The "Fortis Series 2000 MSA" for Year 2001.  

Underwritten by Fortis Insurance Co.  Hospital & Physician  PPO -  Enjoy greater savings by using PPO network hospitals and physicians.  New plan features as of 6/1/01 

Benefits  Summary

Calendar Year Deductible – 


Maximum 1 family member deductibles per calendar year. 
Individual Plan Deductible Family Plan Deductible
$1600 $3200
$2000 $4000
$2400 $4800

Maximum Tax Deductible Contribution to MSA Trustee

 Individual - 65% of deductible

Family - 75% of deductible 

Coinsurance -  The Percentage that the insurance company pays after the deductible until the out of pocket max has been reached.  

100% 80%

Maximum out of pocket  -  After this amount has been reached, plus your deductible, covered expenses are paid at 100% by the insurance company.  

 $0 $1000

With the Fortis MSA you may elect to have claims that would normally go against deductible be paid automatically from your MSA Trustee account. 

Covered Expenses Include

Wellness Visits including - Physical Exams, Immunizations, Pap Smears, Mammograms Covered subject to Deductible and coinsurance limits, $500 Annual Max benefits.

Inpatient and Outpatient Physician and Hospital expenses.

  • Physician Office visits

  • Prescription Drugs 

  • Hospital Semi-Private room

  • Surgery

  • Intensive Medical Care

  • Physician Consultations

  • Anesthesia, Radiology, Pathology

  • Therapy Services

  • Blood

  • X-ray, Lab tests,

  • Pre-Admission Testing

  • Emergency-Illness and Accident

  • Ground and Air Ambulance

  • Complications of Pregnancy

  • Supplies and Equipment

  • Outpatient Treatment of Back/Spine and Neck with $750 annl Maximum.

  • Emergency Room - subject to an additional $75 copayment per visit - waived if admitted.

Subject to deductible and coinsurance

Additional Services

  • Occupational, physical, speech and cardiac Rehab to $3000 per year.

  • Inpatient rehab 100% coverage for 30 days

  • Home Health Care 100% coverage, 160 hours/year.

  • Skilled nursing facility 100% coverage. 30 days

  • Spine/Neck/Back Treatment $750 calendar year max.

  • TMJ  $1000 Lifetime max

  • Organ Transplants to lifetime max of policy at designated provider centers, $100,000 lifetime per organ at non designated provider centers.

 Subject to deductible and coinsurance

Mental Health-

  • Inpatient $2500 max combined per year

  • Outpatient $500 per year

  • Marriage and family counseling are included

 

Subject to deductible and coinsurance

Optional Benefits

Dental and Vision Discounts

  • For just $9.95 a month you get:

  • - Up to 60% off all dental services, including orthodontia, from Dental Network of America, a national network of 13,000 dentists.

  • - Up to 60% off eyeglasses and contact lenses from Coast to Coast, a national network of 10,000 eyewear providers.

  • The discounts apply to an unlimited number of visits for all family members in your household.
Life Insurance  Up to $100,000 Benefit
Supplemental Accident Benefit  -  Benefits are paid at 100% up to $300, $500, or $1000 maximum per occurrence with no deductible.   
Maternity Benefits  - Covered as any other medical service as long as conception occurred after being insured for 270 days with this policy.  

In Texas only - Maternity benefits are covered after a 31 day conception waiting period. 

  • Includes Prenatal Care

  • Routine Delivery Services

  • Routine Inpatient newborn services

  • Coverage for Hypermesis gravidarum, Pre-eclampsia, eclampsia, premature labor, and placenta previa.

Lifetime Maximum Benefits           $8,000,000 

 

This is not a solicitation or offering of insurance and may contain inaccuracies.  Please refer to your benefit certificate for specific limitations and exclusions.  Benefits quoted are for illustration only.  Offerings of insurance and prices quoted are made based only on submitted applications.  This form may not be reproduced or used by any other entities without the expressed permission of Castle Group Health or www.healthinsure.com, copyright 1995- 2001 . Form 26566 Insurance policies are issued and underwritten by Fortis Insurance Company, Milwaukee, WI.

Call us for More Information : 847-559-8100

 

updated 5/24/2001