• Value Plan

• Enhanced Plan

• Dental/Vision Plan

• Plan Administration & Eligibility

• Plan Limitations & Exclusions

• No Medical Questions or Physical Examinations - Guaranteed Issue for Eligible Members

• Freedom to Choose any Health Service Provider

• No Deductibles - First Dollar Coverage

• Fixed Benefit Amounts - Pays Benefits Directly to the Insured

• Pays in Addition to Other Private Insurance

• 100% Voluntary Plan - No Minimum Participation Requirements

Doctor’s Office Visits: $30 (Value)/ $65 (Enhanced) per visit to a doctor’s office for treatment of injury or sickness. 5 visits allowed per covered person per calendar year; 1 of which may be used for wellness care.

Diagnostic Testing: $30 (Value)/ $65 (Enhanced) per visit to a doctor’s office or outpatient facility for medically necessary diagnostic testing and x-rays of an injury or sickness. 3 visits allowed per covered person per calendar year; 1 of which may be used for wellness care.

Child Wellness Visits: $30 (Value)/ $65 (Enhanced) per visit to a doctor’s office for well child care at 11 specified age intervals from birth through age 5. Well child care includes physical exam, laboratory tests, immunizations, and vision and hearing screening.

Hospitalization: $100 per day (Value)/ $300 per day (Enhanced) for overnight stays in hospital for up to 100 days per confinement for injury or sickness. The benefit amount for hospitalization for confinement in an Intensive Care Unit/Coronary Care Unit is doubled for a maximum of 30 days per confinement. Benefits for Mental Illness / Alcohol or Drug Abuse confinements are payable at 50% for a maximum of 30 days per confinement. Benefits for Convalescent Facility confinements are payable at 50% for a maximum of 60 days per confinement; confinement must begin within 3 days of an inpatient hospitalization of at least 3 consecutive days.

Surgery:  $500 (Value)/ $2,000 (Enhanced) for 1 inpatient surgery and $200 (Value)/ $800 (Enhanced) for 1 outpatient surgery (performed in a hospital or outpatient surgery center) per covered person per calendar year.

Emergency Room: $100 (Value)/ $300 (Enhanced) for 2 visits each to the emergency room for injury and for sickness per covered person per calendar year.

Survivor Benefit: Dependent coverage will continue—premium free—for up to 18 months after the end of the
month in which the insured member’s death occurs.

Vision Benefits: $45 per eye exam per covered person per calendar year and $100 toward a set of frames and
lenses or contact lenses per covered person once every two calendar years.

Dental Benefits: Scheduled amounts are payable up to $2,000 per covered person per calendar year for preventative and diagnostic care, restorative treatment, root canals, periodontics ($500 lifetime maximum), oral surgery and orthodontia ($1,000 maximum per course of treatment). Some benefits require a 12 month waiting period before benefits are available. (See Schedule of Benefits below)
 

• Administrator

• Eligibility

• Enrollment Process

• Rate Increases / Policy Cancellation

• Effective date of Coverage

• Survivor Benefit

• Premium Billings

• Payment of Claims

• Evidence of Coverage

• Pre-Existing Limitation of Coverage

• are under age 65;
• are actively at work, performing all the normal duties of their job or, if not employed, performing the normal activities of a person of like age and gender;
• reside in the United States;
• are not in full-time service of the Armed Forces.  

Members’ dependents are also eligible. Spouses (if not legally separated or divorced) and children, including adopted and stepchildren who are unmarried and dependent on the member for support, up to age 19 (26 if a full-time student), and provided they meet the above requirements as well.  Also dependents must be performing the normal duties of persons who are the same age and gender. Newborns are covered from birth provided we are notified of the birth and the appropriate premium is paid within 31 days of birth. Otherwise, the newborn is considered a late enrollee and may not be enrolled until the next open enrollment period.
 

Enrollment Process. Members are given information about the plan design and rates. During the charter
open enrollment period (or any subsequent annual open enrollment period), eligible members may complete
an enrollment form to participate in the plan. Open enrollment is available for new members for 30 days
following completion of any required waiting period (see Eligibility above).

Rate Increases / Policy Cancellation. No individuals can be singled out for cancellation or rate increase under the policy. The Policyholder (association) has the right to cancel the policy on any premium due date by providing 31 days written notice. The insurance company has the right to cancel the policy by providing at least 31 days notice to the Policyholder.

Termination for Members/Dependents. A covered member automatically ceases to be insured on the occurrence of any of the following events:

• he or she requests cancellation;

• the end of the last period for which all required premium has been paid;

• the date membership ends;

• the date he or she reaches age 70;

• the date the association ceases to offer the plan;

• the date the policy terminates.
  

Exclusions and Limitations Applicable To All Benefits
 

Benefits are not provided for injury or sickness of a covered person which results directly or indirectly, wholly orpartly, from:

• Insurrection, rebellion, participation in a riot, commission of or attempting to commit an assault, battery, felony, or act of aggression;

• War or any act of war, whether declared or undeclared, or sickness contracted or accidental bodily injury occurring while on full-time active duty in the Armed Forces of any country or combination of countries;

• Occupational injury or sickness, or any injury or sickness otherwise covered by any Workers’
  Compensation Act, Occupational Disease Law or similar law;

• Operating a motor vehicle under the influence of alcohol as evidenced by a blood alcohol level in excess of the state legal intoxication limit;

• Care or treatment related to intentionally self-inflicted injury or self-induced sickness;

• Charges for which there is no legal obligation to pay, or no charge is made, or in the absence of coverage no charge would be made;

• Charges incurred after termination of coverage;

• Charges for care or services furnished by any agency or program funded by federal, state or local
  government except Medicaid;

• Charges which are not medically necessary for treatment of sickness or injury;

• Unless specifically provided for in the plan, charges for routine physicals or exams or routine immunizations when no injury or sickness is present;

• Charges for medical care, services, or supplies which are not furnished or prescribed by a doctor;

• Charges for experimental or investigational treatment, procedures for research purposes or practices when not generally recognized as accepted medical practices;

• Charges for care, treatment, services or supplies that are not approved or accepted as essential to the
  treatment of an injury of sickness by any of the following:

  • The American Medical Association,

  • The U.S. Surgeon General,

  • The U.S. Department of Public Health,

  • The National Institute of Health;

• Charges related to cosmetic surgery except:

  • to repair disfigurement because of an accidental bodily injury which occurs while covered under the plan, or

  • for reconstructive surgery because of mastectomy which is performed within 12 months of the mastectomy because of malignancy and while covered under the plan, or

  • for treatment of a congenital anomaly in a child born to the insured while covered under the plan;

• Unless specifically provided for in the plan, dental care or oral surgery except for closed or open reduction of fractures or dislocation of the jaw;

• Unless specifically provided in the Plan, charges for treatment of Mental Illness;

• Unless specifically provided in the Plan, charges for treatment of Alcohol or Drug Abuse;

• Unless specifically provided for in the plan, charges for refractions, eyeglasses or their fitting;

• Hearing aids or their fitting;

• Charges in connection with obesity, weight reduction, or dietetic control, except for morbid obesity or
  disease etiology;

• Charges for treatment or services for Temporomandibular Joint (TMJ) Syndrome, orofacial, or myofascial
  syndrome whether medical or dental in scope;

• Charges for reversal procedures in connection with previous male or female sterilization;

• Charges for services related to educational or vocational testing or training;

• Any charges for abortions which are not medically necessary;

• Any charges for outpatient food, food supplements, or vitamins;

• Any charges for prescription drugs or durable medical equipment;

• Surgery to correct vision problems which are not caused by a sickness or injury;

• Charges for treatment of male or female infertility; in vitro and in vivo fertilization of an ovum, or artificial insemination including but not limited to:

  • Drugs and medicines;

  • Diagnostic and surgical procedures including but not limited to:

    • Aspiration of ovarian cysts;

    • Harvesting or obtaining eggs;

    • Other surgical treatment of infertility;

    • Diagnostic laboratory and pathology procedures; and

    • Diagnostic radiology, nuclear medicine and ultra sound procedures;

• Charges made by a surgeon, nurse, dentist or doctor who:

  • Normally lives with the covered person;

  • Is a member of the covered person's family; or

  • Is the covered person's employer or another employee of the employer; or

  • Is contracted for or by a union, employee benefit association, trustee, or similar organization or the employee of a clinic contracted for or by any such organization;

• Charges for custodial care;

• Charges for care, treatment, services, supplies or confinements primarily for the convenience of the covered person, his doctor, his family or other providers;

• Charges related to smoking cessation;

• Treatment received outside of the United States except for emergency treatment while traveling;

• The processing of nuclear fission or fusion, or the processing, use, handling or transporting of radioactive material, including but not limited to nuclear reactors or any weapon of war or explosive device employing nuclear fission or fusion.

Exclusions Specific to the Vision Care Benefits of the Plan

Limitation/Exclusion Specific to Hospitalization and Surgery Benefits of the Plan

Benefits are not provided for injury or sickness of a covered person which results directly or indirectly, wholly or partly, from pre-existing conditions until covered under the plan for 6 continuous months. Refer to the definition of "pre-existing condition" in the administrative section.

Benefits are not provided for any charges or expenses incurred by a covered person which result directly or
indirectly, wholly or partly from:

• Replacement of a tooth extracted prior to the covered person’s effective date;

• Dentures, crowns, inlays, onlays, bridgework or appliances or services for increasing vertical dimensions;

• Denture or bridgework adjustments;

• Replacement of a lost or stolen prosthesis or for a duplicate prosthesis;

• Oral hygiene, diet or plague control instructions and programs;

• Athletic mouth guards;

• Temporary denture or bridge;

• Failure to appear as scheduled for an appointment;

• Tooth re-implantology not resulting from an accident;

• Drugs except for injectable antibiotics administered by a dentist;

• Procedures, services, or supplies, which do not meet accepted standards of dental practice;

• Treatment initiated prior to coverage under the plan, except for comprehensive orthodontic treatment as defined by the policy; or

• Expenses which are not specifically listed in the Schedule of Benefits.

Copyright 2003-2004, SAS, Inc.