person per Cover-

age Period

age Period

age Period

Kidney Stones

$1,500 per Covered Person per Cover- $1,500 per Covered Person per Cover- $1,500 per Covered Person per Cover-

age Period

age Period

age Period

Appendectomy

$2,500 per Covered Person per Cover- $2,500 per Covered Person per Cover- $2,500 per Covered Person per Cover-

age Period

age Period

age Period

Joint or Tendon Surgery

$2,500 per Covered Person per Cover- $2,500 per Covered Person per Cover- $2,500 per Covered Person per Cover-

age Period

age Period

age Period

Knee Injury or Disorders

$2,500 per Covered Person per Coverage Period for both left knee and right knee

$2,500 per Covered Person per Coverage Period for both left knee and right knee

$2,500 per Covered Person per Coverage Period for both left knee and right knee

Gallbladder Surgery

$2,500 per Covered Person per Cover- $2,500 per Covered Person per Cover- $2,500 per Covered Person per Cover-

age Period

age Period

age Period

Mental Disorders

Inpatient:

$100 per day, 31 day maximum per Covered Person per Coverage Period.

$100 per day, 31 day maximum per Covered Person per Coverage Period.

$100 per day, 31 day maximum per Covered Person per Coverage Period.

Outpatient

$50 per visit, 10 visits per Covered Person per Coverage Period

$50 per visit, 10 visits per Covered Person per Coverage Period

$50 per visit, 10 visits per Covered Person per Coverage Period

Substance Abuse

Inpatient:

$100 per day, 31 day maximum per Covered Person per Coverage Period.

$100 per day, 31 day maximum per Covered Person per Coverage Period.

$100 per day, 31 day maximum per Covered Person per Coverage Period.

Outpatient

$50 per visit, 10 visits per Covered Person per Coverage Period

$50 per visit, 10 visits per Covered Person per Coverage Period

$50 per visit, 10 visits per Covered Person per Coverage Period

Option of Waiver of Pre-Existing Conditions Yes

Yes

Yes

Rider

Disclaimer: All benefits are limited to Usual and Customary Fees. Usual and Customary Fees definition may vary by state. Coverage is not limited to the benefits listed; any eligible expenses are subject to plan limitations. Please check the product certificate or master policy for complete details.

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