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Limited Benefit Medical Plan
This benefit packet is intended as a brief summary of the Medical StaffCARE Limited Benefit Medical Plan. The group policy issued to your employer is the official document governing the provisions of this plan. State mandated benefits that apply to this plan will be included even if they are not described in this benefit packet. When you enroll, you will be issued a Summary Plan Description that includes more detailed information. For questions regarding plan specifications, please call 1-866-798-0803.
Covered Medical Expenses
Hospital Bills, Doctor Bills, Lab and X-ray, Home Health Care, Medical Equipment and Supplies, Prescription Drugs, Therapy (see Summary Plan Description for specific therapy coverage).
Rules
- Be administered and ordered by a physician
- Be medically necessary for the diagnosis and treatment of sickness or injury
- Not be excluded by the group policy
Exclusions and Limitations
Medical and Accidental Death and Dismemberment
The following exclusions and limitations apply to expenses incurred by all participants. The exclusions and limitations may vary by state.
No benefits will be paid for loss caused by or resulting from: expenses used to meet any deductible, or in excess of the percentage payable, or in excess of Usual and Customary, work-related injury or sickness, mental or nervous disorders, alcoholism or substance abuse treatment, intentionally self-inflicted injuries, suicide or any attempted threat while sane or insane, declared or undeclared war, serving on full-time active duty in the Armed Forces, commission of a felony, flying as a pilot or crew member of any aircraft, eye examinations, hearing examinations, hearing aids, normal health checkups (except as noted), dental care, treatment other than care of natural teeth and gums resulting from an accident, cosmetic surgery, and services provided by an immediate family member.
Applicable only to Accidental Death and Dismemberment, no benefits will be paid for bodily or mental infirmity, disease of any kind, or medical or surgical treatment for that infirmity or disease, not including bacterial infection or viral infection that is the result of an accidental bodily injury or accidental, involuntary or unintentional ingestion of a contaminated substance.
Pre-existing conditions: No benefits will be paid for a pre-existing condition (one you had within the six month period ending the day before your enrollment date) for the first 12 months of your coverage.
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This does not apply to pregnancy nor to a newborn or adopted child covered from birth or adoption. The exclusion period may be reduced by most previous medical expense coverage ("creditable coverage"), if there is no more than a 63 day break in coverage. You should give us a copy of any certificates of creditable coverage. If you do not have a certificate, but have prior health coverage, we will help you obtain one from your prior plan. There are also other ways to demonstrate you have creditable coverage, so contact us if you need help. All questions about the pre-existing condition exclusion and creditable coverage should be directed to Medical StaffCARE Unit Supervisor, Planned Administrators, Incorporated (PAI), P.O. Box 6702, Columbia, South Carolina 29260, or call us at: (866) 798-0803.
Dental
The plan will pay only for procedures specified on the Schedule of Covered Procedures in the Group Policy. Many procedures covered under the plan have waiting periods and limitations on how often the plan will pay for them within a certain time frame. For more detailed information on Covered Procedures or limitations, please contact PAI.
Vision
No benefits will be paid for: any materials, procedures or services provided under Workers’ Compensation or similar law; non-prescription lenses, frames to hold such lenses, or non-prescription contact lenses; any materials, procedures or services provided by an immediate family member or provided by you; charges for any materials, procedures, and services to the extent that benefits are payable under any other valid and collectible insurance policy or service contract whether or not a claim is made for such benefits.
Short-Term Disability
Short-term disability insurance provides a source of income in case you are unable to work due to a covered sickness or non-work related accident. Although, there is an elimination period that must be met before benefits will be paid, benefits are paid immediately if hospitalization occurs within the waiting period. Short-term disability benefits are not available to persons who work in California, Hawaii, New Jersey, New York, Rhode Island, and Puerto Rico.
Term Life
No Life Insurance benefits will be payable under the Policy for death caused by suicide or self-destruction, or any attempt at it, whether sane or insane, within 24 months after the person’s coverage under the Policy became effective.
The exclusions, limitations, and pre-existing condition exclusion may vary by state. Please refer to your Summary Plan Description for information. |
