| AMLI Benefits |
Benefit Description
Max. Per Year or Visit |
NCE Advantage Plan |
| |
|
300 |
500 |
750 |
1000 |
1000Plus |
| Dr. Office Visits: |
Per Visit
Maximum Visits |
$50
3/yr. |
$50
3/yr. |
$50
3/yr. |
$75
3/yr. |
$75
5/yr. |
Preventive
Care Test:
Payable per preventative care tests listed in policy certificate. |
Per Test
Maximum Visits |
$50
1 |
$50
1 |
$100
1 |
$150
1 |
$150
1 |
Diagnostic, X-Ray
& Lab Tests: |
Per Day
Maximum Visits |
N/A |
$50
2 |
$50
3 |
$75
3 |
$75
5 |
| In Patient Hospital Confinement: |
Per Day
Maximum Days/Yr. |
$300
30 |
$500
30 |
$750
30 |
$1000
30 |
$1000
30 |
ICU/CCU:
The hospital confinement benefit and the hospital ICU benefit will not be paid concurrently. |
Per Day
Maximum Days/Yr. |
$500
10 |
$750
10 |
N/A
- |
N/A
- |
$1000
5 |
Surgery & Anesthesia:
Surgery performed with the Administration of anesthesia by a licensed anesthesiologist or Certified Registered nurse anesthetist. |
Surgery paid as percentage of RBRVS |
50% |
70% |
80% |
80% |
100% |
| Reimbursement based on the Medicare / RBVS benefit schedule. |
Annual Max Not to exceed the Amount of charge Incurred |
Unlimited |
Unlimited |
Unlimited |
Unlimited |
Unlimited |
Anesthesia
When administered by a licensed Anesthesiologist or Certified Registered Nurse Anesthetist. |
Paid as a percentage of the surgery benefit |
20% |
20% |
20% |
20% |
20% |
Accident:
Charges incurred due to injuries received in a covered accident.
(Not available in TX) |
Deductible/Policy Yr.
Payable at:
Maximum Yr. |
$100
80%
$1,000 |
$100
80%
$2,500 |
$100
80%
$2,500 |
$100
80%
$5,000 |
$100
80%
$5,000 |
Inpatient Mental Health:
Treatment as a result of a mental illness. |
Benefit per Day
Max. Days/Policy Yr. |
$150
60 |
$250
60 |
$375
60 |
$500
60 |
$1000
60 |
Outpatient Mental Health:
Treatment as a result of a mental illness. |
Benefit per Day
Max. Days/Policy Yr. |
$25
20 |
$25
20 |
$25
20 |
$25
20 |
$25
20 |
Inpatient Chemical Abuse & Dependence Diagnosis and Treatment:
Confined to a hospital or licensed Institution to receive treatment for Substance abuse. |
Benefit per Day
Maxium Days |
$150
60 |
$250
60 |
$375
60 |
$500
60 |
$500
60 |
| Detoxification Max Benefit: |
12 Days of Active Treatment Per Policy Yr. Per Covered Person |
|
|
|
|
|
Diabetes Supplies:
Equipment & Self-Mgmt.
Education Benefit. |
Diabetes Supplies, Equipment & Self Mgmt. Education Benefit |
$100 Per Policy Yr. Per Covered Person |
$100 Per Policy Yr. Per Covered Person |
$100 Per Policy Yr. Per Covered Person |
$100 Per Policy Yr. Per Covered Person |
$100 Per Policy Yr. Per Covered Person |
Chemical Abuse & Dependence Outpatient Benefit:
Treatment as a result Of Substance Abuse to The maximum shown. |
Benefit Per Treatment
Maximum Visits Per Policy Year |
$25
20 |
$25
20 |
$25
20 |
$25
20 |
$25
20 |
| Monthly Rates (Not inclusive of one time Enrollment Fee) |
| Member |
$163 |
$216 |
$230 |
$279 |
$328 |
| Member & Spouse |
$275 |
$383 |
$410 |
$508 |
$606 |
| Member & Children |
$254 |
$349 |
$374 |
$462 |
$551 |
| Family Rate |
$356 |
$499 |
$536 |
$669 |
$801 |
| Underwritten by American Medical and Life Insurance Company. Group Insurance Policy Number: (50015). Limited Benefit Health Benefit Health Insurance is not basic health insurance or major medical coverage and is not designed as a substitute for basic health insurance or major medical coverage. Benefits may not be available in all states. Benefits may vary from state to state. This document is not a contract of insurance. This document provides only brief descriptions of the coverages available. The policies contain limitations, exclusions, and termination provisions. Full details of the coverage are contained in each policy. If there are any conflicts between this document and each Policy, the Policy shall govern. |
"To speak to an Agent call 214-821-6677 or
toll-free 1-800-462-2322"
NCE Advantage utilizes the MultiPlan Limited Medical Network
maximize consumer savings