I.Q. | Individual health insurance - QualChoice - individual health insurance plans

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A Smarter Health Plan for Individual Health Insurance

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	Individual Health Plan Identification	Deductible (In-Network/ Out-of-Network)	Coinsurance (In-Network/ Out-of-Network)	Out of Pocket Maximum (In-Network/ Out-of-Network)	Lifetime Maximum	PCP/Specialist Office Visit Copay	Emergency Room Copay	Inpatient Copay	Outpatient Surgery Copay
Select	I500A	$500/$1,000	80%/60%	$1,000/$2,000	$5,000,000	$20/$50	$200	Ded/Coins	Ded/Coins
Select	I500B	$500/$1,000	80%/60%	$2,000/$5,000	$5,000,000	$20/$50	$200	Ded/Coins	Ded/Coins
Select	I1000A	$1,000/$2,000	80%/60%	$1,000/$5,000	$5,000,000	$20/$50	$200	Ded/Coins	Ded/Coins
Select	I1000B	$1,000/$2,000	80%/60%	$2,000/$5,000	$5,000,000	$20/$50	$200	Ded/Coins	Ded/Coins
Select	I2500A	$2,500/$5,000	100%/60%	$0/$5,000	$5,000,000	$20/$50	$200	Ded/Coins	Ded/Coins
Select	I2500B	$2,500/$5,000	80%/60%	$2,000/$5,000	$5,000,000	$20/$50	$200	Ded/Coins	Ded/Coins
Select	I5000A	$5,000/$10,000	80%/60%	$2,000/$5,000	$5,000,000	$20/$50	$200	Ded/Coins	Ded/Coins
Select	H5000A	$5,000/$5,000	100%/50%	$0/$5,000	$5,000,000	Ded/Coins	Ded/Coins	Ded/Coins	Ded/Coins

Individual Health Insurance Rate Assumptions:

Rates do not reflect medical Underwriting. Your actual rate may be higher.
A deposit equal to one month of premium will be required before the effective date.
Family deductible and out of pocket maximum are 2X Individual.
Rates include administration costs and commissions.
Unless otherwise stated, this offer replaces and renders all previous offers null and void.
Maternity and TMJ riders are available.
Mental Health and Substance Abuse are not covered.
The rates provided are discounted non-tobacco-user premiums.
Pre-existing limitations do apply.

*Family Deductible: When two (2) covered members of the same family have each met their individual deductible amount during a calendar year, the family deductible amount shall be considered satisfied for that calendar year and no further deductible amount shall be taken from the expenses of any covered family member for the remainder of that calendar year.

**Family Out-of-Pocket Limits: After two (2) covered family members have each incurred an amount equal to the individual out-of-pocket expense limit listed on the Cost Sharing Table, the Plan will pay one hundred percent (100%) of covered expenses for all covered family members for the remainder of the calendar year.

HDHP Notes:

Underlying medical benefit plan must be a Qualified High Deductible Health Plan (HDHP).
The QualChoice HDHP is the only HDHP to be offered.
HDHP plans include a non-embedded deductible and out of pocket. No individual family member's deductible or out of pocket is considered satisfied until the full family deductible or out of pocket amount has been met.
Deductibles and Out of Pocket maximums are calendar year.