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Limited Accident & Sickness Plans Group Benefit Plan Comparison Benefits Value Plan pays: Standard Plan pays: Enhanced Plan pays: Outpatient Accident & Sickness Coverage   Physician Office Visits - 5 visits per covered person per plan year.* $40 Per Visit $50 Per Visit $65 Per Visit Wellness/Child Wellness Visits - 1 visit per covered person per plan year. $40 Per Visit $50 Per Visit $65 Per Visit Diagnostic Testing or X-ray - For medically necessary diagnostic tests and x-rays performed in a doctor’s office or outpatient facility. 5 visits per covered person per plan year. $40 Per Visit $50 Per Visit $65 Per Visit Emergency Room - 1 visit for sickness per covered person per plan year. Applicable for emergency room visits when patient is not confined to the hospital. $250 Per Visit $250 Per Visit $250 Per Visit   Accident Medical Expense   Accident Benefit - Amounts shown are per accident and subject to $100 deductible. Up to $1,000 Up to $2,500 Up to $5,000 Hospitalization   Regular Inpatient Accident & Sickness Stay - Up to 30 days per covered person per plan year. N/A $500 Per Day $1,000 Per Day ICU/CCU - Up to 30 days per covered person per plan year. N/A $1,000 Per Day $2,000 Per Day Maternity N/A $500 Per Day $1,000 Per Day Mental Health and Substance Abuse - Up to 30 days per covered person per plan year. N/A $250 Per Day $500 Per Day Skilled Nursing Facility - Up to 60 days per covered person per plan year. N/A $250 Per Day $500 Per Day Surgery   Inpatient & Outpatient Surgery - Benefit is per covered person per plan year. N/A Up to $1,500 Per year Up to $2,000 Per year Anesthesia - 25% of surgery benefit N/A Up to $375 Per year Up to $500 Per year   Accidental Death & Dismemberment    Principal Sum Amount**: Employee $5,000 $10,000 $25,000                                      Spouse $2,500 $5,000 $5,000                                      Child $1,000 $1,000 $1,000   Healthcare Discount Program   Save up to 40% on Dental care, Prescription drugs, Vision care, LASIK Vision Correction. Avoid unnecessary ER Visits with FREE 24-hour Nurse Hotline service. Included Included Included Monthly Cost*** (100% Employer Contribution): Value Plan Standard Plan Enhanced Plan Employee Only $45.00 $99.00 $142.00 Employee & Spouse $81.00 $188.00 $270.00 Employee & Child(ren) $63.00 $144.00 $205.00 Family $98.00 $232.00 $334.00 Monthly Cost*** (50% Minimum Employer Contribution): Value Plan Standard Plan Enhanced Plan Employee Only $51.00 $114.00 $164.00 Employee & Spouse $93.00 $219.00 $315.00 Employee & Child(ren) $72.00 $167.00 $239.00 Family $113.00 $270.00 $390.00 Other Plan Features (All Plans):  - Guaranteed issue coverage with no medical evidence required.  - No pre-existing conditions, except pregnancy prior to effective date.  - Plans are compliant with HIPAA privacy regulations and are not subject to creditable certificate requirements  - Payroll deduction required for employee-paid premiums  - Multiple plans and payment modes available on a class basis.  - Group size minimum requirement is 2, except for 51+ eligible employees required in CA, CO, CT, FL, IN, LA, ME, MD, MA, NV, NJ, NY, OH, WV  - Review Limited Accident & Sickness Plan Exclusions. Important Note: The Limited Accident & Sickness Plan is not comprehensive major medical insurance. It is a package of benefits and services plan that pays fixed amounts for the most used types of medical services and is designed to help take care of the basic medical care needs of insured employees and their families. This plan pays in addition to any other insurance in force. Please note, also, that this plan is not a Medicare Supplement plan. Enrollment Forms: Employers meeting minimum group requirements in available states may print the following forms, fill out, and fax to Candor Insurance Group (fax number provided on the forms): Group Application and Employee Enrollment Form. If your company is part of a sponsor group, please contact Candor Insurance Group for your specific forms at info@candorig.com or call 800-869-5493. To view these files, you need Adobe Acrobat installed. You can download it free from adobe.com Our Affiliates and Your Privacy: Click here to view important information about the partners we work with to deliver these Limited Accident & Sickness Insurance plans and about how we work together to ensure your privacy. This information is a brief description of the important features of the insurance plan. It is not a contract of insurance. Terms and conditions of coverage will be set forth in the policy underwritten by ACE American Insurance Company. The policy is subject to the laws of the state in which it was issued. Coverage may not be available in all states or certain terms may be different if required by state law. * Plan year means the consecutive 12 months following the group’s effective date of coverage. ** the AD&D benefit has age-based reductions: at age 70, the benefit available is reduced to 65% at age 75, the benefit available is reduced to 40% at age 80, the benefit available is reduced to 20% *** Monthly costs shown include $10 for the non-insured Healthcare Discount Program.