Typical Plan Features of an Individual Health Insurance Policy
In-Network Out-of-Network
Annual Deductible
Individual $1,000 - $ 5,000 $2,000 - $10,000
Family $2,000 - $10,000 $4,000 - $20,000
Annual Out-of-Pocket Maximum
Individual $2,000 - $ 5,000 $4,000 - $10,000
Family $4,000 - $10,000 $8,000 - $20,000
Lifetime Maximum Benefit $1,000,000 - $5,000,000
Physician Visit
General Practitioner $25-50 Co-Pay Carrier Pays 60%
Specialist $35-75 Co-Pay Carrier Pays 60%
Preventative Care (Ages 7 and Up) Co-Pay, then 100% Carrier Pays 60%
up to$300 per Insured after Deductible
per Calendar Year up to $300 per Insured
per Calendar Year
Mammogram, Pap Smears,
PSA, Etc. Carrier Pays 80% Carrier Pays 60%
after Deductible
Child Preventative care
(6 and Under) Carrier Pays 80% Carrier Pays 60%
Immunizations for Children
(6 and Under) Carrier Pays 80% Carrier Pays 60%
Ambulance Carrier Pays 80% Carrier Pays 60%
after Deductible after Deductible
Emergency Room Visits Carrier Pays 80% Carrier Pays 80%
after Deductible after Deductible
for True Emergencies,
otherwise Pays 60%
Urgent Care Facilities Carrier Pays 80% Carrier Pays 60%
after Deductible after Deductible
for True Emergencies,
otherwise Pays 60%
Inpatient Hospital Services Carrier Pays 80% Carrier Pays 60%
after Deductible after Deductible
Outpatient Surgery Carrier Pays 80% Carrier Pays 60%
after Deductible after Deductible
Outpatient Lab, X Rays,
Ultrasound, MRI and CT Scan Carrier Pays 80% Carrier Pays 60%
after Deductible after Deductible
Physical, Occupational and
Speech Therapy Carrier Pays $30 Maximum per Visit per Insured
Durable Medical Equipment Carrier Pays 80% Carrier Pays 60%
after Deductible after Deductible
Mental Health and Substance
Abuse - Inpatient Carrier Pays 80% Carrier Pays 60%
after Deductible after Deductible
Mental Health - Outpatient Carrier Pays 80% Carrier Pays 60%
after Deductible after Deductible
Prescription Drugs
Retail Pharmacy
Brand Name Deductible $100 Deductible
Generic / Brand Name /
Non Preferred Brand Name $10 / $35 / $60 Carrier Pays 50%
Self Injectables Carrier Pays 70% Carrier Pays 50%
Mail Order Pharmacy
Generic / Brand Name /
Non Preferred Brand Name $25 / $85 / $150 Not Covered
per 90 Day Supply
Self Injectables Carrier Pays 70% Not Covered
Types of Health Insurance
Major Medical Insurance
Major medical insurance provides a full spectrum of medical coverage
including hospital stays, outpatient care, and physician visits. It
may also provide coverage for prescription benefits, home health care,
nursing home care, and other healthcare services.
Short Term Major Medical
Short-term major medical is a type of health insurance policy that is
designed for a limited duration, most often ranging from one month to
one year. It will not cover pre-existing conditions and it bases its
benefit payment on expenses incurred for medical care.
Hospital / Surgical Insurance
Hospital or surgical insurance is similar to major medical insurance
but only pays benefits for hospital care and possibly some hospital
outpatient care such as surgery. It does not cover any outpatient
services or prescriptions. It typically has a deductible that must be
paid followed by co-insurance and/or co-payments for cost-sharing
purposes. This arrangement will continue until a certain maximum
out-of-pocket amount is reached and 100% coverage is provided.
Hospital Indemnity
Hospital indemnity insurance pays a specified daily amount when a
covered individual is confined in a hospital. The payment is based on
the occurrence or event of the covered person being hospitalized for a
certain number of days, not any actually incurred expenses. This type
of policy is considered a supplemental type policy and is not meant to
be comprehensive health insurance of any kind.
Hospital / Surgical Indemnity
Hospital / surgical indemnity is a package or combination type of
health insurance that pays benefits based upon a specified schedule.
The payment is based on an occurrence or event, not based on any actual
charges. This type of policy is considered a supplemental type policy
and is not meant to be comprehensive health insurance of any kind.
Cancer Insurance
Cancer insurance is a limited benefit, supplemental insurance
policy. This policy covers a specified type of illness, cancer, and
may not cover all types or forms of the disease. They do not pay
benefits for any other type of disease, illness or injury. This type
of policy is considered a supplemental type policy and is not meant to
be comprehensive health insurance of any kind.
Heart / Stroke
Heart / stroke insurance is a limited benefit, supplemental insurance
policy. This policy covers a specified type of illness, heart disease
including stroke, and may not cover all types or forms of the disease
or condition. They do not pay benefits for any other type of disease,
illness or injury. This type of policy is considered a supplemental
type policy and is not meant to be comprehensive health insurance of
any kind.
Accident
Accident insurance is a limited benefit, supplemental insurance
policy. This policy covers a specified type or types of injury
resulting from an accident. These policies may pay They do not pay
benefits for any other type of disease, illness or injury. This type
of policy is considered a supplemental type policy and is not meant to
be comprehensive health insurance of any kind.
Supplemental
Supplemental health insurance are policies designed to provide
additional coverage and benefits for expenses not ordinarily covered or
covered sufficiently by major medical, hospital / surgical, CHAMPUS, or
Medicare. This type of policy is considered a supplemental type policy
and is not meant to be comprehensive health insurance of any kind.