March 18, 2010

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American Community – Community Flex 100 with Gold Benefits Option – TEXAS

A comparison of the Community Flex 100 with Gold Benefits Option offered by American Community is detailed out below for both Network and Non-Network coverage.

  Network Non-Network
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Network See Provider See Provider
Application Community Flex 100 with Gold Benefits Option Application Community Flex 100 with Gold Benefits Option Application
Brochure Community Flex 100 with Gold Benefits Option Brochure Community Flex 100 with Gold Benefits Option Brochure
Copay In-Network: $40 for Office Visit/$80 for Urgent Care In-Network: $40 for Office Visit/$80 for Urgent Care
Office Visit In-Network: Deductible, then 100% In-Network: Deductible, then 100%
Deductible In-Network:Individual: $5,000, Family: $10,000 In-Network:Individual: $5,000, Family: $10,000
Coinsurance In-Network: 100% coinsurance In-Network: 100% coinsurance
Coinsurance Limit In-Network: 0% coinsurance In-Network: 0% coinsurance
Out-of-Pocket Maximum In-Network: (Includes deductible)Individual: $5,000, Family: $10,000 In-Network: (Includes deductible)Individual: $5,000, Family: $10,000
Lifetime Maximum $5,000,000 per person $5,000,000 per person
Prescription Drugs
  • Discount Drug Card Only
  • Generic Rx
  • Four Tier Copay Rx
    		•
  • Discount Drug Card Only
  • Generic Rx
  • Four Tier Copay Rx
    		•
    Emergency Room
  • Emergency Injuries- $250 copay then network deductible and coinsurance (Copay waived if admitted within 24 hours).
  • Emergency Sickness- $250 copay then network deductible and coinsurance (Copay waived if admitted within 24 hours).
  • Non-Emergency Injuries & Sickness- Not Covered
    		•
  • Emergency Injuries- $250 copay then network deductible and coinsurance (Copay waived if admitted within 24 hours).
  • Emergency Sickness- $250 copay then network deductible and coinsurance (Copay waived if admitted within 24 hours).
  • Non-Emergency Injuries & Sickness- Not Covered
    		•
    Adult Preventative Care In-Network: Deductible, then 100% ($1,000 paid limit per person per CY on specific services) In-Network: Office visit copay and 100% ($1,000 maximum per family member: Immunizations, except for HPV; Lab work performed in the office; Routine Physical Exams; PSA Test & Pap Smears, and Mammograms (Screening)
    Child Preventative Care In-Network: Office visit copay and 100% ($1,000 maximum per family member: Immunizations, except for HPV; Lab work performed in the office; Routine Physical Exams; PSA Test & Pap Smears, and Mammograms (Screening) In-Network: Office visit copay and 100% ($1,000 maximum per family member: Immunizations, except for HPV; Lab work performed in the office; Routine Physical Exams; PSA Test & Pap Smears, and Mammograms (Screening)
    Lab / X-Ray Deductible, then 100% Deductible, then 100%
    Maternity Community Flex 100 with Gold Benefits Option Community Flex 100 with Gold Benefits Option
    Physical Therapy
  • Physical, Occupational, and Speech Therapy- Subject to deductible and coinsurance (20 visits per family member, per calendar year, per type of therapy)
  • Spinal Manipulation- Subject to deductible and coinsurance (Calendar year maximum of $500 per member)
    		•
  • Physical, Occupational, and Speech Therapy- Subject to deductible and coinsurance (20 visits per family member, per calendar year, per type of therapy)
  • Spinal Manipulation- Subject to deductible and coinsurance (Calendar year maximum of $500 per member)
    		•
    Skilled Nursing Skilled Nursing Facility- Subject to deductible and coinsurance (60 days per family member per Calendar Year) Skilled Nursing Facility- Subject to deductible and coinsurance (60 days per family member per Calendar Year)
    Home Health Care Subject to deductible and coinsurance (20 visits per family member per Calendar Year) Subject to deductible and coinsurance (20 visits per family member per Calendar Year)
    Mental Health Not covered Not covered
    Hospital Care In-Network:
  • In-Hospital- Deductible, then 100%
  • Outpatient Surgery- Deductible, then 100%
    		•  In-Network:
  • In-Hospital- Deductible, then 100%
  • Outpatient Surgery- Deductible, then 100%
    		•
    Optional Benefits Dental Benefit ($1,000 maximum per person per calendar year)
  • Type 1 procedures: 6-month waiting period and we pay 80%
  • Type 2 procedures: 12-month waiting period, $100 calendar
    		•  Dental Benefit ($1,000 maximum per person per calendar year)
  • Type 1 procedures: 6-month waiting period and we pay 80%
  • Type 2 procedures: 12-month waiting period, $100 calendar
    		•