Part II
CATASTROPHIC HOSPITAL INSURANCE COVERAGE
ELIGIBLE EXPENSES/MEDICAL SERVICES
Subject to the Deductible Amounts, the Group Policy includes the listed Eligible Expenses/
Medical Services, paid at the Reasonable and Customary charge maximum. Should
Inconsistencies occur with the information provided in this brochure, the terms and
Conditions of the Group Policy, as amended per state law, will apply.
ANESTHESIA AND ADMINISTRATION: Reasonable and
Customary Charges by an anesthesiologist for the administration of
Anesthesia to a Covered Person who is undergoing surgery while
Hospital Confined or in a Same Day Surgery Facility. The
Anesthesiologist must be at the operation solely to render the
Anesthesia service. ANTEX will reduce eligible benefits by 50% if a
Nurse anesthetist, operating surgeon or assistant surgeon
Administers the anesthesia and any incidental fluids as part of a
Covered surgical procedure. Charges include the reasonable cost of
Hospitalization and general anesthesia in order for a Covered Person
To safely receive dental care if he or she is under 8 years of age or is
Developmentally disabled. This benefit does not apply to treatment
Rendered for temporal mandibular join disorders (TMJ).
DOCTOR’S VISITS: Reasonable and Customary Charges by the
Primary attending Doctor for one visit per day while Hospital
Confined.
PATHOLOGY: Reasonable and Customary Charges by a
Pathologist for the interpretation of diagnostic tests or studies while
Hospital Confined or in a Same Day Surgery Facility.
PHYSIOTHERAPY: Reasonable and Customary Charges for
Physical, speech or inhalation therapist services while Hospital
Confined or in a Same Day Surgery Facility.
POST CONFINEMENT THERAPY: Reasonable and
Customary charges that a Hospital, or Hospital-based clinic, bills
For the services and supplies it furnishes to a covered person who is
Not Hospital Confined. The Covered Person must require Post
Confinement Therapy for a Sickness or Injury that caused a
Hospital Stay, or following surgery performed in a Hospital or Same
Day Surgery Facility, that is normally covered by the Group Policy.
The following types of Therapy are eligible under this provision:
Radiation therapy, including treatment planning; Chemotherapy,
Including treatment planning; Physical therapy; Speech therapy; and
Occupational therapy.
RADIOLOGY: Reasonable and Customary Charges by a
Radiologist for the interpretation of diagnostic tests or studies while
Hospital Confined or in a Same Day Surgery Facility.
SAME DAY SURGERY FACILITY: Reasonable and Customary
Charges for care received in a Same Day Surgery Facility. Eligible
Charges will be the fees for the use of the facility and other
Miscellaneous charges made by the facility. If the Covered Person
Stays in the Ambulatory Surgical Center for 18 or more hours,
ANTEX will pay eligible charges up to the average semi-private
Room rate for the use of the facility. The semi-private room rate will
Be consistent with Hospital charges in the area where the
5 Ambulatory Surgical Center is located.
CATASTROPHIC HOSPITAL INSURANCE COVERAGE
ELIGIBLE EXPENSES/MEDICAL SERVICES
CONTINUED
ORGAN TRANSPLANTS: Maximum Benefit for Organ
Transplants per Covered Person is $1,000,000. The organ being
Transplanted must be the organ of primary disease and must be one
Of the following organs: heart, lung, liver, cornea, pancreas, kidney
Or bone marrow and/or stem cells harvested from bone marrow or
Peripheral blood. (Stem cell or bone marrow transplants do not
Have to be the organ of primary disease). We will pay benefits for
The Eligible Expenses that result from charges related to, caused by,
Contributed to or resulting from an Organ Transplant. The Covered
Person must incur the charges during the Transplant Period. We
Will not pay for charges he Covered Person incurs outside the
Transplant Period, except for anti-rejection Drug charges. We will
Pay donor benefits: (a) Up to $15,000 in eligible charges; and (b)
When You or a Covered Person is legally responsible for the
Charges.
TRANSPLANT CENTERS: We have contracted with certain
Specified transplant centers to provide Organ Transplants at a
Negotiated rate. If a Covered Person utilizes a specified transplant
Center, ANTEX will waive the $1,000,000 Maximum Benefit for
An Organ Transplant and the charges will instead be applied
Towards the Group Policy Maximum. All other provisions of the
Group Policy will continue to apply. You or a Covered Person may
Send a written request to ANTEX’s Case Management Department
For a copy of the maximums.
HOSPICE CARE BENEFIT: Reasonable and Customary
Charges for Hospice Care provided by a Hospice agency (Non-
HSA only: up to the Maximum Benefit for Hospice Care shown in
The Certificate Schedule). We will not pay benefits under this
Provision and under another benefit provision of the Group Policy.
We only pay benefits for Hospice Care when: (a) The Hospice Care
Is provided to reduce or abate pain and not for cure; and (b) The
Covered Person’s Doctor certifies that the Covered Person’s life
Expectancy is less than six months.
HSA only: This benefit is not
Subject to the Deductible Amount or any Rate of Payment that is
Less than 100%.
HOME HEALTH CARE: Reasonable and Customary Charges
For Home Health Care up to $40 per visit. There is a limit of one
Visit per day and 60 Home Health Care visits in each Calendar
Year. We count the following as one Home Health Care Visit: (a)
When a Home Health Care provider visits the home to evaluate the
Need for developing a Home Health Care plan; or (b) Up to four
Consecutive hours of Home Health Care. The home Health Care
Must begin within 7 days of a prior Hospital Stay of at least 3 days.
The Home Health Care must be provided in lieu of a Hospital
Stay. The Home Health Care must be for treatment of the same
Sickness or Injury for which the Covered Person was Hospital
Confined. Home Health Care includes the following eligible
Charges: Registered Professional Nurse (R.N.) or Licensed Practical
Nurse (L.P.N.) servies/supplies; Qualified physiotherapist, speech
Therapist or inhalation therapist services/supplies; Medical social
Services worker services/supplies. The services/supplies must be
Medically Necessary to understand the emotional, social and
Environmental factors affecting the Covered Person’s Sickness;
Home health aide services/supplies when under a R.N.’s direct
Supervision; Nutritional guidance when Medically Necessary;
Oxygen and its administration.
HSA only: This benefit is not
Subject to the Deductible Amount or any Rate of Payment that is
Less than 100%.
MAMMOGRAM: Reasonable and Customary Charges in excess of
$25 for one annual screening mammogram per Calendar Year. We
Pay the benefit whether or not the Covered Person is Hospital
Confined. We do not apply charges to the Deductible Amount or
To any Co-Insurance Amount that is less than 100% .
PROFESSIONAL AMBULANCE SERVICE: Reasonable and
Customary Charges for transportation to the nearest Hospital
Qualified to treat Injuries or medical Emergencies.
COMPLICATIONS OF PREGNANCY: If a Covered Person
Suffers Complications of Pregnancy while covered under the Group
Policy, eligible charges incurred for treatment of such
Complications of Pregnancy will be considered for payment as if
They had resulted from Sickness. If an expense does not result solely
From the treatment of the Complications of Pregnancy, then it will
Be deemed due to normal pregnancy and not covered under the
Group Policy.
FOREIGN EMERGENCY TREATMENT: We will pay for
Benefits for eligible charges resulting from charges for Emergency
Treatment that a Covered Person receives in a foreign country.
Benefits payable will be the lesser of: (a) the actual charges for the
Services; or (b) the eligible charges that We would have paid if the
Covered Person had received the Emergency treatment where the
Covered Person resides.
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