Expressed Per Member, Per Policy Year (Excluding AD&D)
Doctor Office Visits
When treated at the doctor’s office for a covered accident or sickness, the carrier will pay up to the $75 benefit maximum, for up to five (5) visits.
Diagnostic, X-ray and Lab Tests
When diagnostic tests and labs are required due to a covered accident or illness, the carrier will pay up to the $50 benefit maximum for up to five (5) service dates.
Preventative Care Test
The carrier will pay up to the $100 benefit maximum for one (1) covered preventative test.
Daily In-Hospital Confinement**
When confined to the hospital due to a covered accident or sickness, the carrier will pay:
| Plan Name |
Per Day |
Number of Days |
| Co-Select 100 |
Up to $100 |
Up to 60 days |
| Co-Select 350 |
Up to $350 |
Up to 60 days |
| Co-Select 500 |
Up to $500 |
Up to 60 days |
| Co-Select 750 |
Up to $750 |
Up to 60 days |
| Preexisting conditions: 12/12 for this feature |
Intensive Care Confinement**
With intensive care confinement due to a covered accident or sickness, the carrier pays up to the benefit maximum:
| Plan Name |
Per Day |
Number of Days |
| Co-Select 100 |
Up to $200 |
Up to 10 days |
| Co-Select 350 |
Up to $700 |
Up to 15 days |
| Co-Select 500 |
Up to $1,000 |
Up to 15 days |
| Co-Select 750 |
Up to $1,500 |
Up to 15 days |
| Preexisting conditions: 12/12 for this feature |
Emergency Care/Urgent Care (Only available in Co-Select 750 plan)
When treatment is received at a hospital emergency room or an urgent care facility due to a covered accident or sickness, the carrier will pay up to $50 for one (1) visit.
Surgical With Anesthesia Benefit
When surgery with anesthesia is needed due to covered accidents or sickness, surgery is paid at 50% of RBRVS up to an annual maximum of:
| Plan Name |
Maximum |
| Co-Select 100 |
$3,000 |
| Co-Select 350 |
$5,000 |
| Co-Select 500 |
$8,000 |
| Co-Select 750 |
$12,000 |
Anesthesia is paid at 20% of the Surgical with Anesthesia Benefit for all Co-Select plans.
Preexisting conditions: 12/12 for this feature |
Ambulance (Only available with Co-Select 500 and Co-Select 1000 plans)
When an ambulance is necessary due to a covered accident or sickness, the carrier will pay up to $50 per trip.
Accident Medical
Subject to a $100 Policy Year deductible, the carrier pays 80% of charges incurred due to covered injuries up to $5,000 with all Co-Select plans.
Accidental Death and Dismemberment (AD&D)
In the unfortunate event of the loss of life or limb in a covered accident, the carrier pays Co-Select participants up to:
- Up to $10,000 for the Primary member
- Up to $5,000 for any covered spouse
- Up to $2,500 for any covered dependant
Dismemberment payment is specific to the type of loss and subject to the same principal amount.
*Insurance features are made available through a group insurance policy issued to SureHealth through the Consumer Health Choice Association. Insurance features are administered by CrossAmerica Health Plans, 100 Eagle Rock Avenue Suite 121, East Hanover, New Jersey 07936 and are underwritten by their affiliated carriers.
**The carrier will not pay concurrently for Daily In-Hospital and Intensive Care benefits. |
