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Core Plus Physician Insurance Plan

by Tony Novak, CPA, MBA, MT, NAHU certified consumer driven health care consultant, originally published September 27, 2010, revised April 22, 2012

This summary is meant as a reference for users of Freedom Benefits insurance exchange. For full information, pricing and secure online enrollment, see the enrollment Web page.

Table of Contents Core Plus Physician plan logo

Plan Benefits Summary Chart

The benefit limits and number of occurrences listed below, apply per covered person, per policy year. For complete details, see the online quote and enrollment page. This chart includes benefits for the physical plan only; the lowest level of price and benefits. For higher amounts of coverage, see the Core Plus Value Plan, Gold plan and Core Plus Platinum plan.

Benefits: Physician Plan
Insurance Pays:
 Doctor Office Visits 100% of Usual & Customary charge
after $30 co-pay*
   Maximum visits: 5 per policy year
 Wellness Visits 100% of Usual & Customary charge
after $30 co-pay*
   Maximum visits: 2 per policy year
 Hospital Room & Board
   1st Day Admission: $250 per day
   Day 2-31 Semi-Private Room: $250 per day
   Day 2-15 ICU/CCU: $250 per day
   Maximum Semi/ICU: 31 days
 Surgery
   Inpatient: $500 per session
   Outpatient: $200 per session
   Maximum IP or OP: 1 per policy year
 Anesthesia
   Inpatient: $125 per session
   Outpatient: $50 per session
   Maximum treatments: 1 per policy year
 Diagnostic, X-Ray, Lab $30 per sitting
   Maximum sittings: 5 per policy year
 Emergency Room $100 per visit
   Maximum visits: 1 per policy year
 Accidental Injury/Accident Medical Expense $500 per injury
   Deductible: $100
   Maximum: 1 per policy year
 Accidental Death & Dismemberment
   Primary: $2,500
   Secondary: $1,250
   Child $625
 Waiting Period (days) for
   Accident Coverage: None
   Sickness Coverage: 30

* $30 doctor's visit co-pay in-network or $30 deductible out-of-network. Network available through AUIC.

Plan Highlights

 
  • No Medical Questions or Physical Examinations
  • Freedom to Choose any Health Service Provider
  • Assignable Benefits - You give your Insurance Card to the Doctor/Hospital and they may bill insurance company.
  • Pays in Addition to Other Private Insurance

Plan Description

Hospital benefits are subject to the waiting period and pre-existing condition limitation described.

- First Day of Admission: You will have coverage up to $250.

- Hospital (Standard): You will have coverage up to $250 for standard, board, miscellaneous medical Hospital charges, and general nursing services for each day You are Confined to a hospital due to a covered Injury or Sickness. This benefit is paid in lieu of a benefit payable for Intensive Care/Cardiac Care Confinement.

 - Intensive Care/Cardiac Care Unit: You will have coverage up to $250 for each day You are Confined to a Hospital in an Intensive Care or Cardiac Care Unit due to a covered Injury or Sickness. This benefit is paid in lieu of a benefit payable for a standard Hospital room.

Maximum Benefit for ALL First Day Admission, Hospital and Intensive Care/Cardiac Care Unit Confinements is 31 days per person per Policy Year.

Surgery: You will have coverage up to $500 for surgery performed while Confined to a Hospital or $250 in an Outpatient Surgery Facility resulting from a covered Injury or Sickness. Limited to 1 surgery (Inpatient or Outpatient) per person per Policy Year.

Anesthesia: When a covered surgical procedure is performed, You will have coverage up to the amount shown in the benefit schedule of the Plan You select, for anesthesia and its administration during the surgery. Limited to 1 (2 for Platinum plan) (Inpatient or Outpatient) per person per Policy Year.

Doctor's Office Visits: 100% of Usual & Customary charge after a $30 co-pay in-network (or $30 deductible for out-of-network) for a Medically Necessary Doctor Visit due to a covered Injury or Sickness, visits will also be for newborn well-care and routine health examinations and immunizations for children aged 5 and under. Limited to 5 visits per person per Policy Year.

Wellness Visits: 100% of Usual & Customary charge after $30 co-pay in-network (or $30 deductible out-of-network) for a routine health examination. Limited to 2 visits per person per Policy Year.

 

Diagnostic Testing:
Basic: You will have coverage up to the amount shown in the benefit schedule of the plan You select, for x-rays, laboratory and other diagnostic tests, ordered or performed by a Doctor that are Medically Necessary due to a covered Injury or Sickness. Limited to 5 sittings per person per Policy Year.

Emergency Room: You will have coverage up to the amount shown in the benefit schedule of the plan You select, for Medical treatment received by a Doctor in a Hospital Emergency Room for a Medical Emergency due to a covered Injury or Sickness. Limited to 1 visit per person per Policy Year.

Accident Medical Expense: You will have coverage up to the amount shown in the benefit schedule of the plan You select, for an accidental Injury that requires Medically Necessary care. Initial treatment for the Injury must be received within 30-days of the date of the Injury. Limited to 1 treatment per person per Policy Year and subject to a $100 deductible.

Accidental Death & Disbursement: You or Your beneficiary will be paid, up to the amount shown in the benefit schedule of the plan You select, for a covered Injury that results in death or dismemberment. Dismemberment is paid as a percentage of the amount shown in the benefit schedule, please see dismemberment table for specific benefits and limits.

Maximum Benefit: Maximum overall policy benefit is $1 million. In addition, each type of benefit is subject to the maximum benefit amount listed in the chart below. Federal law known as the Affordable Care Act that became effective September 23, 2010 removed the lifetime maximum benefit limit for health insurance but as of the date of this publication, no state insurance department has authorized any insurance company to modify any consumer communication to reflect the changes incorporated into the new law.

THIS IS LIMITED MEDICAL INDEMNITY COVERAGE. IT IS NOT MAJOR MEDICAL COVERAGE and is not intended to replace other medical coverage.

There is a 30-day waiting period for Sickness. Limits vary by plan, please review plan options to determine the plan that best suits your needs. Members can be enrolled only once. Duplicate or multiple memberships including United States Fire Insurance Company benefits, is not allowed.

A 12-month Pre-existing Condition Limitation applies to the following benefits: Hospital, including First Day Admission, Hospital Standard room, Intensive Care/Cardiac Care Unit, Surgery and Anesthesia.

Name Clarification

This article addresses "Core Health Insurance", a registered brand name of insurance plans described below and underwritten by United States Fire Insurance Company. Other insurance companies and public media occasionally use the term "core health insurance" to refer to a generic concept of insurance. This article only refers to the officially branded product and not any generic insurance that may use the term "core health".

Approved States

41 states have approved this coverage as of the date of this article's most recent revision: Alabama, Arizona, Arkansas, California, Colorado, District of Columbia, Delaware, Florida, Georgia, Hawaii, Idaho, Indiana, Iowa, Kentucky, Louisiana, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Mexico, Nevada, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, and Wyoming.

This insurance is not approved in Alaska, Connecticut, Illinois, Maine, Maryland, New Jersey, New York, Vermont, and Washington.

 

Eligibility

To be eligible for any Core Health Insurance plans you must:

  • Member of AUIC (application is included with insurance application)
  • over the age of 18, unless an eligible dependent child;
  • under the age of 65;
  • reside in the United States (citizenship is not required);

Eligible Dependent means:

  1. Your lawful spouse; and
  2. Your unmarried child or children who:
    1. Reside in Your home for more than 6-months a year;
    2. Chiefly relies on You for support and maintenance; and
    3. Who is under 19 years of age (the Limiting Age).

The Limiting Age will be extended from the child’s 19th birthday through the child’s 24th birthday provided they are enrolled in a school as a full time student and attend classes regularly at an accredited college or university. “Child” includes stepchild, foster child, legally adopted child, a child of adoptive parents pending adoption proceedings, natural child and child you are required to provide coverage for by court order. Eligible dependent may vary by state.

State Variations

Terms and conditions may vary by state and may change after the publication date of this article. Please review your certificate for any variations.

PPO Network Providers

You have the freedom to choose any medical service provider. This insurance plan does not require network providers. The same level of benefits is paid to all providers regardless of their PPO network affiliations. Any doctor or hospital may be used. There is no reduction in benefits for using an “out-of-network” provider. Note that the cost of a doctors visit is $30 regardless of whether in-network or out-of-network. The difference in name for this fee - "deductible" or "co-payment" reflects a difference in the method in which the claim would be processed but does not affect your benefit.

If a Preferred Provider Organization (PPO) network is available in your area, then you might save money by using a PPO member provider. This feature is automatically added as an available option to your Core Health plan if a PPO network is available in your area. Benefit payments may be made directly to your doctors and PPO member providers are more likely to accept assignment of benefits. Although the willingness to accept assignment is not controlled by the insurance company, this is frequently a practical advantage of using a PPO member provider. More information on the optional PPO network is provided on the page "How Core Health Plans Work".

Physician Referrals

This plan does not require physician referrals for treatment. Treatment provided by any doctor or hospital in the United States may be covered

Pre-certification

This insurance requires pre-certification within 48 hours of an in-patient hospital admission.

Deductibles

This policy does not use deductibles expect for two specific benefits: 1) an out-of-network doctor visit requires a $30 deductible, and 2) the supplemental accident benefit of $500 requires a $100 deductible. For other covered services, the benefits listed in the policy are the exact dollar benefits available; there are no deductibles.

Co-payments

This policy requires a $30 co-payment only for in-network doctor visits. For other covered services, the benefits listed in the policy are the exact dollar benefits available; there are no co-payments.

Co-insurance

This policy does not use co-insurance. The benefits listed in the policy are the exact dollar benefits available; no adjustment is made for co-insurance.

Length of Coverage

This policy continues in force  month-to-month until one of the following occurs: 1) you do not pay a premium by the due date, 2) you notify the plan administrator to cancel coverage, 3) you become ineligible for coverage, 4) the insurance is not longer available under the laws of your state or the U.S. federal government. The  minimum length of coverage is 30 days. There is no maximum length of coverage. Coverage is renewable until age 65.

Enrollment Process

You may enroll online or via paper application. Enrollment cannot be completed by telephone. We strongly recommend online enrollment for improved security and tracking of the application. The first month's payment must be provided in order for coverage to become effective. The first months payment must be provided in order for coverage to become effective.

Changes to Coverage

Changes to coverage underwritten by United States Fire Insurance Company can only be made only if the change is the result of a qualifying life event. A qualifying life event means marriage, divorce, the death of your spouse, or the birth or adoption of a child.

Reapplying After Coverage is Cancelled

If coverage is cancelled for any reason, you may re-enroll 6 months after the cancellation date.

Rate Increases

No individuals can be singled out for a rate increase. Future rate increases are expected to parallel the rate of medical cost inflation.

Policy Cancellation

The Policyholder (AUIC) has the right to cancel the policy as it pertains to all insured's on any premium due date by providing 31 days written notice.

The insurance company has the right to cancel the policy by providing at least 31 days notice to the Policyholder.

Effective Date of Coverage

Coverage becomes effective "next day" (12:01 am) following the date of the completed enrollment form is received or a specified date in the future (can not be more than 60 days in advance), provided that full premium for the coverage has been received.

Termination for Members and Dependents

A covered member automatically ceases to be insured on the occurrence of any of the following events:

  • he or she requests cancellation via written notice
  • the end of the last period for which all required premium has been paid
  • the date membership ends
  • the date he or she reaches age 65
  • the date the association ceases to offer the plan
  • the date the policy terminates

Spouse and children’s coverage terminates concurrently with that of the primary member, or earlier if they no longer qualify as a dependent, or if the primary member requests termination of coverage.

Premium Billings

Online payment is the most popular choice; payments are automatically withdrawn from your credit card or checking/savings account. You can check the status of your payments online. You may also set up email alerts to let you know when payments will be withdrawn.

Another option is to have a bill sent to your resident address. A modal billing fee will be reflected on each bill. Please be advised that a one-time administration fee of $10 will be required at time of enrollment for this payment option.

Payment of Claims

Your provider may bill the insurance company for the eligible insured benefits outlined in your membership plan; you will receive an Explanation of Benefits (EOB) from the administrator explaining what was paid and what you owe the provider. A welcome kit will be issued, which includes ID cards and instructions for filing claims. Members will be given access to the online Customer Care Center where he/she may have access to billing, claim forms, Identification cards, customer surveys, customer services, and more, available 24 hours a day 7 days a week.

Evidence of Coverage

All members will receive a fulfillment kit that will include information about your AUIC member benefits, as well as a certificate of insurance and an identification card.

Pre-Existing Conditions Limitation

(applicable to Hospital, ICU/CCU, Surgery and Anesthesia benefits only).

Pre-existing Condition means a medical condition, Injury or Sickness, not excluded by name or specific description, for which:

  1. Medical advice, Consultation, care or treatment was recommended by, or received from, a Doctor within 12-months immediately prior to the Effective Date of coverage for a Covered Person; or
  2. Symptoms existed within 12-months immediately prior to the Effective Date of coverage for a Covered Person that would cause a reasonable person to seek Consultation, care, or treatment from a Doctor.
“Consultation” means evaluation, diagnosis, or medical advice given without the necessity of a personal examination or visit.

Limitations and Exclusions

Benefits will not be paid for charges or loss caused by, or resulting from, any of the following:

  1. Suicide or any intentionally self‑inflicted Injury (may vary by state);
  2. Any drug, narcotic, gas or fumes, or chemical substance voluntarily taken, administered, absorbed or inhaled unless prescribed by, and taken according to the directions of, a Doctor (accidental ingestion of a poisonous substance is not excluded.);
  3. Commission, or attempt to commit, a felony;
  4. Participation in a riot or insurrection;
  5. Driving under the influence of a controlled substance, unless administered on the advice of a Doctor;
  6. Driving while Intoxicated. "Intoxicated" will have the meaning determined by the laws in the jurisdiction of the geographical area where the loss occurs.
  7. Declared or undeclared war or act of war;
  8. Nuclear reaction or the release of nuclear energy. However, this exclusion will not apply if the loss is sustained within 180-days of the initial incident and:
    1. The loss was caused by fire, heat, explosion or other physical trauma which was a result of the release of nuclear energy; and
    2. The Covered Person was within a 25-mile radius of the site of the release either:
      1. At the time of the release; or
      2. Within 24-hours of the start of the release; or
      3. Occurs while he is in the issue state of this Certificate;
  9. Routine health checkups or immunizations for Covered Person aged 6 and older except as specifically provided; allergy testing;
  10. Surgery to correct vision or hearing; eyeglasses, contact lenses and hearing aids, braces, appliances, or examinations or prescriptions therefore;
  11. Dental care, x-rays, or treatment other than Injury to natural teeth and gums resulting from an accidental Injury and rendered within 6-months of the Injury;
  12. Spinal manipulations and manual manipulative treatment or therapy or physiotherapy;
  13. Weight loss or modification and complications arising therefrom, including surgery and any other form of treatment for the purpose of weight loss or modification;
  14. Rest cures or custodial care, or treatment of sleep disorders;
  15. Treatment, services or supplies received outside of the U.S. except for acute Sickness or Injury sustained during the first 30-days of travel outside the U.S.;
  16. Normal pregnancy or childbirth, except for Complications of Pregnancy;
  17. Any drug, treatment, or procedure that either promotes or prevents conception or childbirth regardless of what the drug, treatment, or procedure was originally prescribed or intended for;
  18. Treatment of temporomandibular joint (TMJ) disorders involving the installation of crowns, pontics, bridges or abutments, or the installation, maintenance or removal of orthodontic or occlusal appliances or equilibration therapy;
  19. Cosmetic surgery. This Exclusion does not apply to reconstructive surgery:
    1. On an injured part of the body following trauma, infection or other disease of the involved part;
    2. Of a congenital disease or anomaly of a covered dependent newborn or adopted infant; or
    3. On a non-diseased breast to restore and achieve symmetry between two breasts following a covered Mastectomy;
  20. The repair or replacement of existing artificial limbs, orthopedic braces, or orthotic devices; dentures, partial dentures, braces or fixed or removable bridges;
  21. Treatment or removal of warts, moles, boils, skin blemishes or birthmarks, bunions, acne, corns, calluses, the cutting and trimming of toenails, care for flat feet, fallen arches or chronic foot strain;
  22. Treatment of Mental or Nervous Disorders, or alcohol or substance abuse, unless specifically provided for under this Certificate;
  23. Prescription medicines;
  24. Any Injury that is caused by flight or travel in, or upon:
    1. An aircraft or other, craft designed for navigation above or beyond the earth's atmosphere except as a fare‑paying passenger;
    2. An ultra light, hang‑gliding, parachuting or bungi‑cord jumping;
    3. A snowmobile;
    4. Any two or three wheeled motor vehicle;
    5. Any off‑road motorized vehicle not requiring licensing as a motor vehicle;
    6. Any watercraft or other craft designed for water use above or beneath the water, except as a fare-paying passenger;
  25. Any accidental Injury where the Covered Person is the operator of a motor vehicle and does not possess a current and valid motor vehicle operator's license;
  26. Services, treatment or loss:
    1. Rendered in any Veterans Administration or Federal Hospital, except if there is a legal obligation to pay;
    2. Payable by any automobile insurance policy without regard to fault. (Does not apply in any state where prohibited);
    3. Which a Covered Person would not have to pay if he did not have insurance;
    4. Provided by a Doctor, Nurse or any other person who is employed or retained by a Covered Person or who is a member of a Covered Person’s Immediate Family;
    5. Covered by state or federal worker's compensation, employers liability, occupational disease law, or similar laws;
    6. Injury or Sickness sustained while on active duty in the armed forces of any country. Upon receipt of proof of service, we will refund, any unearned premium paid on a pro rata basis;
  27. Hemorrhoids, tonsils, adenoids, middle ear disorders, any disease or disorder of the reproductive organs unless the loss is incurred at least 6-months after the Covered Person becomes insured under this Certificate;
  28. Elective treatment or surgery and treatment, procedures, products or services that are experimental or investigative. “Experimental or Investigative” means a drug, device or medical treatment or procedure that:
    1. Cannot lawfully be marketed without approval of the United States Food and Drug Administration and approval for marketing has not been given at the time of being furnished;
    2. Has Reliable Evidence indicating it is the subject of ongoing clinical trials or is under study to determine its maximum tolerated dose, toxicity, safety, efficacy, or its efficacy as compared with the standard means of treatments or diagnosis; or
    3. Has Reliable Evidence indicating that the consensus of opinion among experts is that further studies or clinical trials are necessary to determine its maximum tolerated dose, toxicity, efficacy, or its efficacy as compared with the standard means of treatment or diagnosis.

“Reliable Evidence” means (i) published reports and articles in authoritative medical and scientific literature; (ii) the written protocol(s) of the treating facility or the protocols of another facility studying substantially the same drug, device, medical treatment or procedure; or (iii) the written informed consent used by the treating facility or by another facility studying substantially the same drug, device, or medical treatment or procedure.

THIS IS LIMITED MEDICAL INDEMNITY COVERAGE. IT IS NOT MAJOR MEDICAL COVERAGE and is not intended to replace other medical coverage.

Insurance Company

United States Fire Insurance Company is a member of Fairmont Specialty, a division of Crum & Forster. 305 Madison Avenue, Morristown, NJ 07962 Phone: 973-490-6600 Fax: 973-490-6612 (This is the company's legal address only and is not the address or phone number to use for routine correspondence about your health insurance).

Unrelated Health Plans

Freedom Benefits has received inquiries about other health plans with similar names that are not affiliated with us, the United States Fire Insurances Company or with www.corehealthinsurance.net. The following are NOT affiliated with us:

  • "Core Value Medical Plan"
  • "AMLI"
  • "American Medical Life Insurance Company"

We have no information about or contact with the health plans identified by these terms.

Plan Administrator

Core Health Insurance is administered by SAS-ID, P.O. Box 1086, Janesville WI 53547-1086. Tel. 877-279-7959, Fax 608-755-7955. SAS-ID develops technologies and online marketing solutions for top insurance carriers and nationwide distribution networks. SAS-ID was founded in 1999 and has been a leader and innovator in developing and marketing insurance on the web. SAS-ID was founded by insurance professionals who have a passion to make insurance simpler and more accessible to everyone. SAS-ID is a member of the BBB Online Reliability program.



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This web site is independently owned and managed by Tony Novak operating under the trademarks "Freedom Benefits", "OnlineAdviser" and "OnlineNavigator". Opinions expressed are the sole responsibility of the author and do not represent the opinion of any other person, company or entity mentioned. Tony Novak is not an agent, broker, producer or navigator for any federal or state health insurance exchange but may provide uncompensated advice, reviews and referrals to these official resources. Novak is compensated as an accountant, adviser, affiliate consultant, marketer, reviewer, endorser, producer, lead generator or referrer to some of the other commercial companies listed on this site. Information is from sources believed to be reliable but cannot be guaranteed.