Affordable Choice Plan Comparison – Surgical and Hospitalization Benefits

Diamond Elite PlusPlatinum EliteGold Classic PlusSilver Classic
Inpatient Hospital Confinement
(per inpatient day) $1,000,000 per calendar year limit
Building Benefit Injury Reimbursement
Inpatient Hospitalization benefits increase 25% each year,
years 2-5 for injury related hospital stays
year 2$6,250$3,750$2,500$1,875
year 3$7,500 $4,500 $3,000 $2,250
year 4$8,750$5,250$3,500$2,625
year 5$10,000$6,000$4,000$3,000
Hospital Admission Benefits
(for the first inpatient day per calendar year)
Emergency Room or Urgent Care$375$250$250$125
Surgery Benefit
Limit of 1 daily benefit per calendar year, daily surgical
benefits for both inpatient and outpatient surgery.
The reimbursement schedule for 1 unit is similar
to what is payable under the Medicare Physician Fee
Schedule for surgeries. (Maximum Benefit per calendar year)
3 X Policy
Fee Schedule
2.5 X Policy
Fee Schedule
2 X Policy
Fee Schedule
1 X Policy
Fee Schedule
Ambulatory Surgical Benefit
If outpatient surgery is performed in an Ambulatory Surgery
Center or Outpatient Hospital facility, the benefits payable
include the surgical and anesthesia benefit in addition to
per day ambulatory/outpatient facility benefit.
Assistant SurgeonPays a daily amount per day of surgery
Anesthesiologist Pays a daily amount per day of surgery
Diamond Elite PlusPlatinum EliteGold Classic PlusSilver Classic
Doctor’s Office Visit
(Per day/calendar year)
$100/4 days$75/4 days$75/3 days$50/3 days
Prescription Benefit
(Per day – $750 calendar year maximum)
Outpatient Medical Benefits
Preventive Services (per Colonoscopy, Pap, PSA)
$300/$100/$100 $300/$100/$100 $300/$100/$100 $300/$100/$100
Laboratory Services (per day for surgical pathology/other laboratory
$100/$50 $100/$25 $100/$25 $100/$25
Therapy Services (per day for physical, occupational, speech)$25$25$25$25
Radiology Services (per day: MRI/PET scan/CT scan/mammogram/
other radiology tests)
Calendar Year Limit for all Outpatient Benefits $25 $25 $25 $25
Ground and Air Ambulance
Limit of 2 daily benefits per calendar year for all
ambulance transportation (per day for ground, per day for air)
$150/$1000 $100/$1000 $100/$1000 $100/$500
Allergy Shots and Immunization (child only)$10/$25 $10/$25 $10/$25 $10/$25
Cancer Benefit
Pays for Radiation, Chemotherapy, & Immunotherapy
(per day/40 days per calendar year)
$2,000 $2,000 $1,000 $1,000
Lifetime Maximum$5 million $5 million $5 million $5 million