Old school: STM contract 3X semi private room rate for ICU

The STM $1,000,000 per 3 month period policy will pay, as listed under limitations:
For intensive care the policy will pay a maximum of 3 times the provider's semi-private room rate.
In addition, the network rate is not guaranteed, nor is there a guarantee of direct claims filed to the insurer from the network listed provider. Save a bunch of money up front, chance of even bigger headaches later. And I get complaints from ACA clients about claims, not often, but still.

Any experience with the Swiss Cheese involved in claims with this sort of policy language? This is not unlike insurance "back in the day".

Agents really have to work at explaining this is not 100% paid after the deductible, the way it mostly is with ACA compliant coverage for in network coverage. Sheesh. Feel like I need them to have a claims lawyer review the policy with the client before signing.

No wonder the premium is 80% lower than ACA coverage.

 

Meant to say pay 100% after max out of pocket, of course. Sometimes deductible and max are the same. Not sure why edit function not showing. The STM is 100% (of allowable charges--which have limitations within their definitions/coverage/limitations in contract)
I am going to send a specimen policy and offer to set up an app for eligibility notice on HC.gov, because they lost coverage from group 12/31/17, and if applying within the 60 day limit will have more time than that to enroll in a plan if they change, or one of the couple changes their minds about this type of coverage.
Will definitely be looking at some kind of indemnity plan options, cancer, CI, accident etc., if they are set on having a lower cost/more limitations type of coverage. They can also keep those plans past 65, while under group or ACA, too.

 

What carrier is that?

 

It is a carrier working with Lloyds, but now they have changed their rules, so new policies are only issued if the person is turned down by an admitted carrier for eligibility reasons. They also state that they haven't seen claims so far for ICU that were an issue with the 3X semi-private room.