Group Products

Schedule of Benefits

Core Benefits
Value-Added Elements Packaged with Core
Additional Benefits

Schedule of Benefits (per covered person)
HM Care Advantage offers the ability for employers to select the number of visits and the amount of coverage for each benefit. This puts the employer in control of the offering, helping to set premium price points that can meet the needs of the employer and the individual employee. Depending on the size of the employer group, up to three plans can be designed and offered to the same group.

Core Benefits

Office Visits — Physician/Licensed Practitioner
Sickness or injury visits to a doctor or licensed practitioner; also includes one wellness visit per calendar yearŦ for each covered person.
Visits per calendar year	1-8
Amount per visit	$30-$100

Daily In-Hospital
Hospitalization in a licensed facility as a result of an accident or sickness.
Annual benefit	30, 45, 60 or 90 days confinement per calendar year
Amount per day of confinement	$100-$2,000
Mental or Nervous	Additional in-hospital days for the treatment of a mental or nervous disorder covered at 50% of the Daily In-Hospital benefit amount; maximum 30 days per calendar year.
Substance or Alcohol Abuse	Additional in-hospital days for the treatment of substance or alcohol abuse covered at 50% of the Daily In-Hospital benefit amount; maximum 30 days per calendar year.

Additional Daily Benefit for First Day of Hospital Confinement
Pays an amount equal to one day of the Daily In-Hospital benefit for the first day of confinement.
Amount per admission	An amount equal to the Daily In-Hospital benefit is paid as an additional benefit for the first day of confinement only.
Annual benefit	1-2 admissions per calendar year

Surgery and Anesthesia Services
Surgical procedures and anesthesia services at a licensed hospital, outpatient facility or physician’s office based on the Schedule of Surgical Benefits.
Surgical procedures per calendar year	1-5
Maximum amount per surgical procedure	$500-$2,500 based on the Schedule of Surgical Benefits
Second surgical procedure	If performed during same operative procedure and is through a separate incision or in a separate operative field, benefit will be paid at 50% of the amount payable in the Schedule of Surgical Benefits
Anesthesia amount	20% of Surgical benefit, based on the Schedule of Surgical Benefits

Outpatient Diagnostic Testing
Laboratory, imaging and testing services for accident or illness diagnosis in an outpatient setting.
Test days per calendar year	1-3
Amount per testing day	$50-$500

Value-Added Elements Packaged with Core Plans
Health Information On-Call	Health information through a toll-free telephone number
Health Information On-Line	Internet site providing lifestyle improvement programs, health information and resources on a range of topics, including tobacco cessation, nutrition, weight management and stress management
Pharmacy Discount Card*	Provides discounts for brand and generic drugs with no limits on the number of prescriptions filled per calendar year
Vision Discount*	A routine eye exam provided at no cost to covered persons once every 12 months
Complementary Wellness Discount Program	Discounts on health-related products and services, including fitness center memberships, chiropractic care, acupuncture, vitamins and massage therapy
COBRA Administration	All COBRA-related administration, including employee notification, billing, premium collection and carrier notification is integrated into every plan

*Replaced by insured prescription drug and/or vision coverage when insured coverage is offered.

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Additional Optional Benefits

Provider Network Discounts

Covered persons will receive a discount from network physicians, hospitals, outpatient diagnostic imaging and laboratory providers. Service is provided by MultiPlan.

Hospital Emergency Room
Non-work related injury or illness visit to an emergency room; one visit may be used for illness; additional sick visits paid at Office Visits benefit amount.
Visits per calendar year	1-5
Amount per visit	$100-$500

Inpatient Visits – Physician
Attending physician visits while the patient is hospitalized; limited to one visit per day.
Visits per calendar year	1-6
Amount per visit	$30-$100

Outpatient Hospital Services
Therapies and treatments performed on an outpatient basis.
Treatments days per calendar year	1-8
Amount per treatment day	$25-$500

Daily Intensive Care Unit
Inpatient hospital intensive care services, including intensive care unit (ICU), coronary care unit (CCU), neonatal intensive care unit (NICU) and pediatric intensive care unit (PICU).
Annual benefit	Equal to twice the benefit amount selected in Daily In-Hospital benefit; the Daily Intensive Care Unit benefit and the Daily In-Hospital benefit together will be limited to the maximum number of days selected for the Daily In-Hospital benefit; a covered person is not eligible for the Daily In-Hospital benefit on any day the Daily Intensive Care Unit benefit is payable.
Amount per day	$200-$4,000

Home Health Care
Pays amount shown for home visits for nursing care, home health aid service, physical, speech and occupational therapies, nutritional counseling and medical social services when prescribed by the covered person's physician.
Visits per calendar year	5-20
Amount per visit	$20-$50

Ambulance Services
Ground or air transportation by a licensed ambulance service.
Trips per calendar year	1-3
Amount per trip	$75-$300

Wellness Screening Test
One screening test per calendar year: mammography, colonoscopy, flexible sigmoidoscopy or bone densitometry.
Test per calendar year	1
Amount per test	$25-$150

Wellness Service
One wellness service per year: Pap test, PSA or immunization.
Service per calendar year	1
Amount per service	$25-$75

Dental Insurance
Preventative, diagnostic, basic and major dental services are included with insured dental coverage. Dependent-only coverage is available in certain states.
Maximum per calendar year	Incremental Amounts up to $1,000
Network Discounts	Available in certain states
Other plan level options are available based on state of issue. Ask your broker or HM sales representative for more details.

Vision Insurance*
Covers one in-network eye examination in full and one pair of eligible eyeglasses or contact lenses per benefit cycle. Administered by Davis Vision.
Benefit cycle options	• 12 months exam, lenses and frames • 12 months exam and lenses, 24 months frames • 12 months exam, 24 months lenses and frames • 24 months exam, lenses and frames
* Dependent-only coverage is not available.

Outpatient Prescription Drug Insurance*
Provides prescription drug insurance with discounts and co-pays. Underwritten by Fidelity Security Life Insurance Company.
Tier I	$15 co-pay for generic formulary; $15 for generic oral formulary contraceptives; brand name not covered; benefit maximum per calendar year is $750
Tier II	$10 co-pay for generic formulary; $15 for generic oral formulary contraceptives; brand name not covered; benefit maximum per calendar year is $1,000
Tier III	$10 co-pay for generic formulary; $15 for generic oral formulary contraceptives; $50 co-pay for brand name; benefit maximum per calendar year is $1,000
* Dependents-only coverage is not available.

^Ŧ Calendar year is the employer-defined benefit cycle.

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HM Care Advantage is an HM Life Insurance Company product administered by Key Benefit Administrators (KBA). Based on the plan selected, Medical and Vision coverages are underwritten by HM Life Insurance Company, Pittsburgh, PA, under policy form series HM905, GP902 or similar. For other insured products when available: Dental and Outpatient Prescription Drug coverages are underwritten by Fidelity Security Life Insurance Company, Kansas City, MO, under policy form series M-9037 and M-9031/M-9022. In certain states, Dental is underwritten by Renaissance Life & Health Insurance Company of America, Greenwood, IN, under policy form series DT-300A or DT-310A. Administrative and/or customer support services when available are provided: for Health Information On-Call – Health Dialog Services Corporation; for Complementary Wellness Discount Program – Healthways WholeHealth Networks, Inc.; for Health Information On-Line – HealthMedia® Inc.; for Pharmacy Discount Card – Caremark, Inc.; for Vision – Davis Vision; for Provider Network Discounts – different network discount options exist and are specified at time of offer. Other administrative and/or customer support services may be provided by HM Life Insurance Company and HM Benefits Administrators. Certain exclusions and limitations may apply. See your certificate or other evidence of coverage for details. Coverage or service requested or the use of a specific association, franchise, trust or union may not be available in all states and is subject to all applicable state rules, laws and regulations.