Out-of-Pocket Protection Plan

This is a Hospital Confinement Protection Plan

Monthly Rates

Individual
Issue Age
Additional
18-34 35-44 45-54 55-69
Child Only
Daily Inpatient Hospital Confinement Benefit with Doctor Office Visit
$100 / day $9.25 $9.66 $10.16 $10.41 $1.50
$200 / day $10.16 $11.00 $12.00 $12.50 $2.09

First Hospital Admission Benefit

$2,500 $5.00 $7.08 $9.17 $10.83 $2.92
$5,000 $10.00 $14.17 $18.33 $21.67 $5.83
$6,350 $12.70 $17.99 $23.28 $27.52 $7.41
Optional Benefits
Outpatient Surgery Benefit
$1,000 $7.67 $11.00 $14.33 $16.67 $4.33
$2,000 $15.33 $22.00 $28.67 $33.33 $8.67
$3,000 $23.00 $33.00 $43.00 $50.00 $13.00

Emergency Accident Benefit

$250 up to 4x/year $2.33 $2.33 $2.33 $2.33 $0.92

GAP-Rates 1215
 Individual & Child Individual & Spouse
Issue Age Issue Age
18-34 35-44 45-54 55-69 18-34 35-44 45-54 55-69
Daily Inpatient Hospital Confinement Benefit with Doctor Office Visit Daily Inpatient Hospital Confinement Benefit with Doctor Office Visit
$100 / day $16.50 $16.92 $17.33 $17.67 $100 / day $16.67 $17.50 $18.25 $18.75
$200 / day $18.00 $18.83 $19.67 $20.33 $200 / day $18.33 $20.00 $21.50 $22.50
First Hospital Admission Benefit First Hospital Admission Benefit
$2,500 $7.50 $9.58 $12.08 $13.33 $2,500 $8.75 $12.50 $16.25 $19.17
$5,000 $15.00 $19.17 $24.17 $26.67 $5,000 $17.50 $25.00 $32.50 $38.33
$6,350 $19.05 $24.34 $30.69 $33.87 $6,350 $22.23 $31.75 $41.28 $48.68
Optional Benefits Optional Benefits
Outpatient Surgery Benefit Outpatient Surgery Benefit
$1,000 $12.00 $15.33 $18.67 $21.00 $1,000 $13.33 $19.67 $26.00 $30.00
$2,000 $24.00 $30.67 $37.33 $42.00 $2,000 $26.67 $39.33 $52.00 $60.00
$3,000 $36.00 $46.00 $56.00 $63.00 $3,000 $40.00 $59.00 $78.00 $90.00
Emergency Accident Benefit Emergency Accident Benefit
$250 up to 4x/year $3.25 $3.25 $3.25 $3.25 $250 up to 4x/year $4.17 $4.17 $4.17 $4.17

Individual & Children (up to 3 children) Individual & Family (up to 3 children)
Issue Age Issue Age
18-34 35-44 45-54 55-69 18-34 35-44 45-54 55-69
Daily Inpatient Hospital Confinement Benefit with Doctor Office Visit Daily Inpatient Hospital Confinement Benefit with Doctor Office Visit
$100 / day $29.00 $29.42 $29.84 $30.09 $100 / day $36.33 $37.16 $37.91 $38.50
$200 / day $31.34 $32.17 $33.00 $33.50 $200 / day $39.33 $41.00 $42.50 $43.66
First Hospital Admission Benefit First Hospital Admission Benefit
$2,500 $11.67 $13.75 $16.25 $17.50 $2,500 $15.42 $19.17 $23.33 $25.83
$5,000 $23.33 $27.50 $32.50 $35.00 $5,000 $30.83 $38.33 $46.67 $51.67
$6,350 $29.63 $34.93 $41.28 $44.45 $6,350 $39.16 $48.68 $59.27 $65.62
Optional Benefits Optional Benefits
Outpatient Surgery Benefit Outpatient Surgery Benefit
$1,000 $18.33 $21.67 $25.33 $27.67 $1,000 $24.33 $30.33 $36.67 $40.67
$2,000 $36.67 $43.33 $50.67 $55.33 $2,000 $48.67 $60.67 $73.33 $81.33
$3,000 $55.00 $65.00 $76.00 $83.00 $3,000 $73.00 $91.00 $110.00 $122.00
Emergency Accident Benefit Emergency Accident Benefit
$250 up to 4x/year $4.58 $4.58 $4.58 $4.58 $250 up to 4x/year $6.42 $6.42 $6.42 $6.42

Underwritten by:
ManhattanLife Assurance Company of America
fka Central United Life Insurance Company
10777 Northwest Freeway, Houston, Texas 77092
800-669-9030