Page 3 - Nationwide_Care Access Plan
P. 3
Economy Value Superior
$3,000
Inpatient services (per day) $1,000 $2,000
$4,500
Inpatient hospital confinement $1,500 $3,000
Covers room and board, miscellaneous hospital expenses and general $1,000
nursing while hospital confined. This benefit is not paid if paid under the $1,000 $1,000
ICU/CCU confinement benefit. $60
$40 $50 $9,000
Inpatient ICU/CCU confinement
Covers room and board, miscellaneous hospital expenses, and general $3,000 $6,000 Total payable
nursing while confined in the intensive care unit or critical care unit of a Total payable Total payable as follows
hospital. This benefit is paid in lieu of inpatient hospital confinement.
as follows as follows
Accident Benefit Rider
(maximum of 10 days per covered injury)
Provides an additional benefit per day of inpatient confinement when
confinement is the direct result of a covered injury.
Inpatient physician visits
Covers one physician visit per day during inpatient confinement.
Inpatient surgical services (per surgery)
Total benefit for inpatient surgical service
Covers surgery performed during inpatient confinement. If two or
more surgical procedures are performed through the same incision,
the amount shown applies to the first surgery and 50 percent of the
benefit shown applies to the second surgery. If two or more surgeries
are performed through different incisions, the benefit shown applies to
each surgery.
Surgeon $2,000 $4,000 $6,000
Assistant surgeon $400 $800 $1,200
$600 $1,200 $1,800
Anesthesiologist
$1,300 $2,600 $3,900
Outpatient surgical services (per surgery)
Total benefit for outpatient surgical service Total payable Total payable Total payable
as follows as follows as follows
Facility $400 $800 $1,200
Covers services and supplies provided by the outpatient surgical facility
such as use of the operating room, general nursing, casts, splints and
diagnostics such as radiology and pathology.
(benefit is not payable if surgery is performed in
a doctor’s office).
Surgeon $600 $1,200 $1,800
Covers surgeon’s services when performed at an outpatient surgical
facility. If two or more surgical procedures are performed through the
same incision, the amount shown applies to the first surgery and 50
percent of the benefit shown applies to the second surgery. If two or
more surgeries are performed through different incisions, the benefit
shown applies to each surgery.
Assistant surgeon $120 $240 $360
Anesthesiologist $180 $360 $540
Benefits listed are subject to the per injury or illness deductible, if applicable.
Brochure Care Access Plan L 0518 3
$3,000
Inpatient services (per day) $1,000 $2,000
$4,500
Inpatient hospital confinement $1,500 $3,000
Covers room and board, miscellaneous hospital expenses and general $1,000
nursing while hospital confined. This benefit is not paid if paid under the $1,000 $1,000
ICU/CCU confinement benefit. $60
$40 $50 $9,000
Inpatient ICU/CCU confinement
Covers room and board, miscellaneous hospital expenses, and general $3,000 $6,000 Total payable
nursing while confined in the intensive care unit or critical care unit of a Total payable Total payable as follows
hospital. This benefit is paid in lieu of inpatient hospital confinement.
as follows as follows
Accident Benefit Rider
(maximum of 10 days per covered injury)
Provides an additional benefit per day of inpatient confinement when
confinement is the direct result of a covered injury.
Inpatient physician visits
Covers one physician visit per day during inpatient confinement.
Inpatient surgical services (per surgery)
Total benefit for inpatient surgical service
Covers surgery performed during inpatient confinement. If two or
more surgical procedures are performed through the same incision,
the amount shown applies to the first surgery and 50 percent of the
benefit shown applies to the second surgery. If two or more surgeries
are performed through different incisions, the benefit shown applies to
each surgery.
Surgeon $2,000 $4,000 $6,000
Assistant surgeon $400 $800 $1,200
$600 $1,200 $1,800
Anesthesiologist
$1,300 $2,600 $3,900
Outpatient surgical services (per surgery)
Total benefit for outpatient surgical service Total payable Total payable Total payable
as follows as follows as follows
Facility $400 $800 $1,200
Covers services and supplies provided by the outpatient surgical facility
such as use of the operating room, general nursing, casts, splints and
diagnostics such as radiology and pathology.
(benefit is not payable if surgery is performed in
a doctor’s office).
Surgeon $600 $1,200 $1,800
Covers surgeon’s services when performed at an outpatient surgical
facility. If two or more surgical procedures are performed through the
same incision, the amount shown applies to the first surgery and 50
percent of the benefit shown applies to the second surgery. If two or
more surgeries are performed through different incisions, the benefit
shown applies to each surgery.
Assistant surgeon $120 $240 $360
Anesthesiologist $180 $360 $540
Benefits listed are subject to the per injury or illness deductible, if applicable.
Brochure Care Access Plan L 0518 3
