| Plan Design Unless otherwise noted, all deductibles, maximums and benefit amounts are applied per person and are reset each January 1. |
Integrated Deductible
Amount you pay toward covered expenses before the plan pays benefits |
Individual plan: $2,700
Family plan: $5,400 |
Benefit Percentage
Percentage of covered expenses the plan pays after the deductible |
80% |
Coinsurance
Percentage of covered expenses you pay after the deductible |
20% |
Total Out-Of-Pocket Maximum
After this maximum is met, the plan pays 100% of covered expenses |
Individual: $4,700
Family: $9,400 |
Lifetime Benefit Maximum
The total maximum amount the plan pays per person |
$3 million |
| Outpatient Benefits: Subject to the selected deductible and coinsurance unless otherwise noted. |
| Preventive Services |
First $500 at 100% — additional services are also covered
subject to deductible and coinsurance |
| Mammograms |
Covered — subject to coinsurance, deductible waived |
| Diagnostic Imaging and Laboratory Services |
Covered |
| Outpatient Hospital, Surgical Center or Urgent Care Facility |
Covered |
| Professional Ground and Air Ambulance |
Covered |
| Emergency Room |
Access fee: $75 copay, then subject to deductible and coinsurance —
$75 copay waived if admitted to the hospital |
| Health Care Practitioner Services |
Covered |
| Outpatient Physical Medicine |
Rehabilitation: 20 visits
Chiropractic: 10 visits
Acupuncture: 10 visits |
| Home Health Care |
Up to 130 hours |
| Inpatient Benefits Benefits: Subject to the selected deductible and coinsurance unless otherwise noted. |
| Inpatient Hospital |
Covered |
| Inpatient Rehabilitation Facility |
Up to 10 days |
| Subacute Rehabilitation and Skilled Nursing Facilities |
Up to 45 days |
Assurant Health
