|
Alphabet Health Benefits |
SUMMARY OF BENEFITS BY PLAN OPTION–INDEMNITY PROGRAM |
|
BASIC BENEFITS |
PLATINUM |
GOLD |
SILVER |
BRONZE |
STEEL |
| ANNUAL MAXIMUM BENEFIT |
| Maximum per person |
|
$100,000 |
$75,000 |
$50,000 |
$25,000 |
$10,000 |
| IN-PATIENT HOSPITAL SERVICES* |
Daily Benefit
Maximum Days per Calendar Year
*Includes in-patient Physician visits, doesn’t include OP surgery costs |
|
$2,000
30 |
$1,500
30 |
$1,000
30 |
$600
20 |
$400
20 |
| ICU/CCU BENEFIT |
Additional Daily Benefit
Maximum Days per Calendar Year |
|
$2,000
30 |
$1,500
30 |
$1,000
30 |
$600
20 |
$400
20 |
| INPATIENT MENTAL HEALTH SERVICES |
Daily Benefit
Maximum Days per Calendar Year |
|
$500
15 |
$500
12 |
$500
10 |
$300
10 |
$200
10 |
| HOSPITAL EMERGENCY ROOM CARE |
Benefit per Visit
Maximum Days per Calendar Year |
|
$500
5 |
$300
5 |
$200
3 |
$100
1 |
$75
1 |
| OUTPATIENT HOSPITAL SERVICES |
Daily Benefit
Maximum Days per Calendar Year |
|
$500
3 |
$300
3 |
$200
3 |
$100
3 |
$100
1 |
| SURGICAL BENEFIT |
Maximum Benefit (per surgical procedure)
Surgical Procedure Unit Value |
|
|
$2,500
20 |
$2,500
16 |
$2,500
10 |
$2,100
7 |
| ANESTHESIA BENEFIT |
| Percentage of Surgical Procedure |
|
20% |
20% |
20% |
20% |
20% |
| OUTPATIENT OFFICE VISITS** |
Benefit per Visit
Maximum Visits per Calendar Year |
|
$100
5 |
$85
5 |
$75
5 |
$60
5 |
$50
5 |
| SUPPLEMENTAL ACCIDENT BENEFIT |
| Maximum Benefit per Accident |
|
$1,000 |
$800 |
$600 |
$400 |
$200 |
May be subject to pre-existing conditions. Can be waived for additional premium.
This is not a solicitation for insurance. Benefits listed above are underwritten by Monumental Life Insurance Company. This summary of group limited medical indemnity insurance plan is designed to help you with the process of comparing health insurance options. This plan is not a major medical insurance and is not designed to provide, replace or modify major medical insurance. Depending on your state of residence, some provisions, benefits exclusions or limitations listed may vary.
Approved Plan policy issuance through employer groups and/or associations varies by state. Please contact AHB at 1-888-977- 7777 for details for a specific state. Benefit plan designs are illustrative and approved in most states. Please contact AHB at 1-888-977- 7777 to verify plan availability in a specific state. |
| |
PLATINUM |
GOLD |
SILVER |
BRONZE |
STEEL |
| GROUP TERM LIFE INSURANCE BENEFIT |
Life Insurance per Employee
Life Insurance per Dependent
Accidental Death and Dismemberment
Underwritten by Monumental Life Insurance Company. |
|
$25,000
$12,500
$25,000 |
$20,000
$10,000
$20,000 |
$15,000
$7,500
$15,000 |
$10,000
$5,000
$10,000
|
$5,000
$2,500
$5,000 |
|
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