SEPTEMBER 2009 - Association of Marina Industries

Association of Marina Industries – HM Care Advantage Benet Summary
Benet Schedule Value Standard Premium
Oce Visits – Physician/
Licensed Practitioner
Daily In-Hospital
Additional Daily Benet for First
Day of Hospital Connement
Surgery
Anesthesia
Outpatient Diagnostic Testing
Provider Network
$60 per Visit
5 Visits
$100 per Day
30 Days
$100 First Day
1 Admission
$500 Max. per Surgery
Based on Schedule
2 Surgeries
20% of Scheduled
Surgery Benet
$100 per Testing Day
3 Days
Reduces Fees from
Network Providers
$80 per Visit
5 Visits
$200 per Day
30 Days
$200 First Day
1 Admission
$500 Max. per Surgery
Based on Schedule
2 Surgeries
20% of Scheduled
Surgery Benet
$125 per Testing Day
3 Days
Reduces Fees from
Network Providers
Hospital Emergency Room Not Included $250 per Visit
2 Visits
Inpatient Visits – Physician Not Included $100 per Visit
3 Visits
$100 per Visit
5 Visits
$500 per Day
30 Days
$500 First Day
1 Admission
$1,000 Max. per Surgery
Based on Schedule
3 Surgeries
20% of Scheduled
Surgery Benet
$300 per Testing Day
3 Days
Reduces Fees from
Network Providers
$500 per Visit
3 Visits
$100 per Visit
3 Visits
Daily Intensive Care Unit Not Included Not Included $1,000 per Day
Replaces In-Hospital Days
Outpatient Hospital Services Not Included $200 per Treatment Day
2 Days
Wellness Screening Test
Wellness Service
Outpatient Prescription
Drug Insurance*
(Dependent-only coverage is
not available.)
*Provided by Fidelity Security Life
Insurance Company.
$150 per Test
1 Test
$75 per Service
1 Service
Not Included
(See Pharmacy
Discount Card)
$150 per Test
1 Test
$75 per Service
1 Service
$10 Co-pay Generic
Formulary
$15 Co-pay Generic Oral
Formulary Contraceptives
$50 Co-pay Brand Name
Formulary
$1,000 Max. Benet
$250 per Treatment Day
2 Days
$150 per Test
1 Test
$75 per Service
1 Service
$10 Co-pay Generic
Formulary
$15 Co-pay Generic Oral
Formulary Contraceptives
$50 Co-pay Brand Name
Formulary
$1,000 Max. Benet
Indemnity Benefits shown are per calendar year per covered person. The calendar year is the employer-defined benefit cycle.
This Benefit Summary is not intended to be a complete or legal description of the program of benefits. Certain exclusions and
limitations apply and may vary by state. HM Care Advantage pays a fixed amount for medical services. It does not provide major
medical or comprehensive medical coverage.
Starting at less than $45
per month per employee,
the plans at the left
were developed for the
Association of Marina
Industries .
About HM Care Advantage
HM Care Advantage pays a
xed amount for medical
services. The benets can be
paid directly to the provider
or to the employee, whichever
the employee prefers.
Complementary discount and
wellness programs round out
the coverage offering, and a
provider network helps reduce
out-of-pocket expenses.
Additional value-added
benets include:
• Health Information On-Call
• Complementary Wellness
Discount Program
• Health Information On-Line
• Pharmacy Discount Card**
• Vision Discount
** Replaced by insured prescription
drug coverage when insured coverage
is offered
Monthly Premium Costs Value Standard Premium
Employee $44.11 $95.14 $114.70
Employee + Spouse $80.12 $167.65 $264.31
Employee + Children $81.16 $181.48 $278.14
Family $117.05 $253.83 $397.59
The rates shown above are contingent upon the employer contributing at least 100% of the premium for the lowest priced
employee-only plan.
About HM Life Insurance Company
HM Life Insurance Company is a member of the HM Insurance Group, based in Pittsburgh, PA. HM
Insurance Group, a Highmark Company, oers a product portfolio featuring HM Worksite Advantage —
Critical Illness, Accident and Disability Income plans — and HM Care Advantage, a limited benet
medical plan. HM is a recognized leader in excess loss and reinsurance including Employer Stop Loss,
Provider Excess and HMO Reinsurance. HM Life Insurance Company has received “A-” (Excellent)
ratings from A.M. Best Company, one of the country’s oldest and most respected rating agencies.
Interested in
learning more
Visit AMI's benets site,
www.amiemployeebenets.com,
or call 719.313.9578 to speak to
Shawn, your AMI benets
specialist, who can address
your particular needs.
HM Care Advantage is an HM Life Insurance Company product administered by Key Benet Administrators (KBA). Based on the plan selected, Medical and Vision
coverages are underwritten by HM Life Insurance Company, Pittsburgh, PA, under policy form series HM905, HL902 or similar. For other insured products when available:
Dental and Outpatient Prescription Drug coverages are underwritten by Fidelity Security Life Insurance Company, Kansas City, MO, under policy form series M-9037 and
M-9031/M-9022. Administrative and/or customer support services when available are provided: for Health Information On-Call – Health Dialog Services Corporation; for
Complementary Wellness Discount Program – Healthways Whole-Health Networks, Inc; for Health Information On-Line – HealthMedia® Inc.; for Pharmacy Discount Card
– Caremark, Inc; for Vision – Davis Vision; for Provider Network Discount – MultiPlan and Indiana Health Network. Other administrative and/or customer support services
may be provided by HM Life Insurance Company and HM Benets Administrators. Certain exclusions and limitations may apply. See your certicate or other evidence of
coverage for details. Coverage or service requested or the use of a specic association, franchise, trust or union may not be avail-able in all states.
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