• which manifested itself within the three-month period before the policy date in such a way as would cause an ordinarily prudent person to seek diagnosis, care or treatment from a practitioner;

or
• for which medical advice, care or treatment was recommended by or received from a physician within the three-month period immediately before the effective date of coverage.

If you are eligible for coverage under the federal rules, no preexisting condition exclusion will be applied.

There are several different comprehensive plans offered by the ACHIA. The primary differences between the plans are the annual deductible and the associated out-of-pocket expense limitations. The annual deductible is the amount that you must pay each calendar year for eligible expenses before the plan pays benefits. The out-of-pocket expense limitation is the maximum amount, including the annual deductible, you must pay in any calendar year.

With the exception of the $1000 deductible, Traditional (Non-PPO) plan, the Medicare Carveout and the two Medicare supplement plans, all ACHIA plans pay 80% of the billed charges once you have satisfied the annual deductible, as long as you receive treatment either from a preferred hospital or from a hospital that is not preferred when you do not have reasonable access to a preferred hospital. If you have reasonable access to a preferred hospital and choose to receive treatment from a hospital that is not preferred, ACHIA will pay only 60% of the usual and customary charges. After you have paid charges equal to the out-of-pocket expense limit, ACHIA will pay 100% instead of 80% or 60%.

For those covered under Medicare, ACHIA offers two Medicare supplement plans. The two Medicare supplement plans are standardized Plan A and Plan F. If you are not enrolled in Part B of Medicare, benefits under these plans will not include benefits normally paid by Medicare. These plans do not cover basic prescription drugs, but do cover drugs that are covered by Medicare Part B.

For those under 65 and covered under Medicare, ACHIA offers a Medicare carveout plan. The plan coordinates the benefits of the ACHIA $1000 deductible non-ppo plan with Medicare. The Medicare carveout plan pays 80% of the charges not covered by Medicare (but covered under the ACHIA plan) once the $1000 deductible has been satisfied, and pays 100% of the charges not covered by Medicare (but covered under the ACHIA plan) after you have paid charges equal to the out-of-pocket expense limit including the deductible. This plan differs from the non-PPO plan in that it does not cover drugs whether you have Medicare Part D or not. However, drugs covered under Medicare Part B are covered under this plan.

• detoxification;
• medical or psychiatric evaluation;
• activity or family therapy;
• counseling;
• prescription drugs and supplies.

• Daily semiprivate room and board and other hospital services and supplies
• Professional services that are rendered by a physician or by a registered nurse at the physician's direction
• Legend drugs and medicines requiring a physician's prescription; [Not covered for Medicare carveout or Medicare Supplement Plan A or Plan F unless covered by Medicare Part B.]
• Services of a skilled nursing facility for not more than 120 days in a policy year;
• Home health agency services up to a maximum of 270 visits in a calendar year. Limitations are provided in the policy
• Hospice services for up to six months in a calendar year
• Use of radium or other radioactive materials
• Outpatient chemotherapy
• Oxygen
• Anesthetics and its administration
• Nondental prosthesis and maxillo-facial prosthesis used to replace any anatomic structure lost during treatment for head and neck tumors or additional appliances essential for the support of the prosthesis
• Rental, or purchase if purchase is more cost effective than rental, of durable medical equipment that has no personal use in the absence of the condition for which it was prescribed
• Diagnostic x-rays and laboratory tests
• Oral surgery for excision of partially or completely unerupted impacted teeth or excision of a tooth root without the extraction of the entire tooth
• Services of a licensed physical therapist rendered under the direction of a physician
• Transportation by a local ambulance operated by licensed or certified personnel to the nearest health care institution for treatment of the illness or injury and round trip transportation by air to the nearest health care institution for treatment of the illness or injury if the treatment is not available locally; if the patient is a child under 12 years of age, the transportation charges of a parent or legal guardian accompanying the child may be paid if the attending physician certifies the need for the accompaniment
• Confinement in a licensed or certified facility established primarily for the treatment of alcohol or drug abuse or in a part of a hospital used primarily for this treatment, for a period of at least 45 days within any calendar year
• Diagnosis or treatment of a mental or nervous disorder rendered during the year subject to the Mental or Nervous Disorder Limits
• Second surgical opinions
• One routine mammography each calendar year to insured persons age 35 or over, except benefits will be paid without regard to age or any calendar year limit if the insured person or the insured person's mother or sister have a history of breast cancer
• Treatment of alcoholism or drug abuse, subject the Alcoholism or Drug Abuse Outpatient Maximums
• Formulas necessary for the treatment of phenylketonuria (PKU)
• Treatment for complications of pregnancy to the same extent as for disease: surgical operations for extrauterine pregnancy or for other complications requiring intra-abdominal surgery after termination of pregnancy; pernicious vomiting of pregnancy (hyperemesis gravidarum); and toxemia with convulsions (eclampsia of pregnancy)
• One pap smear including attendent pysicians office visit per calendar year for covered females age 18 or older and one prostrate specific antigen or other effective lab test expenses per year for males age 35 or older as provided by state law.

• Confinement or expenses incurred while your policy is not in force,
• Injuries or disease caused at place of employment subject to workers' compensation benefits,
• Injuries or disease caused in a motor vehicle accident subject to auto insurance coverage or other liability insurance,
• Reconstructive or cosmetic surgery,
• Services that exceed the reasonable to customary charges,
• Services that are deemed not to be medically necessary,
• Services that are not within the scope of the providers license or certificate,
• Eyeglasses, contact lenses, or hearing aids or the fitting of them,
• Dental care not specially covered,
• Services of a registered nurse or physician that resides in the covered person's home,
• Experimental procedure, service, drugs and other supplies,
• Services for which the patient was not charged,
• Self-inflicted injury or sickness, suicide or attempted suicide,
• Treatment for craniomandibular or temporomandibular joint (TMJ) disorders,
• Promotion of fertility,
• Vocational training,
• Expenses associated with pregnancy and childbirth except as described above,
• Services of a resident physician or intern,
• Charges for or related to sex change surgery or gender identity disorders,
• Routine physical, vision, dental, hearing or preventive exams,
• Acupuncture therapy.
• For Medicare carveout and Medicare Supplement Plan A and Plan F, basic prescription drugs unless covered under Medicare Part B.