Plans and Coverage
Know before you pick a health plan that is right for you.
If you find that you've purchased your STM or Limited Med plan in error or it's just not the right plan for you, you can cancel your plan, as long as no claims have been filed, within 10 days of your effective date and you'll get all your money back-guaranteed.
Short-Term Health Insurance
Short Term Medical insurance isn’t for everyone. While it covers some medical expenses, it doesn’t cover everything. See detail plan benefits of each plan to know more about what it covers and what it doesn’t. Short Term Health insurance plan is NOT considered "minimum essential coverage" under the Affordable Care Act and therefore you may be subject to a tax penalty.
Short Term Health insurance or "Short-term, limited-duration insurance" is a limited duration, varies by each state and can be bought in any time of the year. These plans are for people who need temporary health insurance and also can’t afford high major medical plans.
Short Term health insurance is most suited for peoples,
- Between jobs or have been laid off
- Part-time or temporary employee
- Recently graduated
- Can’t afford high premium
- You’ve retired but are too young to be eligible Medicare.
- Missed annual Open Enrollment for ACA /Obamacare plans
How Is Short Term Health Insurance Different From ACA/Obamacare?
|ACA/ Obama care||Short Term Health insurance|
|Cost||Much higher than STM||Less than major medical plans|
|Emergency Room Visits||Yes||Yes|
|Prescription Drugs||Yes||Discount on Prescription drugs|
|Meets ACA Requirements||Yes||NO|
|Pregnancy and Maternity Care||Yes||NO|
|Length of Coverage||Per Policy Period||30 days to 12 months Renewable|
|Mental Health Care||Yes||NO|
Limited Benefit Medical Plan
Limited Benefit Medical plans offers financial protection and pay cash benefits directly to the insured. The products are designed to help fill some of the gaps in your major medical insurance including high deductible and out of pocket expenses.
* Key plan benefits:
- Guaranteed acceptance regardless of current state of health
- Benefits are payable directly to the individual
- Benefits can be used in any way an individual chooses – to cover additional costs like deductibles, co-pays or other out-of-pocket expenses, or to cover household or childcare expenses while hospitalized
- Benefits are payable in addition to any other insurance that may apply
- Attractive additional benefits available:
- Accidental Death & Dismemberment
- Critical Illness benefit
- Custodial Care Facility benefit
- Emergency Care benefit
- Home Health Care benefit
- Hospice Care benefit
- Intensive Care benefit
- Outpatient Surgical benefit
- Post-hospital Recovery benefit
* Not all benefits described are available in each plan selection. Refer to the policy, certificate and riders for complete details.
Care Access Plan
Except as specifically provided for in the policy, Care Access Limited benefit medical plan does not provide any benefits when a covered person receives any of the following treatments, services or supplies:
A pre-existing condition is any disease, accidental bodily injury, illness or physical condition for which a covered person had treatment, incurred charge, took medication, received a diagnosis or advice from a doctor during the 12 month** period immediately preceding the covered person’s coverage effective date or symptoms within the five years* immediately prior to the coverage that would cause a reasonable person to seek diagnosis, care or treatment.
**In the following states, the pre-existing condition time period is 6 months: GA, ID, KY, MA, MI, NH, NJ, NM, NY, ND, WA, and WY.
Preventive care, including routine physical examinations and immunizations (unless the optional Preventive Care Benefit rider is shown as included on the schedule of benefits)
This insurance does not apply to normal pregnancy. Complications of Pregnancy are covered as any other Sickness.
Other Limitations & Exclusions
- Any treatment provided by a government-owned or government-operated facility or by government-employed health care providers
- A weekend hospital confinement occurring between noon on any friday and noon the following Sunday for non-emergency procedures, unless medically necessary or unless surgery is scheduled for the next day
- An illness or injury which arises out of or in the course of any employment for wage or profit or an illness or injury for which you or your covered dependent spouse has or had a right to recovery under any Workers’ Compensation Law or Occupational Disease Law. This exclusion does not apply to an employment related injury or illness if you or your covered dependent spouse is a sole proprietor, partner, or owner eligible under state law to legally elect to not be covered under workers’ compensation and who is not insured under, and who does not have or had a right to recovery for such employment related injury or illness under any Workers’ Compensation Law or Occupational Disease Law.
- Physical or psychological examinations required by any third party, such as by a court or for employment, licensing, insurance, school, sports or recreational purposes.
- An injury or illness incurred while on active duty with the military of any country or international organization, or resulting from war, act of war or participation in a riot or insurrection
- An injury or illness incurred during the commission or attempted commission of a crime or felony or while engaged in an illegal act or while imprisoned.
- An injury or illness, incurred due to, or contracted as a consequence of a covered person being intoxicated or under the influence of illegal narcotics or other drugs, unless the drug is administered by a doctor and taken in accordance with the prescribed dosage.
- An injury or illness for which treatment, services or supplies were received or purchased outside the United States unless the charges are incurred while traveling on business or for pleasure, for a period not to exceed 90 days, and the charges are incurred for an emergency, provided the treatment, services or supplies used in connection with the emergency are approved for use in the United States.
- Treatment, services or supplies for (a) breast augmentation; (b) the removal of breast implants unless medically necessary and related to surgery performed as reconstructive surgery due to an illness; and (c) breast reduction surgery unless medically necessary due to an illness.
- Surgery to correct refractive errors
- Routine eye exams, glasses or contact lenses, or visual therapy
- Routine hearing exams or hearing aids
- Penile implants and fertility and sterility studies
- Voluntary abortion; infertility including impregnation techniques; or reversal of sterilization
- Mental illness disorders; substance abuse; tobacco-cessation programs and products.
- Marriage or family counseling, recreational therapy, equine therapy, educational therapy, social therapy, sex therapy; or sexual reassignments, dysfunctions or inadequacies.
- Meridian therapy (acupuncture) or spinal manipulation.
- Orthotics; treatment, services or supplies related to the feet by means of posting, strapping or range-of-motion studies; or related to paring or removal corns, calluses, bunions or toenails.
- Obesity or weight reduction including all forms of surgery and complications resulting from such surgery; education or training material
- Treatment for which the covered person is not required to pay; or treatment rendered by a person who ordinarily resides in your household or a member of your immediate family
- Custodial care, domiciliary care or rest cures regardless of who prescribes or renders such care; inpatient personal convenience items
Limited Benefit Medical:
Limitations & Exclusions:
In addition to any benefit or coverage specific exclusion, benefits will not be paid for any loss which directly or indirectly, in whole or in part, is caused by or results from any of the following unless coverage is specifically provided for by name in the Description of Benefits section:
- Intentionally self-inflicted injury, suicide or any attempt while sane or insane;
- ILLEGAL OCCUPATION: The insurer shall not be liable for any loss to which a contributing cause was the insured's commission of or attempt to commit a felony or to which a contributing cause was the insured's being engaged in an illegal occupation.
- Declared or undeclared war or act of war;
- Release, whether or not accidental, or by any person unlawfully or intentionally, of nuclear energy or radiation, including sickness or disease resulting from such release;
- An injury or sickness that occurs while on active duty service in the military, naval or air force of any country or international organization. Upon Our receipt of proof of service, the Company will refund any premium paid for this time. Reserve or National Guard active duty training is not excluded unless it extends beyond 31 days;
- Travel or activity outside the United States, Canada or Mexico, except for a Medical Emergency;
- Flight in, boarding or alighting from an Aircraft except as: a fare-paying passenger on a regularly scheduled commercial or charter airline; a passenger in a non-scheduled, private Aircraft used for pleasure purposes with no commercial intent during the flight;
- Travel in any Aircraft owned, leased or controlled by the Policyholder, or any of its subsidiaries or affiliates. An Aircraft will be deemed to be "controlled" by the Policyholder if the Aircraft may be used as the Policyholder wishes for more than 10 straight days, or more than 15 days in any year;
- Bungee-cord jumping, parachuting, skydiving, parasailing, hang-gliding;
- Voluntary ingestion of any narcotic, drug, poison, gas or fumes, unless prescribed or taken under the direction of a Physician and taken in accordance with the prescribed dosage;
- The Insured Person's intoxication. The Insured Person is conclusively deemed to be intoxicated if the level in his blood exceeds the amount at which a person is presumed, under the law of the locale in which the accident occurred, to be under the influence of alcohol if operating a motor vehicle, regardless of whether he is in fact operating a motor vehicle, when the injury occurs. An autopsy report from a licensed medical examiner, law enforcement officer's report, or similar items will be considered proof of the Insured Person's intoxication;
- An Accident if the Insured Person is the operator of a motor vehicle and does not possess a valid motor vehicle operator's license, unless: (a) the Insured Person holds a valid learners permit and (b) the Insured Person is receiving instruction from a driver's education instructor;
- alcoholism, drug addiction or the use of any illegal drug or narcotic except as prescribed by a Physician unless specifically provided herein;
- repair or replacement of existing dentures, partial dentures, braces, fixed or removable bridges, or other artificial dental restoration;
- repair, replacement, examinations for prescriptions or the fitting of eyeglasses or contact lenses.
- Elective Abortion. Elective Abortion means an abortion for any reason other than to preserve the life of the female upon whom the abortion is performed.
- mental and nervous disorders.
- elective surgery or cosmetic surgery, except for reconstructive surgery needed as the result of a Covered Injury or Covered Sickness.
- Experimental or Investigational drugs, services, supplies. For the purposes of this exclusion, "Experimental or Investigational" means medical services, supplies or treatments provided or performed in a special setting for research purposes, under a treatment protocol or as part of a clinical trial (Phase I, II or III). The covered service will also be considered Experimental or Investigational if the Insured Person is required to sign a consent form that indicates the proposed treatment or procedure is part of a scientific study or medical research to determine its effectiveness or safety. Medical treatment, that is not considered standard treatment by the majority of the medical community or by Medicare, Medicaid or any other government financed programs or the National Cancer Institute regarding malignancies, will be considered Experimental or investigational. A drug, device or biological product is considered Experimental or Investigational if it does not have FDA approval or approval under an interim step in the FDA process, i.e., an investigational device exemption or an investigational new drug exemption.
- treatment for being overweight, gastric bypass or stapling, intestinal bypass, and any related procedures, including complications.
- sexual reassignment surgery, sexual transformation surgery, sexual transgendering surgery.
- services related to sterilization, reversal of a vasectomy or tubal ligation; in vitro fertilization and diagnostic treatment of infertility or other problems related to the inability to conceive a child, unless such infertility is a result of a Covered Injury or Covered Sickness.
- treatment or services provided by a private duty nurse.treatment or services provided by a private duty nurse.
- organ or tissue transplants and related services.
- personal comfort or convenience items.
- rest or custodial cures.
- hearing aids.
- An Injury or Sickness for which the Insured Person is paid benefits under any Workers' Compensation or occupational disease law or under any insurance policy that provides benefits to the Insured Person for injuries resulting from an occupational accident.
In addition, benefits will not be paid for services or treatment rendered by any person who is:
- employed or retained by the Policyholder;
- living in the Insured Person's household;
- an Immediate Family Member of either the Insured Person or the Insured Person's Spouse;
- the Insured Person.
*** PRE-EXISTING CONDITION LIMITATION
Benefits under this Certificate are not payable in connection with a Pre-Existing Condition for the benefits shown in the Schedule of Benefits.
This Pre-Existing Condition Limitation shall not apply after the end of the Limitation Period shown in the Schedule of Benefits, commencing on the Insured Person's Coverage Effective Date.
Special Rules For Pre Existing Condition if the Insured Person was covered under His Employer's Prior Plan.
Special rules apply to Pre Existing Conditions if this Plan replaces the Insured Person's Prior Plan and;
- the Insured Person was insured under that plan on the day before this Policy became effective; and
- the Insured Person became insured under this Policy within 31 days of its Policy Effective Date.
The special rules are:
- if the Employer's prior plan did not have a Pre- Existing Condition exclusion or limitation, then a Pre Existing Condition will not be excluded or limited under this Certificate.
- if the Employer's prior plan did have a Pre-Existing Condition exclusion or limitation, then the limited time does not end after the Limitation Period shown in the Schedule of Benefits. Instead it will end on the date any equivalent limit would have ended under the Employer's Prior Plan.
- if the change from the Employer's Prior Plan to this Policy would result in an increase to the amount of benefits for an Insured Person, the benefits for an Insured Person's that is due to a Pre Existing Condition will not increase. Instead benefits are limited to the benefit amount the Insured Person had on the date before the plan change. This applies whether or not the Employer's Prior Plan had a Pre- Existing condition exclusion or limitation.
*** Does not apply to Legion Limited Benefit Medical in California.
Disclaimer: COVERAGE IS SUBJECT TO EXCLUSIONS AND LIMITATIONS, AND MAY NOT BE AVAILABLE IN ALL US STATES AND JURISDICTIONS. PRODUCT AVAILABILITY AND PLAN DESIGN FEATURES, INCLUDING ELIGIBILITY REQUIREMENTS, DESCRIPTIONS OF BENEFITS, EXCLUSIONS OR LIMITATION MAY VARY DEPENDING ON LOCAL COUNTRY OR US STATE LAWS. FULL TERMS AND CONDITIONS OF COVERAGE, INCLUDING EFFECTIVE DATES OF COVERAGE, BENEFITS, LIMITATIONS AND EXCLUSIONS, ARE SET FORTH IN THE POLICY.