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Hospital Indemnity
Insurance Worksheet
INSURANCE
COMPANY
Name Current plan’s out-of-pocket maximum
Medico Insurance Company’s Hospital Indemnity Insurance
Inpatient/observation hospital stay $ _______ / day X _______ days = $ _________
Inpatient mental health services $ _______ / day X _______ days = $ _________
Emergency room services $ _______ / visit X _______ visits = $ _________
Transportation and lodging $ _______ / day X _______ days = $ _________
Optional benets
Ambulance $ _______ / day X _______ days = $ _________
Skilled nursing services
1
$ _______ / day X _______ days = $ _________
Outpatient surgery $ _______ / day X _______ days = $ _________
Outpatient therapy/
Chiropractic services
$ _______ / visit X _______ days = $ _________
Urgent care $ _______ / day X _______ days = $ _________
Lump sum cancer treatment $ _______ / diagnosis X _______ = $ _________
Lump sum hospital connement $ _______ / connement X _______ connement = $ _________
Total Medico Hospital Indemnity insurance pays $ ____________
50
50
1
150
175
100
250
Current Health Insurance Plan Copays
Inpatient hospital care $ _______ / copay X _______ days = $ _________
Inpatient mental health services $ _______ / copay X _______ days = $ _________
Emergency room services $ _______ / copay X _______ days = $ _________
Ambulance services $ _______ / copay X _______ days = $ _________
Skilled nursing services $ _______ / copay X _______ days = $ _________
Outpatient surgery $ _______ / copay X _______ days = $ _________
Outpatient therapy $ _______ / copay X _______ days = $ _________
Chiropractic services $ _______ / copay X _______ days = $ _________
Urgent care $ _______ / copay X _______ days = $ _________
Total out-of-pocket costs $ ____________
Take a moment to see how this plan can work with your current Medicare Advantage plan.
Continued on the back
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34 118 0042 0320 US
1. In Iowa, this rider is called Nursing Facility benet rider. In Pennsylvania, this rider is called Supplemental Skilled Nursing Facility Indemnity
benet rider. In Washington, this rider is called Nursing Facility Indemnity benet rider.
In Pennsylvania, “hospital indemnity insurance” is called, “hospital connement indemnity insurance.” In Arkansas, “hospital indemnity insurance”
is called “hospital connement insurance.” In Colorado, “hospital indemnity insurance” is called “xed indemnity insurance policy.” In Utah,
“hospital indemnity insurance” is called “hospital limited benet indemnity insurance policy.” In Virginia, “hospital indemnity insurance” is called
“limited benet hospital indemnity insurance policy.”
Policy provisions and benets may vary from state to state. Please see the policy and riders for complete details. For costs and further details of
the coverage, including exclusions, restrictions, or limitations and the terms under which the policy may be continued in force or discontinued,
see your producer or contact Medico. Preexisting conditions are not covered during the rst six months after the policy date (may vary by state).
To be eligible for benets, you must receive medically necessary covered care, as dened in the policy. This is a solicitation of insurance, and a
licensed agent/producer may contact you. THIS IS A LIMITED POLICY.
If there is a discrepancy between the yer and the contract, the contract language prevails. This policy is not major medical insurance and
is not a substitute for major medical insurance. It does not qualify as minimum essential health coverage under the Federal Affordable Care Act.
If you purchase this policy only, you will not satisfy the federal requirement that you have health coverage, which has been in effect since Jan. 1,
2014.
Policy forms: HIA63; HIA63(FL); HIA63(IL); HIA63(KS); HIA63(MO); HIA63(MT); HIA63(NC); HIA63(OK); HIA63(OH); HIA63(OR); HIA63(PA); HIA63(TN);
HIA63(TX); HIA63(VA); HIA63(WI)
P.O. Box 10386 | Des Moines, IA 50306
800-228-6080 | gomedico.com
Medico
®
is a registered trademark owned and licensed by Medico Insurance Company.
© 2020 Medico Insurance Company
11F-707
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Completed 18 January 2021

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