Pivot Health Short Term Medical

Pivot Health

Pivot Health offers Short Term Medical (STM) plans in 31 states. The length of the available coverage term varies by state. Below you will find the states where Pivot Health plans are available and the policy term duration’s for their plans in each state.

The Pivot Health STM plan provide an excellent base of protection. However, Short term medical (STM) plans do not cover all the services/treatments mandated under Obamacare (e.g. maternity, preventive care, outpatient mental health services and prescription drugs) and they do not cover any pre-existing conditions.

Therefore, to enhance your overall coverage, you can also add any or all the following supplemental benefits available on our US Supplemental Coverage page to make your overall plan as comprehensive as you want:

• Accident Protection Plans
• Critical Illness Plans
• Cancer and Dread Disease Treatment Plans
• First Day Hospital/ICU Stay Protection
• 100% Preventive Care (Per ACA/Obamacare guidelines)
• Additional Outpatient Benefits
• Prescription Drug coverage
• Dental and Vision 

About Pivot Health

Pivot Health is an insurance product development, management and marketing company led by an experienced team of health insurance professionals that has managed more than $7 billion of insurance premium. The company has proprietary products and dedicated relationships with many national carriers.

Plans are administered by Allied National, which is a leading national Third Party Administrator of health plans. 

Pivot Health Coverage

Pivot Health offers three separate sets of plans. Availability varies by state. The three sets of plans are as follows:

Pivot Health Classic STM plans offer four different plan options with varying deductibles, coinsurance percentages and out of pocket limits. The Classic plans include the following…

• Up to $1,000,000 in benefits per coverage period
• Doctor office visit co-pay benefits (Classic Deluxe and Choice Plans)
• Prescription drug co-pay benefits (Classic Deluxe Plan)
• Urgent Care co-pay benefits (Classic Deluxe and Choice Plans)
• Access to Telemedicine 24/7
• Choice of reduced policy maximums to reduce premium costs
• Freedom of choice of any provider (See Reference Based Pricing below)!

• For more details see the: Pivot Health STM Brochure
  NEW! As of September 19, 2022, enhanced benefits are now available on Pivot Classic STM plans in AZ, FL, GA, IL, IN, MI, NE, TX, WI. These benefits include:
  No deductible:
  Routine Wellness exam paid at 100% up to $200 – No waiting period
• • Childhood immunizations and routine service coverage

  Subject to Deductible and coinsurance:
  Annual OB-GYN exam, mammogram, ovarian cancer monitoring, colorectal cancer and prostate screening benefits

• Inpatient and Outpatient Mental Health and Substance Abuse benefits
• Organ transplant benefits
• HIV coverage
• Joint, neck, and spine injury coverage
• Plus other enhanced features

For more details see the new, updated: Pivot Health Classic STM Brochure for these states

Pivot Health Quantum PPO STM plans offer two different plan options with varying deductibles, coinsurance percentages and out of pocket limits. The Quantum PPO plans include the following…

• Up to $1,000,000 in benefits per coverage period
• Access to the Cigna nationwide PPO network (See below)
• Preventive exam one time per coverage period
• Doctor office copays on Copay plan
• In-network prescription drug copays with no deductible on Copay plan
• In-network out-of-pocket maximum capped at $10,000
• In-network annual OB-GYN exam, mammogram, ovarian cancer monitoring, colorectal cancer and prostate screening subject to deductible and coinsurance
• Childhood immunizations not subject to deductible
• Supplemental accident coverage included for injuries
• Organ transplants

For more details see the: Pivot Health Quantum STM Brochure

Pivot Health Epic STM plans offer two different plan options with varying deductibles. The Epic plans include the following: 

• Up to $1,000,000 in benefits per coverage period
• Access to the Cigna nationwide PPO network (See below) or 
• Reference Based Pricing payment model (See below)
• All plans pay 100% of covered charges after meeting the deductible (In network on PPO plans)
• Preventive health exams (after 3 months of coverage)
• Child immunizations paid at 100%
• Preventive wellness coverage for the whole family including prostate and colon cancer screening, mammograms and OB-GYN annual exams
• Optional Supplemental Accident benefits providing 100% coverage for medical expenses related to accidental injury
• Optional prescription drug benefits on plans (including contraceptives)
• As soon as next day effective dates available

For more details see the: Pivot Health Epic STM Brochure

Both PPO Network and NO Network (Reference Based Pricing) Options

Reference Based Pricing Model:

Pivot Health Classic STM plans are set up differently than health plans that utilize a PPO or HMO or other type of provider network. There is NO network with these plans. Consumers can see ANY doctor or hospital facility. Billing is repriced based on the usual and customary fee schedule which is stated on the medical plan ID card. This is known as “Reference Based Pricing.”

Here is a short video with more information on Pivot plans and Reference Based Pricing.

The Pivot Health short term medical claims reimbursement system is set up to guarantee that no member will be responsible for a balance bill due to the discount taken for charges above the Medicare Reference Pricing amount, subject to the terms outlined in the certificate of insurance. This insurance plan reimburses medical providers based on a percentage above Medicare allowable amounts, paying:

• 150% of Medicare allowable amount for medical facilities

• 125% of Medicare allowable amount for physician claims

If a provider wishes to review and discuss the allowed amount or initially objects to the reimbursement amount, the provider is connected to the repricing vendor. The repricing vendor is authorized to negotiate a settlement.

NOTE: As your agent I am here to help you through the process if a provider attempts to bill you (aka balance billing) for an amount above the allowed amount that these plans pay.  Once you are covered, I will provide you with the information needed to submit any balance bill from a provider to Pivot for processing.

PPO Network Plans: 

Pivot Health Quantum PPO STM plans utilize the Cigna nationwide PPO network. The network has broad access to medical providers in urban, suburban and rural markets throughout the country, and online tools to help you manage your healthcare.  

• Access to more than 1 million national providers
• 6,360 hospitals in-network
• Members pay on average 49.8% less compared to the national discount 

Find a provider in the network by visiting the Cigna PPO Network page.  Enter Address, City or Zip in the search bar, and under “Medical Plans” select the “PPO/Choice Fund PPO” network. 

Reference Based Pricing or PPO Network Plan Choice:

Epic STM plans offer the choice of plans with the Cigna nationwide PPO network (like the Quantum plans) or with a Reference Based Pricing payment model (like the Classic plans).

Pivot Health Prescription Coverage and Formulary Information

Here is information on the current prescription formularies used in the Pivot plans that provide prescription coverage:
The Pivot Quantum PPO Copay and Epic PPO plans utilize the Cigna RX formulary
The Pivot Epic Base and Classic STM Deluxe and Standard plans use the Cerpass RX formulary

Current State Availability and Plan Duration’s

Classic STM plans are available in the following states: 

AL, AR, AZ, DE, FL, GA, IA, IL, IN, KY, LA, MI, MO, MS, NC, ND, NE, NV, OH, OK, OR, TN, TX, VA, WI, WV, WY

Quantum PPO STM plans are available in the following states: 

AL, AR, AZ, DE, FL, IL, IN, KY, LA, MS, NE, NV, OH, OK, TN, WV, WY

Epic STM plans are available in the following states: 

AL, AR, AZ, FL, GA, IA, IL, IN, KS, KY, LA, MI, MO, MS, NC, ND, NE, NV, OH, OK, SC, TN, TX, VA, WI, WV

Plan duration’s for all Pivot plans by state are as follows: 

States with 364-day plans:

AL, AR, AZ, FL, GA, IA, IN, KS, KY, LA, MO, MS, NC, NE, OH, OK, TN, TX, WI, WV, WY

States with 364 days X 2 plans:

FL, TX
States with 330 days X 3 plans:
KY, SC
States with 364 days X 3 plans:
AL, AR, AZ, DE, FL, GA, IA, IL, IN, KY, LA, MI, MO, MS, NC, ND, NE, NV, OH, OK, OR, TN, TX, WI, WV, WY

States with 90 to 180-day plans (and limitations):

All states above plus the following –

IL – (Limited to 180 days of coverage with one carrier, then individual must wait 60 days from the termination of the last short term policy issued by the same company before enrolling again)

MI – (Limited to 180 days of coverage with one carrier, then individual must wait 60 days from the termination of the last short term policy issued by the same company before enrolling again)
NV – (Limited to 185 days of coverage out of any 365-day period, then individual must wait 180 days from the termination of the last short term policy issued by any company before enrolling again).
VA – (Limited to 6 months or less of coverage in a 12 month period.)
OR– (Limited to 90 days of coverage with one carrier, then individual must wait 60 days from the termination of the last short term policy issued by the same company before enrolling again)

NOTE: For plans allowing more than one 180-day policy per year, pre-existing conditions will be credited back to the initial application.

Pivot Health Supplemental Benefits

Pivot Health offers a variety of different supplemental plan options that you can include with your STM plan. Plan availability varies by state. For all supplemental plans you can view plan details, see availability for your state, run quotes and apply for these plans at the “Quote and Apply” link below.

Latitude Accident and Critical Illness Plans:

There are two available plans. Latitude Select and Latitude Preferred. You can view plan details, run quotes and apply for these plans at the link below.

Latitude Select: 

Benefits on this plan are as follows: 

• Accident Medical Expense – Up to $2,500 Per Person/Per Accident
• Critical Illness – $2,500 lifetime benefit
• Hospital Stay – $250 per day (up to 10 days per year)

Monthly Costs:

Individual – $29.95, Family – $59.95

Latitude Preferred: 

Benefits on this plan are as follows: 

• Accident Medical Expense – Up to $5,000 Per Person/Per Accident
• Critical Illness – $5,000 lifetime benefit
• Hospital Stay – $500 per day (up to 10 days per year)

Monthly Costs:

Individual – $49.95, Family – $99.95

Brilliant Dental (with optional Vision):

There are two available dental plans (Low and High) and one vision plan. These dental plans include:

• Eligibility for ages 18 -100+ (child dependents accepted)
• No waiting periods for benefits
• Option to start coverage the next day after enrollment
• Some benefits and annual maximums increase at the beginning of the second and third coverage periods
• Routine cleanings paid at 100%
• X-rays covered
• Basic services, like fillings, sealants and extractions
• Major services, like crowns, oral surgery and implants
• Orthodontia option available for children under age 19

Vision Plans:
Individuals can also enroll in vision insurance at the time of application and save on costly but necessary vision expenses like exams, prescription lenses, frames and more. Coverage includes:

• One exam every benefit period
• Exams, contacts, frames covered in full if in network (subject to co-pays and maximums)
• Low vision benefits – professional services for severe visual problems

You can view plan details, run quotes and apply for these plans at the link below. For more details see the: Brilliant Dental Brochure

Note:At this time Brilliant Dental/Vision plans are only available with the purchase of a Pivot STM plan.  

Pivot Health Short Term Medical Quote and Apply Online

The easiest way to quote and apply is through Pivot Health’s secure online application link as follows:

Click Here to Quote and Apply

See if one of our alternative health plan solutions is right for you

 If you would like to discuss your health insurance options to see if one of these Pivot Health STM plans (combined with a Fixed Benefit plan and/or our other US Supplemental Plans) are right for you, please go to the link above with the image that says CALL ME and schedule a call with me on a day and time that works for you, and I will call you to review your options.