www.fammed.washington.edu/network/sfm/Heartburn (GERD) 10.15.03.doc

AIM HealthMax for Members & Their Employees A Limited Benefit Health Insurance Plan Not a Major Medical Health Plan Affordable Coverage for Individuals & Families INSURED BENEFITS INCLUDE: Any Doctor or Choose a Network High Hospital & Surgical Benefit ( No annual Maximum) Optional Insured $10 Co-pay Rx Card Daily Hospital Benefit up to 100 Days Annually
Surgeon Charges up to 100% of Medicare Reimbursement
Doctor Visits up to Seven Per Year Maternity Coverage Anesthesia Benefit
$ 400 for Lab & X-ray Up to $150 for Preventive Care
$ 25 , 0 00 Critical Illness Policy ( Optional Benefit ) The Solution Card discount plan via The Solution Card.
The Solution Card is not insurance,
but you can save up to 50% on health
care. Members will have access to high
quality networks of fully credentialed
professionals and practitioners
throughout the United States. You
may already be using many of these
providers. Continue using them and
save money at the same time.
Solution Card is not a substitute
for traditional health insurance. It is
a discount program that allows for
substantial savings for you and your
family. *Benefit amounts are based on the High Plan. This policy has a pre-existing
conditions limitation. During the first 12
months following your effective date of
coverage, no coverage will be provided
for the treatment of a pre-existing
condition. A pre-existing condition is
defined as a condition, regardless of
the cause of the condition, for which
medical advice, diagnosis, care or
treatment was recommended or
received during the 12 months before
your effective date. PLAN BENEFITS Doctor Visits Daily Hospital Confinement Surgical Benefits (same benefit inpatient & outpatient) Diagnostic, X-Ray & Lab Benefit (DXL) Wellness Care Accident Benefit PPO Network Repricing for Hospital, Doctor and Outpatient Services http://www.multiplan.com PLAN HIGHLIGHTS Guaranteed Renewable Assignable Benefits Stable Rates First Dollar Coverage (No Co-pays) 50 State Availability Fully insured INPATIENT MEDICAL EXPENSE BENEFITS Daily Hospital Benefit*
Hospital benefit of $ 3 , 0 00 first day and $1,000 per day thereafter (max of 100 days) per covered person, per calendar year. Unlimited re -admission. ICU/CCU Hospital Benefit*
Plan will pay $1 , 000 per day (max of 15 days) annually . Surgical Benefit*
Plan provides scheduled benefits for surgery per incident (maximum for any one surgery is 100% of Medicare reimbursement). Benefits are paid on inpatient or outpatient basis There is No Yearly Maximum . Anesthesia Benefit*
Plan provides a 2 5 % benefit ( this benefit is calculated by multiplying the surgeons benefit times 2 5 %). OUTPATIENT MEDICAL EXPENSE BENEFITS O ffice Visit* $ 100 paid per visit for up to Seven visits per calenda r year per covered person. Surgical & Anesthesia Benefit*
Same as inpatient coverage. Wellness Benefit* $ 1 5 0 paid per covered person per year for wellness visit . Prescription Discount*
See Member RX. Diagnostic Tests, X-Rays & Lab Testing* $400 paid for up to Five visits per person per calendar year for diagnostic tests, x-rays and lab testing. Benefits paid on inpatient or outpatient basis. OTHER BENEFITS PPO Network Discounts The plan offers Multiplan PPO network repricing when network providers
are used. Multiplan offers one of the largest seamless national networks.
Over 5 00,000 providers in 50 states. Visit http://www.multiplan.com to locate a provider. Accident Benefit ( as an option ) Up to $ 5 , 0 00 paid per accident, subject to $100.00 deductible and 100%
coinsurance per accident. One accident
per covered person per year. The Solution Card Discounts on prescriptions, dental care,
vision care, chiropractic care and more H ealthMax Benefit Summary A Limited Benefit Health Insurance Plan not a Major Medical Health Plan Martin Unger
800-986-4786
getaquote@gmail.com 800-986-4786 getaquote@gmail.com AIM HealthMax A Limited Benefit Health Insurance Plan not a Major Medical Health Plan Health Max Plan Benefits Benefit Details Physician Office Visit Benefit: The carrier will pay the benefit amount as shown if you seek treatment for a covered
illness or injury. $100 per office visit up to Seven per year/ per each person in family. Preventive Care Benefit: The carrier will pay the benefit
amount shown. $150 per visit, one visit per year. Hospitalization Admission & Confinement Benefit: The
carrier will pay the benefit amount shown if you are admitted
to a hospital as a patient because of a covered sickness
or injury. You are allowed unlimited hospital stays per year,
however, you will be limited to 100 total days per year
including first day hospital stays. $3,000 1st day, $1,000 per day thereafter.
Maximum 100 Days. ICU/CCU Benefit: The carrier will pay the benefit amount
shown if you are admitted to a hospital as a patient because
of a covered sickness or injury. You are allowed unlimited
ICU/CCU stays per year, however, you will be limited to 15 Maximum 15 Days.
total days per year including first day ICU/CCU stays. $1,000 per day Diagnostic Testing & Lab Benefit: The carrier will pay
up to the benefit amount for all diagnostic testing (x-rays)
and laboratory fees at the reimbursement rate shown. This
benefit pays up to a limit of Five per year. $400 per visit, five visits per year. Surgical Benefit (Inpatient or Outpatient): The carrier will
pay up to the benefit amount shown for required surgery
because of a covered procedure. Reimbursements are
based on the Medicare/RBRVS benefit schedule. 100% of Medicare/RBRVS* benefit schedule.
Anesthesia Benefit 25% of Surgeons Benefit AIM Xtra Rider: An addional plan that will pay the benefit
amount as shown per covered Critical illness. There is only
one CI allowed per covered person per lifetime. In addition This rider will increase the Hospital benefit by $500 per day
this rider pays an extra $500 per day (31 days) in the hospital
because of sickness or injury. ($1,000 per day ICU/CCU) benefit is for the entire family) Optional Rider: $25,000 Critical Illness for Primary & Insured Spouce
& $1,000 per day if the insured is in ICU or CCU (The hospital The Limited Benefit Medical Plan is an individual insurance benefit program. The individual insurance benefits vary depending on the plan selected. These benefits are provided under the individual insurance policy and are subject to the insurance companys underwriting guidelines, exclusions, limitations, terms and conditions of coverage as set forth in the insurance policy and certificate, which includes a pre-existing limitation and other restrictions. This insurance is not basic health insurance or major medical coverage and is not designated as a substitute for basic health insurance or major medical coverage. This is a limited medical plan that provides for limitations to the coverage for each benefit. The limitations are disclosed above. *RBRVS is the methodology used by the federal government to determine benefits payable under Medicare. This is a limited benefit plan and may not cover all medical expenses for an illness or injury once the maximum plan payment limits per covered person, per calendar year are reached. AIM HEALTHMAX ELIGIBILITY
Individuals eligible to apply for coverage: 1. Individuals between ages 18 and 59 2. Dependent children under age 19.
3. Unmarried dependent children with proof of full-time student status between the ages 19 and 25.
4. Legal resident of United States.
5. Individuals not in full-time service of the Armed Forces (military).
6. Individuals not eligible for Medicare.
7. Individuals not receiving disability benefits or workers compensation. Medical underwriting requirements: Individuals disabled and unable to work will be declined coverage. Pre-existing conditions: During the first 12 months following your effective date of coverage, no coverage will be provided for the treatment of a pre-existing condition. A
pre-existing condition is defined as a condition, regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was
recommended or received during the 12 months before your effective date. Terms of coverage: Coverage remains in effect as long as you pay the required premium charges on time, and as long as you maintain membership eligibility. Coverage will
be terminated if you become ineligible due to any of the following circumstances:
a) Non-payment of premiums and fees, b) Residency requirements, c) For other reasons permissible by law. (Unless you have had continuous prior coverage for 12 months with a break of less than 63 days) Massage Therapy An accepted way to relieve tension and stress,
massage therapy is also a part of many physical
rehabilitation programs. Various techniques
involved include:
Massage: Soft tissue manipulation to reduce
stress, fatigue and improve circulation.
Bodywork: Techniques to affect structural
changes to the body.
Somatic: A body/mind system embracing more
than just physical manipulations. Physical Therapy Your membership provides access to a national
network of over 1,000 physical therapy and
rehabilitation facilities at savings of 15%. Our
providers will give you discounts on a wide
range of outpatient rehabilitation services,
including:
Physical Therapy Occupational Therapy
Pediatric Therapy Hand Therapy
Speech/Language Therapy Health Club Membership Discounts Be assured of guaranteed best available
corporate rates with The Solution Card.
There are more than 2,500 participating
fitness facilities such as Curves, Golds Gym,
Jazzercise and many locally owned facilities. Locate a Provider by Visiting: http://www.thesolutioncard.com The Solution Card is not
insurance. This plan provides
discounts at certain healthcare
providers for medical services.
This plan does not make payments
directly to the providers of medical
services. The plan member is
obligated to pay for all healthcare
services but will receive a discount
from those healthcare providers
who have contracted with Alliance
HealthCard, Inc. and Alliance
HealthCard of Florida, Inc. Enrolled members of HealthMax
Limited Benefit Health Insurance Plan will also
be enrolled into the following discount plan: The Solution Card This plan is not insurance but you can save up to 50% on health care. The Solution Card is an innovative and
exciting concept that allows individuals to
save a significant amount of money on their
health care costs. A member will have access
to high quality networks of fully credentialed
professionals and practitioners throughout the
United States. The Solution Card is not a
substitute for traditional health insurance. It is
a discount health care program that allows for
substantial savings for you and your family. Dental Care Enrolling with The Solution Card means
immediate savings on your next dentist visit,
good at over 60,000 participating Cigna
dental providers. Its one of the few plans that
includes discounts for nearly every type of
dental procedure, including crowns, x-rays and
fillings, as well as orthodontia, periodontics
and endodontics. There are no pre-existing
conditions or waiting periods. Even if you use
this benefit only twice a year, youll receive
remarkable savings of over 30% off average
area charges. Vision Care Plan Reliable, high quality eye care services
delivered by a network dedicated to the vision
care and welfare of The Solution Card
members combined with unlimited choice of
quality products. Select from independent
optometrists, ophthalmologists and opticians
(approximately 20,000 nationwide) and
retail locations such as LensCrafters, Pearl,
JCPenney, Sears and Target. Significant
savings of 15% to 60% on eye exams, mail
order contact lenses, Luxotica frames, etc. The
programs also apply to LASIK and PRK laser
vision procedures. Prescription Drug Plan You are entitled to discounts of 15% to 60%
on all retail prescription drugs. There are no
exclusions for brand name drugs or generic
drugs. The Solution Card is accepted at over
58,000 retail pharmacies. Purchases via mail
order are eligible for higher discounts on select
medications, as well as high-tech and injectable
drugs. For details of these programs and our
mail service program, call 877-210-4720 Diabetes Care Discount Plan The Solution Card offers a comprehensive
diabetes maintenance program to help you
take charge and manage your chronic diabetes
conditions and increase patient compliance for
a quality of life enhancement. The program
provides access to a full line of state-of-the-art
glucose meters, test strips, lancets and oral
diabetic medications. Members can experience
over 50% savings every month compared to
average retail prices on diabetes maintenance
supplies and oral diabetic medications. Hearing Care Plan Have access to the nations largest network of
audiologists with more than 1,500 locations.
Receive a FREE hearing aid evaluation and
enjoy discounts of up to 20% for other services
and supplies. No charge for annual follow-up,
cleaning and check of hearing aids purchased
through The Solution Card. Chiropractic Care Plan There is a large body of evidence suggesting
that lower back pain is more effectively treated
using chiropractic services over traditional
medical treatments. This is often more cost
effective with greater patient satisfaction.
Some chiropractors specialize in sports-related
injuries, neurology, orthopedics, pediatrics,
nutrition, internal disorders or diagnostic
imaging. With The Solution Card you can
choose from 19,000 licensed chiropractors
across the nation, have access to a FREE
consultation, then save up to 50% on all
diagnostic services and 20% to 40% for other
services and supplies. No limits on your choice
of therapy or number of visits per year. 24-Hour Ask a Nurse Hotline You will speak with a registered nurse who can
answer your questions and provide you with
health and medical information. All interactions
are kept strictly confidential. You can get
information about symptoms, medical terms,
procedures, diseases, treatment options and
medications. Complimentary Alternative Medicine Acupuncture Acupuncture has been used in China for over
3,000 years as a major component of their
healthcare system. Many Americans are now
embracing the practice for a variety of illnesses:
Migraine, Arthritis, Sciatica, Insomnia, Stress
and Addictions. Additional AIM HealthMax Membership Benefits HealthChoice A Limited Benefit Health Insurance Plan This product is Managed for AIM by Insurance Resource Group 20 Madison Avenue
Valhalla, New York 10595 AIM Xtra Hospital & Critical Illness Rider S MART C HOICE FOR INCREASING HOPSITAL AND CRITICAL ILLNESS COVERAGE HOSPITAL BENEFIT The plan pays on an Indemnity basis $500 per day in the hospital for 31 days per calendar year. Plan also pays an additional $500 per day if the insured is in ICU or CCU for an additional 31 days per calendar year. These benefits and amounts are in addition to a ny other benefits received by the policy. CRITICAL ILLNESS BENEFIT $ 25,000 One Time Benefit The insurance carrier (A.I.G ) will pay one time benefit of $25,000 for the diagnosis of a critical illness. Family coverage will cover both the primary insured and their spouse. Pre-existing conditions are covered after 12 consecutive months of coverage. The policy has 10 Critical Illnesses that are covered . ( please see next page) M ONTHLY R ATES Employee $ 88.00 Employee + 1 $ 1 55.50 Family $ 175.00 This is a rider that you can add or buy by itself. It is not the HealthMax plan.


The Need for Critical Illness Insurance All AIM members that enroll into AIM Xtra Rider will have a $25,000 Critical Illness Benefit Coverage Critical Illness Diagnosis If an insured person is diagnosed with a critical illness, listed below, by a physician, the Company will pay a benefit subject to the
Benefit Payment Conditions and Schedule of Benefits of the plan selected. Once a 100% of the maximum benefit amount has been
paid for an insured person, coverage terminates and no further benefits are payable to that insured person. Life Threatening Cancer Pays benefits if an insured person is first diagnosed with life threatening cancer, more than 90 after the persons effective date
of coverage. (The benefit is 10% payment after 30 days and before 90 days.) Heart Attack Pays benefits if an insured person is first diagnosed as having suffered a heart attack more than 30 days after the persons effective
date of coverage. Kidney (Renal) Failure Pays benefits if an insured person is first diagnosed with having suffered kidney (renal) failure more than 30 days after the persons
effective date of coverage. Stroke Pays benefits if an insured person is first diagnosed with having suffered a stroke more than 30 days after the persons effective date
of coverage. Coma Pays benefits if an insured person is first diagnosed as being comatose more than 30 days after the persons effective date of
coverage. Coronary Artery Bypass Graft Pays 25% of the benefit amount if an insured person is first diagnosed with a condition that necessitates a Coronary Artery
Bypass Graft and receives the Coronary Artery Bypass Graft more than 30 days after the persons effective date of coverage. This
benefit is paid once per lifetime. Loss of Sight, Speech or Hearing Loss of Sight, Speech or Hearing Pays benefits if an insured person is first diagnosed with loss of Sight, speech or Hearing
more than 30 days after the persons effective date of coverage. Major Organ Transplant Pays benefits if an insured person is first diagnosed with a condition that necessitates a Major Organ Transplant and receives that
Major Organ Transplant more than 30 days after the persons effective date of coverage. Paralysis Pays benefits if an insured person is first diagnosed as being paralyzed more than 30 days after the persons effective date of
coverage. Severe Burns Pays benefits, depending on the severity of the burn, if an insured person is first diagnosed with having suffered a Severe
Burn more than 30 days after the persons effective date of coverage. These are brief descriptions of the coverage available under the policy. The policies will contain limitations, exclusions and
termination provisions
AFFORDABLE GENERIC PRESCRIPTION PLAN S MART C HOICE FOR O UTPATIENT P RESCRIPTION D RUG S AVINGS FOR AIM Members How to Use Your Prescription Drug Plan The plan pays medically necessary prescription drug charges in excess of the co-pay
amount. Benefits are obtained through the use of an identification card that will be issued
to the employee upon enrollment. To fill a prescription, an employee must present the
card and the Physicians prescription to a participating pharmacy and pay the applicable
co-payment.
Benefit Highlights: $10 co-pay for all generic medications. No deductibles, No waiting periods, No restrictions due to pre-existing
conditions. No claim forms to complete savings are provided immediately. Acceptance at over 53,000 pharmacies nationwide including Walgreens, CVS,
Wal-Mart and Rite Aid stores. Savings on medications not covered on the formulary. Brand-Name Drugs: Discounted price as adjudicated at the time of purchase. The Affordable Generic Prescription Plan is available based on the following monthly premiums and are payable through convenient payroll deduction. Supply of generic drug subject to the maximum annual benefit of: $1,500 Per Insured Person, annually. M ONTHLY R ATES Employee $ 12.00 Employee + 1 $ 18.00 Family $ 26.00 AIM HealthMax Health Plans Enrollment Application Kit Please review the checklist below before you send your Enrollment Application. PLEASE PRINT CLEARLY AND USE BLACK INK TO COMPLETE APPLICATION. Application must be received by the 15th of prior month to be approved for the 1st of the following month. A Limited Benefit Health Insurance Plan Not a Major Medical Health Plan If you need assistance filling out the Enrollment Application, please contact your agent or broker. Agent/Broker: Telephone: Applicant must complete Sections I, II, and III of the Enrollment Form. Applicant must complete Sections IV (Billing Form). . Paying via check: Make check payable to Insurance Resource Group. Paying via EFT: Include copy of a voided check with Enrollment Application.
Monthly invoices are subject to a $10.00 Billing Fee. No charge for monthly Electronic Fund Transfers (EFT).
Must pay first months (premium, admin fee, association dues and one time fee).
Application must be received by the 15th of prior month to be approved for the 1st of the following month. Paying via check: Mail completed Enrollment Application to: Paying via EFT: Fax legible and completed Enrollment Application to: Attn: Enrollment Department This product is administered by Insurance Resource Group Martin Unger 800-986-4786 Martin Unger 5070 NW 96th Way
Coral Springs, Fl 33076 1-775-254-2881 APPLICANT NAME (Last, First, Middle Initial) GENDER Male Female DATE OF BIRTH (MM/DD/YYYY) SSN HOME ADDRESS CITY STATE ZIP CODE BILLING ADDRESS (Address, City, State, Zip) If different from home address HOME PHONE WORK PHONE Occupation/Job Title: Employee Class: Not Applicable Hire Date: Not Applicable Hrs/Wk: Not Applicable Employer Name & Address: Not Applicable Section/Dept. #: Not Applicable Annual Salary $: Not Applicable Employee ID: Not Applicable Plan: Not Applicable [Units] Not Applicable Rider: Not Applicable Monthly Premium $: Not Applicable Plan: Not Applicable [Units] Not Applicable Rider: Not Applicable Monthly Premium $: Not Applicable Plan: Not Applicable [Units] Not Applicable Rider: Not Applicable Monthly Premium $: Not Applicable AIM LIMITED BENEFIT HEALTH INSURANCE PLAN ENROLLMENT FORM (PAGE 1) SECTION I Plan Selection - FORM MUST BE FILLED OUT IN BLACK BALLPOINT INK - PLEASE PRINT CLEARLY COVERAGE DESIRED (Check Appropriate Box) Individual Only Individual and Spouse Individual and Child(ren) Family SELECT PLAN (Check Appropriate Box) NYSBA Requested Effective Date (1ST DAY OF MM/YYYY) SECTION II GENERAL INFORMATION - PLEASE PRINT CLEARLY SPOUSE/DEPENDENT NAME RELATIONSHIP TO APPLICANT DATE OF BIRTH SSN SECTION III SPOUSE AND DEPENDENT INFORMATION - PLEASE PRINT CLEARLY - Please indicate additional dependents on a duplicate sheet. [This limited medical plan includes a discount program that is not health insurance. The program provides discounts at certain health care providers for medical and ancillary services. The program does not make payments directly to the provider of services, and members are obligated to pay the provider the discounted rate at the time of service. Participating providers are subject to change without notice and are not available in all areas. Actual savings may vary.]
I understand that Limited Medical Plan covered persons are covered by individual insurance benefits. The individual insurance benefits vary depending on plan selected. These benefits are provided
under an individual insurance policy underwritten by American Medical & Life Insurance Company and are subject to the exclusions, limitations, terms and conditions of coverage as set forth in the
insurance certificate which includes, but is not limited to, limitations for pre-existing conditions. This is not basic health insurance or major medical coverage and is not designated as a substitute for basic
health insurance or major medical coverage. This is a limited medical plan that provides for limitations to the coverage for each benefit. The limitations are disclosed in the policy and certificate which are
made available at the time of enrollment.
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or
conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed
five thousand dollars and the stated value of the claim for each such violation. Signature of Applicant X Signed at (City) Signed at (State) Date Signed SELECT NETWORK (Check Appropriate Box) Multipla n Rx card Option BANK NAME BANK ROUTING NUMBER BANK ACCOUNT NUMBER Voided check is required and must be legible. No monthly charge for EFT. CHECK OR MONEY ORDER ( Make payable to Insurance Resource Group. There is a $30 insufficient funds fee ) INITIAL PAYMENT : I will pay my 1st months premium, admin fee, association dues and one time enrollment fee via check/money order. My check/money order is enclosed with the Enrollment Form. MONTHLY PAYMENT: Send me a monthly invoice to pay my monthly premium, admin fee and association dues. I agree to pay an additional fee of $10 to receive a monthly invoice. ELECTRONIC FUNDS TRANSFER ( Fill out EFT Authorization Form below and include a legible voided check.) INITIAL PAYMENT : EFT my bank account for 1st months premium, admin fee, association dues and one time enrollment fee. EFT occurs between the 15th and 20th of the month prior to the effective date. MONTHLY PAYMENT: EFT my bank account for the monthly premium, admin fee and association dues. EFT occurs between the 15th and 20th of the month prior to the next months coverage. I understand this authority is to remain in full force and in effect until IRG has received written notification from me of its termination in such time and such manner as to afford IRG and depositor a reasonable opportunity to act on it. I
have the right to stop payment of a debit entry (deduction) by notification to IRG three business days or more before this payment is scheduled to be made. Please be aware that your bank statement will reflect the debit as IRG-HEALTH. - & APPLICANT SIGNATURE (REQUIRED) X PRINT NAME DATE ACCOUNT HOLDER SIGNATURE ( REQUIRED if paying via EFT) X PRINT NAME DATE Rep Name: R ep Signature X Date Telephone: Rep Code : PAYMENT OPTIONS (Check Appropriate Box Below) PLEASE ATTACH A CHECK MARKED VOID TO ENSURE ACCURACY AIM HealthMax LIMITED BENEFIT HEALTH INSURANCE PLAN ENROLLMENT FORM (PAGE 2) SECTION IV BILLING FORM - FORM MUST BE FILLED OUT IN BLACK BALLPOINT INK - PLEASE PRINT CLEARLY SELECT MONTHLY PREMIUM Health Max AIM XTRA (Rider) Individual Only $305 $88.00 Individual and Spouse $554 $155.50 Individual and Child(ren) $505 $155.50 Family $729 $175.00 CALCULATE MONTHLY PREMIUM
Step 1. Enter Premium Selected: $ Step 2. One Time Enrollment Fee: $85.00 Step 3. Optional RX Fee (12.00 Single / 18.00 E+1 / 26.00 Family) $ ______
Step 4. Total Contribution at Enrollment Add Steps 1 $ EFT AUTHORIZATION FORM FORM MUST BE FILLED OUT IN BLACK BALLPOINT INK - PLEASE PRINT CLEARLY LU 5460 Lisa Unger 800-986-4786

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