Essential Plus STM
States Available:
AL, AK, AZ, AR, CO, DC, DE, FL, GA, HI, IL, IN, IA, LA, ME, MI, MS, MO, NE, NV, NM, OH, OK, PA, SC, SD, TN, VA, WV, WI & WY
Note: Additional States will be available soon: CA, ID, KY, MD, MT, NH, NC, ND, OR, RI, TX, UT, WA
More states will become available in months to come.
Exclusive features include:
• Coverage for Participation in Intercollegiate Athletics• Up to $750,000 Lifetime Maximum per Covered Person• Coverage up to 12 months at a time• Unlimited reapplies in most states• Choice of deductibles - $250, $500, $1,000, $2,500, $5,000, $7,500 or $10,000• Coinsurance options of 80% or 50% up to either $5,000 or $10,000• Freedom to choose any doctor or hospital• Foreign Travel (medical care while in a foreign country) covered up to $25,000 (After a $250 benefit deductible)Underwritten by:
Starr Indemnity & Liability Company
Rated “A” (Excellent) by A.M. Best Company
What medical expenses are covered?
The following benefits are for Insured and each Covered Dependent subject to the plan Deductible, Coinsurance Percentage, Coinsurance Limit and Lifetime Maximum of 750,000. Benefits are limited to the Usual, Reasonable and Customary charge for each Covered Expense, in addition to any specific limits stated in the policy.
• Inpatient Hospital miscellaneous charges and average semi-private room rate up to $1,000 per day• Intensive or Critical Care & miscellaneous charges up to $1,250 per day• Doctors Office and Urgent Care Center - up to $25 per visit, up to 4 per Coverage Period• Outpatient Hospital or Emergency Room Care (includes emergency room doctor) - up to $500 per day• Foreign Travel (medical care while in a foreign country) after a $250 Benefit Deductible up to a $25,000 Maximum per Coverage Period• Skilled Nursing Facility $30 per day up to a maximum of 30 days per Coverage Period• Ambulatory Surgical Center or Outpatient Hospital Surgical Facility• Surgeon services in the hospital or ambulatory surgical center up to $2,500/surgery or $5,000/Coverage period• Assistant Surgeon services up to 20% of surgeons benefit• Anesthesia services up to 20% of surgeons benefit• X-ray exams, laboratory tests and analysis, radioactive isotope therapy, oxygen, casts, splints, crutches, braces, surgical dressings, artificial limbs or eyes, rental of medical supplies• Ambulance Ground or Air Maximum Benefit of $250 per trip• Blood or blood derivatives and their administration• Mammography• Inpatient prescription drugs• Interscholastic or Intercollegiate Organized Competitive Sports• Home Health Care up to $40 per visit up to a Maximum of 40 visits per Coverage Period• Hospice Care up to $5,000 Maximum per Coverage Period• Acquired Immune Deficiency Syndrome (AIDS) up to $10,000 Maximum per Coverage Period• Temporomandibular Joint Disorder (TMJ) up to $3,500 Maximum per Coverage Period• Gallbladder surgery up to $2,500 Maximum per Coverage Period• Organ tissue transplants up to $50,000 Maximum per Coverage PeriodNote: This is a brief description of the plan benefits, which may vary by state..
Rx 4 Tier Drug Card (Automatically included): *
With Advanced Benefits four tier prescription discount drug card, you pay up to $10, $20 or $50 for Formulary or Generic drugs and receive a generous discount on your Brand Name drugs. This card is accepted at over 43,000 pharmacies throughout the United States. The net-work includes pharmacy chains as well as thousands of independent pharmacies throughout the country. This is automatically included at
no extra cost with Essential STM Lite Plan.
What is Pre-Admission Certification?
This plan requires a Pre-Admission Certification by a Professional Review Organization service prior to in-patient hospitalization or surgery. You must call the service within 10 days prior to an elective or non-emergency hospitalization or surgery; or within 48-hours following an emergency admission, or as soon as reasonably possible if the person’s medical condition prevents or delays such notification; or within 48-hours of delivery (96 hours for cesarean section) for
complicated childbirth or as soon as reasonably possible. Failure to pre-certify will result in a reduction in benefits of 50%.
How does Usual, Reasonable and Customary affect my benefits?
We may use and subscribe to a standard industry reference source that collects data and makes it available to its member companies in order to determine the amount that should be considered as Usual, Reasonable and Customary for services
and supplies.
The policy defines Usual, Reasonable and Customary to mean: The fees or charges for medical services or supplies which are usually charged by the provider for the service or supply given and the average charge for the service or supply in the
locality in which the service or supply is received; whichever is less; or with respect to treatment or medical services, treatment which is reasonable in relationship to the service or supply given and the severity of the condition.
Do I have the option to use any doctor or hospital?
Yes, there is no PPO or HMO Network requirement to receive full benefits.
What is the Pre-Existing Conditions Limitation?
We will not provide benefits for any loss caused by or resulting from, a Pre-Existing Condition. A Pre-Existing Condition is defined as any medical condition or Sickness for which medical advice, care, diagnosis, treatment, consultation, or medication was recommended by or received from a Doctor within the 5 years immediately prior to a
Covered Person's Effective Date of Coverage. (The Pre-Existing Conditions Limitation varies by state and may be less than 5 years.)
When does coverage start?
You can select your insurance to be effective as early 12:01 a.m. the day following the transmission date of your application. However, you can choose a later effective date, but not to exceed 60 days from the date of transmission. All coverage is subject to approval of your application and payment of your first premium.
When does the STM coverage terminate?
Essential STM Lite will automatically terminate on the earliest of the following dates:
The Expiration date of your coverage; the date the Group Policy Terminates; the date the insurance under the Group Policy is discontinued; the due date of a premium payment, if is is not paid by the end of the 31 day grace period; the date you be-
come eligible for Medicare; your dependent’s coverage ends when your coverage terminates or the dependent becomes eligible for Medicare; or the dependent cease to be eligible; the date you enter full-time active duty in the armed forces of any
country or international organization; the date we determine fraudulent statements or material misrepresentation has been made by you or with your knowledge in filing a claim for benefits.
What services and charges are not covered?
The following is a partial list of services or charges not covered by Essential STM Lite:
• Not medically necessary, except as specifically defined in the policy• Payable by Medicare or Workers’ Compensation coverage• Payable under any automobile insurance• Declared or undeclared war, participation in a riot; illegal act or occupation, or an attempted felony or assault• Pregnancy or childbirth, except for Complications of Pregnancy• Maternity and new born treatment prior to hospital discharge• Infertility or sterilization treatments or procedures• Mental Illness or Nervous Disorders, attempted suicide or intentionally self-inflicted Injury• Learning disorders, attention deficit disorder or hyperactivity, or autism• Alcoholism or abuse, drug addiction or abuse• Cost of programs, treatment, or procedures for tobacco use cessation• Dental or orthodontia care, eye exams or glasses, hearing aids, or sleeping disorder• Cosmetic or reconstructive procedures, except as specifically covered• Outpatient Prescription or Legend Drugs, or any over the counter medications or vitamins• Experimental or investigational services• Transplant services to the transplant donor• Foot conditions, acne or varicose veins or treatment of obesity• Services or supplies furnished or provided by an immediate family member• Skydiving, scuba diving, hang or ultra light gliding, all-terrain vehicle, dirt bike, snowmobile, go-cart, boat or aircraft• Racing with a motorcycle• Any sports for pay or profit, or participation in rodeo contests;• Certain surgeries during the first 6 months• Medical care received outside of the United States or its possessions in excess of the Foreign Travel BenefitThe limitations and exclusions may vary by state.
Please see the Policy/Certificate of Insurance for detailed information about these and other plan limitations and exclusions.
Who is Starr Indemnity & Liability Company?
Starr Indemnity & Liability Company is an admitted insurer rated “A” (Excellent) by A.M. Best Company. Starr Indemnity & Liability Company has sole financial responsibility for it products.
Cost:
The cost of this product is dependent upon area and thus to obtain additional information, please complete the information form below.
If you are interested in speaking with a Trustway TEAM Advisor about rates and products for Primary Health Insurance that covers athletic injuries please complete the information below:
Name:
Phone:
Email:
School:
State:
Approximate # of Students Needing Coverage:
For Additional Products and Services offered by Trustway T.E.A.M. Services please proceed to the right hand column.
Thank you for the opportunity for us to be a part of your health care team and we look forward to working with you.
