KANSAS HEALTH INSURANCE ASSOCIATION
HEALTH INSURANCE POLICY HIGHLIGHTS AND COMPARISONS

The following table is NOT a complete summary nor explanation of your plan benefits.
Complete details of your plan benefits are available in the policy.

Benefits Plan A - $500 Plan B - $1,000 Plan C - $1,500 Plan D - $2,500(Single)* Plan D - $4,950(Family)* Plan E - $5,000 Plan F - $7,500
Calendar Year Deductible Single: $500 $1,000 $1,500 $2,500 Not applicable $5,000 $7,500
Aggregate Family: $1,000 $2,000 $3,000 Not applicable $4,950 $10,000 $15,000
In Network Co-insurance Single: 70% of the next $5,000; then benefits paid at 100% 70% of the next $5,000; then benefits paid at 90% 70% of the next $5,000; then benefits paid at 100% 70% of the next $2,667, then benefits paid at 100% Not applicable 70% of the next $5,000; then benefits paid at 90% 70% of the next $10,000; then benefits paid at 90%
Aggregate Family: 70% of the next $10,000; then benefits paid at 100% 70% of the next $10,000; then benefits paid at 90% 70% of the next $10,000; then benefits paid at 100% Not applicable 70% of the next $3,667, then benefits paid at 100% 70% of the next $10,000; then benefits paid at 90% 70% of the next $20,000; then benefits paid at 90%
Out of Network Co-insurance Single: 50% to Lifetime Max., does not apply toward Out-of-Pocket Max. 50% to Calendar Year Max., and Lifetime Max., does not apply toward Out-of-Pocket Max. 50% to Lifetime Max., does not apply toward Out-of-Pocket Max. 50% of the next $1,600, applies toward Out-of-Pocket Max. Not applicable 50% to Calendar Year Max. and Lifetime Max., does not apply toward Out-of-Pocket Max. 50% to Calendar Year Max., and Lifetime Max., does not apply toward Out-of-Pocket Max.
Aggregate Family: 50% to Lifetime Max. does not apply toward Out-of-Pocket Max. 50% to Calendar Year Max. and Lifetime Max., does not apply toward Out-of-Pocket Max. 50% to Lifetime Max., does not apply toward Out-of-Pocket Max. Not applicable 50% of the next $2,200, applies toward Out-of-Pocket Max. 50% to Calendar Year Max. and Lifetime Max., does not apply toward Out-of-Pocket Max. 50% to Calendar Year Max. and Lifetime Max., does not apply toward Out-of-Pocket Max.
Benefit Percentage after deductibles and Co-insurance 100% 90% 100% 100% 100% 90% 90%
Calendar Year Maximum None $100,000 None None None $100,000 $100,000
Individual Lifetime Maximum $1,000,000 $1,000,000 $1,000,000 $1,000,000 $1,000,000 $1,000,000 $1,000,000
Prevention Services (Mammograms, PAP Smears, Childhood Immunizations, Prostate Exams) See policy for specific details. Benefits paid at 100% after $25 co-pay. Max. annual benefit of $250 Benefits paid at 100% after $25 co-pay. Max. annual benefit of $250 Benefits paid at 100% after $25 co-pay. Max. annual benefit of $250 Same as any other illness (State mandate benefits apply) Same as any other illness (State mandate benefits apply) Benefits paid at 100% after $25 co-pay. Max. annual benefit of $250 Benefits paid at 100% after $25 co-pay. Max. annual benefit of $250
In-patient Hospital Care Same as any other illness. $1,000 penalty for failure to obtain pre-admission review. Same as any other illness. $1,000 penalty for failure to obtain pre-admission review. Same as any other illness. $1,000 penalty for failure to obtain pre-admission review. Same as any other illness. $1,000 penalty for failure to obtain pre-admission review. Same as any other illness. $1,000 penalty for failure to obtain pre-admission review. Same as any other illness. $1,000 penalty for failure to obtain pre-admission review. Same as any other illness. $1,000 penalty for failure to obtain pre-admission review.
Physical/ Speech/ Occup. Therapy Covered Covered Covered Covered Covered Covered Covered
Oral Surgery Covered Covered Covered Covered Covered Covered Covered
Chiropractic Services Limited to 20 visits per calendar year, $20 per visit Limited to 20 visits per calendar year, $20 per visit Limited to 20 visits per calendar year, $20 per visit Limited to 20 visits per calendar year Limited to 20 visits per calendar year Limited to 20 visits per calendar year, $20 per visit Limited to 20 visits per calendar year, $20 per visit
Maternity: (Maternity deductible will NOT apply towards the Calendar Year Deductible and Calendar Year Deductible will NOT apply towards the Maternity Deductible) Benefits subject to a separate $1500 deductible first Policy Year, thereafter covered same as any other illness. Benefits subject to a separate $1500 deductible first Policy Year, thereafter covered same as any other illness. Same as any other illness (Maternity Deductible will not apply) Same as any other illness (Maternity Deductible will not apply) Same as any other illness (Maternity Deductible will not apply) Same as any other illness (Maternity Deductible will not apply) Same as any other illness (Maternity Deductible will not apply)
Emergency Room Covered Covered Covered Covered Covered Covered Covered
Ambulance Covered, subject to plan limitations Covered, subject to plan limitations Covered, subject to plan limitations Covered, subject to plan limitations Covered, subject to plan limitations Covered, subject to plan limitations Covered, subject to plan limitations
Durable Medical Equipment Covered Covered Covered Covered Covered Covered Covered
Prescriptions Coverage available through the Prescription Network Provider WILL BE MANDATORY. Coverage will be based on the cost of a generic, if available. If not available or if the prescription requires Name Brand, coverage will be based on the Regular Charge of the prescription. Applies to Calendar Year Deductible, then payable at 50% of cost. Applies to Out-of-pocket maximum.
In-patient Mental Health All In-patient benefits for mental disorders and substance abuse are subject to an annual maximum benefit of the lesser of 30 inpatient days or $7,500 in benefits. One inpatient day may be exchanged for two partial hospital days.
Out-patient Mental Health First visit paid in full; then paid at 70% after $25 co-payment for visits 2-20. Not subject to deductible. Plan D benefits paid same as any other illness.
Skilled Nursing Care Covered for a maximum of 120 days per calendar year in licensed skilled nursing facility.
Home Health Covered for a maximum of 270 services per calendar year

Out-of-pocket expenses associated with Non-network charges will NOT be applied toward satisfaction of the Out-of-Pocket on Plans A, B, C, E and F.

* Plan D Maximum Out of Pocket Expenses shall not exceed $3,300 single and $6,050 aggregate family including covered benefits for both in and out of network

* Plan D is offered as a Medical Savings Account allowing for tax advantaged savings for Sole proprietors, and sub chapter S corporations and individuals that previously held a qualified MSA health plan.

* Plan D deductibles and co-insurance are subject to change according to IRS code section 220 in relation to the CPI.
* Consult your tax attorney, accountant, or other qualified advisor for information relating to the steps necessary to establish a compliant MSA plan.

Covered Services

Subject to the program provisions, the KHIA plan will cover charges for medical services or supplies provided by or prescribed by a health care professional licensed to provide or prescribe such care. The enclosed Plan Highlights and Comparisons identifies major categories of covered benefits and distinguishes how these benefits are reimbursed under the six Plans available.

Inpatient Hospital Care
  • Semi-private room and board and care
  • Operating, delivery and recovery rooms and supplies
  • Prescribed drugs, injections, solutions
  • Blood
  • Miscellaneous services and supplies
  • Maternity care (separate deductible applies to plans A&B)
  • Nursery charges
  • Diagnostic services
Physician Care
  • Inpatient medical care
  • Medical care provided in the office and home
  • Surgical services
  • Assistant surgeon
  • Anesthesia services
  • Second surgical opinion
  • Consultation services (Inpatient only)
  • Obstetrical care (separate deductible applies to plans A&B)
  • Diagnostic services
  • Certain oral surgery
Preventive Care
  • Immunizations for children
  • Pap smears and mammograms
  • Prostate exams
Other Providers of Care
  • Home health agency care
  • Ambulatory surgical center care
  • Physical, occupational & speech therapy
  • Skilled nursing facility care
Outpatient Hospital Care
  • Emergency care for injuries
  • Medical emergencies Mandatory)
  • Pre-admission testing
  • Surgery
  • Diagnostic services
  Other Services and Supplies
  • Prescription drugs (Participating Express Script Pharmacies)
  • Prosthetic appliances other than dental
  • Ambulance services


Note: Certain limitations apply to the treatment of mental illness, drug abuse and chemical dependency.
Note: Separate $1500 maternity deductible (applies first Policy Year only to plans A & B)


Services Not Covered

Following are some of the services that are not covered by the KHIA program:

  • Charges in excess of regular charge - regular charges are limited to network agreement or usual, customary and reasonable (UCR) charges
  • Care that would otherwise be covered under a government program
  • Care for any condition resulting from any act of war or while on active or reserve military duty
  • Inpatient hospital admissions primarily for diagnostic or therapy purposes, except when medically necessary
  • Services provided after termination of the KHIA coverage
  • Care and services that are not expressly specified in the KHIA Policy
  • Experimental services and supplies
  • Acupuncture, homeopathy and naturopathy
  • The difference between the hospitals most prevalent charge for a semiprivate room and a private room
  • Personal supplies or services which are non-medical or non-prescribed
  • Eyeglasses or hearing aids or examinations for their prescription or fitting
  • Convalescent, domiciliary or custodial care
  • Intentionally self-inflicted injury or sickness occurring as a result of taking part in a felony
  • Injury or sickness covered by Workers' Compensation, occupation disease law or similar laws whether or not you claim those benefits
  • Eye surgery if corrective lenses would alleviate the problem
  • Cosmetic surgery other than for injuries or conditions which occurred while this policy was in force
Cost-Management Provisions
These cost-management features are designed to reduce unnecessary and inappropriate use of health care services. But while they help keep the cost of care down, it is never at the expense of care that is medically needed.

Pre-admission Authorization and Re-authorization: Authorization must be obtained prior to any non-emergency admission to a hospital or an alcoholism facility. If additional days are needed, reauthorization will be necessary. If you choose to receive care from a non-network provider in the network service area, you are responsible for obtaining pre-authorization and re-authorization. In addition, your co-payment will increase to 50% of covered charges, and these expenses will not apply toward the co-payment maximum. If you receive care from a non-network provider outside the network service area, you are also responsible for obtaining pre-authorization and re-authorization.

If you fail to do so, all benefits otherwise payable under the policy will be reduced by a $1,000 penalty. This penalty is separate and distinct from any other deductible or co-payment amounts required under this contract and does not accumulate toward said other amounts. Benefits will then be paid at applicable co-pays and percentages required under the contract. The phone number to call for Pre-admission Authorization and Re-authorization is to CMS at 1-800-323-0208.

Concurrent Review, Discharge Planning and Retrospective Review: Hospital confinements and costs are closely monitored both during and after a hospital stay. If it is determined that hospital care is no longer required, both the member and the physician will receive written notification. The member is encouraged to leave the hospital or to use alternative, less costly type of care if necessary. Additionally, certain inpatient claims are reviewed after payment to ensure that they were paid appropriately and to identify any unusual patterns in the use of health care services.

Pre-existing Condition Limitations

Your KHIA policy will not cover expenses incurred during the first 90 days after its Policy Date for a pre-existing condition. A pre-existing condition is any condition for which medical advice, care or treatment was recommended or received from a medical practitioner as to such conditions during the six-month period immediately preceding the effective date of coverage.

We will pay only for eligible expenses incurred after such 90-day period. However, if you were covered under another policy which provided hospital, medical or surgical expense benefits and coverage under that policy terminated less than 31 days prior to coverage beginning under this policy, the 90-day period will be waived to the extent the pre-existing condition limitation period was satisfied under the previous policy. No pre-existing condition exclusion shall be applied to a federally defined eligible individual applying for coverage within 63 days of the termination of coverage under another policy which provides hospital, medical or surgical expense benefits.
Limited Inpatient Benefits for Treatment of Mental Illness, Alcoholism, Drug Addiction and Chemical Dependency: Inpatient benefits for substance abuse are limited to a maximum of 5 days per inpatient admission, up to a maximum of 15 days per lifetime for detoxification. Inpatient benefits for mental disorders and substance abuse combined is a maximum of 30 days per calendar year or a maximum of $7,500, whichever comes first.
Caution: The KHIA policy provides attractive benefits. However, it is recommended that you consider the following points:
  • Even though your current health care program may have some coverage restrictions, it may still represent your best health care coverage based on the premium/benefits provided.
  • No benefits are payable during the first 90-day period for pre-existing conditions unless specifically waived.
  • KHIA coverage can be continued for each covered person only while he/she remains a Kansas resident.
  • This document contains only a summary of benefits and exclusions of the KHIA program. Complete details of benefits and exclusions and the terms under which they are provided are contained in the KHIA benefit booklet issued to the member when his/her coverage is approved.
  • Referring agents are not authorized to amend or alter the terms of the KHIA policy, nor are referring agents authorized to bind KHIA in any way.


 



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