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Limited Benefit Plan Designs
Limited Benefit Plans
An affordable employee benefit alternative for any business
that has employees without health care coverage or any business
faced with the out-of-control costs of typical group health
insurance plans. The health care indemnity plan provides coverage
for employees not currently covered by an employer provided health
care plan and it provides coverage for the employee exposure that
exists in high-deductible full coverage health plans even when
combined with Medical or Healthcare Reimbursement Accounts.
Plan Highlights:
- Employer may choose from four limited medical benefit plans
The plans include an RX benefit and employee life with AD&D
- Employee may elect to purchase dependent term life
- Employer will receive one consolidated billing
- Employer will make one payment per month for all Sterling
Benefit Solutions benefits
- Employee will complete one application for all benefits selected
by employer
- Coverage is guarantee issue for groups meeting
participation/contribution requirements
- COBRA administration services are available
Eligibility Requirements:
- Eligible employees must work a minimum of 15 hours per week
- Minimum of 5 enrolled lives in a group - must meet participation
requirements
- Employer specified waiting period for employee eligibility
- Dependent children under age 19 (25 if full time student) are
eligible for coverage
Employee Claim Payment Options
Using this limited medical indemnity plan is easy for your
employees and has two payment options for paying providers depending on
the method the provider chooses:
- Option 1: Health care provider collects charges in excess
of the benefit amount at the time services are provided. Employee
assigns plan benefits to the health care provider who files a claim
under the indemnity plan. Any benefit payment that is due will be
paid directly to the health care provider.
- Option 2: Health care provider collects the full amount
due at the time services are provided. Employee files a claim for
recovery under the indemnity plan. Any benefit payment that is due
will be paid directly to the employee.
Limited Medical Benefit
The WIBA limited benefit plans provide the following types of benefits
requested by most employers and employees.
- Physician office visits - maximum of six visits per person per
calendar year
- Outpatient X-ray and lab benefit - maximum of three testing days
per person per calendar year (n/a on WIBA Plan A)
- Prescription Drug Card - $10 (generic formulary) or $15 co-pay
(generic formulary oral contraceptives) $1500 annual maximum per
person.
- Wellness visits - up to $150 per person per calendar year
- Immunizations for children up to age 6 - covered under wellness
benefit
- Pregnancy benefit - covers any normal pregnancy
- Emergency Room Accident benefit - covers treatment within 72
hours of accident
- Inpatient Hospitalization - 24 hour stay required
- Hospital Admission benefit - Requires a 24 hour hospital stay,
pays once per person per calendar year (n/a on WIBA Plan A)
- ICU benefit - maximum of ten days per person per calendar year
- Inpatient and Outpatient Surgical benefit - benefits paid per
schedule (n/a on WIBA Plan A)
- Ambulance benefit - $50 per trip, maximum $150 per person per
calendar year (n/a on WIBA Plan A)
- Employee has no deductible to meet under this plan.
Prescription Drug Benefit
The prescription drug benefit is available with all limited medical
plans. The prescription drug benefit provides:
- Coverage for formulary generic drugs.
- Requires a $10 co-payment for each covered formulary generic
drug ($15 co-pay for covered formulary generic oral contraceptives)
- Maximum of $1,500 per person per calendar year
- Discount on brand name and non-formulary generics
Provider
American Sterling Insurance Services, Overland Park, KS.
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