Page 9 - Nationwide_Care Access Plan
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Precertification
Precertification is a screening process used to determine if the proposed inpatient confinement or outpatient
chemotherapy or radiation treatment is medically necessary and appropriate. Failure to obtain the required
precertification will result in no benefits being paid. Precertification is required at least seven days prior to each
non-emergency inpatient confinement and within 48 hours of inpatient admission or as soon as reasonably possible
for emergency inpatient confinement. Precertification is also required seven days prior to receiving outpatient
chemotherapy and radiation therapy. Precertification is not pre-authorization or pre-approval of coverage and it does
not guarantee payment of benefits. Payment of benefits will be determined in accordance with and subject to all the
terms, conditions, limitations and exclusions of the policy.
Termination of insurance
A covered person’s insurance under the Policy will terminate on the earliest of the following: the date of termination
of the Policy; the premium due date following the date a written request to terminate coverage is received; the date
the premium is not paid; the date of death; the last day of the month following the date of attainment of age 65; the
last day of the month following the date of Medicare eligibility; the last day of the month following termination of
membership with the policyholder; or the date the person enters the armed forces. A dependent spouse’s coverage
also terminates on the premium due date following a divorce or legal separation.
A dependent child’s coverage will terminate on the premium due date following the date the child ceases to meet
the definition of an eligible dependent
Intentional misrepresentation or fraud in the application for coverage may result in rescission. There is no
reformation in this iteration of hospital indemnity insurance.
Coordination of benefits
The Care Access Plan does not coordinate benefits with other health insurance plans.
Hospital definition
A hospital is an institution that: operates pursuant to law; has 24-hour nursing services by registered nurses; has a
staff of one or more doctors; provides inpatient therapeutic and diagnostic services for illness or injury; provides
facilities for major surgery or has a formal arrangement with another institution for surgical facilities; and is approved
by the Joint Commission on the Accreditation of Health Care Facilities as a Hospital (JCAHO); the American Hospital
Association (AHA); the American Osteopathic Healthcare Association (AOHA); the American Osteopathic Association
accreditation (AOA); or the Commission on Accreditation of Rehabilitation Facilities (CARF) accreditation.
The definition of a hospital does not include: A rest or nursing home, home for the aged or convalescent home; a
skilled nursing facility; an extended care facility; hospice; a place for custodial care; or a birthing center.
Pre-existing condition definition and limitation
A pre-existing condition is a disease, accidental bodily injury, illness or physical condition for which a covered person:
had treatment; incurred charge; took medication; or received a diagnosis or advice from a doctor; during the 12-month
period (Idaho is six months) immediately preceding the covered person’s coverage effective date.
Covered benefits are payable for a pre-existing condition after the insured person has been continuously covered
under the policy for 12 consecutive months. This does not apply to a newborn or newly adopted child placed for
adoption under age 18 if such child is enrolled for coverage within 31 days from the date of birth or date of adoption or
placement for adoption.
Brochure Care Access Plan L 0518 9
Precertification is a screening process used to determine if the proposed inpatient confinement or outpatient
chemotherapy or radiation treatment is medically necessary and appropriate. Failure to obtain the required
precertification will result in no benefits being paid. Precertification is required at least seven days prior to each
non-emergency inpatient confinement and within 48 hours of inpatient admission or as soon as reasonably possible
for emergency inpatient confinement. Precertification is also required seven days prior to receiving outpatient
chemotherapy and radiation therapy. Precertification is not pre-authorization or pre-approval of coverage and it does
not guarantee payment of benefits. Payment of benefits will be determined in accordance with and subject to all the
terms, conditions, limitations and exclusions of the policy.
Termination of insurance
A covered person’s insurance under the Policy will terminate on the earliest of the following: the date of termination
of the Policy; the premium due date following the date a written request to terminate coverage is received; the date
the premium is not paid; the date of death; the last day of the month following the date of attainment of age 65; the
last day of the month following the date of Medicare eligibility; the last day of the month following termination of
membership with the policyholder; or the date the person enters the armed forces. A dependent spouse’s coverage
also terminates on the premium due date following a divorce or legal separation.
A dependent child’s coverage will terminate on the premium due date following the date the child ceases to meet
the definition of an eligible dependent
Intentional misrepresentation or fraud in the application for coverage may result in rescission. There is no
reformation in this iteration of hospital indemnity insurance.
Coordination of benefits
The Care Access Plan does not coordinate benefits with other health insurance plans.
Hospital definition
A hospital is an institution that: operates pursuant to law; has 24-hour nursing services by registered nurses; has a
staff of one or more doctors; provides inpatient therapeutic and diagnostic services for illness or injury; provides
facilities for major surgery or has a formal arrangement with another institution for surgical facilities; and is approved
by the Joint Commission on the Accreditation of Health Care Facilities as a Hospital (JCAHO); the American Hospital
Association (AHA); the American Osteopathic Healthcare Association (AOHA); the American Osteopathic Association
accreditation (AOA); or the Commission on Accreditation of Rehabilitation Facilities (CARF) accreditation.
The definition of a hospital does not include: A rest or nursing home, home for the aged or convalescent home; a
skilled nursing facility; an extended care facility; hospice; a place for custodial care; or a birthing center.
Pre-existing condition definition and limitation
A pre-existing condition is a disease, accidental bodily injury, illness or physical condition for which a covered person:
had treatment; incurred charge; took medication; or received a diagnosis or advice from a doctor; during the 12-month
period (Idaho is six months) immediately preceding the covered person’s coverage effective date.
Covered benefits are payable for a pre-existing condition after the insured person has been continuously covered
under the policy for 12 consecutive months. This does not apply to a newborn or newly adopted child placed for
adoption under age 18 if such child is enrolled for coverage within 31 days from the date of birth or date of adoption or
placement for adoption.
Brochure Care Access Plan L 0518 9
