information is power and having it at the right time can ... network inc. through knowledge comes...
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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 NETWORK INC.W67 N222 Evergreen Blvd. #202
Cedarburg, WI 53012-2645Phone: (262) 375-4190
Fax: (262) 375-3732www.TaxpayersNetwork.org TNI 2/04 GN1659
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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.
GET 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 (262) 375-4190.
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.
ITC-50 Hotel Program• Receive hotel discounts of up to 50% at more than 5,100 hotels around the world.
Association Travel Club• Save 2% on domestic air travel tickets.• Save 2 to 5% on motor coach tours.• Receive up to a 50% cruise fare discount.• Receive a free $100,000 travel accident insurance policy.• Save on car rental with discounts at Avis, Hertz, Alamo, and National.
PowerNet Global Communications• 5.4¢ 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 $15.95 a month. Includes
unlimited e-mail, nationwide access, and more than 36,000 news groups.
Page 3 of 4Page 2 of 4
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.
GET 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 (262) 375-4190.
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.
ITC-50 Hotel Program• Receive hotel discounts of up to 50% at more than 5,100 hotels around the world.
Association Travel Club• Save 2% on domestic air travel tickets.• Save 2 to 5% on motor coach tours.• Receive up to a 50% cruise fare discount.• Receive a free $100,000 travel accident insurance policy.• Save on car rental with discounts at Avis, Hertz, Alamo, and National.
PowerNet Global Communications• 5.4¢ 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 $15.95 a month. Includes
unlimited e-mail, nationwide access, and more than 36,000 news groups.
Page 3 of 4Page 2 of 4
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 NETWORK INC.W67 N222 Evergreen Blvd. #202
Cedarburg, WI 53012-2645Phone: (262) 375-4190
Fax: (262) 375-3732www.TaxpayersNetwork.org TNI 3/04 GN1659
Page 1 of 4Page 4 of 4
SMSM
M e d O n e P l u s ®
HEALTH INSURANCE FOR INDIVIDUALS AND FAMILIES
TEXAS
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A Company To Rely OnIt 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, Inc. and underwrittenby United Wisconsin Life Insurance Company. Now these two companies havebecome one company known as American Medical Security Life InsuranceCompany (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 and are notadministered or underwritten by us. These services are available to all AMS customers and residents of Texas.
ELIGIBILITYIf you’d like to apply for a MedOne Plus health insurance plan,you must be a member in good standing of the TaxpayersNetwork Inc. (TNI) Association, age 18 or over and under age65. All applicants must meet the insurer’s underwritingrequirements and be U.S. citizens or be in the U.S. by a validpermanent visa or green card. A copy of the visa or green cardis required. Your dependents who wish to have coverage mustbe a lawful spouse and/or unmarried child under age 25 or adependent grandchild of the applicant who is not yet age 25.
EARLYCARE COVERAGEIf you need to purchase coverage for a child only, choose froma MedOne Plus health insurance plan. EarlyCare coverage isalso ideal for providing child protection as an alternative to employer-sponsored coverage, or for grandparents who wantto ensure grandchildren have coverage.
Parents or legal guardians can apply for coverage for eligiblechildren. Eligible applicants include unmarried children andgrandchildren age 14 days and under the age of 25. Parents orlegal guardians must also be members in good standing of theTNI Association.
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Insurance plans provide only limited benefits for services provided by non-network providers. Benefits received from non-network providers are subject to a separatenon-network deductible and coinsurance limit. The Classic Benefit plan (Non-PPO) is available, please see your agent for details.
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 underthe 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.
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
Inpatient and Outpatient Facility Charges
Physician Inpatient Hospital Visit
Emergency Room Charges Copay is waived if immediately confined
AmbulanceAir 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 prescriptioncosts do not apply toward your individual orfamily out-of-pocket maximum.
Network Office Visit: Copay then 100%Non-network: Deductible then 70% coinsurance
Network Office Visit: Copay then 100%Non-network: Covered maximum $50 per calendar yearNetwork X-ray/lab: Deductible then coinsurance (PSA, pap smear, and mammogram)Non-network: Covered maximum $50 per calendar year
Deductible then coinsuranceSee page 5 for XL buy-up option
Deductible then coinsurance
Vision Network Provider: $10 copay, then 100%Vision Non-network Provider: Payable to a maximum of $38 after $10 copay
Deductible then coinsurance
Deductible then coinsurance
$100 copay then deductible and coinsurance
Deductible then coinsurance
Drug discount program
Choose from the following deductibles; $0, $500 or $1,000, then the following benefits apply:
Retail: Generic drug: $15 copay; 34-day supply,Brand name: 50% coinsurance; 34-day supply
Mail Order: Generic drug: $30 copay; 60-day supplyBrand name: $60 copay; 60-day supply
$5 Million
$30 $40
None
Network Non-network
$11,000 $12,000$11,500 $13,000$12,500 $15,000$15,000 $10,000$17,500* $15,000$10,000* $20,000*Not available with $30 copay
100% 70%
$0 $13,333
$0 $4,000
$5 Million
$30 $40
None
Network Non-network
$1,500 $,,1,000$1,750 $,,1,500$1,000 $,,2,000$1,500 $,,3,000$2,500 $,,5,000$5,000 $10,000
80% 50%
$10,000 $8,000
$2,000 $4,000
$5 Million
$30 $40
None
Network Non-network
$1,500 $,,1,000$1,750 $,,1,500$1,000 $,,2,000$1,500 $,,3,000$2,500 $,,5,000$5,000 $10,000
50% 50%
$8,000 $16,000
$4,000 $8,000
MEDONE PLUS FEATURESPPO BENEFIT PLAN
100% OPTIONPPO BENEFIT PLAN
80% OPTIONPPO BENEFIT PLAN
50% OPTIONNot available with all networks
THE FOLLOWING APPLIES TO 100%, 80%, AND 50% OPTIONS
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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 isseen. A maximum of $300 per occurrence of covered expensesis payable at 100%, with remaining charges subject tocopayments, deductibles, and coinsurance. The initial treatmentmust be received within 72 hours of the accident or injury,and the claim for expenses must be received within 90 days ofthe 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 additional security in case of the death of a family member(spouse, child age 14 days to age 25). Dependent Term Lifecoverages are available only to dependent family memberscovered on the medical insurance 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 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)
60% of eligible expenses(after deductible)
50% 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
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OPTIONAL BENEFITSOptional Benefits are available at an additional cost.
Prescription Drug Coverage OptionsThe 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.)
XL (X-ray and Lab) OptionThe XL Option pays 100% up to $150 per covered person, percalendar year for PPO routine and non-routine x-rays and laboratory tests. Eligible x-ray and lab charges in excess of theXL benefit are subject to normal plan benefits. This benefitdoes not apply to services rendered in a hospital setting.
The XL Option is available with the $30 and $40 copay plan designs.
MedOne Dental Insurance Plan BenefitsCombining MedOne Dental insurance with your MedOne Plushealth insurance plan gives you a more comprehensive coveragepackage. When elected, MedOne Dental replaces the CAREINGTONInternational Discount Dental Program. (See page 6.)
MedOne Dental delivers some of the same coverages as employer-based dental programs.
Product Details
Coverage Information:
• MedOne Dental coverage is available only at the time aMedOne Plus health insurance plan is applied for or upto 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.
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 all AMS customers and residents of Texas.
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.
Nurse Healthline, Inc.*Registered nurses provide free medical and provider informationtoll free 24 hours a day, 365 days a year. Approximately one-thirdof Nurse Healthline, Inc. calls provide information for homeself-care. Consider the savings of time and money.* Services are provided through a contractual agreement with our affiliate,Nurse Healthline, Inc.
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, anurse to e-mail or phone, 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 by selecting a PPO insurance planand visiting network providers when you need treatment.
Prescription DiscountAlthough this is not an insurance benefit, you may realize savingswhen you purchase your prescription drugs at a memberpharmacy. You pay the entire cost of your prescription drugbut at the discounted cost. (See page 4 for buy-up options.)
Dental DiscountsAMS and CAREINGTON International have an agreement toprovide MedOne Plus insureds with a dental discount cardprogram. Thousands of participating dentists nationwide present discounts on a variety of common dental services —from cleanings and exams to crowns and prosthetics. A dentalinsurance plan with broad coverage is available to replace theCAREINGTON discount program. See page 5 for more information.
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.
INSURANCE PLAN FEATURESTravelCare®The TravelCare benefit allows insureds who are traveling outside their networks’ primary service areas to receive care from providers affiliated with Private Healthcare Systems, Inc.(PHCS), a nationwide PPO network. Receive care from a PHCSprovider and get network-level coverage — that may meanless out-of-pocket expense for you. To receive this insurancebenefit, select an insurance plan design using a PPO.
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 management professionals 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 you select 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 Plus health insuranceplans include $10,000 Term Life and AD&D insurance forthe primary 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.
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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 sickness for any insured female. Complications do notinclude expense for 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 for cleft lipand cleft palate. To continue coverage, an application formmust be received by AMS within 31 days from the date of birth.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 60 visitsper calendar year.
Skilled Nursing CareIncludes coverage for room, board, routine services, andskilled nursing 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 $700,000.Transplant 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 travel benefit. This lifetime maximum covers lodgingfor 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 network if aPPO insurance plan is chosen.
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; and physical, respiratory, andoccupational therapy.
Wellness BenefitThe following services are available to each covered person:
• Routine physical exam
• Routine lab tests
• Prostate screening (PSA) — Coverage includes prostatecancer screening, when ordered by a physician, for menage 50 and over who are asymptomatic or men age 40and over with a family history of prostate cancer. Thescreening includes a prostate specific antigen blood test.
• Pap smear
• Mammogram — Benefits are covered annually the sameas any other radiological exam for covered females age35 and over.
Combined non-network benefits are covered to a maximum of$50 per calendar year for routine services. Services are notcovered when using a Classic Benefit Plan or if they are beingdone for employment, school, travel, buying insurance, marriage,or family planning.
Other Covered ExpensesCovered services include radiology and pathology tests and prescription 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 a PPOinsurance plan is chosen.
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Diabetes ManagementMedically necessary diabetes treatment, equipment, suppliesand outpatient self-management training and education servicesare covered subject to applicable copayment, deductibleand coinsurance.
Screening and Hearing ImpairmentCoverage includes a screening test for hearing for childrenfrom birth through 30 days; and necessary diagnostic follow-upcare related to the screening test from birth to 2 years old,subject to applicable copayment and coinsurance.
MammogramsBenefits are covered annually the same as any other radiologicalexam for covered females age 35 and over.
Complications of PregnancyComplications of pregnancy are extended from the normalbenefit to include any insured female.
Special Dietary FormulasDietary formulas for inheritable diseases are covered the sameas prescribed drugs.
Licensed DieticianCovered services are payable the same as any sickness, ifprovided under the recommendation of a M.D. or D.O.
Bone Mass MeasurementCoverage includes medically accepted bone mass measurementsfor the detection of low bone mass and to determine theperson’s risk of osteoporosis and fractures associated withosteoporosis. The following are considered qualified individuals:postmenopausal women who are not receiving estrogenreplacement therapy; individuals with vertebral abnormalities,primary hyperparathyroidism, or a history of bone fractures;and individuals who are receiving long-term glucocorticoidtherapy or being monitored to assess the response to or efficacyof an approved osteoporosis drug therapy.
Prostate Cancer ScreeningCoverage includes prostate cancer screenings, when orderedby a physician, for men age 50 and over who are asymptomaticor men age 40 and over with a family history of prostate cancer.The screening includes a prostate specific antigen blood test.
OTHER COVERED EXPENSESTemporomandibular Joint Dysfunction (TMJ)Coverage is limited to diagnosis, surgery, and is payable on thesame basis as benefits for other medically necessary diagnosticand/or surgical treatment of skeletal joints.
Chemical DependencyTreatment in a licensed facility is covered the same as any sickness. (Includes alcohol and controlled substance addiction.)
Serious Mental Illness BenefitCovered expenses for serious mental illness are limited to 45inpatient days per calendar year and 60 outpatient visits per calendar year, subject to applicable copays, deductible or coinsurance amounts. Serious mental illness includes schizophrenia; paranoid and other psychotic disorders; bipolardisorders (hypomanic, manic, depressive and mixed); majordepressive disorders (bipolar or depressive); pervasive developmental disorders; obsessive-compulsive disorders;and depression in childhood and adolescence.
Manipulative TherapyManipulation and treatment of spine and other body structuresto restore normal function of nerve system. Covered the sameas any other sickness.
Prescription Birth Control Pills & DevicesCovered the same as any prescription drug.
Emergency CareEmergency care services are covered at the network benefitlevel for PPO members if the member cannot reasonablyreach a network provider, and until the member can reasonablybe transported to a network provider.
Hospital Stay for Mastectomy & Related ProceduresCoverage 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.
Reconstructive Surgery after MastectomyCoverage includes reconstructive surgery subject to copayment,deductible, and coinsurance.
Childhood ImmunizationsCovered immunizations are included from birth through 6 yearsof age, not subject to copayment, deductible and coinsurance.
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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 12 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).
BILLING OPTIONSWhen you choose a MedOne Plus insurance plan, you have theoption to have annual, semiannual, or quarterly direct billing.Monthly and other mode of payments can be made by automaticbank draft withdrawals or list billing. Credit Cards (VISA®,Discover®, or MasterCard®) will also be accepted for the firstmonth 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 individualfor the remainder of that calendar year. The family out-of-pocketmaximum is twice the individual amount. To reach a familydeductible maximum, two members of your family must eachmeet an individual deductible. Once the family out-of-pocketmaximum is met, no additional deductible or coinsurancewill be taken for any family member for the remainder ofthat 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.
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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 Texas, the insurer is required to notify you that you may bean eligible person for coverage from the state-sponsored riskpool. If we decline you coverage, you may be eligible for theTexas Health Insurance Risk Pool. Any person who continuesto be a resident of Texas and a citizen of the United Statesshall be eligible for coverage from the Risk Pool if you havedocumentation of at least one of the following:
• A written refusal or rejection based on health reasons,by a health carrier, for substantially similar individualhospital, medical or surgical coverage.
• A certification from an agent or salaried representativeof a health carrier on the Health Pool’s certificationform, stating that the agent or representative is unableto obtain substantially similar individual hospital, medicalor surgical coverage for you from a carrier representedby the agent because, based on the health carrier’sunderwriting guidelines, you will be declined for coverageas a result of a medical condition.
• An offer of substantially similar individual hospital,medical or surgical coverage with riders excluding certainhealth conditions you have (for example, a health carrierwill provide coverage to you with an exclusion of coverageof your diabetes, heart disease, cancer, etc.).
• A rate quote from a health carrier offering to providesubstantially similar individual health coverage at ratesthat are higher than the rates of the Health Pool.
• A diagnosis of one of the medical conditions specified bythe Board of Directors of the Health Pool.
• Proof that health coverage has been maintained forthe previous 18 months with no gap in coveragegreater than 63 days, the most recent coverage withan employer-sponsored plan, government plan orchurch plan.
Each person of a dependent who is eligible for coverage fromthe pool shall also be eligible for coverage from the pool. Inthe instance of a child who is the primary insured, residentfamily members shall also be eligible for coverage.
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. Reinstatementis not guaranteed.
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 guaranteed for the first 12 months of coverage providing youmaintain residence in the same geographic location.Thereafter, we reserve the right to periodically adjust the premium rates charged for your coverage under the Policy. Wewill provide you with advance written notice a minimum of 60days prior to the effective date of a premium change, unlessstate law requires 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, wewill 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 overpaidpremiums; or
• Request payment from you for any amount of underpaidpremiums.
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 misrepresentation underthe 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 given state.
• 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 licensed todo 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.
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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 • Any weight lossmethod • Attempted suicide or intentional self-inflicted injuryor sickness while sane or insane • Blood products replaced bydonation 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 rentdurable medical equipment that exceeds the cost to purchase the item • Custodial care • Dental surgery except asdefined under the Policy • Dental treatment from chewinginjury or dental implants • Drugs obtainable without a writtenprescription • Emergency room treatment if no emergencyexists • Exams, x-rays, and tests for routine physicals whenusing a non-network provider or if exams, x-rays, and tests are being done for employment, school, travel, buying insurance, marriage, or family planning • Expense for whichno benefit is described • Experimental or investigative procedures, devices, or drugs • Eye exams, eyeglasses, contactlenses, or surgery to improve eyesight • Hearing aids or exams • Hospital costs for admission from 8 a.m. Friday tomidnight Sunday except for an emergency or scheduled surgery • Immunizations • Items used only for comfort such asa humidifier • Learning disabilities or developmental disorders, testing or training for education or vocation, visiontherapy, or speech therapy except for injury or functionaldefect • Marriage, family, or sex counseling • Multiple surgeries done at the same time; secondary procedures arecovered up to one-half the cost of each additional procedure • Normal pregnancy • On-the-job injury or sicknessfor you and your spouse unless enrolled and approved by us for the On-the-Job Protection Benefit • Orthognathic reconstructive surgery • Plastic or cosmetic surgery unless forreconstruction caused by a covered injury, sickness, or mastectomy • Pre-admission testing in a hospital not donewithin seven days before scheduled admission • Pre-existingconditions • Prescription drug charges except in hospital orhospice, unless the prescription drug rider is purchased • Private duty nursing • Riot • Routine injection of drugs • Sclerotherapy for varicose veins • Services and supplies furnished by a government plan, hospital, or institution unless by law you must pay • Services and supplies not medically necessary, not recommended/approved by a doctor,or not provided within the scope of a doctor’s license • Services and supplies charged in excess of the maximum allowable charge • Services or supplies provided by your
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, procedureor occurrence.
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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-inflictedinjury while sane or insane • Broken appointments • Changingvertical dimension, restoring occlusion, bite registration, orbite analysis • Charges for dental services that are not documented in the dentist’s records • Correcting congenitalmalformation • Cosmetic procedures • Cost to complete claimforms • Dental implants and related services • Dental treatment,appliance, or device related to periodontal splinting, correctionof abrasion, erosion, attrition, abfraction, bruxism, ordesensitizing of teeth that can be restored by other means • Diagnostic casts • Due to your participation in a riot or committing a felony • Duplicate dentures • Engaging in anillegal occupation • Expenses incurred during a waiting period• For services incurred prior to you and your covereddependent’s effective date under the Policy • Gold foilrestorations • Harmful habit appliances • Hospital and relatedanesthesia charges • Initial placement of full or partialdentures, or bridges, to replace natural teeth lost before theeffective date of insurance • Lab procedures • Local anesthesia• Myofunctional therapy • Occurring during or arising fromyour course of occupation or employment • Occlusal guards • Oral hygiene instruction • Orthodontia • Orthognathic surgery• Participating in a professional or semi-professional contestfor compensation, wage or salary • Photographs • Physicaltherapy • Plaque control • Precision or semi-precisionattachments • Procedures not included in the classes ofeligible dental expenses, not dentally necessary, not renderedor not rendered within the scope of the dentist’s license • Procedures that cost in excess of the maximum allowablecharge • Provided by a government plan or educationalinstitution as allowed by law • Removal of sound functionalrestorations; temporary crowns and temporary prosthetics • Replacement of bridges, crowns, inlays, onlays, or veneerswithin seven years of the last replacement, except for loss ofnatural tooth • Replacement of bridges, crowns, dentures,inlays, onlays, or veneers if they can be repaired or restored • Replacement of full or partial dentures within five yearsof the last replacement, except for loss of natural tooth • Replacement of lost or stolen appliances or retainers •Services not incurred by the insurance termination date • Services payable by workers’ compensation, whether you areeligible or are covered • Services received outside the U.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 • Thermonuclear or atomic explosion orresulting exposure to radiation • Treatment of fractures, cysts,TMJ or related conditions • Treatment of halitosis and anyrelated procedures • War or military service.
employer or provided after insurance terminates • Services orsupplies provided free of charge • Sex change operations and complications; testing and treatment for impotency or infertility; any treatment, procedure, drug, or device to promote conception • Skilled nursing facility confinementbeyond 30 days per calendar year • Sterilization • Strained orflat feet; instability or imbalance of feet or ankles; orthopedicshoes or supplies; cutting or removal of corns, calluses, ortoenails except for diabetes or similar disease • TMJ andrelated disorders (except for diagnosis and surgical treatment) • 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 • War or military service • 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 • On-the-job injury or sickness • Participating in a riot • Sickness unless a direct result of covered injury or fromaccidental ingestion of a contaminated substance • Suicide orintentional self-inflicted injury or sickness • Voluntary takingof sedative, drug, or inhaling gas unless prescribed oradministered by a doctor • War or military service.
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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 AMS5000TX.
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BR-0405-10-1-00 1/05
SM
(800) 232-5432 • www.eAMS.com
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