information is power and having it at the right time can mean … · 2005. 10. 31. · make it...

TA X PA Y E R S N E T W O R K I N C .

THROUGH KNOWLEDGE COMES VALUE

Information is power and having it at the right time can

mean significant savings for you. TNI is an association

devoted to ensuring you have the information you need to

make the best choices for your life and your pocketbook.

TAXPAYERS NETWORKW67 N222 Evergreen Blvd. #202

Cedarburg, WI 53012-2645Phone: (920) 662-1492

Fax: (920) 662-1517www.TaxpayersNetwork.org TNI 8/05 GN1659

TAXPAYERS NETWORK INC.

MEANS VALUE

TNI began in 1992 as Taxpayers Network Inc. Currently an Ohio-based nonprofit association, this company arose from the desire tomake it easier for the American consumer to receive informationabout taxpayer dollars and how to get the best deal for his or herincome.

This association has grown into a network of individuals and small business owners across the nation—a network ofinformed, prepared consumers who are realizing significant value for their money.

MAKES THE MOST FOR YOUR MONEY!

As a dues-paying member, you will receive a TNI quarterlynewsletter that provides tips for small businesses and individualsto manage their money more wisely. Your spouse and minorchildren are also entitled to all the benefits of your membership.

A TNI membership allows you to relax, knowing your association is working hard to maximize your consumer dollars.

Don’t let another minute go by without realizing the savings and information TNI can bring you or your company.Become a TNI member today! For more information about amembership, call us today at (920) 662-1492.

ASSOCIATION BENEFITS

Dental Discounts• Receive discounted fees for preventive services. All other services, save 15%.

Chiropractic Discounts• Free consultation! 30-50% savings on all other services.

Access to Health Insurance• Available in selected states.

Hearing service discounts• Save up to 60% on hearing aids.

Vitamin Discounts Catalog• Save up to 50% on more than 4,500 health products, including Enzymatic

Therapy products.

Home Medical Equipment• Receive access to thousands of products.

MEDICARD Emergency Medical Information Card• Receive a card with microfiche containing your medical and prescription records.

Motorclub Discount Emergency Roadside Assistance• Obtain emergency assistance 24 hours a day, 365 days a year.

Car Rental With Discounts At Avis, Hertz, Alamo, and National.

PowerNet Global Communications• 4.9¢ a minute long distance with no monthly fee.

Pre-employment Background Reports and Investigative Services Discounts• Members use this service for their personnel needs.

Vision Discounts• Save 20 - 60% on eyeglasses and other retail eyewear from 10,000 vision

professionals nationwide and on contact lenses ordered by mail.

Save 10 - 30% on eye exams and surgical procedures from ophthalmologists.

Alternative Medicine Plan• For only $24.95 a year, receive access to deep discounts at more than 9,000

providers of complementary and alternative medicine for you and your household members.

Global Frontiers, Inc.• Receive unlimited dial-up access to the Internet for $14.95 a month. Includes

unlimited e-mail, nationwide access, and more than 36,000 news groups.

TA X PA Y E R S N E T W O R K I N C .

THROUGH KNOWLEDGE COMES VALUE

Information is power and having it at the right time can

mean significant savings for you. TNI is an association

devoted to ensuring you have the information you need to

make the best choices for your life and your pocketbook.

TAXPAYERS NETWORKW67 N222 Evergreen Blvd. #202

Cedarburg, WI 53012-2645Phone: (920) 662-1492

Fax: (920) 662-1517www.TaxpayersNetwork.org TNI 8/05 GN1659

M e d O n e S e c u r i t y SM

PPO Facility Copay Benefit planHealth Insurance for Individuals and Families

Oklahoma

Page 1 of 12

of 12

TRUST, SERVICE, AND ACCESSIBILITY—THAT’S AMERICAN MEDICAL SECURITYIt goes without saying that your health is important, and it’s also important tochoose a health insurance company you can rely on. For many years, individualsand their families have relied on the health insurance products designed,administered, and marketed by American Medical Security (AMS).

We realize that one health insurance plan doesn’t suit everybody’s needs, so wedesigned a portfolio of insurance plans to choose from. We’re confident you’llfind the insurance plan and options that fit your needs and budget.

But that’s not all. We add unparalleled service to our insurance plans. For example,a helpful customer service representative will answer the phone when you callour home office — 24 hours a day, 365 days a year. You won’t find any electronicphone menus to work your way through.

We also provide you with a toll-free number you can call to speak to a registerednurse*. These nurses will give you medical information 24 hours a day, 365days a year.

Customers also have access to the AMS Health Discovery Center*. This interactiveonline resource provides health and pharmaceutical information that may helpyou manage your health care.

When you add our service to the products we market, you have a company youcan rely on for your health insurance needs — a company that incorporatesthe small-town values of its home town of Green Bay, Wis., into its everydaybusiness practices.

As you examine the benefits, features, and services described in this brochurewith your professional agent, we’re confident you’ll be reassured that yourhealth insurance needs will be in competent hands. We invite you to join theAMS family of satisfied customers.

* These noninsurance services are provided through contractual agreements with third parties andare not administered or underwritten by us. These services are available to most AMS customers.

of 12

MEDONE SECURITY — FOR THE PEOPLE, BY THE PEOPLE!MedOne Security is a different kind of health insurance plan created for people who are looking for:

• A premium-saving high deductible plan.

• Protection against potential losses due to major illnesses and injuries.

• AMS’ superior customer service.

If you’ve ever found yourself paying for benefits you don’t use, MedOne Securityis the choice for you. With a high deductible, you receive protection againstfinancial losses due to major illnesses or injuries while assuming responsibilityfor many of your routine health-care costs. As a result, you pay lower monthlypremiums. In addition, you receive the same discounts and value-added servicesthat are included with all our health insurance plans.

ELIGIBILITYIf you’d like to apply for a MedOne Security health insurance plan, you must bea member in good standing of the Taxpayers Network Inc. (TNI) Association, age18 or over and under age 65. All applicants must meet the insurer’s underwritingrequirements and be U.S. citizens or be in the U.S. by a valid permanent visa orgreen card. A copy of the visa or green card is required. Your dependents whowish to have coverage must be a lawful spouse and/or unmarried child underage 19. If the child is a full-time student at an accredited school, college, oruniversity, coverage is provided to age 25.

EARLYCARE COVERAGEIf you need to purchase coverage for a child only, choose from a MedOneSecurity health insurance plan. EarlyCare coverage is also ideal for providingchild protection as an alternative to employer-sponsored coverage, or forgrandparents who want to ensure grandchildren have coverage.

Parents or legal guardians can apply for coverage for eligible children. Eligibleapplicants include unmarried children age 14 days to 19 years or to age 25 ifthe child is a full-time student at an accredited school, college, or university.Parents or legal guardians must also be members in good standing of theTNI Association.

of 12Insurance plans provide only limited benefits for services provided by non-network providers. Benefits received from non-network providers are subjectto a separate non-network deductible and coinsurance limit.

Lifetime MaximumPer insured

Office Visit Copay OptionsA fixed fee that you pay toward office visitcharges.

Deductible OptionsThe amount of covered expenses you pay eachcalendar year before benefits are paid under the Policy.

Coinsurance OptionsThe level of coverage provided by the insuranceplan after the calendar year deductible is satisfied.

Coinsurance LimitA shared percentage paid by you and the Policy.

Individual Out-of-Pocket Maximum The maximum amount you pay per calendaryear for covered expenses, plus deductible.

Inpatient and Outpatient Facility ChargesThe facility copays apply to both Network andNon-network facility charges.

Physician Office VisitIf no copay is selected, charges for the office visitare payable after deductible then coinsurance.

Wellness BenefitIf no copay is selected, charges for the office visitare payable after deductible then coinsurance.

Radiology (X-ray) Test/Pathology (lab) Test

Surgery and Anesthesiology Fee

Routine Vision Exam

Physician Inpatient Hospital Visit

Emergency Room Charges Copay is waived if immediately confined.

Ambulance (Air or ground)

Prescription DrugDrug Discount Program is not an insurance benefit.

Prescription Drug Coverage OptionsIf you choose brand when generic is available,you pay the difference between the two.

Separate prescription drug deductibles are perperson, per calendar year. Your prescription costsdo not apply toward your individual or family out-of-pocket maximum.

MEDONE SECURITY FEATURES 100% OPTION 80% OPTION 50% OPTIONNot available with all networks

$500 inpatient copay and $250 outpatient copay, then deductible, then coinsurance when choosingdeductible options from $1,000-$4,000.

-OR-$1,000 inpatient copay and $500 outpatient copay, then deductible, then coinsurance when choosingdeductible options from $5,000-$10,000.

Network Office Visit: Copay then 100%Non-network: Deductible then 70% coinsurance

Network Office Visit: Copay then 100%Non-network: Not CoveredNetwork X-ray/lab: Deductible then coinsurance (PSA, pap smear, and mammogram)

Non-network: Not Covered

Deductible then coinsurance


Vision Network Provider: $10 copay, then 100%Non-network Vision Provider: Payable to a maximum of $38 after $10 copay


$100 copay then deductible and coinsurance


Drug discount program

Choose from the following deductibles; $0, $500 or $1,000, then the following benefits apply:

Retail: Generic drug: $15 copay; 30-day supply,Brand name: 50% coinsurance; 30-day supply

Mail Order: Generic drug: $30 copay; 90-day supplyBrand name: $60 copay; 90-day supply

$5 Million

$40 None

Network Non-network

$15,000 $10,000$17,500 $15,000$10,000 $20,000

100% 70%

$0 $13,333

$0 $4,000

$5 Million

$30 $40

None

Network Non-network

$11,000* $12,000$11,500* $13,000$12,000* $14,000$14,000* $18,000$15,000* $10,000$17,500* $15,000$10,000* $20,000*Not available with $30 copay

80% 50%

$10,000 $8,000

$2,000 $4,000

$5 Million

$30 $40

None

Network Non-network

$11,000* $12,000$11,500* $13,000$12,000* $14,000$14,000* $18,000$15,000* $10,000$17,500* $15,000$10,000* $20,000*Not available with $30 copay

50% 50%

$8,000 $16,000

$4,000 $8,000

THE FOLLOWING APPLIES TO 100%, 80%, AND 50% OPTIONS

of 12

OPTIONAL BENEFITSOptional Benefits are available at an additional cost.

Prescription Drug Coverage Options

The prescription drug coverage options provide benefits for covered expenses including the generic version of a prescriptiondrug or the brand-name drug if no generic exists.

Coverage options include $0, $500 and $1,000 deductiblesthen applicable copayment or coinsurance for covered genericand brand-name drugs. (For description of benefits, see page 4.)

MedOne Dental Insurance Plan BenefitsCombining MedOne Dental insurance with your MedOneSecurity health insurance plan gives you a more comprehensivecoverage package. When elected, MedOne Dental replaces the CAREINGTON International Discount Dental Program. (See page 6.)

MedOne Dental delivers some of the same coverages asemployer-based dental programs.

Product Details

Coverage Information:

• MedOne Dental coverage is available only at the time aMedOne Security health insurance plan is applied for orup to 45 days after the application is signed.

Waiting Period Information:

• Waiting periods apply from the original effective date ofMedOne Dental coverage. (See chart.) Credit for coveragewith a prior carrier is not applicable to the waiting periods.A waiting period is the period of time before the insuredis eligible for benefits under the Policy.

Supplemental Accident BenefitThe Supplemental Accident Benefit (SAB) provides first-dollarcoverage for each accidental injury. SAB benefits are payablethe same whether a network or a non-network provider is seen. A maximum of $300 per occurrence of coveredexpenses is payable at 100%, with remaining charges subjectto copayments, deductibles, and coinsurance. The initial treatment must be received within 72 hours of the accident orinjury, and the claim for expenses must be received within 90 days of the accident or injury.

Voluntary Term Life and AD&D InsuranceProtect your family against financial misfortune caused by deathor accidental dismemberment by purchasing one of our optionalTerm Life and AD&D Insurance benefit levels — up to $300,000of coverage is available (subject to underwriting approval.)

Voluntary Dependent Term Life InsuranceThis Dependent Term Life Insurance option provides additionalsecurity in case of the death of a family member (spouse, childage 14 days to 21 years, or a child who’s a full-time studentuntil age 25). Dependent Term Life coverages are availableonly to dependent family members covered on the medicalinsurance plan. (See chart.)

Voluntary Dependent Term Life Amounts

Spouse Age/Amount Chart:

Age Amount0-40 $7,500

41-50 $6,00051-55 $4,50056-60 $3,00061-64 $1,50065+ None

Dependent Child:$5,000 for each covered dependent childage 14 days to 19 years, or if a full-time student, until age 25.

Calendar-Year Deductible

Calendar-Year Maximum

PreventiveOral evaluations and cleanings (twice per calendar year)Topical fluoride treatments (for dependent children up to age 16)

Basic ServicesX-rays; sealants for dependent children (up to age 16); nonsurgical extractions; simple restorative services; stainless steelcrowns on primary teeth; repair of crowns, inlays, bridgework, or dentures

Major ServicesEndodontics; periodontics; crowns, inlays, onlays, and veneers;oral surgery; dentures, bridges, and partials

$50 per person(3 per family maximum)

$750 per person

80% of eligible expenses(after deductible)



N/A

N/A

No waiting period

6-month waiting period

18-month waiting period

MedOne DENTAL SERVICES BENEFITS WAITING PERIOD

of 12

VALUE-ADDED SERVICES AND DISCOUNTSThese noninsurance services are provided through acontractual agreement with third parties, and are notadministered or underwritten by us. These services areavailable to most AMS customers.

Customer ServiceWe never sleep. Whenever you call our home office, a customer service representative will answer the phone —24 hours a day, 365 days a year. You can expect prompt,friendly service and accurate information about claims, benefits, and general coverage around the clock.

24-hour Nurse Line and Audio LibraryFrom rashes to headaches, allergies to stomach pain, the 24-hourinformation program is a great source of general healthinformation to supplement your physician’s care. Simply call the24-hour Nurse Line toll-free at any time on any day of the weekto speak with an experienced registered nurse about your healthconcerns. You also have the option of listening to prerecordedinformation on many health topics in the Audio Library.

The 24-hour Health Information Program's intent is to providegeneral information regarding common health questions orconditions. If you have a specific question relating to a conditionor medical course of treatment for yourself or others, pleaseconsult your physician. If you believe you need emergencyservices, call 911, or its local equivalent, or go to the nearestmedical facility for treatment.

AMS Health Discovery CenterSM (Discovery Center)The Discovery Center may help you control the quality andcosts of your health care. It’s an interactive online resourcethat contains extensive information about medical conditionsand treatments, prescription and over-the-counter drugs andtheir costs, hospital rankings, questions to ask your doctor,and more.

PPO Plan OptionsWith all of our insurance plans, you have the freedom to visitthe doctor you feel most comfortable with — the doctor youtrust. You can save money with MedOne Security a PPO insuranceplan and visiting network providers when you need treatment.

Prescription DiscountAlthough this is not an insurance benefit, you may realize savings when you purchase your prescription drugs at a member pharmacy. You pay the entire cost of your prescriptiondrug but at the discounted cost. (See page 4 for coverage options.)

Dental DiscountsAMS and CAREINGTON International have an agreement toprovide MedOne Security insureds with a dental discount cardprogram. Thousands of participating dentists nationwide present discounts on a variety of common dental services — fromcleanings and exams to crowns and prosthetics. A dental insuranceplan with broad coverage is available to replace the CAREINGTONdiscount program. (See page 5 for more information.)

INSURANCE PLAN FEATURESTravelCare®If covered insureds and dependents need medical care whenoutside their PPO area, they may be able to take advantage ofnetwork-level coverage through TravelCare. When traveling orattending school, they can locate the nearest provider simplyby calling the customer service number listed on the back oftheir ID card.

On-the-Job ProtectionOn-the-Job Protection offers 24-hour coverage for eligible medicalexpenses due to work-related injury or sickness. Some occupationsare ineligible. Ask your agent about On-the-Job Protection.

Non-Tobacco Use DiscountIf you don’t use tobacco, you may receive premium savings!

Get the most from your plan!When you precertify treatment, our health-care managementprofessionals can advise you and your physician of the coverageavailable for your treatment. By offering sensible, cost-effectivesolutions, we encourage you to manage your health care andget the most from your insurance plan.

PPO NetworksA network of credentialed doctors, clinics, hospitals, and otherhealth-care providers are contracted to provide medical servicesat negotiated fees. Your benefits may be greater when youselect a PPO network and use network providers. Networkproviders are compensated for services covered under thePolicy at predetermined rates which are usually less than theprovider’s customary rates. Network provider charges for coveredservices are considered reasonable and customary. AMS mayreplace the network at any time. You’ll receive advance noticeof any change.

Term Life & AD&D InsuranceWhere allowed by state law, MedOne Security health insuranceplans include $10,000 Term Life and AD&D insurance for theprimary insured. An EarlyCare insured automatically receives$5,000 Term Life and AD&D Insurance where allowed by the state.

Receive up to $1,000 CashIf you find an overcharge on a hospital or medical bill, wemay pay you up to 50% of the savings, up to $1,000 cash percalendar year.

of 12

Hospital and Other Facility Charges Covered services include semi-private room and board, intensive care, and other facility charges, such as inpatientand outpatient care and emergency room fees.

Complications of PregnancyComplications of pregnancy are covered the same as any sicknessfor any insured female. Complications do not include expensefor normal pregnancy and childbirth.

NewbornsCoverage is included for a newborn or sick baby for 31 daysfrom birth. It includes surgery and treatment of injury, sickness, birth defects, and medically necessary treatment forcleft lip and cleft palate. To continue coverage, an applicationform must be received by AMS within 31 days from the date ofbirth. An additional premium may be required.

Home Health CareCovered services include part-time physical, respiratory, occupational, and speech therapy and part-time or intermittentskilled home care and health aide services. Covered to 20 visitsper calendar year.

Skilled Nursing CareIncludes coverage for room, board, routine services, and skillednursing care for 30 days per calendar year.

Hospice CarePart-time nursing care and home health aide services areincluded up to eight hours a day. Physical therapy, services,supplies, prescription drugs, and case management arealso included.

TransplantsWhen using the Transplant Provider Network, eligible servicesare covered at 100% after a $5,000 copay per transplant to a$1 million lifetime maximum. Outside the Transplant ProviderNetwork, eligible services are covered at 70% after a $10,000copay per transplant to a lifetime maximum of $1 million. Thetransplant benefits are combined to a total maximum of$1,000,000 per lifetime, per insured. (Copays do not track tothe insurance plan’s total out-of-pocket maximum.)

When the covered transplant patient travels more than 100miles from home to use the Transplant Provider Network, theinsurance plan provides a $5,000 lifetime maximum perinsured lodging benefit. This lifetime maximum covers travel,food, and lodging for the patient and one companion.

Covered services include the transplant of kidney, liver, pancreas,heart, lung, kidney/pancreas, heart/lung, allogenic bone marrow,autologous bone marrow, stem cell, and donor expenses asdefined in the Policy. Subject to prior approval. Artificialorgans are not covered.Note: The transplant provider network is separate from the medical networkif a PPO insurance plan is chosen.

VSP® DiscountsLaser Vision Discounts: VSP has made arrangements with lasersurgery facilities and doctors to offer its members discountsthat average 20% to 25%. Eyewear Discounts: VSP doctors offervaluable savings, including a 20% discount on pairs ofprescription glasses (lenses and frame) not covered by an eyewearbenefit. You can also save 15% on the cost of your contact lensexam when you receive contact lens services from VSP.

COVERED EXPENSESBenefits are subject to applicable copayment, deductible,coinsurance, and maximum allowable charges. All benefits forservices are subject to Policy provisions.

Physician Visit ChargesCovered services include physician office visits.

Other Medical Professional ChargesCovered services include physician hospital visits; non-routineinjections and injectable drugs; physical, respiratory, andoccupational therapy.

Wellness BenefitWhen received from a network provider, the following routineservices are available to each covered person:

• Routine physical exam

• Routine lab

• Prostate screening (PSA)

• Pap smear

• Mammogram

Services are not covered when using a non-network provider,or if services are being done for employment, school, travel,buying insurance, marriage, or family planning.

Other Covered ExpensesCovered services include radiology and pathology tests andprescription drug benefits (if a Prescription Drug Coverageoption is purchased).

Surgery and Anesthesiology ChargesCovered services include surgery, anesthesiology, post-operativecare, and oral surgery performed in a physician’s office or in ahospital as an inpatient or outpatient.

Vision ExamCoverage includes one comprehensive eye exam every 12months including refraction. Benefits are payable at 100%after a $10 copay when services are received from a visionbenefit network provider.

Benefits are payable to a maximum of $38 after a $10 copay whenservices are rendered by a vision benefit non-network provider.Note: The vision benefit network is separate from the medical network if aPPO insurance plan is chosen.

of 12

Dental Coverage for Anesthesia & HospitalizationCoverage for anesthesia, hospital and ambulatory surgicalcenters and physician expenses that are associated with anymedically necessary dental procedure are provided to a coveredperson who is severely disabled or to a minor child who is 8years of age or under and has a medical or emotional conditionwhich requires hospitalization for general anesthesia for dentalcare. Prior authorization may be required for either inpatientor outpatient hospitalization for dental care. Covered same asany sickness.

BILLING OPTIONSWhen you choose a MedOne Security insurance plan, you havethe option to have annual, semiannual, or quarterly directbilling. Monthly and other mode of payments can be made byautomatic bank draft withdrawals or list billing. Credit Cards(VISA®, Discover®, or MasterCard®) will also be accepted for thefirst month premium only.

MAXIMUM ALLOWABLE CHARGEWe use a number of national standards to determine maximum amounts payable for medical services. If chargesfrom a non-network provider are above these maximumamounts, the insured person may be subject to additionalcharges (above copays and coinsurance).

OUT-OF-POCKET MAXIMUMThe out-of-pocket maximum is a specific limit on the amountof covered expenses you pay per calendar year. When anindividual out-of-pocket maximum level has been reached,you no longer pay deductible or coinsurance for that individual for the remainder of that calendar year. The familyout-of-pocket maximum is twice the individual amount. Toreach a family deductible maximum, two members of yourfamily must each meet an individual deductible. Once thefamily out-of-pocket maximum is met, no additionaldeductible or coinsurance will be taken for any family memberfor the remainder of that calendar year.

Non-network deductibles and coinsurance amounts credittoward both the network and non-network out-of-pocketmaximums. The network deductible and coinsurance applyonly to the network out-of-pocket maximum. Copays do notapply toward out-of-pocket maximums and are collectedbefore and after the out-of-pocket maximums have been met.

OTHER COVERED EXPENSESCoverage for Adoptive ChildrenIf the insured has filed a petition to adopt, coverage includescare of any minor under the care of the insured at the samelevel of other family members. Coverage begins at birth if thepetition is filed 31 days from birth; otherwise, coverage beginsat the filing date of the petition. Subject to the terms and conditions of the Policy coverage for actual and documentedmedical costs associated with the birth of an adopted childwho is 18 months of age or younger is provided.

Manipulative TherapyManipulation and treatment of spine and other body structuresto restore normal function of nerve system. Covered the sameas any sickness.

Mandatory Hospital Stay for Mastectomy & RelatedProceduresCoverage includes inpatient care for an insured for a minimumof 48 hours following a mastectomy and 24 hours following alymph node dissection for the treatment of breast cancer.

Child Health Supervision ServicesCovered services for covered dependent children include physicalexams, immunizations, and related services from birth to age18. Limitations apply.

ImmunizationsThe basic immunization series from birth to age 18 is covered; notsubject to applicable deductibles, copayments, and coinsurance.

Diabetic ManagementMedically necessary diabetes treatment, equipment, supplies,outpatient self-management training, and education servicesare covered.

Bone Density Screen Coverage is provided for females 45 years of age or older toinclude coverage for bone density test when the test isrequested by a primary care or referral physician up to$150 per test.

MammogramCovered expenses for physician and facility services arepayable at the same physician office visit benefit level. Theplan allows one exam age 35-39 to a maximum of $115 andone exam yearly age 40 and over at no charge to the patient,not subject to deductible, copayment, or coinsurance.

NewbornTransportation of a covered newborn to the nearest hospitalcapable of providing the medically necessary treatment.

of 12

We reserve the right to adjust administrative and/or servicefees. We will notify you prior to any change.Coverage is guaranteed renewable except when:

• Premium was due and not paid.

• We determine fraud or material misrepresentationunder the terms of the contract.

• We do not renew all insurance plans with the same typeand level of benefits in the state.

• We no longer sell similar health coverage in a givenstate.

• You or your dependents no longer reside in the networkservice area, if covered by a network insurance plan.

• You move to a state where, by law, we are not licensedto do business.

• The group Policy terminates.

You may terminate insurance at any time by providing us writtennotice prior to the requested termination date. The terminationdate will be the first of the month. Insurance will terminate at12:01 a.m. Central Standard Time on the termination date.

Health Insurance Portability and Accountability Act of 1996(HIPAA)The Health Insurance Portability and Accountability Act (HIPAA)requires various changes to individual health insurance plans.In some states, the insurer must guarantee issue such insuranceplans to eligible persons who lose coverage under a priorgroup health plan. Such persons are not required to satisfyanother pre-existing condition limitation. The new insurermay require copies of a Certificate of Creditable Coverage todetermine how to apply the pre-existing condition limitation.Eligible individuals are guarantee issue to a state-sponsored(risk pool) plan.

An eligible person means a person who meets all of the following requirements:

• Has a total of 18 or more months of continuous creditablecoverage.

• Most recent prior creditable coverage was under a grouphealth plan, and the group health plan was not terminatedfor fraud or intentional misrepresentation of material fact.

• Most recent prior creditable coverage was not terminatedfor nonpayment of premium by the individual.

• Is not eligible for coverage under Medicare or Medicaid.• Has elected continuation coverage under COBRA or a

similar state program, and has exhausted or will soonexhaust this coverage.

• Is not covered by another plan.• Has had less than a 63-day break in coverage from the

most recent group plan.

INSURANCE PLAN PROVISIONSPre-existing Condition LimitationAll medical insurance plans include a pre-existing conditionlimitation.

A pre-existing condition means (1) a condition for which a person received medical care, treatment, services, medication,diagnosis, or consultation 6 months before the insured person’s effective date of coverage or (2) a condition that produced symptoms that are distinct and significant enough to establish the onset of a condition or that the condition manifested itself, where a person learned in medicine wouldbe able to diagnose the condition because of those symptoms,or where the symptoms would cause an ordinarily prudentperson to seek diagnosis or treatment. Pre-existing conditionsare covered after a period of 12 months, during which timethe person has been continuously covered under the Policy.

We will waive the pre-existing limitation for conditions thatare fully and completely disclosed on the application; however, we may place an exclusion or impairment rider on a certain condition(s).

Rating and RenewabilityPremium rates are calculated based on a variety of factors. Asallowed by state law, these factors may include geographiclocation, provider network, distribution channels, selectedbenefits, age, gender, tobacco use, classes, health status of youand your insured dependents, the length of time you areinsured under the insurance plan, health status of the entirepool of insureds in which you are included, administrativecosts, and other factors. Your initial premium rates are guaranteedfor the first 12 months of coverage providing you maintainresidence in the same geographic location. Thereafter, wereserve the right to periodically adjust the premium ratescharged for your coverage under the Policy. We will provideyou with advance written notice a minimum of 30 days priorto the effective date of a premium change, unless state lawrequires additional notice.

Premiums may also change on the next premium due after thedate when:

• You or your insured dependent attain a higher age;

• A dependent is added to or terminated from the insuranceplan; or

• Any benefit is changed, including but not limited to,increases or decreases in a benefit, or the addition orremoval of a benefit from the insurance plan.

If a premium change is for one of the reasons stated above, we will notify you as soon as possible about the change.If we find that premiums are incorrect, we will:

• Make a refund to you for any amount of overpaid premiums; or

• Request payment from you for any amount of underpaidpremiums.

of 12

LIMITATIONS AND EXCLUSIONSPlease read carefully.

MedicalNo medical insurance coverage is provided for any of the following unless specified elsewhere as a covered benefit for:

Alcoholism, drug abuse, mental or nervous disorders • Anytreatment or supply for hair loss or growth (except for wigs orother scalp prosthesis for any insured who receivedchemotherapy or radiation treatment for cancer) • Any weightloss method • Attempted suicide or intentional self-inflictedinjury or sickness while sane or insane • Blood products replacedby donation or blood storage except for scheduled surgery • Bonyprotuberances or misalignment of forefoot and toes includingbunions, spurs, and hammertoe • Care provided by a familymember or by a person residing with you • Cesarean-sectiondelivery • Civil or criminal battery or felony • Cost of brand-namedrugs in excess of the cost of generic drugs • Cost to rent durablemedical equipment that exceeds the cost to purchase the item• Custodial care • Dental surgery except as defined under thePolicy • Dental treatment from chewing injury or dental implants• Drugs obtainable without a written prescription • Emergencyroom treatment if no emergency exists • Exams, x-rays, andtests for routine physicals when using a non-network provideror if exams, x-rays, and tests are being done for employment,school, travel, buying insurance, marriage, or family planning• Expense for which no benefit is described • Experimentalor investigative procedures, devices, or drugs • Eye exams,eyeglasses, contact lenses, or surgery to improve eyesight •Hearing aids or exams • Hospital costs for admission from 8 a.m.Friday to midnight Sunday except for an emergency or scheduledsurgery • Immunizations • Items used only for comfort such asa humidifier • Learning disabilities or developmental disorders,testing or training for education or vocation, vision therapy, orspeech therapy except for injury or functional defect • Marriage,family, or sex counseling • Military Services • Multiple surgeriesdone at the same time; secondary procedures are covered upto one-half the cost of each additional procedure • Normalpregnancy • On-the-job injury or sickness for you and yourspouse unless enrolled and approved by us for the On-the-JobProtection Benefit • Orthognathic reconstructive surgery • Plasticor cosmetic surgery unless for reconstruction caused by acovered injury, sickness, or mastectomy • Pre-admission testingin a hospital not done within seven days before scheduledadmission • Pre-existing conditions • Prescription drug chargesexcept in hospital or hospice, unless the prescription drug rideris purchased • Private duty nursing • Riot • Routine injectionof drugs • Sclerotherapy for varicose veins • Services and suppliesfurnished by a government plan, hospital, or institution unlessby law you must pay • Services and supplies not medicallynecessary, not recommended/approved by a doctor, or notprovided within the scope of a doctor’s license • Services andsupplies charged in excess of the maximum allowable charge• Services or supplies provided by your employer or providedafter insurance terminates • Services or supplies provided free

Creditable coverage includes health insurance coverage andother health coverage, such as coverage under other grouphealth plans, short-term medical coverage, Medicaid,Medicare, military-sponsored health care, and similar plans.Creditable coverage does not include accident-only coverage,long-term care coverage, liability or workers’ compensationinsurance, automobile medical payment insurance, or othersimilar insurance.

Reinstatement of CoverageIf your coverage has lapsed for nonpayment of premium, you may be able to apply for reinstatement of coverage (not available in all states). If your coverage lapses and reinstatement is available in your state, you’ll receive information about how the process works. Reinstatement isnot guaranteed.

SUBROGATION/RIGHT OF REIMBURSEMENTWe subrogate to the extent of our payment when a party causesor is liable to pay for our insured party’s injury or sickness.Insureds are required to repay us from any settlement, judgment,or any other payment received from any other source.

PRECERTIFICATION PENALTYCertain procedures that you or your doctor do not precertifywith us are subject to a penalty of 10% of covered eligiblecharges to a maximum of $1,000 per confinement, procedure,or occurrence.

of 12

contest for compensation, wage or salary • Photographs • Physical therapy • Plaque control • Precision or semi-precisionattachments • Procedures not included in the classes of eligibledental expenses, not dentally necessary, not rendered or notrendered within the scope of the dentist’s license • Proceduresthat cost in excess of the maximum allowable charge • Providedby a government plan or educational institution as allowed bylaw • Removal of sound functional restorations; temporarycrowns and temporary prosthetics • Replacement of bridges,crowns, inlays, onlays, or veneers within seven years of the lastreplacement, except for loss of natural tooth • Replacement ofbridges, crowns, dentures, inlays, onlays, or veneers if they canbe repaired or restored • Replacement of full or partial dentureswithin five years of the last replacement, except for loss ofnatural tooth • Replacement of lost or stolen appliances orretainers • Services not incurred by the insurance terminationdate • Services payable by workers’ compensation, whetheryou are eligible or are covered • Services received outside theU.S. except for emergency treatment for pain • Services renderedby a family member or someone who lives with you or providedfree without insurance • Sterilization fees • Teeth that are notperiodontally sound or have a questionable prognosis asdetermined by us • Treatment of fractures, cysts, TMJ or relatedconditions • Treatment of halitosis and any related procedures.

VisionThe following vision expenses are not covered:

Any eye examination, or any corrective eyewear, required byan employer as a condition of employment • Corrective surgicalprocedures such as, but not limited to, Radial Keratotomy,Photo-refractive Keratectomy and corneal modulation • Corrective vision treatment of an experimental or investigativenature • Medical or surgical treatment of the eyes • Orthoptics orvision therapy training and any associated supplemental testing.

This is an outline only and not intended to serve as legal interpretationof benefits. Reasonable effort has been made to have this outline representthe intent of contract language. However, the contract language standsalone and the complete terms of the coverage will be determined by theGroup Master Policy TNI1000.

of charge • Sex change operations and complications; testingand treatment for impotency or infertility; any treatment,procedure, drug, or device to prevent or promote conception• Skilled nursing facility confinement beyond 30 days percalendar year • Sterilization • Strained or flat feet; instabilityor imbalance of feet or ankles; orthopedic shoes or supplies;cutting or removal of corns, calluses, or toenails except fordiabetes or similar disease • TMJ and related disorders •Treatment of the following conditions during the first sixmonths you are insured by the Policy: hemorrhoids, hernia,tonsillectomy or adenoidectomy (except covered for anemergency), and varicose veins • Treatment outside of the U.S.except for an emergency • Well baby care.

Accidental Death & DismembermentNo accidental death and dismemberment benefit is payablefor loss resulting from:

Air travel or flight except as fare-paying passenger • Committingor attempting to commit civil or criminal battery or felony •Driving while legally intoxicated or while using non-prescribeddrugs • Military service • On-the-job injury or sickness •Participating in a riot • Sickness unless a direct result of coveredinjury or from accidental ingestion of a contaminated substance• Suicide or intentional self-inflicted injury or sickness • Voluntarytaking of sedative, drug, or inhaling gas unless prescribed oradministered by a doctor.

DentalThe following dental expenses are not covered:

Any dental supplies including, but not limited to take-homefluoride, prescription drugs and nonprescription drugs • Anydental procedures for which benefits are payable under themedical insurance provision of the certificate • Athletic mouthguards • Attempted suicide or intentionally self-inflicted injurywhile sane or insane • Broken appointments • Changing verticaldimension, restoring occlusion, bite registration, or bite analysis• Charges for dental services that are not documented in thedentist’s records • Correcting congenital malformation • Cosmeticprocedures • Cost to complete claim forms • Dental implantsand related services • Dental treatment, appliance, or devicerelated to periodontal splinting, correction of abrasion, erosion,attrition, abfraction, bruxism, or desensitizing or teeth thatcan be restored by other means • Diagnostic casts • Due to yourparticipation in a riot or committing a felony • Duplicatedentures • Engaging in an illegal occupation • Expenses incurredduring a waiting period • For services incurred prior to youand your covered dependent’s effective date under the Policy• Gold foil restorations • Harmful habit appliances • Hospital andrelated anesthesia charges • Initial placement of full or partialdentures, or bridges, to replace natural teeth lost before theeffective date of insurance • Lab procedures • Local anesthesia• Military service • Myofunctional therapy • Occurring during orarising from your course of occupation or employment • Occlusalguards • Oral hygiene instruction • Orthodontia• Orthognathicsurgery • Participating in a professional or semi-professional

(800) 232-5432 • www.eAMS.com

BR-0426-20-1-00 9/05 Page 12 of 12

Insurance products are underwritten by American Medical Security Life Insurance Company, a wholly owned subsidiary of PacifiCare Health Systems, Inc.

information is power and having it at the right time can mean … · 2005. 10. 31. · make it...

Documents