American Health Shield Plan Highlights - Fairmont Specialty Group  (FSG)

Plan Highlights

• What is Short Term Health Insurance?
• Eligibility Requirements
• Covered Medical Expense Highlights
• Coverage Effective Date
• Coverage Termination Date
• Extension of Benefits After Termination
• Renewability
• Payment Options & Methods
• Money Back Guarantee

What is Short Term Health Insurance?

According to a 08/2005 U.S. Department of Commerce report*, 45.8 million Americans are without health insurance coverage.  Don't risk being a statistic - without health insurance coverage, an unexpected illness or injury could be financially devastating!

* U.S. Census Bureau / U.S. Department of Commerce / Economics and Statistics Administration

The American Health Shield - Short Term Medical is a quality, affordable plan of temporary medical insurance designed specifically for healthy people who are temporarily without health insurance.  This plan offers coverage from 30-days to 180-days or up to 12-months in most states that can become effective as early as tomorrow and be paid for in one single payment or easy monthly installments.

Ideal protection for persons: 

• Between jobs, laid off, on strike

• Attending school or recently graduated 

• Employed part-time or temporarily 

• Waiting for permanent health insurance to begin 

• Temporarily without health insurance for most any reason 

American Health Shield - Short Term Medical is not an HMO or PPO plan.  In the event of an illness or injury, and you may receive treatment from any licensed healthcare provider or facility anywhere in the U.S.

 Eligibility Requirements

Who is eligible to apply for the American Health Shield - Short Term Medical:

• You and your spouse, age 18 to 64 and 11 months, and your unmarried dependent children age 15 days through 18 (24, if a full-time student) that live with you.

To be considered for coverage, persons listed on the application form must:

• Be a US citizen (or permanent resident for the past 12 months) and have a Social Security Number;

• Not be traveling outside the U.S.;

• Live in a state where this plan of insurance is available; 

• Not be covered by major medical, group health, hospital, governmental, or other medical insurance coverage that will not terminate prior to the Effective Date of this plan;

• Not be pregnant or the expectant father of an unborn child; 

• Not have been declined for health insurance within the past 12 months and/or received consultation or treatment (within the past 5 years) for any condition identified on the application form; 

• Not participate in hazardous activities or sports. 

Child only coverage is available for your eligible, unmarried dependent child (age 2 through 18) that live with you.  Enter the oldest child as the applicant, and all other child(ren) as dependents.  Child(ren) only applications must be signed by a parent or legal guardian, then mail or fax all pages of the completed application to:

Short Term Medical Department
PO Box 20594
Tampa, FL 33622-0594
1-727-799-9093 (Facsimile)

Covered Medical Expense Highlights

The American Health Shield - Short Term Medical provides benefits for Covered Medical Expenses related to covered Injury or Sickness, which are:  1) not in excess of Usual and Customary Charges; 2) not in excess of a maximum benefit amount; 3) made for services and supplies which are a Medical Necessity and listed as Covered Medical Expenses in the Policy or Certificate issued by Fairmont Specialty Group.  

• Hospital Charges: average semi-private room rate, medical care and treatment

• Surgery in a Hospital or Ambulatory Surgical Center

• Physician Services for diagnosis, treatment and surgery

• Intensive Care: up to three times the average semi-private room rate

• Skilled Nursing Facility: up to $30 per day for 30 days

• Ray Exams, Laboratory tests and analyses

• X-Ray and Radioactive isotope therapy, anesthesia, oxygen, casts, splints, crutches, braces, surgical dressings, artificial limbs or eyes, rental of medical supplies

• Blood or blood plasma and their administration

• Ambulance Services: $250 per emergency

• Organ Transplants: $50,000 lifetime maximum

• Acquired Immune Deficiency Syndrome (AIDS): $10,000 lifetime maximum

• Home Health Care: up to 40 visits

• Hospice Care: up to $5,000

• Spinal Manipulation/Adjustment: up to $1,000

• Mammography, pap smear and screens

• Gallbladder Surgery: up to a $2,500 lifetime maximum

• Knee injury or disorder: up to a $2,500 lifetime maximum for both left and right knees

Usual and Customary Charges means the lesser of: 1) the actual charge; 2) what the provider would accept for the same service or supply in the absence of insurance; or 3) the reasonable charge as determined by Fairmont Specialty Group, based on factors such as: a) the most common charge for the same or comparable service or supply in a community similar to where the service or supply is furnished; b) the amount of resources expended to deliver the treatment rendered; c) charging protocols and billing practices generally accepted by the medical community or specialty groups; or d) inflation trends by geographic region.

Pre-Admission Certification: This plan requires a Pre-Admission Certification by a Professional Review Organization prior to in-patient Hospitalization or surgery.  A Covered Person or their Attending Physician must call the Professional Review Organization: 1. For elective or non-emergency Hospitalization or surgery, at least 10-days prior to the date of proposed Hospitalization; 2. Within 48-hours of an emergency admission; or 3. Within 48-hours of delivery for complicated childbirth.  Non-compliance with the Pre-Admission Certification procedure will result in a reduction in benefits of 50%, unless the Covered Person is incapacitated and unable to contact the Professional Review Organization. In such cases, the Covered Person must contact us as soon as possible. 

Covered Medical Expenses and Benefits vary by state. Detailed information about these and additional Covered Medical Expenses is listed in the Policy or Certificate issued by Fairmont Specialty Group to approved applicants.

Payment Options & Methods

American Health Shield - Short Term Medical let's you choose the payment option (single or monthly payment) and payment method (automatic bank draft, credit card, or personal check) that's most convenient for you.  Additionally, once coverage commences, premium rates are guaranteed for the length of the Coverage Period issued!  Note - If you prefer to make payment(s) by personal check or money order, you must mail your completed application form and initial payment to Fairmont Specialty Group.

 Payment Options

• Single Payment - If you know the exact length of time you'll need this coverage and prefer to make one single payment for the entire Coverage Period, this payment option is ideal. Simply select the exact total number of days you need coverage (30-day minimum / 180-day maximum) and pay for that Coverage Period.

• Monthly Payments - If you are unsure how long you'll need this coverage or prefer the convenience of making monthly installment payments, this option is ideal.  Each monthly payment is for 30-days or 1-month of coverage, up to the 180-day or 12-month maximum Coverage Period.  If your need for this coverage ceases before your Coverage Period expires, simply stop making monthly payments and your coverage will terminate at the end of the period you last made payment for. 

Payment Methods

• Personal Check:  You will receive payment coupons with your Policy or Certificate.  The 1^st payment coupon will reflect a credit equal to your initial payment.  Subsequent monthly payments, must be received by Fairmont Specialty Group on or before the payment due dates shown on payment coupons.

• Automatic Bank Draft or Credit Card: Your initial payment and subsequent monthly payments will be automatically debited (on or immediately following the payment due dates) from your bank account or your MasterCard / VISA that is identified on the Electronic Payment Authorization form. If you wish to discontinue coverage before your Coverage Period expires, simply mail or fax your written request for termination to Fairmont Specially Group and we will discontinue future automated electronic debits. Note - 5 days advance written and signed notice from the Primary Insured is required to ensure future credit card debits are discontinued.
  
  

Coverage Effective Date

If you submit the application form and initial payment via:

Internet or facsimile, the earliest date that coverage can begin (if approved by Fairmont Specially Group) is 12:01 a.m. on the day after Fairmont Specially Group receives the completed application form and valid electronic payment information.  A later effective date may be requested, but no more than 30 days following the application date.  Note - payment must be made by automatic bank draft or MasterCard / VISA.

U.S. Mail, the earliest date that coverage can begin (if approved by Fairmont Specially Group) is 12:01 a.m. on the day after the postmark date stamped by the U.S.P.S. on the envelope in which Fairmont Specially Group receives the completed application form and payment for the total amount due.  If the U.S.P.S. postmark date is not legible or present, the earliest date that coverage can begin is the day after the completed application form and payment for the correct plan cost are received by Fairmont Specially Group.  A later effective date may be requested, but no more than 30 days following the application date.

IMPORTANT - The coverage Effective Date is determined by Fairmont Specially Group and will be shown in the Policy or Certificate that is issued.  No agent or agency has the authority to bind, modify or issue coverage.  Issuance of coverage is subject to Fairmont Specially Group’s acceptance of the submitted application form and your initial payment for the American Health Shield - Short Term Medical.

Coverage Termination Date

Coverage will terminate on the earliest of the following dates:

The last day of the period through which the premium is paid; The date the Covered Person ceases to be eligible; or the Coverage Period expiration date. 

Extension of Benefits After Termination

If a Covered Person is receiving benefits for a Hospital Confinement on the date the Coverage Period, Policy or Certificate terminates, benefits will continue in accordance with the terms of the Policy or Certificate for as long as that Confinement remains continuous and the Covered Person is Totally Disabled by reason of such Injury or Sickness. However, in no event will coverage continue beyond the end of the 90-days following the date Coverage Period, Policy or Certificate terminates.

Note - Benefit payments for such condition both before and after the Termination Date are subject to all applicable benefit maximum limits.  Once the "Extension of Benefits After Termination" provision has been exhausted, all benefits cease to exist, and under no circumstances will further payments be made. 

Renewability

The American Health Shield - Short Term Medical is not renewable nor intended to be permanent coverage.  Coverage will terminate upon expiration of your Coverage Period.  However, you may be eligible to apply for another Coverage Period following the expiration of your previous Benefit Period.  If a new Coverage Period is applied for and issued by Fairmont Specially Group, there is no continuous coverage between any previous and current Benefit Period.  Any condition or symptom, which occurred under a previous Coverage Period, may be treated as a pre-existing condition under a subsequent Coverage Period.  Note - In no event will Fairmont Specially Group issue successive Coverage Periods totaling more than 365 days.  

Money Back Guarantee

Immediately following Fairmont Specially Group’s receipt and approval of your submitted application form, a Policy or Certificate will be issued and mailed to your residence/home address.  Please read the Policy or Certificate carefully.  It is important to us that you understand and are satisfied with the American Health Shield - Short Term Medical insurance plan.  If you are not satisfied that this coverage will meet your insurance needs, simply return the Policy or Certificate with your written and signed request for cancellation within 10 days after you receive it.  Coverage will be canceled as of the effective date and you will receive a full refund of your initial payment - no questions asked!