HomeMy WebLinkAboutAgreement A-16-711 with Hartford Life Accident Insurance Company.pdfAgreement No. 16-711
H A RTF ORD LI FE AND ACCID ENT I NSU RA NC E C O M P ANY
Ha rtfo rd, Connecti cut
(A stock in surance company)
wi ll pay benefits acco rdi ng to th e condi t ions of thi s Po li cy .
S ig ned for the Company
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lis a l e vin , Secre t ory Mi ch ael Co nca n no n, Presiden t
NOTI C E T O B UY E R : T h is Poli cy may not cove r a ll o f t he cost s a ssocia t e d with m edica l c a r e incurre d b y the
b uyer d urin g the p e ri od of coverage. T h e b u yer is a d vised to review carefull y a ll P o li cy limita tio n s .
This is n o t a s t and a r d ize d M ed ic a r e S u pple m e n t Pla n .
Pol icy h o lde r Na m e : Cou nty of F resno Po lic y N um b e r : AG P-3229
P oli cyh o lde r Addres s : 2200 Tula re Street, Suit e 1400
F res no , CA 9372 1
P o licy Effecti ve Dat e : Jan uary I , 20 I I
P o licy R e n ewa l Da te : J anua ry 1/1 /17 -12 /3 1/17
R ENEW A BILI TY : Except fo r material m isrepresen tation, coverage under the Po licy wi II contin ue by t i mely
paym ent of p remi um u n til th e fir s t to occur of:
a) t he date the Policy is cancell ed; or
b) th e date the In sured Pe rson ceases to qua lify wi thin a class of persons e li gi b le for cover age u nder t he
Po licy.
Accepted b y
Po li cyho lder
F orm S R P-12 7 0 A-B-1 (3229)
Printed in U.S .A.
T ab le o f Co n te nts
(A ll s ection s m a y n o t be r equired)
Schedule
Contract P rovisions
Defini ti o ns
Period o f Coverage
Benefits
Extens ion of Benefits
Limitati o ns
Exclu s ions
C laims
Cou n tersig n ed by
Licensed Res iden t Agent
SCH E D ULE-E LI G IBILITY
THE SC H E D ULE OF BENEF ITS S HOWS THE BE NEFITS FOR WHIC H THE E LIGIBL E PERSON(S)
ARE C OVERE D. THE POLI CY MAY D ESCRIB E BENEFITS NOT IN C L UD E D IN ALL PLANS. PL EASE
CHECK THE SCH E D ULE OF B ENEFITS TO D ETERM I NE S P EC IFIC C OVE RAGE UN DE R THE
POLIC Y.
E li gible Perso n : E li g ible Persons are d escribed below. C lass I is e ligible for In sured P erson and Dependent's
Coverage. C las s 2 persons are not e li gible for In s ured Person Coverage, but may enroll their E li gible Depende nt s for
D e pend e nt 's Cover age.
C lass Description o f E lig ibl e Persons
I All Retired E mplo yees of the Policyholder w ho are e ntitl ed to Medicare.
3 Al l widow/w idowers of a deceased spouse who was an active or retired employee of the Po li cyholder.
E ligibl e De p e nd e nts: E li g ible Pe r sons may a pply for Dependent's Coverage. Eligible Dependents a re described
be low (if a pplicable to thi s Policy).
Des cription of E li g ible S pou se
The E ligible Person's Spouse w ho is e ntitl ed to Med icare, prov ided th e spouse is not legall y separated or divorced
from the Person.
E ligibility Restriction s: T he El ig ib le Person mu st enroll for coverage under ei th er thi s Policy or th e R e lat ed Poli cy in
order to enroll for Dependent's Coverage.
If a husband and wife are both El ig ible P ersons, onl y one may apply for In s ured Person Coverage with the othe r
cover ed as a Depende nt o nl y. A Spouse's Senior Medica l In su ra nce Pl an Be ne fit mu s t be the same as the E lig ibl e
Pe rson's. However, thi s will not apply if the E li g ibl e Person is cover ed by the Re lated Po li cy.
In no event wi ll a person be e li g ible for coverage unde r th is Po li cy if he or s he:
a) is e ngaged in active e mploym en t or is the Spouse of a person e ngaged in active employment, and is
covered by a n e mployer's hea lth plan w hi c h is primary payor to Medicare; o r
b) is covered by Medicaid; o r
c) has a nother Seni or Me d ica l Insura nce po li cy or certi ftcate in fo rce; or
d) is not covered by Medicare.
E nrollme nt Peri o d : Each El ig ible Re tir ed Employee must enroll fo r cove rage un der the Poli cy d u ring a n enrollment
pe r iod.
The initial enrollment period begins on t he Po li cy Effective Date and e nds on th e 60th consecuti ve day following the
Policy Effective D ate.
Persons who become e li gible fo r coverage after the enrollment period mu s t e nroll for coverage during the 60
consecutive days fo ll owing th e date they first become Eli g i b le Persons.
We may establ ish late r periods of open e nrollm ent by mutual agreement w ith the Poli cyho ld e r.
Form S RP-12 70 B (3229)
2
SC H EDULE-BENE F IT S AN D AMO UN T S
T H E SCH E DULE OF BENEF ITS SHOWS THE BENE F ITS FOR WHICH THE E LIGIBLE PERSON(S)
ARE C OVERED. TH E POLICY MAY DESC RIB E BENEFITS NOT I NCLUDE D IN ALL PLANS. PL EASE
C H EC K THE SC HED UL E OF BENEFITS TO DETERM INE S P EC IF IC COVE RA GE UN DE R THE
POLI CY . (*ALWAY S INCLUDED)
Be nefits and Amo un ts : A Covered Person's plan will be the one plan tha t the Eligible Person elected from the
Schedu le as shown below a nd on the following page(s). The election mu st be in accordance with the Eligibili ty
provisions a nd all othe r te rm s of the Poli cy.
BENEF IT
Hospital Confinement Benefit
Day of Confi nem e nt
I st to 60th Day
61 st to 90th Day *
Lifetime Reserve Period
After Lifetim e Reserve Peri od
Skilled Nurs ing Facil ity Benefit
Da y of Confinement
2 1st to I OOt h Day
BEN EF IT
Medicare Part B Deductible
Benefit Eli gible Expenses
Medical Care Benefit *
Medica re Part B Excess
Cha rges Be nefit
BENEF IT
Fore ign Trave l Emergency
Medical Treatment Benefit
Fo rm S RP-1270 C -B ( 3229)
Se ni or Medical In s urance Pl a n Be nefits
AMOUNT PAYABLE
Medicare Part A Deductible
Dai ly Coinsu rance Charge (25% of Part A Deductible pe r day)
Dai ly Coi nsurance Charge (50% of Part A Deductible pe r day)
I 00 % of Hospital Expen ses for each Day of Confi nement fo r an additional
365 da ys of Confi neme nt per lifet ime
Daily Co in s urance Cha rge (12 1/2% of Part A Deduc tibl e per day)
Senio r Medical In s uran ce Pl a n Ben efits
AMO UN T PAYABLE
Medicare Part B Deductible
20% of Medicare Eligib le Expenses after the Medicare Part B Deductible
100% of the difference betwee n the actual Medicare Part B
charge as billed and the Medicare approved Part B c harge.
Additi ona l Se ni or Medica l In s ura nce Pl a n Be n e fit s
AMOUNT PAYABLE
80% of the Foreign Travel Eme rgency Medical Treatment Benefit
Dedu ctible amount: $250
Life time Maximum Ben efi t Amount: $50,000
3
SC H E D ULE -B ENEFITS AN D AMOUNTS (Conti nued)
A dditio n a l Seni o r Medical Ins ura n ce Pla n Be n e fi ts
TH E SCH E D UL E O F B ENEFITS S H O W S T H E BENEFITS F OR WHIC H T H E E LI G IB LE P E RSON(S)
A RE COVERED. TH E PO LIC Y MAY DESC RJB E B ENEFITS NO T INCLUD E D I N AL L P L ANS. P LEASE
C H EC K T H E SCH E DU L E OF BENEFITS TO D ETE RM I NE S P EC I F IC COVERAGE UN D E R T H E
PO LICY. (*ALWAYS I NCL U DE D)
Ho spice Care Benefit *
B lood Deducti b le Benefit *
Medicare coin su rance charges fo r pre sc rip tion d r ugs and
inpatient respite care
Fi rst 3 pints of b lood under Medicare Part A and Medicare Part
B
STATE MAN DATE D B ENEFITS
T h e fo ll ow in g Be n efits a r e a d ded t o the Po li cy a nd Ce r t ifi cat e. W ith respect to res idents o f:
C alifo rni a : Cervical Cancer Screenings Benefit
Mammography Benefit
Colo r ado: Mammography Benefi t
Prost ate Cancer Screening Benefit
Co nnectic ut: Home H ea lth Aide Ser v ices Benefi t
Mammog raphy Screening Be nefi t
De laware: Scal p Hair Prosth es is
Inherited metabolic diseases
Low protein modified formula or food products
Medical formula o r food
Washi n g t o n , D.C.: Can cer Screening Be nefit
Hawa ii : Me ntal Health and Alcohol and Drug Abuse Treatment Benefits
Iowa: Mammography Benefit
Ma in e: Mammography Coverage Benefit
A lcoholis m and Drug De p en d ency Benefit
Mental and Nervous Di sord er Benefit
Form S RP-1270 C-B (Con tinu ed ) (3229)
4
See Benefit
See Benefits
See Benefits
S e e Benefits
See Benefits
See Be nefit
See Benefit s
See Benefit
See Benefits
SCH E D ULE-BENEFITS AND A M OUNTS (Continued)
T H E SC H E D UL E OF B ENEF ITS S HOWS T H E BENEFITS FOR W HI C H T H E E LIG IBLE PER SO N(S)
ARE COVERED. TH E PO LI CY M AY D ESCRIBE BENEFITS NOT I NCL U D E D I N A L L P LANS. PLEASE
C H EC K THE SC H E D U L E OF B ENEF ITS TO D ETERMI NE SPECI F IC C OV E RAGE UN D E R T H E
P OLICY.
STATE MAN DATED BENEF ITS (Co ntinued )
T h e fo ll ow in g Be n e fit s a r e a dd ed t o the Po li cy an d Certi fi ca t e. W ith res p ect t o r es id e nts o f:
Massachu se tts: Confinem ent fo r T reatment of Alcoholi sm Be ne fi t
Confi nemen t for Treatment of Mental and Nervous Di so rders Be nefi t
Outpatie nt T reatment of A lcoho li sm Be nefit
Outpatient T rea tm ent of Me nta l and Nervous D iso rd ers Be nefit
Mammography Screening Bene fit
Cyt o logic Screeni ng Benefit
Enteral Fo rm u las Benefit See Be ne fit s
Mo nta n a: Mammography Screeni ng Benefi t See Be nefit
New J e r sey: Pros ta t e Cancer Screening Benefit
At Home Recovery Benefit
Preventive Medical Care Benefit
Mammography Coverage Benefit
Wilm 's Tumo r Benefit
P e nnsylva ni a : Phenylketonuria Treatment Benefit
Rh od e Is la nd : At Home Recovery Be nefit
So uth Dakota: Mam mogra ph y Benefi t
Phe ny lketonuria Treatment Benefit
Texas: Mammography Screen ing Benefit
V irg inia: Pap Smear Benefi t
Mammography Coverage Benefit
See Bene fit s
See Be ne fit
See Benefit
See Benefits
See Benefit
See Be nefits
5
SCHEDU LE -B ENE FITS A ND AMO UN T S (Con ti nued )
TH E SCH E D UL E O F B ENE FITS S HOWS T H E BENEFITS FOR WHIC H T H E E LI G IBL E P E RSO N(S)
ARE C OVERED. TH E POLI C Y MAY DESC RIB E B ENE FITS NO T I NC L UD E D I N A LL PLANS. PLE A SE
C H EC K THE SCH E D UL E O F BENEFITS TO D ETE RMI NE S P EC I F IC C O VE RAGE UN DE R TH E
POLIC Y.
ST AT E M AN DAT E D BENEF ITS (Co ntinue d )
The fo llowing Be n e fit s are add ed to the P o licy and C ertific ate. With r es p ect to r es id e n ts o f:
Wis cons in: Mental and Nervous Di sord e rs, A lcohol is m a nd Dru g A buse Benefi t
Chiropract ic Services Be nefit
Equipment and S up pl ie s fo r D iabe te s Tre a tm e nt Benefit
Ki d ney Disease T reatm ent Be nefit
No n-M ed icare App rove d Skill ed Nurs ing Facil ity Be ne fit See Be ne fi ts
Form S RP-12 70 C -B (Continu ed ) (3229)
6
SC H EDULE-PREM I UMS
Indivi du a l Premiums: Premiums for each Covered Person are stated below.
The premiums stated in th is sec ti on are for mo nthly per iods of cove rage. Semi-annual pre miums a re 6 times and
annual premium s a re 12 t im es those stated . If a premium becomes due for a different pe ri od of time, it will be
determined pro rata.
Individu al Se ni or Medical In s uran ce Plan Monthly Premiums
$239.95*
*A $13.95 per person per month administrative fee for services which inc lude but are not limited to bill ing ,
enrollment, claims payment and customer service is included in the per person per mo nth premium.
Cove red Perso n Pre mium Due Oates : The first premium for each Covered Per son is due on th e date he or she
becomes cove red under t he Pol icy. Each Premium after the in itial premium is due at the end of the period for whic h
his or her preceding premium was pa id .
Grace Period : After the initia l premium , a gra ce pe ri od of 3 1 day s fro m th e Covered Person Pre mium Due Date is
allowed eac h Insured Person for payment of eac h premium due afte r hi s or he r initia l premium. A Covered Perso n's
cove rage w ill be continued during t he grace period. If he or s he In cu rs a cove red loss d uring the g race perio d, the
Insu red Person wi ll be li ab le to us for payment of any premium acc ruin g dur ing the pe riod we co ntinued coverage in
for ce under th is provision. The grace per iod will not con tinue cove rage beyond a date stated in a Term in at ion
prov ision.
Poli cy Premium : The premium for this Po licy is t he sum of Ind iv idu al Premium s for each Covered Perso n.
Poli cy Premium Due Oates : The Po lic y Premi um is payab le o n :
a) the Policy Effecti ve Date; and
b) the I st day of each month thereafter, wit h respec t to each Cove red Per son whose premium beco me s due on
suc h date, s ubject to th e Individual Grace Period provision.
Each Policy Pr emium is due on o r in advance of the date it becomes payable. The Policy term in ates on the last day of
th e period fo r which premiu m is paid.
Form S RP-12 70 0 -A (3229)
7
SC HED ULE-PREMIUM S (Conti nu ed )
Policy Premium Pa y me nt: The Policy Premiums are to be paid to us by the Po li cyholder. However, the y may be
paid to us by any ot her person according to a mutual agreement among the other person, the Policy holder and us.
C hange of Policy Premium s: We hav e the right on an y Premium Due Date to change the ra te at whic h future
premiums wil l be ca lcul ated. Thi s includes the ri ght to c hange premium rate s fo r a be ne fit that applie s to all
ind ividuals of the same class and geographic location.
Rates may be cha nged based on:
a) c hanges in Medicare ;
b) the claim s experie nce of thi s Po licy;
c) state or fede ra l legi s lati o n affectin g Se nior Medi callnsurance Poli cies; or
d) the exp erience of all group s on which we write Senior Medical In s ur ance Pla n Be nefit s
We will give th e Po licyholder adva nce written not ice of any change in pre mium rates at le ast 30 da ys (in New Jersey
and New Mex ico 60 days) pri o r to the Premium Due Date on wh ic h the change is to become effect ive.
Policy holde r Grace Period Provis ion: A grace period of 3 1 days is all owed for payment of each premium due after
the first un less the Policy is cancell ed on or before the due date. The Polic y will cont inue in force during the grace
period. The Policyholder is li able to us for th e payment of premium accrui ng for the period the Po li cy continues in
force.
Form S RP -12 70 D-C (Rev.) (3229) Rev ised 9/04
8
CONTRACT PROVI S IO NS
E ntire Contract: The entire contract between the Policyho ld er and us consists of this Policy and an y forms made a
part of this Pol ic y at issue.
All statements made by the Policyholder or the Covered Person will be deemed represe nta ti ons and no t war ran tie s .
No statemen t made to e ffe ct this insurance will:
a) void th e insurance; o r
b) reduce benefits unl ess it is in wr itin g and s igned by t he Policyho lder or th e Insured Person.
C han ges: We re serve the right to make cha nge s in the Policy. We will g ive the Policyho lder 30 da ys advance
wri tte n notice of any change.
o agent ha s authority to change or waive an y part of thi s Pol icy . To be valid, any change or waiver mu st be in
writin g, approved by one of our officers and made a part of thi s Policy .
Tim e Period s: All periods begin and end at 12 :0 I A.M., Standard Time at the place where thi s Policy is deli ve red.
Certific ates : We will g ive individual Certificates to:
a) the Polic yholder; or
b) any oth er person according to a mutual agree ment among the other pe rson , the Policyholder and us;
for delivery to Insured Pe rsons.
The Cert ifi cates will state the feature s of thi s Policy whi ch are important to In sured Pe rsons.
30 Day Right to Exam in e Certific ate: The In s ured Person has a 30 day ri ght to examine his or her Certifi cate. If
the In s ured Per son is not sat isfied, he or s he ma y return it to us wi thin 30 days of the date of it s delivery. In that
eve nt , we wi ll cons ider it void from the Certificate effective date and any premium paid wil l be refunded to e ither the
Polic yholder or Ins ured Person. Any claims paid will be ded uct ed from the refund.
Data F urnis h ed by Policy holder : The Policyhold er, or an y other per son designated by the Policyholder, may keep
the important insura nce records on all Covered Persons . Th e Po li cyho lder or its de s ig nee mu s t give us information,
when a nd in the manner we a s k, to admini ster th e in s urance provided by thi s Pol icy .
T he Policyholder or designee will , upon our request, g ive us :
a) the names of all person s initia ll y eli g ible ;
b) the name of all additiona l person s wh o be co me e li g ib le ;
c) the names of all person s who se bene fi t is to be chan ged;
d) th e names of all persons who se in s uran ce is ca ncelled ; and
e) any data necessary to calcu late premium s .
The Policyholder's failure to report a person's te rmination of in s urance does not continue the cove rage be yo nd the date
of termination.
Th e Policyholder's insurance records will be op en for our in s pection at a ny rea sonable tim e.
Form S RP-12 70 G-1 (3229)
9
CONTRACT PROVIS IONS (Continu ed)
Clerica l Err o r : Clerical erro r (wheth er by the Policyholder , the Pl an Administrator, or us) in keeping the records
having to do with th is Poli cy, or dela ys in making ent ri es on the records, will no t void the insurance of any person if
that insurance wou ld otherwise have been in effect. Such clerica l erro r will not extend the insu rance of any perso n if
that insu rance would ot herwise have ended or been reduced as provided by this Po licy.
When a cl e ri cal e rror is found , premiums and benefits wi ll be adjusted based on the true facts and this Poli cy.
Polic y Cancell a tio n : This Pol icy may be cance lled at any time by wr itten notice mailed or delivered by us to the
Po li cyholder o r by the Policyholder to us. If we cancel, we wi ll mail or deliver th e not ice to the Policyholder at its
last address shown in our records.
If we cance l, it becomes effective on the later of:
a) the date stated in the notice; or
b) the 31st day after we mail or del iver the notice.
If th e Poli cy holde r ca nce ls, it becomes effect ive o n the later of:
a) the date we receive the notice;
b) the date stated in the notice ; o r
c) the 31st day after th e notice is delivered or mailed.
In either event:
a) we will prompt ly return any unea rn ed premium paid ; or
b) th e Policyholder will pr ompt ly pay any earned premium wh ich ha s not bee n paid .
Any earned or un earned premium will be determined on a pro rata basis.
Cancellation will be wit hout prejudice to any claim which origi nated prior to the effective date of the cancellation.
No t in Lieu of Worker's Co mpen sation : Thi s Po licy does not sat isfy any requirement for wo rker's compensa tion
insu rance.
C onformity with Law : If any provis ion ofthis Policy is contrary to the law of the juri sdiction in which it is
delivered , s uch provis ion is hereby amended to conform to that law .
Form S RP-12 70 H (3229)
10
GENERAL DEFINITlONS
NOT ALL DEF IN ITI ONS ARE A PPLICA BLE TO A COVERED PERS ON'S C OVERAG E UN D E R THE POLICY.
PLEASE C H ECK THE SC H E D ULE OF B ENEFITS.
Ag e means a Covered Person's attai ned age on any pr emium due date.
Ca le nd ar Year mean s a period of 12 consecut ive month s, starting on Ja nu ary I and e nd in g on December 31 of the
sa me yea r.
Co nfin ed or Confinement mean s bein g an In patient in:
a) a Hosp ital ; o r
b) a Skilled N ur sin g Facility wi th res pect to Sk ill ed N ursing Fac il ity coverage, if any;
due to S ickne ss or Inj ury.
Covered Person means an Eli gible Perso n or Elig ible Depende nt wh il e cove red und e r the Po li cy.
Da y of Co nfin e me nt mean s a day of Inpatient Con finem ent in:
a) a Hospita l; or
b) a Sk il led N ur sin g Facility wit h respect to Sk ill ed Nursing Fac ili ty cove rage , if a ny;
fo r which a daily room and board c harge is made for a fu ll Da y of Confine ment.
Hos pic e Care mean s Med icare approved med ical and s upport se rvices needed to ma nage sym ptom s and relieve the
pain of a termina l illness. The services mu s t be provided throug h a Med icare approved Ho s pice Care Pro gram.
Ho s pice Care include s but is not limit ed to :
a) nurs ing care, the rap ies, medical s upplie s and applianc es;
b) s hort-term Inpat ient resp ite care; and
c) Ph ys ician , home health aide and counse ling se rvi ces.
Hospital mean s an institut io n which:
a) is approved by Med icare;
b) operate s pursuant to law ;
c) prima r ily and continuou sly provides medic al care and treatment on an Inpat ient bas is for sick and
inj ur ed pe rso ns at t he patient's expen se ;
d) operates diagnos ti c a nd major surgica l facili ti es ei th er:
I) on it s premi ses; o r
2) in facilit ies availa bl e to th e Ho sp ital on a prearran ge d bas is;
e) operates und er th e s upervi sio n of a staff of Phy sicians ; a nd
f) provide s 24 hou r nursing se rv ice by or under the super vision of regi stered g raduate nurse s (R.N.).
Ho s pital does no t mean any institution or part the reo f which is used pr imarily a s :
a) a nursing home , convalescent home, or Ski ll ed Nu rsing Facility;
b) a place for re st, cu stodial , ed ucat ion al or rehabilitory ca re;
c) a place for th e aged ; or
d) a place fo r drug addicts or alcoholic s.
Ho s pital Expe n ses mea ns:
a) Medicare Part A Eligib le Expe nses for tr eatment pr ovi ded and bi ll ed by the Hospital;
b) afte r the Li fetime Re serve Period , Ho s pita l Expen ses of the kind that wo ul d have been covered by Med icare
had Medicare Part A Bene fit s not been ex hau sted.
Form SRP-1270 1-1 (3229)
I I
GENE RAL DEFI N ITI ONS (Continued)
N O T A L L DEF INI TIONS A R E APP LI CA B LE TO A COVE R E D P ER SO N'S COVE RA GE UN D E R T H E PO LI C Y.
P LEASE C H ECK T H E SC H E D ULE OF B ENEF ITS .
Inp atient mean s Confinement in:
a) a Hos pital ; or
b) a Sk ill ed Nursing Facility with re s pect to Sk ill ed Nursing Facilit y coverage, if any ;
fo r wh ich a room and board charge is made.
In s ured Pe rson means an Eligib le Perso n whi le he or she is covered by t he Policy.
M e dical Care mea ns any profess iona l or outpatient treatment, se rvice , or suppl y wh ich is covered by Medicare Part
B.
M edicare means Title XV III of th e Socia l Sec urity Act of 1965 , as amended.
Medicare E li gible E xp enses means health care ex pe nses covered by Medicare to the extent recognized as reasonab le
by Medicare.
Me dica re Part A Bene fit P eriod mea n s a per iod of time duri ng whic h a Medicare be nefic iary is Ho s pi tal or Sk ill ed
N ur sing Fac ility Confined. A Medica re Part A Be nefit Pe ri od:
a) beg ins when a Medica re benefic iary is admitted to a Ho s pi tal as an Inpatient; and
b) e nds when he or s he has not been Co nfi ned in a Hospi tal or Ski ll ed Nursing Facility for 60 consecut ive days.
Medica re Part A De ductible mean s the deductible amount wh ich a Covered Perso n is requ ired to pay under
Med icare for t he expenses Incurred at the beg in ning of a Medica re Part A Be nefit Period.
M e dica re P a rt B Deduc tibl e means the deductible amou nt which a Covered Perso n is requi red to pay unde r
Medicare Pa rt Beach Calenda r Yea r for Medica re Eligible Expen se s.
Mental and Nervous Diso rders mea ns any neu rosis, psyc hone uro sis, psy chopathy, psy cho sis, or menta l or
emotional di sease or d iso rder of any ki nd.
Ph ys ici a n mean s any lega ll y qualifi ed Ph ys ician or su rgeon or any medical practition er of the hea lin g arts who is
acting with in th e scope of his o r he r li cense.
Policy Benefit P e ri od fo r Me dicare Part A Elig ible Expe nses mean s a Medicare Part A Be nefit Period as defi ned ,
bu t does not inc lude:
a) a ny Day of Co nfinement before the Covered Person's effective date; or
b) any Day of Confi nement after the Covered Person's term ination date, exce pt as stated in the
Ex tens ion of Be nefits prov ision.
Form S RP-12 70 J-1 (32 29)
12
GENERAL D E FI NITIONS (Co nti nu ed)
NOT ALL D EFI N I T IONS A R E A P PLI CABLE TO A COVER E D PE RSO N 'S C O VE RAGE U DER TH E POLIC Y .
PL EASE C H ECK T H E SC H E D U L E OF BE N EFI TS.
P oli c y Be n efit Pe ri o d fo r M e dica re Pa rt B Eli g ibl e Ex pe n ses means a Cale ndar Yea r qua rter, but doe s no t inc lud e
a ny period of tim e:
a) be fo re the Cove red Perso n's effective date ; or
b) afte r t he Cove red Perso n's te rmi na t ion date, excep t as sta ted in th e Ex te ns io n of Be ne fit s prov ision.
Relat ed P olicy me a ns t he Po licy ho lder's Emp loyee Hea lt h Pla n.
Request mea ns wr itte n requ es t made on t he fo rm s we furni s h for maki ng t he re que st.
S ic kness me ans a perso n's Si c kn ess or disease. Howeve r, Si ckness fir s t man ifes ted before a Co ve red Person's
effec ti ve date will be s ubject to t he Po li cy's Pr e-exist ing Co nd itio n Limit at io n.
S kill ed N urs in g Facili ty me an s an inst itu tio n t ha t :
a) o pe rates purs ua nt to law;
b) in ad di ti o n to roo m a nd boa rd accommodati o ns, is pr imaril y engaged in prov iding s killed nurs ing
care unde r t he s up e rv isio n o f a Ph ysic ia n ;
c) provides co nt in uo us 24 hour a day nursi ng service by or unde r the su pe rvision of a reg istered
g radu ate nur se (R.N.); and
d) mai nta in s a dai ly me dic a l reco rd of eac h pat ie nt.
Sk ill ed N ur s ing Fac ili ty does not mea n any institu ti on o r part th ere of wh ic h is used ma in ly as a ho me or pl ace :
a) fo r the aged, o r for res t, c us tod ia l or ed ucat iona l care;
b) fo r drug add icts o r a lc o ho lic s;
c) fo r th e t reat me nt o f Me nta l a nd Ne rvous Di so rders.
S kill e d N u rs in g Fa cility Ex p e nses mea ns Medicare Pa rt A Eli gibl e Ex pe nses fo r se rv ices prov ided and bill ed by a
Ski ll ed N ur sin g Facili ty.
Tota ll y Di sabled means:
a) d isa bl ed by a n Inj ury or S ic kn ess that co ntin uous ly Co nfin es a Covere d Perso n in a Hos pi tal or Skilled N urs ing
Fac ilit y; or
b) if not Con fin ed, cont in uo usly disab led by an Injury or S ickn ess whic h a Cove red Pe rso n's Ph ysic ia n certifies
prevents h im or he r fr om e ngag ing in t he no rm a l ac tivit ies of a pe rso n of like age a nd sex in go od he a lth .
Us ua l a nd C us t o mary C harge means th e preva ili ng c harge made by most pr ov iders o f a given se rv ice in th e
ge ogra ph ic area whe re the se rv ice is received. In no event wi ll the Usua l and Custo ma ry Charge e xceed th e actua l
amount c ha rged .
W e , u s o r o ur means th e co mpany name d on the face page of th is Po li cy.
Fo rm S RP-1270 K-1 (3229)
13
INSURED PERSON PERIOD OF COVERAGE
In s ured Person Effecti ve Date: An Eli gible Per so n will be co me cove red by th e Po li cy on :
a) th e Poli cy Effe cti ve Dat e ; or
b) The Po li cy Effective Date if we rece ive hi s or her Requ es t fo r coverage prior to th e Po lic y Effe cti ve Date;
or
c) th e fir st day of the month o n o r nex t fo llowi ng th e date he or she beco me s an Eli g ibl e Person; or
d) th e fi rst day of th e month a fte r we receive th e Requ es t, if it is received at any other time ; or
e) with res pect to an El ig ibl e Pe rson w ho att ain ed Age 65 wh ile cove red by th e Rela ted Poli cy , th e date s tated
in th at Policy's "Conve rs ion at Age 65" pr ov ision;
s ubj ect to payment of th e re quired premi um.
Requ est for Cha nge in In s ur ed Person's Coverage (if ava il ab le under this Policy): If the Insured Person Reque sts
to ma ke a change in coverage, th e change w ill beco me effe cti ve on th e fir st day of the mont h afte r we rece ive th e
Reque st pro vid ed :
a) th e In s ured Person is el ig ibl e fo r th e change requ es ted ; and
b) th e required pre mium is pa id .
If th e Requ est in c reases co ver age , th e amount of the in crease will be s ubj ect to th e "Pr e-ex istin g Condition
Limitati o n" provi s ion.
Insured Person Termination : Th e In su red Perso n's coverage und e r th e Po li cy will ce ase on th e fir st to occur of:
a) th e dat e the Policy is ca nce ll ed;
b) th e Pr em ium Du e Date th at th e req uired prem ium for his or her cove rage is not paid , s ubj ect to the G race
Peri od provi s ion ;
c ) th e date we or th e Po lic yho lder cance l cove rage for a Class of Perso n to wh ic h he or s he belongs;
Ho weve r if th e In sur ed Pe rson is e li gibl e for cov er age under the Pol icy beca use he or s he is the wid ow/wi dowe r o f an
acti ve emp loyee of the Po li cy holder the Insured Perso n 's cove rage will cease on the Pr e mium Du e Date on or next
fo ll owing th e date he o r s he remarr ies .
G race Period : A grace pe ri od of 3 I day s is a ll owed for pay ment of eac h pre miu m due afte r th e fi rs t premi um. We
will co ntinu e the ins ura nce d ur ing th e grace peri od. I f an Eligib le Pe rson In cu rs a cove red los s d uri ng th e Grace
Period , the Poli cy ho ld e r wil l be li able to us for payment of any pr emi um accru in g during th e peri od we con tin ue d
co ver age in force under the pr ov ision . The G race Peri od will not con tinu e coverage beyo nd a da te stated in a
Termin ation Pr ovi sio n.
Fo rm S RP -12 7 0 L-A-1 (3229)
14
COVE R ED PO USE P ERIO D OF COVERAGE
PO U E COVE RAG E WILL B E I. DI CATED 0~ T il E C II EDl'LE OF BENEFITS , IF A I'PLICA BL E. I F T il E SCI l ED LE
DO E OT HOW A 'EFFECTI VE DAT E FOil C OVERAGE FOil T il E S POUS E, T il E 'li E Oil li E IS NOT C OVERED
ll DER T ill POLICY.
Covered S p o use E ffective Da te : An Eli gible Pe rson's pouse wi ll become covered by the Po li cy on:
a) th e Po li cy Effecti ve Date if we receive the E li g ibl e Person's Req uest for th e Spouse's coverage p rior to th e
Policy Effective Date;
b) th e fir s t day of the month af ter we rece ive the Eli g ibl e Person's Request fo r the Spouse's coverage if it is
rece ived at any other time; or
c) w ith respect to a Spouse who attain ed Age 65 w hil e covered by the Related Pol icy, t he date s tated in that
Po li cy's "Con version at Age 65" provi sion ;
s ubj ect to payment of the required premium.
However, in n o event will a Spouse become covered under the Po li cy:
a) before the date he or s he qua lifi es as an El igible Spouse; o r
b) before the E li g ible Pe rson's effective date of coverage u nder e ither the Policy or the Related Pol icy.
Requ es t for C han ge in S p o use's Cove rage: If the In sured Pe rson Requests t o m ake a c ha nge i n S pouse's coverage,
the c ha nge will become effecti ve o n the first day of the mon th after we receive the Request provided:
a) the pouse is eligib le for the c hange requested; and
b) th e required premium is paid.
If th e Req uest increases coverage, th e amount of the increase wi ll be su bject to the "Pre -existing Cond iti on
Limi ta ti on" prov ision.
S pouse Termination: Spous e coverage und e r the Po li cy will cease on the firs t to occur of:
a) th e date the Po li cy is cancell ed;
b) the Pre mium Due Da te that the required premium for hi s or her coverage is not paid, s ubject to the G race
Pe riod provision;
c) w ith respect t o a Covered Spouse, the Premium Due Da te on or next fo ll owin g the date he or she is
Di vo rced from the Eligib le Person, unless conti nu ed in accordance with th e Spouse Conti nua t ion
provision;
d) th e date we o r the Pol icyholder cancels coverage for a Class of Persons to which he or she belo ngs.
S pouse Continuati o n : If a Covered Spouse is Divorced while covered unde r the Policy, he o r s he may cont inue hi s
or her coverage under th e Policy. We mu st receive the Requ est and required premium to contin ue coverage und er the
Policy w ithin 3 1 days of the date coverage terminates. Sole ly for t he pu rpose of conti nuing the coverage under the
Policy, th e Spouse will be cons idered the Ins ured Person. However, thi s will not cont in ue the coverage beyond a date
the covera ge would normally cea se under a Spouse Termina ti on provision o f the Policy. A ny coverage conti nued by
th is provis ion will te rm in a te on the Premium Due Date on o r nex t following the date the Spouse re ma rri es.
Divorce/Divorced m ean s a nnulme nt , dissoluti on of m arri age, or le gal separation fr o m th e Insured Pe rson.
Cover e d S p o u se Grace Period : A g race pe riod of3 1 days is a ll owed for paymen t of each premium due after t he
firs t. W e w ill contin ue th e insurance during the g race period. If a Covered Spouse Incurs a Covered loss dur ing the
Grace Period, the Policyho ld e r wi ll be liable to Us for payment of any premium accruing during th e period We
continued coverage in force u nder thi s provis ion . The g race period wi ll not con tinue coverage beyond a date stated in
the Terminat ion Provis io n .
F o rm S RP-12 70 M -A (3229)
15
CONVER S ION PRIVILEGE
APPLIC ABLE TO A L L PLANS
If a Cove re d Person's cove ra ge und e r th e Po licy te rmina tes be cau se th e Po lic y is cancell ed and not repl aced by
a noth e r gro up policy , he or she will have th e ri ght to req ues t co nve rsion wit ho ut g iving med ica l evidence o f
in s ur ability.
The Covered Person mu s t:
a) ma ke writte n application for co nve rsion; a nd
b) pa y th e initial pr emium ;
within 3 1 days aft er he or she ceases to be covered unde r the Poli cy .
The co nve rsion po li cy:
a) will have th e pr ovis ions, limita ti ons and excl usio ns on t he fo rm we are iss uing for t his pu rpo se at the t im e
o f co nve rs ion;
b) w ill base premium s on o ur rates in effec t fo r new appli cants of the Covered Perso n's Age , sex a nd
geogra phi c locati o n at th e tim e of conver sio n.
Th e Cove red Person will be given a c ho ice to e lect co nver sio n co verage wh ic h :
a) pr ovid es simil ar bene fit s to th e Seni or Medi ca l Ins ur ance Plan he o r s he had unde r the Polic y; or
b) pr ovid es th e minimum be nefits req uired by law fo r a Med icare Supp lemen t po li cy .
Co nv ersion cove rage iss ued to th e Covered Pe rson und e r the Co nve rsion Pri vi lege beco mes e ffective o n th e da te of
hi s or her termin ati on and will be in lieu of a ll o th er be ne fit s under th e Pol icy.
Form S RP-12 70 M-B (3229)
16
SEN I OR MEDI CA L I N RAN CE PLA N BEN E FITS
THE SC H E D L E OF B ENEFI TS AND AM O UNT WILL I D I CATE THE BENEFITS APPLICABLE TO EACH
C OVERED PE R SON WHILE COV E R E D U D E R THE POLICY.
HOSPITAL CONF I NEMENT B ENEFIT
When a Cove red Person is Confined in a Hospi ta l, we will pay the benefit stated below. The Co nfi nement must be a
Medicare ap pro ved Confinement. A Covered Per son mu s t Incur expenses for the Confineme nt while he o r s he is
covered by this benefit.
1st t o 60th Da y of Hos pital Co nfin e m e nt : For the fir s t 60 Days of app ro ved Confinement during a Medicare Part A
Benefit Period , Med icare pays a ll Ho s pital Expenses except the Medicare Part A Deduc tible .
We cover the Medicare Part A Dedu ctib le if it is indicated on the Covered Person 's Schedule of Benefits a nd
Amounts.
6 1 s t t o 90t h Day o f Hosp ital Co nfin ement: From the 61 st to 90th Da y of approved Confinement du ring a Medi care
Part A Benefit Period , Medicare pays all Hosp ital Expenses excep t a dai ly Coinsurance C ha rge equa l to 25 % of the
Medicare Part A Deductib le.
If a Covered Perso n 's Schedule of Benefi ts and Amoun ts in d icates coverage for this portion of the Benefit, We pa y
the Medic are Part A Coinsurance Charges the Covered Perso n Incurs from the 61 st to 90t h Day of Co nfinement.
Life tim e Rese r ve Period : Regu lar Medi care Ho spital benefits end on the 90th Da y of Confinemen t du ri ng a
Medicare Part A Benefit Period. After the 90th day , Medicare grant s a 60 day Lifetime Re se rve Pe riod. These 60
addi ti onal days can be used only once in a lifetim e. Medicare a llows a person the choice of us ing the days or sav in g
th em for the future. If he or she uses the days, Medicare pa ys al l Ho s pital Expenses Incurred during the Lifetime
Reserve Period excep t a daily Coinsu rance Charge equal to 50% of the Medicare Part A Deductib le.
We pay the Medicare Part A Coinsurance C harges during the Lifetime Reserve Peri od. If the Covered Person saves
the day s fo r future use, we limit our dail y payment to 50% of the Medicare Part A Deductible.
Afte r th e Lifetime Re serve Period : After the Lifetime Re se rve Per iod ends (or wo uld have ended if used), we will
pay the percentage s hown on Your Schedule of Benefit s and Amou nt s of Hosp ital Expenses In cu rr ed for each Day of
Confinement during a Med icare Part A Benefit Period . Our payme nt period will be limited to an add itional 365 Days
of Confineme nt per pe rson per lifet ime.
Form S RP -127 0 N-B-1 (3229)
17
SENIOR MEDICAL IN SU RAN CE PLAN BE NEF ITS (Co ntinued)
THE SCHED ULE OF BENEFITS AN D AMOUNTS WILL I N DI CATE TH E B ENEFI TS APPLICABLE TO EACH
C OVE R E D PERSON WHILE C OVERED UND ER T H E POLI C Y.
S KILLE D NU RS ING FACILITY BENEF IT
When a Covered Perso n is Confined in a Skilled urs ing Facility, we will pay the benefit stated below. The
Con fi nement must be a Med icare Approved Confinement. A Cove red Person must Incur expenses for the
Confinement while he or s he is cove red by this benefi t.
1s t to 20th Da y of S kill ed N ursin g Facility Confin e me nt: For the first 20 Days of Approved Confinement during a
Med icare Part A Bene fit Peri od, Medicare Part A pa ys a ll Skil led Nursin g Facility Expenses.
We pay nothing from the I st to 20th Day of Confineme nt.
21 st to I OOth Da y of S kill e d Nursing Facility C onfinement : From the 21st to IOOth Day of Approved Confinement
during a Medicare Part A Benefit Period , Med ica re pays a ll Ski ll ed Nu rsing Facility Expenses except a daily
Coi nsu rance Charge eq ual to 12 I /2% of the Medicare Part A Deduct ibl e.
If a Covere d Perso n 's Schedule of Be nefits and Amounts indicates cove ra ge for this portio n of the Benefit, We pay
the Medi care Part A Co insurance C harges the Covered Per son Incurs from the 21st to I OOth Day of Confinement.
EXTEN DED S KILL E D NU RS IN G FACILITY BENEF IT
10 1st to 365th Day of Skille d Nursing Facility Co nfinement: Afte r the I OO th Day of Confinement during a
Medicare Part A Benefit Period , Med icare benefits for Skilled Nu rs in g Facility Confinement s end.
If a Covered Person's Schedule of Benefi ts and Amounts indicates coverage for this portion of the Benefit , We pay
the le sse r of:
a) the dail y amount stated in the Sc hedule; or
b) the room and board expense Incurred ;
from th e I 0 I st to the 365t h Day of Confinement.
Medicare Approved Confineme nt: Med icare only approves Skilled Nurs in g Facility Co nfin ement tha t provides
skill ed, medicall y necessary care:
a) at a level meeting Medicare sta ndard s; and
b) commenci ng withi n 30 days of disc harge from a Hosp ital Confinement of at leas t 3 consecutive days.
Our benefit under this plan is lim ited to th ose Days of Confinement which Med ica re approves, or wo uld have
approved had Med icare be nefits for the Co nfinement not been ex hausted.
Form S RP-12 70 0-B-1 (3229)
18
S EN IOR M E DI C AL I NSU R ANCE PLAN B ENE FITS (Continued)
TH E SC H E D L E OF B E 'EFITS A D AM O TS WIL L I N DI CATE T H E B ENEFI TS A PPLI CA B LE TO EAC H
C OV E R E D PE R SO WH I L E C OV E R E D UND E R TI-l E PO LI C Y .
M E DI C AL C ARE BEN EFIT
After the Medicare Part B Deductible, Medicare pays the pe rce n tage s hown in the Schedule of Benefits and Amounts
of Med icare Part B E li gible Expenses. The portion of an expense which is more tha n Medi care cons iders reasonable:
a) is not a Medicare Part B Eligible Expense;
b) is not covered by Medicare; and
c) is not covered under t h is benefit.
l fa Covered Pers o n 's Schedule of Benefits and Amounts indicates coverage for the portion ofthe Benefit, we will
pay the perce n t age s hown in the Schedule of Benefits and Amounts ofthe Medicare Part B El igible Expenses afte r the
Medicare Part B Deducti ble is met each Calendar Year. The Expenses must be Incurred by a Covered Person while
covered by the benefit.
Ex penses applied toward the Medicare Pa rt B Deductible are not covered under thi s benefit.
MEDIC AR E PART B E XCESS C HARG ES B ENE FIT
!fa Covered Person 's Schedule of Bene fit s a nd Amounts indica te s coverage fo r t h is Benefit, we wi ll pay a percentage
of the difference between:
a) the actual Med icare Part B charge as billed; and
b) the Medicare approved Part B charge;
after the Medicare Part B Deductibl e is met eac h Ca lendar Year. Ho wever, our payment will not exceed any charge
li mit actio n establi s hed by Medicare o r state law. The ex penses mu st be Incurred by a Covered Person while covered
under thi s benefit.
However, we will not pay thi s benefit i f:
a) the p rovid e r of the Medical Care accep ts Medicare assignme nt; or
b) the service or s uppl y is no t covered by Medicare Pa rt B .
The Out-of-Poc ket Expense Amount is:
a) s tated in th e Schedu le of B e nefi ts and Amounts; and
b) applies to each Covered Person each Calendar Year.
Only Out-of-Pocket Expenses can be used to meet the Out-of-Pocket Expe nse Amount.
Out-of-Pocket Expen s es means :
a) the portion of an expense, covered und er Me dicare Part B , w h ich is more than Medicare considers reasonable,
up to th e Us ual and Customary C harge ; plu s
b) expenses used to m eet the Med icare Part B Deductib le to the extent the Medicare Part B Deductible is not
covered unde r the Po licy .
Out-of-Pocket Ex penses d o not include expenses that are excluded o r limited u nder the Policy.
E xpe nses In curred Durin g Las t 3 M o nths o f a Cale nd a r Yea r : If:
a) a Covered Pe rson In c urs Out-of-Pocket Expens es during the last 3 months of a Calendar Yea r; and
b) those expenses are applied to hi s or her Out-of-Pocket Expense Amount during the Calend a r Year;
the n, a Covered Person's Out-of-Pocket Expense Amount for the next Calenda r Y ear will be reduced by the amount o f
those expenses.
Form S RP-12 7 0 P-B-2 (3229)
19
SEN IOR MEDICAL IN SURANCE PLAN BENEFITS (Continued)
THE SCHED ULE OF BENEFITS AND AMOUNTS WILL I NDI CATE THE BENEFITS APPLI CABLE TO EACH
COVER ED PE R SO WHILE COVERED UNDER THE POLICY.
FOREIGN MEDICAL T R EATMENT BENEFIT
Foreign Medical Treatment Benefit: We will pay th e reas o nable expense Inc urred by a Covered Person for Foreign
Medical Treatment provided he or s he receives the first Foreign Medical Treatment:
a) while covered by this benefit; a nd
b) wi thin the first 180 days oftravel Outs ide of the Un it ed States per Cale nd ar Year.
This benefit w ill be limited to treatment recei ved during a Foreign Medical Treatment Benefit period. The Foreig n
Medical Treatment Benefit Pe ri od:
a) begins o n the date of the first Foreign M edical Treatment; and
b) e nd s 90 consecut ive days later.
This benefit will not cover any part of a Confinement th at ex tends beyond that 90 day benefit period or any service or
s u pply received after that 90 day benefit period.
Thi s benefit wi ll not cover Foreign Medical Treatment if a Covered Person:
a) leaves the U nited States primarily to se e k Fore ign Me d ical Treatment for a Sickn ess or Injury ;
b) has no legal obl igation to pay for t he treatment; or
c) receives the treatment during a Calend ar Year in which he or s he travels o r re s id es Outside of the Untied States
for 6 consec uti ve months o r longe r.
In add it ion, this benefit will no t cover Foreign Medical Treatment if Medicare approves the treatment (in whic h event,
the regular benefits of the Senior Medi cal Ins uranc e Plan Benefit s app ly).
Ho weve r, if:
a) a Covered Person must re m a i n Outside of the U nited States more than 6 mo nths because of a n Inju ry or
S icknes s th at p reve n ts return to t he United S tates; and
b) he or s he has es tabli s hed a Foreign Medical Treatment Benefi t Perio d fo r that Sickness or Injury within the first
180 days of trave l, a s s tated above;
then, w e will continu e thi s benefit for that Sickness or l njury unt il the e nd of the Fore ign Medical Treatment Be nefit
Period.
Foreign Medical Treatment means a n y medicall y necessary Confinemen t, service or s upply received Outside of the
Un ited States provided the s ame medical treatment, if rece i ved in the United States :
a) wo uld be cons idered re im bursable treatment under Medicare;
b) wo uld be considered in general use and of demons trated val ue in the diagnos is a nd treatment of Sickness or
Injury by United Stat e s Physic ians ; and
c) would not be considered in a re s earch or experi m ental s tage by United States Ph ysician s .
Outside of the United States mean s outside the territorial limits of:
a) the 50 United States and the D is tric t o f Col umbia; and
b) Puerto Ri co, the Virgin Is lands , Guam and Ameri ca Samoa.
When th is benefit is pay able , no other benefits of the Policy wi ll be provided fo r any ex pe nse w hi ch is covered under
th is Foreign Medical Treatment Benefit.
Fo rm S RP-1270 Q-A (3229)
20
SENIOR M E DICAL I NSU RANCE PLAN BENEFITS (Contin ued)
T H E SC H E D U L E OF B E E F ITS AN D AM O U TS WILL I N DI CAT E T H E BEN E F ITS A PPLICA BLE T O EACH
C O V ERE D P ER SO N WI-IILE COVER E D UND E R TH E POLI C Y.
FOREIG N TRAV E L E M E R GE NC Y M E DI C AL TRE ATM ENT B E N E FIT
Fore ign Tra vel Emergency M edic al Treatm e nt Be nefit: W e wi ll pay t he pe rcentage o f the e x penses Incu rred by a
C overe d Pe rso n for Fore ign Trave l Emergency Med ical T reatme n t if:
a) the Covere d Pe rson has sati s fi e d the Cale nda r Yea r Dedu c tib le; a nd
b) th e fi rst expe n se was Inc ur red w it h in the first 60 days of tra ve l Outs id e of the U ni te d States.
Paym e nt un de r the be ne fi t wil l be limi te d to the Life tim e M ax im u m Be n efi t Amo unt.
T he Pe rcenta ge Pa yabl e, Ded uc t ib le A moun t and L ifet i me Max im um Be ne fi t Amounts are s hown in t he Sc he d ul e of
Be ne fit s a nd A mounts if a Co ve re d Pe rson 's Schedule of Be ne fit s and Amoun ts i nd ic ates cove rages fo r th is B e nefit.
T h is be ne fi t w il l n o t co ve r F o rei g n T ravel Emergency Medi cal T reatm e n t if a Cove red Person:
a ) le ave s the United Sta tes p r im a ril y to seek Fore ig n T ravel Eme rg ency M e dical T re a tment fo r a S ickness o r
Inju ry ;
b) has no lega l obligati o n to pay fo r t he trea tm e nt; o r
c ) rec e ives the treatm e nt during a Calenda r Year i n w hi ch he o r she travel s or res ides Outs id e of t he Uni ted States
f or 6 consec uti ve mon ths o r longer.
In addi t io n, th is be ne fit will no t cover Fo re ig n T ravel Em e rgency M edi cal T re at ment if Me di c are a pproves t he
trea tme n t (in w hi c h event, the other benefits of th e Pl an a ppl y.)
Whe n thi s bene fit is payabl e, no othe r bene fit s of t he Po li cy w ill be pro v id ed for a ny ex pense w h ich is cove red under
t h is Fo re ig n Trave l E m e rgency Me di cal Treatme nt Be ne fi t.
Fo reign Travel Em e r gency M edic al Tre atm e nt m eans an y med icall y ne cess ary Confine m e n t, s ervice , o r s uppl y
needed imme d iate ly due to Injury o r Sickness of s udde n and u nex pected o nset whi le th e C overed Pe rson is Outs ide of
the United Sta tes provided the s a me med ical t reatme nt , if rece ived i n the U ni ted Sta tes:
a) would be co ns ide re d re im bu rsable tre at me nt u nder M ed ic are;
b) would be co ns idere d in gene ra l use and of demo nstrate d value in the di agn os is a nd treatment of S ic kness or
Inju ry b y Unite d States Phys ic ia ns ; a nd
c) wo uld not be cons id e red i n a researc h o r expe ri menta l stage by U nited Sta tes P h ys ic ians.
Outs ide of the United S tates m e a ns out s ide th e te rri to r ia l limits o f :
a) th e 5 0 United St ates a nd the D is tri c t o f Co lumbi a; a nd
b) Pue rto Rico, th e Virg i n Is la nd s, Gua m a nd A me rica n Samoa.
Form S RP-1270 Q-D (3229)
2 1
SENIOR MEDICAL INSURANCE PLAN BENEFITS (Co ntinued )
T HE SCHEDULE OF BENEFITS AND AMOUNTS WILL IN DI CAT E THE B ENEF ITS AP PLI CA BLE TO EAC H
C OVERED PERS O N WHIL E COVERED UNDER THE POLI C Y.
PRIVATE DUTY NUR S I NG BENEFIT
D R1 G HO S PITAL CONFINEMENT
If a Covered Perso n 's Schedu le of Be nefits a nd Amount s indicate s cove ra ge for th is Benefit , We will pay the le ss er
of:
a) the expe nse Incurred ; or
b) th e Pri vate Duty Nursing Maximum Bene fit Amoun t;
fo r each s hift of private duty nursin g se rvice , up to the Maximum N umber of Shifts per Cal endar Ye a r.
The pri vate du ty nur sing se rvic e must be provided to a per so n whil e he o r s he is:
a) cove red und er thi s benefit ; and
b) Confined in a Ho spital.
The private d uty nur sing se rv ices mu st be charged dire ctly to a Covered Person by the Nurse and not c harged by th e
Ho spital.
Nurse means:
a) a Regi stered Gradua te Nu rse (R.N.); or
b) a Li ce nsed Practical N ur se (L.P .N.);
who is not a member of a Covere d Person's Fa mil y.
Famil y means a Covered Person's:
a) c hildren , parent s, s pou se, broth er or sister; or
b) s pouse's chi ldren, pare nts, brother, or sister.
We will not pay for more th an 3 s hi ft s of private du ty nurs ing ser vices per da y. A s hift co ns ists of at least 3
con secut ive hours of nursin g ca re . Shifts of more th a n 3 hours but less than 8 hours will be pa id on a pro-rata basi s.
The Max imum Benefit Amo unt and t he Maximum Number of Shifts are stated in th e Schedul e, if a Cove red Per son 's
Sc hedu le of Benefi ts and Amount s ind icate s coverage for th is Ben efit.
Form S RP-1 270 Q -B (3229)
22
SENIOR MEDI CA L INSURANCE PLAN BENEFITS (Con tinued)
THE SC H E D ULE OF BENEFITS AN D AMOUNTS WILL I N DI CATE THE BENEFITS APPLICABLE TO EACH
COVERE D PE RSON WHILE COVERED UND E R T H E POLICY.
M E DI CARE PART B DE DUCTIBL E BENEFIT
If a Covered P erson 's Schedule of Benefits and Amounts i ndicates coverage for this benefit, We w ill pay the
Medicare Part B Eligi ble Expenses Incurred b y a Covered Person used to satisfy the Medicare Part B De ductible each
Calendar Year.
The Medicare Part B E li g ibl e Ex penses must be Incu r red by a Covered Person wh il e he or s he is covered under this
benefit.
Form S RP-1270 Q-C (3229)
23
SEN IOR MEDICAL INSU RAN CE PLAN BENEFITS (Continued)
THE SC H E D ULE OF BENEFITS AN D AMOU TS W I LL INDICATE THE B ENEFI TS AP PLI CA B LE TO EACH
COVERED PERSO N WHILE C OVERED UN D E R TH E POLI C Y .
OUTPATI ENT PRESC RIPTI ON DR UG BENE FIT
We w ill pay a percentage of the prescr ipti on drug expenses a Cove red Person In curs each Cale ndar Year in excess of
the Prescription Drug Calendar Yea r Deductible . The prescription drug mu s t be:
a) lawfull y obtai nable in the United States only upo n a Ph ys ic ian's written presc ript ion;
b) needed to treat the Covered Pe rson's Injur y o r S ickn ess; and
c) purchased from a lice nsed pharmacy while he or s he is covered by thi s benefit.
We wi ll not pa y more than the Maximum Benefit Amount pe r Ca lendar Year.
Th is ben efit does not cover:
a) the adm ini strat io n of any pre sc ription drug or ot her subs tanc e or the cost of equipment to admin iste r the drug
suc h as a sy rin ge;
b) any prescription or refill which exceed s the greate r of:
I) a 34 day supply; or
2) 90 day s uppl y fo r mail ord er;
c) any experimental drug;
d) any pre scription drug received whi le an inpatient in a Ho s pita l, convalescent home , Skilled Nursing Facility or
similar in stituti o n; or
e) the cost of any pre scription dru g to the extent the Covered Pe rson is no t legall y ob li gated to pay.
The Percentage Pa yab le, Deductible Amount and Ben efit Amount are shown in the Schedule of Be nefits and
Amo unts if the Covered Perso n is covered for this Benefit.
Form SRP-12 70 Q -E (3229)
24
S E NIOR M EDI C AL INSU RA NCE PLAN BENEF ITS (Cont inued)
T H E C H E D L E O F B ENEF IT S A D AMO NT S W I LL I N DI CATE T H E B EN E F ITS A P P LI C ABL E TO EACH
C O VE R E D P E R ON W HI LE C O V E R E D N DE R T il E P O LI C Y .
AT HOME R ECO VE RY BENEF IT
!fa Cove red Pe rson's Ph ys ic ia n ce rt ifies tha t the Covered Pe rson req ui res t he se rvices of a Care Provider for Home
recovery fro m a S ick ness, Injury or surge ry for which a Home Care Pl an of T reatmen t was ap prove d by Medicare,
and if a Co vered Perso n 's Sc hedul e of Bene fi ts and Amou nts indica tes coverage fo r th is Benefi t, then we will pay t he
lesser o f:
a) th e expe nse Incu rre d; or
b) th e At-Home Recove ry Max imum Amou nt pe r vis it ;
fo r sho rt te rm At -H o me Recove ry Visits, up to the Maxi mu m Benefi t Amount per Ca lendar Year.
The At-H ome Recovery Vis its must be:
a) prov id e d to a pe rson whi le he or s he is covered unde r this benefit;
b) pr im aril y to provide se rvices w hich ass ist in Ac tivities of Da il y Living;
c) provided on a vis iting bas is in th e Cove red Pe rson's Home; and
d) provi ded w hi le th e Covered Pe rson is receivi ng Med icare -a pproved ho me care se rvices o r within 8 weeks afte r
the service date o f the last Med icare home health care visit.
The Cove red Pe rson's a tten d in g Ph ysicia n mu st cert ify tha t th e speci fi c type a nd freq ue ncy of At-Home Recovery
se rvices are necessa ry beca use o f a cond it io n for whic h a ho me ca re plan of trea tm e nt was app roved by Med icare.
This be ne fit will not pay for:
a) At-Home Recove ry Vi sits pa id fo r by Med icare or ot her gove rnm e nt progra ms;
b) At-Home Recovery Vi sits prov id ed by fam il y members , unpai d volunteers or prov iders who a re not Care
Provi d ers, as defi ned;
c) mo re t ha n the number of Medicare approved home health care v is its unde r a Med icare app roved home care
p lan of t rea tmen t ; or
d) more than 7 visits in any o ne week.
T he Maxi mum Amoun t per visit, the Maximum visits per week and the Max imum Benefit Amou nt are show n in the
Schedu le of Benefits and Amou nts if the Cove red Perso n is covered for t his Be nefit.
Ac ti v iti es of Dail y Li v in g means those daily act ivities necessa ry for a pe rson to perform in order to functio n
in dependentl y, inc lu ding, bu t not lim ited to , bat hing , dressing, pe rsona l hygiene , tra ns ferring, eat ing , a mbu lating,
ass istance wit h d ru gs t ha t are no rma lly self-administered and chang ing bandages or o th er dressings.
At-Ho me Rec ove r y Vi sit mea ns the pe riod of a visit req uir ed to prov ide at-ho me recovery care, wi th ou t li mit o n the
du rat io n of t he visi t, exce pt eac h consecutive 4 hours in a 24 hour per iod of services pro vided by a care provide r is
co nsi de red one visit.
Ca r e Prov id e r means a du ly qu a lifie d or lice nsed ho me hea lt h a ide or homemaker, personal ca re aide or nur se
prov ided t hro ug h a li censed ho me hea lt h ca re age ncy or refer red by a li ce nsed refe rr a l agency or licensed nur ses
reg istr y.
Home mea ns a place used by the Covered Person as a place of residence. It may be th e Covered Person's ow n
dwelli ng, an apartme nt, a re lative's home , a home for the aged or some other type of ins titut io n, provided that s uch a
place would qualify as a residence fo r Home Healt h Care services covered by Medicare. A Hos pital or Sk illed
Nu rsing Fac il ity is not co nsidere d t he Covered Person 's home.
Fo rm S RP-12 70 Q-F (3229)
25
SEN IO R ME DI CAL I NSU RA NCE P LAN BENEFITS (Contin ued)
T H E SC H EDULE OF B ENEFITS AND AMO U NT S W I LL I N DIC ATE THE BENEF I T S APPLI CABLE TO E AC H
COVE R E D P E R SON W HILE COVER E D UN D E R T H E POLI CY.
P R EVENTIVE ME DI CAL CARE B ENEFIT
If a Covered Person's Schedule of Benefits and Amounts i ndi cates coverage fo r this Benefit, We w ill pay the actual
charges up to the Medicare approved a mo unt fo r expenses In c urred by the Covered Pe rson fo r:
a) an a nnua l c lini cal preventive medical hi story and phy s ical exami natio n (wh ich may include Preventive
Sc reenin g Tests o r Services) a nd patient e ducati o n to add ress preventive health measures; and
b) Preventive Screenin g Tests a nd Services, as defined; and
c) in fluenza vaccine adm in istered at a ny appropriate t im e during the year; and
d) Tetanus and Di phtheria boos ter every I 0 years; and
e) any ot her tests or preventive measures determined to be appropri ate by the attending P hysician.
The expenses mu st be Inc urred by a Covered Perso n whi le covered by this benefit.
Our paym e nt w ill be limited to th e Maxim um Benefit Amount per Calendar Yea r shown in th e Schedule of Benefits
a nd Amounts, if a Covered Pe rso n 's Schedule of Benefits and Amou nts indica tes coverage for th is Benefit.
Preven tive Scr ee nin g Test s a nd Preven t ive Se r v ices means one or more of the fo ll owing, the frequency of w hich is
conside red medicall y ap propriate:
a ) fecal occult bloo d tes t and/or d igital rectal exami natio n;
b) mam mog ram ;
c) dipstick urina lys is for hematuri a, bacteriu ria a nd pro te ina uri a;
d) pure to ne (air on ly) hea rin g screening tes ts, admini s tered o r o rd e red by a physic ia n;
e) serum c holesterol scree ning (every 5 yea rs);
f) thy roid fu nc ti o n test; and
g) di abetes screening.
Form S R P-1270 Q-G (3229)
26
SEN IOR MEDI CA L INSU RANCE PLAN BEN EFITS (Cont in ued)
T H E SC HEDU LE OF BENEFITS AND A MOUNTS WILL I N DI CATE THE BEN EFITS APPLICABLE TO EACH
C OVERE D PERSON WHIL E C OVER E D UN D E R THE POLIC Y .
HO SPICE CA RE BENEFIT
APPLI C ABLE TO ALL PLA S
Unde r Med icare, a te rmina ll y il l pe rson may e le ct to re ceive Ho s pice Care benefi ts in s tead of most regular Medicare
Part A a nd Part 8 benefits. Then, Medicare pay s all approved Hospice Care charges except coins ura nce cha rges fo r
Inpa ti ent re s pite care , drugs and biolog icals.
When a Covered Perso n elects to receive Ho s pi ce Ca re, we wi ll pay the Medicare Coinsurance Charges which he or
she Incurs.
The Hospice Care mu s t:
a) be approved by Medicare; and
b) be rece ived wh il e covered by thi s benefit.
Wh en thi s benefit is payable, no other be nefits of th e Poli cy will be prov id ed for any expense wh ich is cove red under
this Hosp ice Care benefit.
Form S RP -1270 R-A (3229)
27
SEN IOR MEDICA L I NSU RA NCE PLAN ADDITIONAL B ENEFITS (Co ntinued )
THE SC HEDULE O F B ENEFITS AN D AMO NTS W ILL I N DICATE T H E B ENEFI TS APPLICA BL E TO EACH
C OVERE D PERSON WHILE C OVE R E D UN D ER T H E POLICY.
STATE MANDATED BENEFITS
With res pects to res idents of the followin g states, the followin g benefits are added t o the Po lic y and Certificate:
Ca lifornia:
Ca ncer Screenings Ben e fit
We w ill pay the Usual and Customa ry charges not covered by Medicare for mammog raph y and cervical
ca nce r sc reenings Incurred by a Covered Person each Calendar Year.
Co lo r a do:
Mammograph y Benefit
We will pay for mammography cove rage for routine and certain diagnostic sc reenin gs on a calendar year
bas is. Routine screening mu st include the following:
a) for women age 35-40, one baseline mammogram ;
b) for women aged 40-50, one screening every two calendar years (once each calendar year fo r
women with risk factors to bre as t cancer as determined by her ph ysi cian ); and
c) for women aged 50-65, o ne sc reenin g annua ll y, on a calendar year bas is.
!fa Covered Person ha s not ut ili zed the ro utine mammograph y be nefit during a calendar year, then the benefit
wi ll apply to one diagnos tic sc reening for that year.
If more than one diagnostic screening is provided in a calendar yea r, th e policy's other dia gnostic service
benefits prov is ions will apply.
Diagnostic Screening as used in th e benefit , me a ns th e use of procedures including phys ical examinations,
rad io log ical ima gin g, surgica l tec hniques , and any new technologies approved by the board for detecting
whether abnormal ities of the breas t are malignant or be nign.
Sc re ening means the conduct of ph ys ical examinations, v is ual inspections, or other medical te sts exclusively
for the purpose of ascertaining th e existence of any ph ys iolog ical abnorma lity wh ich mi ght be indicative of the
presence of disease. Sc reen in g in c lude s diagnos tic sc re enin g se rvice s.
Pros trate Ca ncer Sc reening Benefit
We wi ll pay for an annual pros tate sc reeni ng for the early detection of pr os tat e cancer:
a) for men ove r 50 years of age ; and
b) for me n ove r 40 years of age who a re in hi g h ri sk categories.
Coverage may not be subject to deductibles a nd mu st be the lesser of:
a) $65; or
b) the ac tu al charge for the sc reening.
The scree nin g ma y be performed by any qua lified medi ca l profess iona l, including a urologist , int e rni st,
ge neral practitioner, do ctor of osteopathy, nurse pr ac tition er or ph ys ician ass istant.
The sc reeni ng mu st include at lea st the followin g te sts:
a) a prostate-s pec ific anti gen (PSA) blood test ; and
b) a di g ital rectal exam in at ion.
Form P A-3057 (ER ) (322 9)
28
SEN IOR MEDICAL I NSURANCE PLAN AD DITIONAL BEN E FITS (Continued)
TH E C H E D LE OF B ENEFITS AND AMO NTS WILL I ND I CAT E THE B ENEFITS APPLICABLE TO EACH
C OVERE D P E RSON WHIL E COVE R E D NDER T H E POLI CY.
STATE MANDATED BE NE FITS (Continued)
With res pects t o r esid e nts of the following s t ates, the followin g benefits arc added to the Po lic y a nd Certificate :
Conn ectic ut:
H ome Health Aide Services Benefit
M edicare pays for home hea lth care that is medically necessary if certain conditions are met. Covered ser vices
may includ e those of a home health a ide.
When th e services of a home health aide are not covered by Medicare, we will pay up to a max imum amou nt
of $500 each Calendar Year for the Usual and Customary expenses that a Covered Person incurs fo r home
health services, provided:
a) the Covered Person's atte nd ing Phys ician certifi es in writing that s uch services a re medically necessary;
b) such services are provided by a Connecticut licensed home health care agency; and
c) the Covered Person receives such se r vices while covered by this benefit.
Mammography Scree ning Benefit
We w ill pay a Covered Person 's expenses In curred for one screen ing by Low-Dose Mammography for the
presence of occult breast cancer for each Ca lendar Year.
Low-dose Mammograp hy means x -ra y exa m inati o ns of the breast us in g eq u ipmen t with a n average radiation
exposure d e li ve r y of less than o n e rad mid -breast, w ith 2 views fo r each b reast.
Delaware:
Scalp Hair Prosthesis
We will provide coverage for medical o r hospi tal expenses and also provide coverage for other prostheses, must
prov ide coverage for expenses for a sca lp hai r prosthesis worn for hair loss suffered as a result of alopecia ar eata,
re sulting from a n autoimmune disease. This coverage mu st follow the same lim itation s and guidelines as other
prostheses, b ut such coverage need not exceed $500 per year.
Thi s coverage may be s ubject to a nnual deduct i bles a nd co-insurance p rovisions as long as they are appropriate and
consiste nt wi th those established for o th er benefits under the pla n of coverage. Written notice of the availabili ty of
such coverage mu s t be de l ivered to the insured, participant, policyholder, s ubscriber and beneficiary upon enrollment
and an n ua ll y thereafte r.
The following terms are defined in thi s section as fo ll ows:
Prosth eses: means arti fi cial appliances used to re p lace los t natu ra l stru ctures. They include, but are not li mi ted to,
artificial arms, legs, breasts, or glass eyes.
Scalp Hair Pros thesi s : means artificial s ubst itutes for scalp hair that a re made specificall y for a specifi c indi v idual.
Form PA-9411
29
SEN IOR MED ICAL INS URANCE PLA N A DDITIO NAL BEN E FITS (Con tinued)
THE SC H ED U LE OF BENEFITS AN D A MOUNTS WILL I N DICATE THE B ENEF I T S A PPLICA BLE TO EA C H
COVER E D PER SON WH I LE COVE RE D UNDE R TH E POLI C Y.
STATE MANDATED BENEF ITS (Contin ued)
With res pects to res idents of th e fo ll ow in g s tates, th e followin g benefits are added to the Po lic y a nd Certificate:
De laware Continued :
The followin g terms are defi n ed:
Prov ide coverage for medical formu las and foods , low pro te in mod ified form ula s and mod ified food products that are
prescri bed as medically necessa ry for the th erapeutic treatme nt of inhe ri ted metabolic d iseases, and are administered
under the di rection of a physician.
The foll ow ing terms are defi ned in this section as follows:
In herite d metabo l ic diseases: refers to diseases caused by an inh e rited abnormality of biochemistry. The words
"inhe ri ted metabo li c di seases " a lso inclu de any d iseases fo r whic h Delaware screens newborn babies.
Low prote in modified fo rm ula o r food prod uct: means a formula or food product th at is specially formulated to have
less than I gram of protein per se rving a nd int ended to be used under the direction of a physician for the dietary
treatment of an inhe r ited metabo lic disease. It does not incl ude a natural food that is nat urally low in protein.
Med ical fo rmu la o r food: means a formu la o r food tha t is inte nde d fo r the dietary treatmen t of an inher ited metabolic
disease fo r whic h nutr it iona l req uire ment s and res tri ctio ns have been es tab lished by med ical research a nd is
fo rmulated to be co ns um ed o r ad mini stered e ntirely und e r the directi o n of a physician.
Washington , D.C.:
Ca ncer Screening Be nefit
We wi ll pay th e Usual a nd Custo mary cha rges Incu rred by a Covered Person and not covered by
Me dica re fo r :
a) o ne ma mm ogra phy screen ing eac h Ca le nd ar Yea r; and
b) one cerv ica l cance r scree ni ng each Ca lendar Year or mo re frequently if cert ified by a
Physician tha t suc h cervical cancer screenings are med ica ll y necessary.
Hawa ii :
Menta l Hea lth a nd Alco h ol and Dru g Abu se Treatment Benefit
Cove re d bene fit s for me nta l health , alco hol de pende nce and drug depe nd e nce shall be:
a) li mit ed to those se rvices certi fied by Medi ca re's li ce nsed physic ia n or psycho logist as med ical ly or
psyc holog icall y necessary at t he least cos tly app rop riate level of care; a nd
b) not less than thirty days of in-hospita l services per year. Each day of in-hospi tal se rvices may be
exchanged fo r two days of no nhosptial residential serv ices, two days of partial hospita li zation services
or two days of day treatment services.
Phys ic ian or psyc hologist vis its sha ll not be Jess th a n th irt y visits per year to hospi tal or nonhospita l fac ilities
or to menta l hea lt h o utp ati e nt faci liti es for day treat men t or part ia l ho s pita lization services. The benefi t fo r
outpat ient services sha ll no t be less tha n twe lve visit s per year.
Form P A-305 7 (E R) (3229)
30
SEN IOR MEDICAL I NSURANCE PLAN ADDITIONAL B ENEFITS (Co ntinued )
T H E C H EDULE OF BENEFITS AND AMO NTS WILL I N DI CATE THE BENEFI TS APPLICABLE TO EACH
C OVERE D PE RSO N WHILE COVERE D NDER T H E POLIC Y .
STATE MANDATED BENEF ITS (Co ntinued )
With r espects to residents of the following s tates, the foll owing benefits a r e added to the P olic y a nd Certificate:
Hawa ii (Co ntinu ed):
Alcohol a nd Drug Dependence Be n e fit
Detoxi fi cat ion provided in a ho s pital or nonhosp it a l facilit y which has a written affi li at ion agreement with a hosp ita l
for eme rgency, medical and mental health s upp o rt se rvi ces. Services are covered under the in-h os pita l se rvices but
not und e r the treatment epi so de limitation . Services include:
a) room and board;
b) diag nos ti c x -rays;
c) laboratory tes tin g; and
d) dru gs, equ ipment use, special therapies and s uppli es.
Alco hol and Drug Depe nd ence Treatment is delive red throu g h in-h ospita l, nonhospita l res idential or day treatment
s ub stance abuse se rvice s. A licensed physician o r cert ified psyc ho logist s hall determine that this individua l s uffers
from alco hol or drug depend e nce or both. Substance abuse se rvices s ha ll incl ude services whi ch a re requi red for
licen s ure and accre ditat ion.
Excl ud ed from thi s benefit are:
a) detox ifi ca ti on se rvi ces ;
b) educational program s to whic h drinking or drugged dr ivers are refe rred by the jud ic ia l system; and
c) services perform ed by mutu a l se lf-help g ro ups.
Outpatient se rvices for dr ug and alco ho l dependence sha ll be prov id ed und e r:
a) an individ ua lized treatment pl a n approved by a lic e nsed phys ic ian or cert ifi ed psychologis t; a nd
b) be reasonably expected to pr oduce rem ission o f the patient 's conditio n .
Mental Illn ess Ben e fit
Menta l illn ess benefits s hall be limit ed to coverage for diagnosis an d treatment of ental disorders. All mental helath
se rvices s ha ll be pro vided under an ind ividua li sed treatmen t plan approved by a licensed phys icia n o r psychologist
an d mus t be reasonab ly expected to im prove the patient 's cond ition .
In -ho s pita l and nonhospital res id e ntia l mental hea lth services s ha ll be prov ide d in a ho spi ta l or nonhospital re sid ential
fac ili ty ,
Mental heal th pa rti al ho s pita li zat ion s hall be provided by a hos pita l or a me ntal health ou tp ati ent fac ili ty.
Menta l health outpatient se rvices are in c luded as part of th e cove red out patient services.
Fo r thi s bene fit , the following defin ition s app ly:
Alcohol d epend e nce me ans any use of alcoho l whi ch produces a pattern of pa thol og ica l use caus in g impai rment in
soc ial o r occupational fun ct ioning o r pr odu ces phy siolog ica l depe nde ncy evide nced by phys ical tolerance or
withdrawal.
Form PA -3057 (E R) (3229)
3 1
SEN IOR MEDICAL I NSURANCE PLAN ADD ITIONAL BENEFITS (Conti n ued)
THE SCHEDULE OF BENEFITS AND AMOUNTS WILL l NDlCATE THE BENEFITS APPLICABLE TO EACH
COVERED PERSON WHILE COVERED U DER THE POLlCY.
STATE MANDATED BENEFITS (Continued)
With r espects to resid e nts of the following s t a t es, the following ben efi t s are added to the Po lic y and Certificat e:
H awaii (Continued):
Alcohol or drug dependence o utpa ti ent services means a lcohol o r drug dependence nonresidentia l treatment
provided o n an ambulatory basis t o patients w ith alcohol or drug dependence proble ms that includes psychiatric or
psychological int erventions prescribed and performed by state licensed physicians or psychologists who have been
certified in accordance with set laws.
Certified s u stance abuse s taff means professiona ls and paraprofess ional w ith current ful l certi ficat ion as substance
abuse counselors o r program adm ini strators.
Day treatment services means treatme nt se r vices provided by a hospit al, me ntal health outpatient facility, or
nonhos pital fac ility to patients w ho, because of their cond iti ons, require more than periodic hourly service . Day
treatment services s ha ll be presc ribed by a ph ysician or li censed psyco logist and carried out unde r the s up e rvi s ion of a
physic ian or li censed psyc hologi st. Day treatment se rvice s require :
a) le ss than twenty-fou r hours of care; and
b) a minimum of three hours in any one day.
Detoxification services means the process whereby a person into x icated by alcohol o r drugs or a person who is
dependent upon alco hol or drugs or bo th is ass isted through the period of time necessary to eliminate, by metabolic or
other means, the intoxicatin g alcohol or drug dependency factors, as determined by a licensed phys ician, whi le
keeping the physiological ri s k to the person at a minimum.
Drug depe ndence means a ny pattern of pathological use of drugs causing impairment in soc ial or occupational
functioning and producing psychological or physilogical dep e nde ncy or both, evidenced by phy sica l tolerance or
withdrawal.
H os pita l means a fac ili ty licensed a s a hosp ital by the department of healt h and accredited by the Joint Commission
on Accreditation of Health Care Organizations.
In-hospital ser vices means the provi s ion of medical, nursin g, or therapeutic services twenty-four hours a day in a
hos pital.
Mental health outpatient facility mean s a mental health establishment, clinic, in s titution, center, or commun ity
mental health center, that provides for the diagnosis, treatment, care, or rehabi litation of mentall y ill persons, t hat has
been acc red ited by the Joint Commiss ion on Accreditation of Health Care Organizations or th e Comm iss ion on
Accreditatio n of Rehabilitation Facilities.
M e nta l illn ess o r mental disorder means a syndrome of clinically s ig nificant psychological, b iol ogical, or
behavioral ab normali tie s that re s ults in personal d istres s or s uffering, impairment of capacity fo r fu nctioning, or both.
Epilepsy, senili ty, mental retardat ion, or ot her de velopmental di sabi litie s and addic tion to or abuse of into x icating
s ub stances do not in a nd of themselves constitute a mental di sorder.
Form PA-3057 (ER ) (3229)
32
SEN IOR MEDICAL IN SU RA NCE PLAN ADDITIONAL BENEF ITS (Co ntinued )
THE SC H E D ULE OF B ENEFITS A 'D AMOUNTS WILL I NDI CATE THE B ENEFITS APPLICABLE TO EACH
C O VE R E D PE RSON WHILE C OVE R E D UN D ER THE POLICY.
STATE MANDATED BE NE FITS (Co ntinued )
With r es pect s to residents of the followin g s tates, th e followin g benefits are added to the Polic y and Ce rtificate:
Hawaii (Co ntinued):
Nonhospital facility means a fac il ity for the care or treatment of alcohol dependent , d ru g dependen t, or me nta ll y ill
pe rsons, wh ich ha s been accredited by the Joint Comm ission on Accreditation of Health Care Organizations of the
Commission on Accreditation of Rehab ili tation Fa cilities and, if residentia l, has been li censed as a spec ial treatment
facilit y by the department of health.
Non ho s pital res idential services mean s th e provisions of medical , psyc hological , nursing, counseling, or therapeutic
serv ice s to patient s s uffering from alcholo dep ende nce, drug dependence or mental illness by a nonhospital re si dential
facility, according to individuali zed treatment plans.
Partial hospitali7..ati o n se rvices mean s treatm e nt se rvices pr ov ided by a hospital or mental health outpatient facility
to patient s w ho, because of their conditions, require mo re than periodic hou rly se rvi ce. Partia l hospitalization services
s hall be pre scribed by a physician o r licensed psyc hol og is t. Parti al ho spitalizat ion se rvices require Jess than twen ty-
four hours of care and a minimum of three hours in any one day.
Substance abuse se rvices means the provi s ion s o f medical , psycholog ical, nursi ng, counse ling, or therapeutic
se rvices in re s ponse to a t reatment plan for alcohol or drug dependence o r both which sa il in clude , when appropriate,
a combina tion of aftercare and individual , group and famili y co nse lin g se rvices prov ided by certified s ub s ta nce abuse
staff.
Treatment episode mean s one admi ss ion to an accred iated hospital or nonhospital facility, or o ffi ce of a state-
li ce nse d phys ic ian or psychologist ce rtified for trea tm ent ofalcho l o r drug dependence o r both stipulated in a
prescribed tre atent plan and which would ge nerally pr od uce remiss ion in those who com plet e th e treatment. The
presc rib ed treatme nt plan ma y include:
a) th e provi s ion of s ub stance abuse serv ices in more than one location; and
b) in-hospital , nonho s pit a l residential, day trea tment or alc hol or drug de pe nden ce outpaitent services
or any combination thereof. An adm iss io n for on ly detoxification service s s hal l not constitue a
tr eatme nt epi sode.
Iowa :
Mammog raphy Benefit
We wil l pay a Covered Perso n's expen ses In cu rr ed for one scree nin g by Low-do se mammograph y for th e pre sence of
occ ult breast cance r for eac h Calend ar Yea r.
Low-dose Mammograph y mean s x-ra y exa min atio ns of th e breast using equipment with an ave ra ge radiation
ex po s ur e deliver y of less than one rad mid-breast, wit h 2 views for each breast.
Form PA -3057 (E R) (3 229)
33
SENIOR MEDI CAL I NSU RA NCE PLAN ADDIT IONAL B ENEFITS (Con tinued)
THE SCHED ULE OF B ENEF ITS AND AMOUNTS W I LL IN DI CATE THE BEN EFITS APPLI CABLE TO EAC H
COVERED PE RSON W HI LE COVER ED UNDER T H E PO LI CY.
STATE MAN DATE D BENEFITS (Con t inued )
W ith r es p ects t o r esidents of t h e fo ll owing sta t es, t h e fo ll owi n g ben efits a r e a d ded to t h e Policy a nd Certifi cat e:
Mai ne:
Mamm ogr a ph y Cover age Be n efit
We will pay the actual charge incurred by a Covered Person for one Sc re ening Mammogram for th e prese nce
of occult bre ast cancer each Calendar Year to the e x tent th at it is not covered by Medicare . This benefit is
s ubject t o a ny d eductibles or coin sura nce amounts.
Sc r eening Ma mm og r a m means x-ray exami nat ions of the breast u sing equipme nt with a n average radiation
ex pos ure de livery of less t han one rad mid-breast, wi th 2 views for eac h breast.
The definition of Preve ntive Screen ing Tests and P reventive Se r v ices d efini t io n (if a ny ) has been deleted in
its e ntirety and repl ace d by the f o llowing:
P r eve ntive S creening Tests and Preventive Services means o ne or more of the follow in g, the freque ncy o f w hich is
cons idered medicall y appropriate:
a) fecal occult blood tes t and/o r di gi tal rectal examin ation ;
b) dips ti c k urinalysis for hematuria , bacte riur ia a nd proteinauria;
c) pure tone (ai r only) hearing sc re en in g te s ts , administered or ordered by a phy s ician;
d) serum chole st erol scree n ing (eve r y 5 years);
e) thyroid fu nction test; and
f) di a betes screening.
Alcoh o lis m a n d D r ug D epend e n cy B e n e fit
To th e exte nt not cove red by Medicar e, we wi ll pay fo r the expens e in c urred by a Covered Perso n fo r the
treatme nt of a lc o holi s m o r drug depe ndency, subject to the fol lowing limitati ons per Cale nd ar Yea r :
a) 30 days for inpati ent o r resid e nti a l care in a Hos pital o r nonhospital re s ide nti a l faci I ity; a nd
b) a maximum be nefit amount of $1000 for o utpatient v isits.
We will no t pay for more th an the following per li fet ime :
a) 60 days for inpatient or resid ential care in a Hos pital o r nonhos pital res idential facility; and
b) a maxim um benefit amount of$25 ,000 for o utp atient v isi ts;
for the treatme nt of a lco holism or d rug dependency, s ubject to all th e rul es and lim itations of the Po li cy.
In no event w ill thi s rid e r pro v id e coverage whi c h duplicates Medicare be nefi t s o r w hi ch e xceeds the
max imum amount payab le under the Po li cy.
Fo rm P A-3057 (E R ) (3229)
34
SEN IOR MEDIC AL I NSU RA NCE PL AN A DDITIO N AL B ENEF ITS (Continued)
TH E SC H ED ULE OF B ENE FI TS AN D AMO U TS WI LL I N DI C ATE TH E BE NEFI T S A PP LICA BL E TO EA C H
C OVER E D PE RSON WHIL E CO V ER ED UN D ER T H E PO LI C Y .
S T ATE MAN DA T E D B E N EF ITS (Co ntin ued )
With r es pe c t s t o r esid e nts of the fo ll owin g s t ates, t he foll owin g b e n e fi ts are a d ded t o the P o li cy a nd Ce rtificate :
Main e (Co ntinu ed ):
M e nta l and Ne r vo us Di so rd e r Be n e fi t
To t he extent not covered by Med icare, we will pay t he expense incurred by a Covered Person fo r the t reatment of t he
fol lowing Mental and ervou s D isorders :
a) schizophrenia;
b) b ipolar di sord er;
c) pervas ive developmen tal d isorder, or autism;
d) chil dhood sch izophrenia;
e) psychoti c depress ion, o r involutiona l m e la ncholia;
f) paranoia;
g) panic disorder; a nd
h) m ajor depressi ve di s orde r.
T he benefit w ill be li m i ted to:
a) 60 days fo r in patient care ; and
b) 50% of the reasonable a nd customary charge fo r outpa t ient o r da y tr ea t ment care, o r any
combina ti o n of t he two, to a m ax i mu m of$2,000;
per calendar yea r , w ith a lifetime maxim u m amount of $100,000.
We w ill pay th e expense incu rred by a Covered Pe rson for treat m e nt o f all o t her M e n tal a nd Nervous D iso rders the
same as a n y ot her Sickness.
This ben efit w i ll be limi ted to:
a) t he coins urance a m o u nt app licable to any o t he r Sickness, fo r in patient or day treatment to a maximum o f30
days; a n d
b) 50% of th e rea sonab le a nd custo m ary charge for outpat ient treat ment care, to a max i mum of$1 ,500;
per calendar year, with a lifet ime max imum of$50,000.
Mas sachu setts :
Confin e m e nt fo r T r ea tm e nt o f A lco ho li s m Be n efi t
W e w il l pay th e expense incurred for the fir s t 30 days pe r Cale ndar Year of Con fine m ent in a hospital o r s pecia l ized
fac ili ty for In pati ent t reatment of a lcoholi s m , to t he extent not covered by Med icare.
Confine m e nt fo r T r eatm e nt o f Men t a l and Ne r vou s Di s o r der s Bene fit
We w ill pay th e expens e incu r red fo r Confinement in Hospital for the treatment of Mental and Nervous Di sorde rs the
same as a n y oth e r Sickness. Howe ver, if the Covered Pe rson is con fined to:
a) a m e nta l h ospi tal u nder the d irection and s upervi sion of the Depart ment of Mental Health of the
Com mon wealt h of Massachusetts; or
b) a p r ivate mental hosp ita l licensed b y the Departmen t of Mental Health of the Commonweal th of
Massachusetts;
we wi ll li m it our payment to t h e expense incur red fo r up to 60 days of Confinement per Calendar Year, to th e
exte n t n ot covered by Med icare.
F o rm P A-3057 (E R) (3229)
35
SE NIOR M E DICAL I NSU RA NCE PLAN A DDIT ION AL B ENEFITS (Co n tin ued )
T H E SCH E DU L E OF B ENEFITS AN D AMO U NTS W I L L I N DI CATE T H E BENEFITS APP LiCA BL E T O EACH
COVER E D P ER SON W HI LE C OV E RED UN DE R THE POLiCY.
STAT E MAN DAT E D B ENE FITS (Continu ed )
With r es pects to r esid e nts o f th e f oll o win g st a t es, th e fo ll owin g be n e fits are a dde d to th e P olicy and C ertificate :
M a ssac husetts (Con ti n ued):
Outpatie n t T r eatme nt o f A lco h o lis m Be n efit
We wi ll pay th e e x pense inc u rred fo r o ut patient tr eatm e nt of a lc o ho lis m to t he extent not covered by Medi care
up to a maximum of$500 pe r Cale nd a r Year.
Outpatie nt Treatm e nt o f M e nta l a nd Ne r vo us Di sord e rs Be ne fi t
We w ill pay the e x pe nse incurred fo r outpa ti e nt treatme nt of Menta l and Nervo us Di so rde rs to t he e xte nt
no t covered by Medi ca re pro vi ded by:
a) a co mpre he ns ive heal th se rvice orga ni zatio n;
b) a li c e nsed o r accred it ed hospital;
c) a community me ntal health cente r, mental heal th c li n ic , o r da y care cente r which f urn is he s me nta l
he a lt h se rv ices, if a pp roved by t he De pa rtm e nt of Me nt a l Heal th of the Commonwealth of
Massach usetts; o r
d) cons ul tati o ns o r di agnos ti c o r treatme nt se ss io ns provid e d by:
I. a f ull y li censed psycho t hera pi st w ho d e vo tes a s ubs ta ntial am o un t of t ime to t he pr acti ce of psychiatry ;
2 . a lice nsed psychologist ;
3. a li censed i nde pe nde nt c li ni c a l socia l wo r ker; a nd
4 . a certified cli n ica l spec ialist in psychi a tr ic a nd me nta l he alth n urs ing, provided suc h ser v ices a re
w it hi n the scope of h is o r he r practice ;
in excess of the Me d icare a ppro ved amount.
If Me di c a re d e n ie s pa y me nt for treatmen t , we w ill st ill provid e coverage up t o $500 max im u m per Calendar
Year.
Mammography Scree nin g B e n e fit
We w ill pay th e expense i ncurre d by a Covered Perso n fo r o ne sc ree ni ng by Low-do se ma mmogra p hy each
Ca le ndar Year t o the ex te nt th at it is not covered by Medi care.
Low-d o se Ma mmography means the x -ray exam i na t ion of the breast us in g eq u ipm ent spec ifi c a lly for ma m mogra ph y
with a n a ve r age radi a t ion expos ure del ivery of less th an o ne rad mid -b reast, w it h two v iews fo r e ac h breas t.
Cyt ologic Scr ee ning Be n efit
We wi ll pay the expense incurred by a Covered Pe rso n fo r o ne Cytologic Screeni ng (Pap s mear) pe r Cale nd a r
Yea r to t he extent that it is not co vered by M e di ca re.
Fo rm PA-3057 (E R ) (3 2 2 9)
36
SEN IOR M E DI CA L I NS URA NCE PLAN A DDITIONAL B ENEF ITS (Continued)
T H E SC H E D UL E OF B ENEFI TS AN D AMO U NTS WILL I ND I C ATE T H E BENEF I T S A PPLI CABLE TO EA C H
C OVE R E D PE R SON WH I LE C OV E R E D U D ER THE PO LIC Y .
STATE MAN D AT E D B ENEFITS (Co n t inued)
W it h r esp ect s to r eside nts of th e f oll owin g s tates, t he fo ll owi n g b e n e fits a r e ad d ed t o t h e Po lic y a nd C ertifica t e :
M a s sac husetts (C o ntinue d ):
E nte r a l Fo rmula s Be n e fit
We wi ll pay the expense incurred for non-pres cription entera l formulas medica ll y necessary for the treatment
of ma labsorp t io n caused by:
a) C h rohn's disease;
b) ulce rative colitis;
c) gastroesophageal re fl ex ;
d) gastro i ntest i na l motili ty; or
e) chronic i ntestin a l pseudo-obstructio n;
to the exten t no t covered by M edicare.
Mamm ogr a phy Scr ee nin g Be n e fit
We w ill pay t he lesser of:
a) $70; o r
Mo nta n a:
b) the ac t ual c ha rge in curred by a Covered Person ;
fo r o ne sc reen ing by Low-dose Ma m mography for the prese nce of occu lt breas t cancer fo r each Calendar Year to the
ex tent that it is not covered by Medicare.
Low-dose Mammography means x-ray exami nations of the breast using equipment with a n average radia t ion
expos ure delivery of less than one rad m id-breast, with 2 v iews for each b reas t.
New J e r sey:
Prostra t e Ca n ce r Scr eening Be n e fit
We wi ll pay fo r an annua l diagnostic examination including but not li mi ted to, a di gital rectal examinatio n and a
prostate-specific antigen test fo r men age:
a) 50 and over who a re asymptomati c; and
b) 40 and over w ith a family h istory of prostrate cancer or other prostrate cancer risk factors.
This bene fi t w ill be provided to the same extent as for any o th e r medical condi t ion unde r thi s policy.
A t H o m e R ecover y B e ne fit
If a Covered Pe rso n 's Pychi s ican certifies that the Covered Person require s the se rvices of a Care P rovided for Home
recovery or Re habilitatio n from a S ickness, Inj ury or s urgery, then we will pay t he lesser of:
a) the expense Inc urred; o r
b) the A t Home Recovery Maxim um Amount per v is it;
fo r s hort term At Ho me Recovery Vis i ts , up to the M axi mu m Benefit A mount per Calendar Year.
F o rm P A-3057 (E R ) (3229)
3 7
SENIOR MEDICAL INSURANCE PLAN ADDITIONAL BENEFITS (Continued)
THE SCHED ULE OF BENEFITS AND AMOUNTS WILL INDICATE THE BENEFITS APPLICABLE TO EACH
COVERED PERSON WHILE COVE R ED UN DER THE POLICY.
STATE MANDATED BENEFITS (Co ntinued)
With respects to residents of the following states, the following benefits are added to the Policy and Certificate:
New Jersey (Co ntinu ed):
The At Home Recovery Vi sits must be:
a) provided to a person while he or s he is cove red unde r thi s benefi t;
b) primaril y to prov id e services w hi c h ass is t in Activit ie s of Dai ly Living ;
c) prov ided on a visit ing basis in th e Covered Person 's Home.
This benefit w ill not pay for :
a) At Home Reco ve ry Visits paid for by Medi care or o th er government prog rams;
b) At Home Recovery Vi s its provided by family membe rs, unpaid volunteers or pro vi ders who a re not Care
Providers , as defined;
c ) More than 7 visits i n any one week.
De finition s for thi s benefit a re as fo ll ows :
Activities of Daily Living mean s those daily ac ti vitie s necessary for a person t o perform in order to function
independentl y, includ i ng, but not limited to, bathing, d re ss ing, personal hygiene, transferri ng , eating, ambu lat in g,
assistance with drugs th at a re normall y se lf-admin iste re d and changing bandages or o ther dress ings.
At H o m e Recovery Visit mea ns the period of a visit required to provide a t home recovery care, witho ut li mit o n the
duration o f th e visit, except e a ch consecutive 4 hours i n a 24 hour period of se rvi ces provid ed by a care provider is
consid e re d one vis it.
Care Provider means a duly qualifie d or licen sed ho me health a id e or homemake r, persona l care aide o r nurse
provided throug h a li ce nsed home heal th care agency or referr ed by a li censed re ferr al age ncy or li censed n urses
registry .
Home means a place used by the Covered Pe rson as a place of residence . It may be the Covered Person 's own
dwe lling, an apartment, a re latives' home, a home for the aged or so me other ty pe of in stitution. A Hospital or Skilled
N urs ing Facility is not co nsi dered the Covered Pe rson 's home .
Rehabilitation mean s aiding a patient in order to ass ist in the development of independent li ving c apa bilities in order
to attain reduction of phys ical o r mental disability.
Form P A-3057 (ER) (3229)
38
SEN IOR M E DI C AL I NSU RA NCE PLA N ADDITIONA L BENE FITS (Co ntinued )
TH E SC H E D U L E OF B EN EFITS AN D AM O U TS WI L L I DI CATE TH E B ENEFITS A PPLI CA BLE T O EAC H
CO VE R E D PE R SO N WHIL E C OV E R E D U D E R TH E POLI C Y .
STATE MA NDAT ED BENE FITS (Co ntinued )
With res pects to res idents of th e followin g s tates, the fo llowing benefits a r e add ed to the Po lic y and Certifica te:
Ne w J e rsey (Co ntinued):
Preve ntive Medical Care Bene fit
We will pay the actual charges up to th e Med ica re approve d amount for expen ses In cu rred by the covered Person for:
a) an ann ua l clin ical preventive medical hi s tory and phy s ical examination (w hich ma y in c lude Prev en tive
Screen ing Tests or Se rvice s) a nd patient educati on to ad dress preven tiv e hea lth me asures; and
b) Preventive Screen ing Tests and Serv ice s, as defined: an d
c) Influenza vaccine admini stered at any appropraite time during the yea r; a nd
d) Tetanus and Diptheria booster every I 0 years; and
e) other te sts or preve ntive measures determin ed to be appropriat e by the attending Phys icia n.
The expenses must be In c urred by a Covered Person wh ile covered und e r thi s benefit.
Our payment will be limited to th e Maximum Bene fit Amount per Ca len dar ear shown in the Schedule.
Preventive Screenin g Tes ts and Preve ntive Se r vic es mea ns one or mo re of the followi ng, th e freq uenc y of wh ich is
cons idered medic a ll y appropriate:
a) fec a l occult blood te st and/or digita l rectal exa mini ati on;
b) dipstick ur inaly sis for hematuria , bacteriuria and proteinauria;
c) pure tone (ai r only) hearing sc re ening te sts, administered or orde red by a physician ;
d) se rum cholesterol sc reen ing (e ve ry 5 yea rs);
e ) thyro id function test; and
f) diabetes sc reening.
Mamm ography Coverage Benefit
We will pay the ac tual c harge incur red by a Covered Perso n for one screenin g by Lo w-Dose Mammograph y fo r the
presence of occult breast cancer for each Calendar Year to th e ex te nt th at it is not cove red by Medicare.
Low-Dose Mammog raphy mean s x-ra y exa min a ti ons of th e brea st us in g equipment with an ave ra ge radiation
expos ure deliver y of less than one rad mid-brea st, with 2 views for each brea st.
Wilm 's Tumor Benefit
We will cover the expenses Incurred by a Cove red Perso n for the treatment ofWilm's T umor th e same as any other
cove red Sickness to the extent that it is not covered by e ith e r Medicare Pa rt A o r Pa rt B.
Form PA-3057 (E R) (3229)
39
SENIOR MEDICAL INSURANC E PLAN ADDITIONAL BENEFITS (Continued )
THE SCI I E D LE OF B ENEF ITS AND AMOUNTS WILL IN DICAT E THE BENEF ITS APPLICABLE TO EAC H
C OV E R E D PERS O N WHILE COVE R E D UN DER THE POLICY.
STATE MANDATED BENEFITS (Co ntinued)
With r es pects to resid e nts of the foll owi n g states, the following benefits are added to the Policy and Certificate:
Pennsy lvania:
Ph e ny lketonuria Treatment Benefit
We will cover the cost of nutrition a l supplemen ts (form ul as) as medically necessa ry for the th e rapeutic treatment of
phenylketonuria , branched chain ketonuria, galactosem ia, and homocystinu ria as ad mini stered und er the direct ion of a
Ph ys ician.
Rhode Is la nd :
At Home Recovery Benefit
If a Cove red Perso n's Phys ician cert ifies that the Covered Perso n requires the services of a Ca re Provider for
Home recovery from a Sickness, Injury or s urgery for which a Home Ca re Plan of Treatment was ap proved by
Medic are, then we will pay the le sser of:
a) the expe nse Incurred; or
b) the At-Home Recove ry Maxim um Amou nt per visit;
for s hort term At-Home Recove ry visits , up to the Maximum Benefit Amount per Ca lenda r Year.
The At-Home Recovery Visits mus t be :
a) provided to a person whil e her or s he is covered under thi s benefit;
b) pr ima ril y to provide services whi ch assist in Activities of Dail y Livi ng;
c) provi ded on a visiting bas is in the Covered Person's Home ; and
d) provided wh il e the Covered Perso n is rece iving Med ica re-approved home care serv ices or within
the Covered Person 's attend in g Ph ysicia n mu st certify that the spec ifi c type and frequency of At-Home
Recovery services are necessa ry because of a co ndition for which a home care plan of treatment was
app roved by Medicare.
Thi s ben e fit will no t pay for:
a) At-Home Recovery Visi ts paid for by Medi care or other government programs;
b) At-H ome Recov ery Visits provided by fami ly me mbe rs, unpaid vo lu nteers or providers who a re
not Care Pr ov iders, as defined;
c) more than the numb er of Medicar e approved ho me health care visit s under a Medicare approved
home ca re plan of treatment; o r
d) more than 7 vis its in any one week.
Maximum Amount per visit , the Max imum visits per week and the Maxim um Benefit Amount are shown below:
Form PA-3057 (ER) (3229)
Maximum Amount per vis it: $40
Ma ximum visi ts per week: 7
Max im um Benefit Amount: $1,600 per Calendar Year
40
SEN IOR MEDIC AL I NSURANCE PLAN A DDITIONAL BENEF ITS (Continued)
THE SCHEDULE OF BEN EFI TS AND AMOUNTS WILL I ND I CATE THE B ENEFITS APPLI CABLE TO EACH
C OVERED PE R SON WHILE C OVER E D UND E R THE POLI CY.
STAT E MANDATED BENEFITS (Cont inued)
With res pect s to r es idents of the following sta tes, th e followin g benefits are added to the Policy a nd Certificate:
Rhode Is land (Co ntinu ed):
Definition s fo r thi s benefit are:
Ac tivities of Dail y Living mean s those dai ly activit ie s necessary for a person to perform in order to function
independently, inc lud in g, but not limited to , bathing , dress in g, pe rsona l hyg iene, tr ans ferring. eati ng , amb ul a ting,
ass istance w ith drugs that are normal ly self-admini s tered and hanging bandages or other dres s ing s.
At-Home Recovery Visit mean s the per iod of a vi s it required to provide at-h o me recovery care, without limit on the
duration of the vis it , except each co ns ecutive 4 hour s in a 24-hour period of se rvices prov ided by a ca re provider is
considered one vis it.
Ca re Provider mean s a duly qual ifi ed or licens ed home hea lth aide or homemaker , per so na l care aide or nurse
provided through a li cen sed home health care agency or referred by a licen s ed referra l agency or li cen sed nur se s
reg istry.
Home mea ns a place used by th e Covered Person as a plac e of reside nce. It may be th e Cove red Person's ow n
dwe llin g , an apartm e nt, a re lative 's hom e, a hom e for th e aged or s ome ot her type of in stitut ion, provid ed that such a
place wou ld qua lify as a res id ence for Home He a lth Care services covered by Medicare. A Ho spita l or Skilled
Nu rsing Faci li ty is not conside red th e Cove red Per son 's hom e.
Al so for the res id ents of Rh ode Is land: Medical coverage mu st be pro vided for seriou s me nta l illn ess o n the same
basis as cove rage for othe r illne ss es and di sea ses. Co ve rage mu st include the same dura ti onal limit s and deductible s
as for other illn esses and disease s. Thes e heal th care ben e fits apply o nl y to services delivered with in the state of
Rhode Island.
Se ri ous Mental Illn ess mean s a ny mental di s order that c urre nt medica l science affirms is caused by a bio logica l
di s ord er of th e brain and that s ub sta nti a ll y li mit s the life ac tivities of the Ins u red Perso n wit h the il ln ess . Th e term
includes , but is not limited to:
a) s chi zop hren ia;
b) s chi zoaffecti ve di sorder ;
c) delusional disorde r;
d) biopla r affec ti ve di s orders;
e) major depression
f) ob sess ive compu ls ive disorde r.
Medical coverage mean s inpati ent ho s pitali za tion and o utp atient medication vi s its. In patie nt co ve rag e in case s where
continuous hospita lization is medicall y necess ary is li mi te d to 90 c onsecutive day s.
Form PA -3 05 7 (ER) (3229)
41
SEN IO R MEDI CAL I NSURANCE PLAN A D D IT IONAL B ENEFITS (Continued)
T H E SCHED LE OF BENEFI TS AND AMOUNTS WILL I ND ICATE THE BENEF ITS APPLICABLE TO EACH
COVE R ED PERSON WH I LE COVER ED UNDE R THE PO LI CY.
STATE MAN DATE D BENEF ITS (Co nti nue d )
W ith r es p ects to r es id e n ts of t he fo ll ow ing states, t he fo ll ow in g benefi ts are a dd ed t o t h e Po l icy an d Certifica t e:
So ut h Da k ota:
Ma mmograp h y Be n e fit
To the extent no t covered by Medicare, we w ill pa y th e ex pen se in c urred for o ne sc reening by Low-dose
Mammograph y for the presence of occult breast ca nce r for each Calendar Year a s fo ll ows:
a) for women aged 3 5-39, one baseline mammogram;
b) for women aged 40-4 9, one scree ning e very two years; a nd
c) for women aged 50 or over, o ne sc reening an nu a ll y.
Low-d ose Mamm og r a ph y means x -ray exam in ations of th e breas t us in g equipment wit h an average radi a tion
exposure delivery of less t han one ra d mid-breas t, with 2 views for each breas t.
Phe ny l ke t o nu r ia T r ea tm ent Be n e fi t
We will cover the expenses lncuned by a Covered Pe rso n for the treatment of Phe ny lketon uri a the same as any
covered Si ckn ess to the ext ent tha t it is not covered by e ith e r Medicare Part A or Part B.
Texas:
Ma mm og r aphy Scr ee nin g B e n efi t
We wi ll pay a Covered Person's expe nses In curred for one screening by Low-dose Mammography for th e
presence of occult breast cancer each Calendar Year as follows:
a) 20% of the Us ua l and Custo ma ry Charge for sc reening which is not covered by Medicare; or
b) 20% of the Medicare Elig ible Expenses fo r sc reeni ng which is covered by Me dicare afte r the Medicare
Part B Deductibl e is met.
Low-d ose Ma mm ograph y mea ns x -ray exami nation of the breast using e qu ipment wi th an ave rage radiation
expos ure deli ve ry of less t ha n one rad mid -br eas t, wit h 2 views fo r each breas t.
V irg ini a:
Pa p S m ea r Be n e fi t
We wi ll pay th e expenses incurred by a Covered Person for one pap s mear per Cale ndar Year, inc luding those
performed by a ny F DA -approved gyneco logic cyto lo gy screening technologies . Pay ment under thi s bene fit will not
duplicate pay me nts made under any other benefit of the Policy o r by M ed icare.
Ma mmogr a phy Cover age Be n efit
a) for women aged 35-39, we w ill pay for o ne basel in e mammogram;
b) for women aged 40-49 , we w ill pay for one ma mm ogram screening every 2 yea rs; a nd
c) for wome n aged 50 and over, we w ill pay for one mammogra m scre e nin g a nnuall y.
Cove ra ge may be limited to $50 pe r screenin g a nd is s ubj ect to do ll ar limits, d eductibles and coi ns ura nce which are
no less favorab le than for physical illness genera ll y.
Form P A-3057 (E R) (3229)
42
SEN IOR MEDI C AL I NSURANCE PLAN A DDITION AL BENEF ITS (Cont inued)
T H E SC H E D UL E OF B ENEFI TS AN D AMOUNTS W I LL I N DICATE T H E B ENEFI TS APPLICABLE TO EACH
C OVERED PE R SO N WH ILE C OV E R E D UN D E R THE POLIC Y .
STATE MANDAT ED BENEF ITS (Co ntinu ed)
With res pects to residents of th e foll ow in g s tates, th e fo ll ow in g benefits a re a dded t o th e Policy a nd Certificate :
Virg ini a (Co ntinu e d):
Mammogram s must be:
a) o rd ered by a hea lth ca re pr ac titi oner acting with in the scope o f h is or her lice nse ;
b) perfo rm ed by a reg iste re d tech nolog is t;
c) inte rpr eted by a qu ali fi ed radi o logis t;
d) pe rform ed u nd e r the dire c tion of a perso n license d to practice medi c ine a nd s urgery , and ce rtifi e d by the
American Board of Rad iology or a n equ iva lent exa mining body ; a nd
e) a co py of th e mammogra m rep ort mu st be sent or delivered to th e health pr ac titioner who ordered it.
T he equipme nt used to pe rform th e mammogram mu s t meet the Virgi ni a Depa rtm e nt o f Hea lth radiati on protec tion
regu lat ions a nd the film mu st be reta ined by th e radiol gic facili ty pe rfo rmin g the exami na ti on.
Wisconsin :
Menta l a nd Ne r vo us Dis o rd ers, A lcoho li s m and Drug Ab use Be nefit
The Covered Person wi ll rece ive a benefit whe n we rece ive proof t hat, whil e in s ured, he or she In c urs expe nses for
th e treatment of Me nt al and ervo us Disorde r, alcoholism or drug abuse. The benefit wi ll be equa l to the actual
c harges In cu rred fo r In pat ient, outpati e nt se rvices and Trans itio na l Treat men t arran ge me nt s up to the fo ll owing
max im um s:
a) inpat ie nt se rvice s up to a Ca lendar Yea r ma ximum of the lesse r of:
I. th e fir st 30 days of Confinemen t in a Ho s pital; or
2 . th e fi rst $7,000.00 of charges minu s a I 0% copay ment ;
b) ou tp ati ent se rvices up to a Ca lendar Yea r maximum of $2,000.00 min us a I 0 % co pay ment ;
c) Trans itio na l t reatment a rra nge men ts up to a Ca le nd ar Yea r maximum of$3,000.00 minu s a 10 % copayment.
The combined maximum be ne fit paya bl e und er a), b) and c) will be eq ua l to $7,000.00 eac h Ca le nd a r Year.
T r a ns iti o na l Treatm e nt mean s serv ices fo r the treatm e nt of ervous or Menta l Di s orde rs or alcoholism or ot her
drug abuse pr ob le ms that a re pr ov id ed to a Cove red Perso n in a Je ss restricti ve manner than are in patient hospital
se rvices but in a mor e inte ns ive manner than are o utp ati en t serv ices.
On ly t ho se expenses not elig ib le un der Medicare w ill be co ns ider ed for reimbursement und e r thi s be nefit.
C hiro prac ti c Services Benefit
We wi ll pay 100% of th e Usua l and Custom a ry Charges Incur red by the Cove red Pe rso n fo r the di agnosis and
tr eat ment of a co nd ition o r compl ai n by a li censed chiropractor whi le in s ur ed by us. T reatme nt mu st be with in the
sco pe of t he ch iropractor 's p rofe ss iona l li cense and must be for a co nditi on th at wo u ld have bee n covered if provided
by a Ph ysic ian o r os teopa th.
Fo rm PA-3057 (ER) (3229)
43
SEN IOR ME DI CAL I NSU RA NCE PLA N A DDITIO N AL BENE FITS (Continued)
T H E SCH E D ULE O F B ENEFITS AN D AMO NTS W I L L I NDI CATE T H E BENEF ITS A PPLICA B LE T O EAC H
C O VE R ED P E R SO N W HI LE C O VE R E D UN D E R T H E PO LICY.
STATE M AN DA TE D BENE FITS (Co ntinued)
With r es p ec ts to r es id e n ts of the fo ll owin g s ta tes, th e foll owin g b e ne fits are add ed t o the P oli cy and Certificate:
Wi sco nsin (Co ntinu ed ):
Equipm e nt a nd S uppli es for Di a betes Trea tme nt Ben efit
The Covered Person will receive a ben e fit if expenses a re incurred for the following :
a) the insta ll atio n and use of an in sulin infu sion pump ;
b) other equipment o r supplies in the treatment of diabetes;
c) medication used to control diabetes , including, but not limited to , insu lin ;
d) diabetic self-management education pr ogram s.
We will pay 100% of th e Usual and Customary charg es In cu rred even if Medicare refu ses to pay. Ho weve r, any
benefit paid will not exceed the expense actually Incurred and will not duplicate pa yments made under any other
provi sion s of this Polic y or by Medicare.
Benefits for an insulin infus ion pump a re limited to the purchase of o ne pump per Calendar Year. The Covered
Perso n mu st use an infusion pump fo r 30 da ys prior to th e in itial, but not replacement , purc hase.
Kidn ey Di sease Trea tment Benefit
We wi ll pay the expense Incurred for medically necessary Hosp ital Confinement and outpatient kidney di sease
treatment that the Covered Perso n receives while insured with us. Coverage is limited to expenses for dial ysis,
tra nsp lantat ion and don or-related se rvice s which are eligible under Medicare .
The maximum benefit payab le per Calendar Year is $30 ,000.
No n-Medica r e App roved S kill ed Nurs in g Fac ility Be ne fit
We wi ll pay the expense Incurred fo r treatment rec eived by the Covered Perso n while Confined in a
non -Medica re app roved licensed Skilled Nursing Facility for which no Medicare Part A benefits are payable . The
Confinement in the licensed Sk illed Nursing Care Facility mu st be because of the sa me or re lated Injury o r
Sickness for whic h t he Covered Perso n was previously treated.
The daily payable rate sha ll be no less tha n the maxi mum da il y rate established fo r Ski ll ed Nursing Faci lity care
in that fac il ity by the De partme nt of Hea lth and Soc ial Serv ices . T he max imu m we will pa y is li mited to 30 days
per benefit period.
Form P A-3 057 (E R) (3229)
44
SENIOR MEDICA L I NSU RA NCE PLAN ADDITIONAL BENEF ITS (Cont inu ed)
THE SCHEDULE OF BEN EF ITS AND AMOUNTS W I LL I N DI CATE THE B E EFITS APPLICABLE TO EACH
COVER E D PERSON WH I LE C OVER E D UNDER THE POLI C Y .
BLOOD D E D UCTIBLE BENEFIT
APPLICABLE TO ALL PLANS
Med icare does not cover the fir st 3 pints of blood received under Medicare Part A o r Medicare Part Beach Ca lendar Year.
We pay the expenses a Covered Pe rson In curs for the se first 3 pi nt s of blood, or equiva lent quan tit ies of packed red blood
cells, as defined under federal regulat io ns:
a) under Medicare Part A, except to the extent benefits for th e Part B Blood Deductible have been paid; or
b) under Medicare Part B, excep t to the exte nt benefits for the Part A Blood Deductible have been paid.
The expenses must be Inc urred while a Covered Person is covered by thi s benefit.
Form SRP-1270 R-B-1 (3229)
45
SEN I O R MEDICA L I NSURANCE PLAN A DDITIONAL B ENEF ITS (Continued)
THE SCI I ED LE OF B ENEFI TS AND AMOUNTS W I LL I N DI CATE T H E BENEFITS A PP LICABLE TO EACH
COVER E D PE R SON WH I LE COVER E D UND E R T H E POLI CY.
EXTENS ION OF B ENEFITS
A P P LI CA BLE TO A LL PLANS
If a Covere d Pe rson is Totally Di sabled on the date his o r her coverage term inates, we w ill extend the Poli cy Be nefit
Peri od for expenses In cur red as th e result of t ha t disabi lity , subj ect to a ll Policy benefit provisio ns , exclus ion s , and
limitation s .
For Medi ca r e P a rt A E lig ible Exp e n ses : A Po li cy Benefit Pe ri od for Medicare Part A Eli gible Ex pe nses w hich is
establ is hed pri o r to te rmination extends until t he first to occur of:
a) the date the Covere d Person has not been Confin ed in a Ho spital or Skilled Nurs in g Facility for a period of 60
c o nsecutive days ; or
b) the 365th day after termination.
If a Cove red Perso n's coverage terminates while he or s he is receiving approved Hospice Care, th e Hospice Care benefits
of the Po licy will continue until t he end of th e Hos pice Care benefit period, as defined by Medicare.
For Med icare P a rt B E ligi bl e Expen ses: T he Policy Bene fit Period for Medicare Part B E li g ibl e Expenses extends until
th e e nd of the Ca lendar Year quarte r following termination as show n below:
Termina ti o n M o nth
J a nua ry , Februa ry , March
April, May, June
J uly, August, September
October, November, Decem ber
Extens io n Date
June 3 0 of sam e year
S eptember 30 of same year
Decembe r 3 I of same year
March 3 I of nex t year.
GENERAL LI M ITATIONS
APP LI CA BLE TO AL L PLANS
L imitatio n : If a Covered Pe rson h as not enrolled in both Medicare Pa rt A a nd Part B, we will pay the benefits under the
Policy as if he or s he had enro ll ed in both parts of Medicare.
Form S RP-1270 S-I (3229)
46
PRE-EXISTING CON DI T ION LIMITATION
APPLI C ABLE TO ALL PLANS
Pre-existi ng Conditio n mean s a n y Injury o r S ickness for w hi c h a Covered Person received medical advice or treatment
w ithin the 6 mo nth pe ri od im mediately before:
a) hi s or her effecti ve date of coverage; or
b) the effective date o f a n in c rease in coverage;
wh ichever is appl icab le.
Co nditio ns Prior t o E ffectiv e Date : Du r ing t he first 6 mont hs from a Covered Pe rson's e ffecti ve date of insurance,
expenses Incurre d for Pre -ex isting Cond iti o ns a re no t covered.
C h a n ge from a Related Policy : I f a Covered Pe rson's coverage has converted wi thout i nte rrupt ion:
a) fro m t he Relate d P o licy;
b) to thi s P o li cy;
we w ill cred it toward sati sfacti on o f the above Pre-Exist ing Cond iti o n Limitation the peri od that he or s he was
cont in uously covered by the Re lat ed Po li cy i mmediate ly before t he conversion. Any expenses Incurred wh ic h are payable
under a n Ext e ns ion o f Bene fi ts p ro vis io n o f the Related Policy w ill not be payable under this Policy.
Re place ment Cover age : If th e Covered Pe rson:
a) has purc hase d coverage under th is Po licy in order to rep lace coverage und e r a prior Senior M ed ical In surance
Pl a n pol icy; and
b) he o r s he provides p roof of coverage under suc h prio r Senior Medical Insurance Plan policy;
we will c re d it toward satisfacti o n of this Po l icy's Pre -ex isting Condition Lim itation t he period t hat he o r she was
contin uous ly covere d by the p ri o r Seni o r Med ica l Insurance Pl a n policy imme d ia te ly before hi s o r her e ffective da te under
thi s Po li cy.
However, if benefi ts under th is Po licy a re greater t han those provided by the p rio r policy, the 6 month Pre -exist ing
Cond it io n Lim it ation of thi s Polic y w ill a p p ly only to the i ncreased bene fit s.
Conditions Prior to Effective Date of Increase in Cove ra ge : D urin g the fi rs t 6 months fol lowi ng the date a Covered
Person m a kes a c ha nge in cove rage that inc reases benefits, the increased po rti on of th e bene fi t wi ll not be payable fo r
ex pe nses Incurred due to Pre -existi ng Cond ition s.
Thi s Limita ti o n wi ll not appl y to a n y i nc rease i n coverage d ue to c ha nges i n Med ica re be nefits.
Form S RP-12 7 0 S-2 (3229)
47
The Poli cy doe s not cover:
I . any expense that is:
GENE RAL EXCLUS IO NS
APPLI CABL E TO ALL PLA NS
a) not a Med icare Eligib le Expense; or
b) beyo nd the limit s imposed by Medicare for s uch expense; or
c) excluded by name o r s pec ific de sc ript io n by Med icare;
except as s pec ifi call y prov ided under t he Pol icy ;
2 . any port io n of a cove red expense to th e ex tent paid by Medicare ;
3. any ben e fit s payable under o ne benefit of th e Polic y to the extent payable under anot her benefit of the Po li cy; and
4. cove red expenses Incurred afte r cove rage te rminates except as stated in the Extension of Benefit s provi sion .
Fo rm S RP-12 70 T-1 (3229)
48
CLA IM PROVIS IONS
APPLICABLE TO ALL PLANS
Not ic e of C laim : The person who has the right to claim benefits must give us written notice of a claim within 20 days
after a covered loss begins. If notice cannot be given within that tim e, it must be given as soon as reasonably po ssible.
The notice should include the In sured Person's name and the Policy number. Send it to The Hartford's approved Claims
Administrator.
C la im Forms : When we receive the notice of claim, we wi ll send forms to the c laimant for giving us proof of lo ss. The
forms will be se nt withi n 15 day s after we receive the notice of claim. Ifthe forms are not received, the c laimant will
sati s fy the proof of lo ss requirement if wrinen proof of the occurrence, cha racter and extent of the loss is sent to us.
Proof of Loss : Proof of loss must be se nt to us in wri ting within 90 days after:
a) the end of each month of ou r liabi lity for periodic payme nt claims; or
b) the date of the lo ss for all other claims.
If t he cla im ant is not ab le to se nd it within th at time , it may be se nt as soon as reasonably po ssi b le witho ut affecting the
claim. T he additiona l time a llowed ca nnot exceed one yea r unle ss the claimant is legally incapacitated.
Time of C laim Pa y me nt : We will pay any be nefit due:
a) on a monthly basis, after we receive the proof of loss. while the loss and our liability continue; or
b) immediat e ly after we recei ve the proof of loss following the end of our liability.
We will pay any other benefit due immediately afte r we receive the proof of lo ss.
Pay ment of C laim s: We wil l pay any benefits due and not assigned, to the In su red Person, if living. Otherwise, we will
pay:
a) any benefits due for a loss wh ich occurred prior to the Insured Person's death to his or her estate;
b) any benefits due to a Covered Depe ndent's loss to the Dependent.
If a be nefit due is payab le to a m in or, it will be pa id to his o r her guardia n. If a benefit due is payable to the Insured
Perso n's Depende nt and he or she die s, it wil l be paid to the Dependent's es tate. If a benefit due is payable to:
a) the Depende nt's estate;
b) a minor ; or
c) a person not competent to give valid release for payment;
we may pay up to $1,000 of the benefit due to so me other person.
The other person will be so meone related to the In s ur ed Person by blood o r marriage who we bel ieve is entitled to the
payment. We will be relieved of further re spons ibility to the exten t of any payment made in good fa it h.
If the Ins ured Person provide s us with a Written Release to do so, we may , at our option, pay benefits d irectly to the
in stitution or person rendering:
a) Hospital services; or
b) nursing, medical, or s urgical services;
unless th e In sured Perso n or the person to whom the benefit is payable requests otherwise in writing no later than the time
the proof of lo ss is filed with us.
Written Relea se mean s any wrinen direction from the In su red Person to pa y benefits to the institution or person
rende rin g the service. We wil l not require that the se rvices be rendered by a part icular institution or person.
Form SRP-1270 U (3229)
49
CLAIM PROVIS IO NS (Continued)
APPLICABLE TO ALL PLANS
Assignment: The Insured Person may assign the benefits of thi s Pol icy to th e institutio n , o r person re ndering service as
allowed in t he P ayment of Clai ms provision. The In sured Person may no t assig n the Poli cy in any other way or to any
o th er perso n.
Ph ysica l Exa min ation s : Whil e a c laim is pending we have th e right at our ex pense to have the person w ho has a loss
examine d by a Phys ic ian whe n and as often as we fee l is necessary.
Legal Actions : Legal action cann ot be taken agai nst us:
a) before 60 days fol lowin g th e date proof of loss is se nt to us;
b) after 3 year s fo ll ow ing the date p roof of loss is due.
C h anges to Medicare: Benefits are adjust ed an nu a ll y to reflect cha nges in the federal gove rnment's Medicare program.
These c hanges may cause increases o r decreases i n benefit amounts payable under the Poli cy.
T he a mount of Medicare E li g ible Expe nses covered as the res ult of an increase in o ur benefits cannot be used to satisfy
any deductible unde r the Senio r Medical In s ura nce Pl an Be nefits.
However, this in crease in benefits due to a reduction in Medicare payments will not app ly if the provider accepts
Medicare Assignment for the Medical Care.
Form S RP-12 70 V (3229)
50
THE POLICY UND ER W HIC H THIS CER T IFICA T E IS ISSUED IS
N OT A STANDA RDIZED MEDICA R E SUPPLEMENT PLAN.
CE RTIFICAT E OF SEN IO R ME DI CA L INSU RANC E PLAN BENEF ITS
Ha rtfo rd Li fe a n d Accide nt I ns u ra nce Compa ny
Ha rtfor d, Conn ec ti c ut
Po li cy ho ld e r Na me: Coun ty of F r es no
Po li cy N umb e r : AGP -3229
30 Day Ri g ht to Ex amin e Ce rtifi cate: We urge you to exa mine th is Certifi cate cl ose ly. If you a re n ot
sa ti s fied , r e turn it t o us within 3 0 d ays of th e d a t e of it s d e li ve r y. In th a t eve nt, we w ill co nsid e r it void fr o m
th e Certifi cate e ffe ctive d a t e a nd a ny p r e m ium p a id will be re fund ed t o t h e P oli cy ho ld e r . An y cl a im s p a id
will b e d ed uc ted fro m th e r efund .
No tic e t o bu ye r : The Poli cy may n ot cove r a ll of the costs assoc ia ted with medical care in c u r r ed b y yo u
durin g th e pe ri od of cove r age. You a r e a d vised to rev iew ca re full y a ll Po li cy limita t io ns conta in ed in this
ce rtifi ca t e.
R ene wabili ty : Except for ma te ri a l mi srepr esen tation , coverage un de r the Policy wi ll continue by tim e ly payment
of prem ium unt il the fir st to occur of:
a) the da te the Po licy is ca ncelled; or
b) the date th e Ins ured Person ceases to qualify withi n a class o f pe rsons e li g ible for cove ra ge und er the
Po licy .
We have issued a Polic y to th e Pol icy holder. The pro visio ns of th e Poli cy which a re importa nt to you are
s um ma ri zed in thi s Certifi ca te; cons isting of th is fo rm, the Schedul e wi t h th e mo s t rece nt effective date and a ny
additional fo rms which ha ve been made a part of thi s Ce rtifica te. Thi s Ce rt ifi ca te rep laces a ny certifica te s which
may have been give n to yo u earlier for the Poli cy. The Policy alone is th e on ly co ntrac t under whi c h pay ment wi ll
be made . Any d iffe rence be tween the Po li cy and th is Certifica te will be sett led acco rdin g to th e provi s ion s of the
Po licy . Th e Po li cy ma y be insp ec ted at th e office of th e Policyholder.
Lisa levin, Secr e tary Michael Conca nnon, President
Fo rm S RP-127 0 C RT A-B-1 (3229) S MIP
1
YO U R SCH E D UL E O F B ENEFITS S HOWS THE B ENE FITS FOR WHIC H YOU AND OR YO U R
COVER E D S POUSE A R E COVE RE D. THIS CERTIFI CAT E MAY D ESCRIB E BEN EFITS NOT
INCLUDE D IN YO U R PARTICU LAR PLAN. PL EASE C H ECK YOU R SC HE DULE O F
BENE FITS TO DETERMINE SP EC IFI C COVE RA GE U ND E R TH E POLIC Y.
SEQUENCE O F CONT ENTS
G enera l De finit ions
In s ur ed Pe rso n Peri od of Cove rage
Covered Spo use Period of Coverage
Se ni or Medi ca l Insura nce Plan Benefit s
Ex ten sion of Be ne fit s
Gene ra l Lim itati ons
Pre-E x ist ing Co nd itio n Limit atio n
General Ex cl us ions
Clai m Prov isions
GENERAL DE FI N ITIO NS
(Not A ll De finiti o ns A re A pplica ble To A Covered Person 's Co verage U nd e r The Policy, P le ase C heck Your
Sch edule Of B e ne fits)
A g e me ans a Cove red Perso n's atta ined age on any premium du e d ate .
Cale ndar Ye ar mean s a per io d of 12 co nsecut ive months, sta rti ng on Janu ary l and e nd ing on Dece mb er 3 ! of the
sa me yea r.
C onfin e d o r C onfin e me nt mean s be ing an Inpat ient in:
a) a Hos pi tal; or
b) a Skill ed Nurs ing Faci li ty with re spect to Skill ed Nursing Fac ili ty cove rage, if an y;
d ue to Sickn ess o r Inju ry .
C overed P e rson means yo u, while co vered un de r th is Po li cy or yo ur Eli g ibl e De penden t if he or she is covered
und er th is Poli cy.
Day o f C o nfine m e nt means a day of Inp at ie nt Confinem ent in :
a) a Hos p ital ; or
b) a Skilled N ur s ing Fa cili ty wit h re s pect to Skil led Nu rsing Fac il ity cover age, if any;
fo r wh ich a dail y room and board c harge is made fo r a fu ll Day of Co nfi neme nt.
H ospice Care mea ns Medi ca re approved medi cal a nd sup po rt servi ce s need ed to manage sy mp to ms and re li eve th e
pai n of a termin al i lln ess. The se rvice s mus t be prov id ed thr o ugh a Med ica re a pproved Hos pice Care Program .
Hos pice Care in clud es but is not limited to:
a) nurs ing car e, the rap ies, med ica l s upp li es and a pp liance s;
b) s ho rt -term Inpat ient res pite care ; and
c) Physic ian, ho me hea lt h a ide a nd co unse li ng se rvice s.
2
G EN ERAL D E F IN IT IO NS (Co ntinu ed)
(Not A ll De fini t io ns Are A pplica bl e T o A Cove re d Pe rs o n's C ove rage U nde r T h e P o li c y , Pl e ase C heck Your
Sc he dule O f Be ne fi ts)
H o s pita l mea ns a n in st itu tio n w h ic h:
a) is a ppr ove d by Medi ca re;
b) ope rates purs ua nt to law;
c) pr im ar il y and co nt inuous ly prov ides med ica l care an d treatme nt o n a n Inpa tient bas is for s ic k a nd inj ure d
pe rsons at the patie nt's ex pense;
d) ope rates di agnos tic a nd major s urg ica l faci lities ei th er:
I) on its pr emi ses; or
2) in fa ci lities ava ilabl e to th e Ho spita l on a pr earranged bas is;
e) opera tes under th e s up e rvi s io n of a staff of Phys icians; and
f) pr ov id es 24 ho ur nur si ng serv ice by o r un de r the s uperv isio n of reg iste red g raduate nurse s (R.N.).
Hos pita l do es not mean a ny in stitu ti on o r pa rt the reof whi ch is used pr ima r il y as :
a) a nurs in g home, co nvalescen t home, or Skilled ursi ng Fac ili ty;
b) a pla ce fo r rest, cus todi a l, educ ati ona l o r rehab il itory care;
c) a p lace for the age d; or
d) a pl ace for dr ug a dd ic ts or a lco ho lics.
H o s pita l E xp e ns es mea ns :
a) Med icare Part A Eligib le Ex pe nses for tr ea t me nt prov id ed and bi ll ed by th e Ho spi ta l;
b) a ft e r th e Life tim e Rese rve Pe riod, Hosp it a l Ex penses of the ki nd th at wo uld have bee n cove red by
Medi care had Med icare Pa rt A Bene fi ts not bee n ex ha usted.
In c urre d mea ns th e dat e a Cove red Pe rson rece ive d t he pa rt icul ar trea tm ent , se rvice, o r s uppl y th at gave rise to an
expe nse.
Injury mea ns bo di ly Inj ury o f a perso n res u lti ng fr o m acc id ent. Howe ver , Injury that oc curred pr ior to a C ove red
Pe rso n's effecti ve dat e of coverage wi ll be s ubject ro the Policy's Pr e -ex is ting Cond iti o n Limit a tion.
Inpa ti e nt me ans Co nfin e me nt in :
a) a Hosp ita l; or
b) a Sk illed ursing Faci lity w it h res pect to Sk ill ed Nu rs ing Fac ilit y coverage, if a ny;
fo r wh ich a roo m a nd boa rd ch arge is made.
Medica l C a re mea ns a ny pr ofessio nal o r outpa tient treat ment , serv ice, or s uppl y w hich is covered by Medi ca re
Pa rt B.
M e di ca re mea ns T itl e X VIII of th e Soc ial Secu rit y Act o f 1965, as a men de d.
Medi ca re E li g ibl e Expense s mea ns health care ex pe nses covered by Me di ca re to th e ex tent recogn ize d as
reaso na ble by Med ica re.
Medi ca re P a rt A Be ne fit P e ri o d mea ns a per iod of tim e during whi ch a Med ica re be ne fi c iary is Hos pit a l or
Sk ill ed N ur s in g Fac ility Con fin e d . A Medi care Pa rt A Be ne fit Period :
a) begins whe n a Med ica re bene fi ciary is ad mi tted to a Hos pita l as a n Inp at ient ; a nd
3
b) end s w he n he o r s he has no t b ee n Confi ned in a Hos p ital o r Ski ll ed Nurs ing Faci li ty for 60 c onsecutive
da ys .
GENERAL DEFINITIONS (C ontinued)
(Not All Definitions Are Applicable To A Covered Pers on's Coverage U nder The Policy, Plea se Check Your
Schedule Of Benefits)
Medicare Part A Deductible means th e deduct ib le amount w h ic h a Cove red Pers on is re q uired t o pay un der
Med icare fo r th e expe nses Inc urr ed at t he beginni ng of a Med icare Pa rt A Be nefi t Pe r iod .
Medicare Part B Deductible means the deduc t ible amoun t which a C overed Person is req uire d t o pay unde r
Med icare Pa rt B each Cale ndar Year fo r M e d icare Eli g i bl e Ex pens es.
Mental and Nervous Disorders mea n s an y ne uros is, psy chone uros is, psyc hopathy , psychosi s , o r mental o r
em oti o na l d isease o r d iso rde r of a ny kind .
Physician means any legall y q ual ified Ph ys ic ian or s urgeon o r any med ical pra ctit io ne r of t he healing a rt s who is
acti ng wi thin the scope o f h is o r her license.
Policy Benefit Period for Medicare Part A Eligible E xpe nses means a Medi care Part A Be nefit Pe r iod as
de fine d , but doe s no t include:
a) any Day of Confi ne ment before the C o vered Pe rso n's effecti ve d ate ; o r
b) a ny Da y o f Confi ne ment afte r the Covered Pe rson's terminatio n d a te, e xc e pt as sta ted in th e Ext en s io n of
Benefits p rovis ion.
Policy Benefit Period for Medicare Part B Elig ible Expen ses means a Calendar Year quarte r, but does no t
i nclude a ny period of ti me :
a ) be fo re th e Covered Pe rso n's effec tive date ; o r
b) after t he Covered Pe rs on's te rm inatio n date , exce pt as sta ted in th e Ex tension of Benefi ts pro v is io n.
Related Policy means th e Po licy ho lder's E m p lo yee Gro u p Health Pla n.
Request means wri tte n req ue s t made o n th e fo r ms we fu rn is h for mak in g th e req uest.
Sickness means a pe rs on's S ickne ss o r d isease. However, S ickness first ma n ifes ted be fore a Cove red Pers on's
effecti ve d ate w ill be s ubj ec t to t he Po lic y's Pre-exi st i ng Cond itio n Limitation.
Skill ed Nursing Facility means an ins titution tha t :
a) ope rates p urs uant to law;
b) in ad di t io n to room a n d board a ccom modations , is pr imaril y engaged in provi d ing s k ill ed nu rs in g care
und er the su pe rv is ion of a P hysician ;
c) provides continuous 24 ho ur a day nu rs in g se rv ic e by or und er the s uper vi s io n of a re gi s tered g radua te
nurse (R.N.); and
d) ma i nta ins a da il y me di cal record of each patien t.
Skilled Nurs ing Facility d oes not mea n any ins t itut ion or part thereof which is us ed ma in ly a s a home or place :
a) f or the aged , or fo r res t, c ustod ia l o r ed uc ationa l care;
b) fo r drug addicts o r a lcoholics;
c ) fo r th e t rea tm en t o f M e ntal a nd N e rvou s D iso rd e rs.
4
GENE RA L DE FI NITIO NS (Co ntinu ed )
(Not All Definition s Are Applicabl e To A Covered Person 's C ov e r age Under The Polic y, Please C h eck Your
Schedule Of Be ne fits)
Skill ed Nursing Fa cility Exp e nses means Med ica re Part A Eligible Expe nses for se rvices prov ided and billed by a
Skil led ursing Facility.
Totall y Di sabled mean s:
a) di sabled by an lnj ury or Sickness th at con tinu ous ly Confines a Covered Pe rson in a Ho s pital or Ski lied
urs ing Facility; or
b) if not Confined , co ntinu ous ly di sa bled by an Injury or Sickness which a Cove red Person's Ph ysic ian
ce rtifie s pr eve nt s him or her from engaging in the normal ac tivitie s o f a pe rso n of lik e age and sex in good
hea lth.
Us ual and C us tomary C harge mea ns the prevailing charge made by mo s t pr ov id ers o f a gi ven se rv ice in the
geographic area where the se rvice is re c ei ved . In no eve nt will the Usual and Cus tomary Charge exceed the actual
amount charged.
We, us or our mean s th e com pan y named on the face pa ge of thi s Cert ificat e.
You or Yo ur mean s the person named on the Schedule.
I NSURE D P E R O N PE RIOD OF C OVE RA GE
In s ured Perso n Effective Date : You will become covered by the Polic y on the E ffec tive Date o f the Schedule
tha t fir st s how s coverage for you .
Re quest fo r C han ge in In s ured Perso n 's Cove r age (if av ailabl e und e r th e Po lic y): If you Request to make a
change in your cove rage, the change will become effective on the fir s t day of the month after we rece ive the
Reque st provided:
a) yo u are eligible for the change requested; and
b) the required premium is paid.
If the Requ est inc reases cove rage, the amount of th e inc rea se wi II be s ubj ect to the "Pre -existing Condition
Limitati o n" prov ision.
In s ured Pers on Termin a tion : Your coverage wi ll c ea se on the fir st to occur of:
a) the date the Pol icy is cancelled;
b) the Premium Du e Date that the requ ired prem ium for yo ur cove rage is no t paid , s ubje ct to the Grace Pe riod
prov is ion ;
c) the date we or the Pol icy holder cancel cove rage for a Class of Person to w hic h yo u belong ; or
Howeve r, if yo u are e li gible for coverage und e r the Polic y becau se You are the widow/wid ower of an active or
ret ired employee of th e Policyholder, yo ur coverage will cease on the Pre mium Due Date on or next followi ng the
date Yo u remarry.
5
I NSURED P ERSO N P E RIO D OF COVERAGE (Continue d )
Individu a l G r ace Pe riod : A grace pe ri o d of 3 1 days is a ll owed for payme nt of each prem ium due a ft er t he fir s t
premium . W e will cont i nue the i ns ur ance d uri ng the g race peri od . If a Covered Pe rson Inc urs a c o ve red loss
during the g race p eri od, you w ill be liab le to us for payme nt of any pre mium accru ing during the pe riod we
conti n ue d c ove rage in f orce und e r t hi s provision. The grace peri od wi ll no t continu e coverage beyo nd a date s tated
in a T e rm ination provis io n .
COVERED S P OUSE P E RJ O D OF COVE RAGE
If you are ins ured for Spou se coverage, it w ill b e indicated o n you r S c h e dule of Be n efits .
Des criptio n o f E li g ible S p o use
Yo ur S po use w ho is e nt it led to Medicare by reaso n of Age , provi ded he o r she is not lega ll y sepa rated or
di vorced from you .
C o ve red S p o u se E ffec ti ve Da t e : Y o ur El ig ib le Spouse w ill beco me covered by t he Policy o n t he Effective Date o f
th e Schedule t hat firs t shows coverage for him o r her. If you r Sched ule does no t show an effective date for
coverage fo r your Spouse , the n he o r she is N O T covered un der the Po li cy.
Req uest fo r C h a n ge in S p o u se Cover age (if avail a ble und e r th e Po li cy): If yo u Request to make a change in
your S pouse 's covera ge, th e c h ange w ill become effec tive o n th e fi rs t day of th e mo nt h after we rec e ive th e Req uest
provide d :
a) Yo ur S po use is e li g ib le fo r t he c ha nge requested; a nd
b) the required pre mium is pa id .
If the Re quest increases co ve rage, t he a mo unt of t he increas e wi II be subj ect to the "Pre-e xisting Cond ition
Limitati o n" p rovis ion.
S p o use Cover age Termina tio n : De pe nd e nt coverage under the Po licy will cease o n t he fi rst to occur of:
a) the d a te the Po licy is can ce ll ed;
b) th e Pre mi um Due D ate t hat th e req ui red premi um fo r h is o r her coverage is not pai d, subj ect to t he Cove red
S pou se G race Pe rio d pr ovision;
c) the Pre m ium Du e Date on or next fo ll owin g t he d ate he o r she is Di vo rced from you, u n less continued in
accorda nce wi th the Spouse Cont i nu a t io n provision;
d) the date You r cove rage cea ses unde r t he Policy;
e) th e date we or th e Po licy ho lder cance ls coverage fo r a Class of Persons to wh ic h you belong.
S p o use C ontinuat io n : If a Covered S po use is Di vorced whil e covered under the Po licy, he o r s he may cont inu e
h is or he r cove rage u nde r the Po licy. We mu st receive th e Req uest and req ui re d pre m iu m to c ont in ue t he cove rage
unde r t he Po licy withi n 3 1 d ays of th e date coverage term inates.
S o le ly for the purpose of continui ng t he cove rage under th e Po li cy, your Spouse will be cons idered the In s ured
Pe rso n. Howeve r, thi s w ill no t contin ue t he c overage beyond a da te t he coverage would norma ll y cease under t he
Spo use Te rm ina t io n provis io n of the Po licy. Any coverage continued by t h is provis ion will term ina te o n t he
Pre mi um Du e Date on o r nex t fo ll owing th e date you r Spouse remarries.
Divo r ce/D ivo rced means a n nul ment , di ssol ut ion of marri age, or legal separ a t ion fr o m th e Ins ure d Pe rson.
6
COVERED S PO USE PERIOD OF COVE RAGE (Continu ed )
If yo u are in s ure d for S pou se covera ge, it will be indi ca ted o n yo ur Sc hedul e of Benefits.
Cove red pou se Grace Period : A Grace Pe ri od of 3 1 da ys is allowed fo r pa yment of eac h premium due after the
fir s t. We will cont inue the ins urance du rin g th e Grace Period. If a Cov ered Spou se Incurs a cove red loss during
the Grace Period , you will be li able to us for pa yme nt of any pre mium acc ruin g durin g the period we co ntinued
coverage in force unde r thi s pro vis ion. The Grace Per iod will no t continue coverage beyond a date sta ted in the
Termin ation provi s io n.
CONVE RS ION PRIVILEGE
APPLI CA BLE TO ALL PLANS
If a Cove red Pers on's coverage under the Polic y termin a tes becau se the Policy is cancelled and not rep laced by
ano ther group policy , he or s he will have the ri g ht to reque s t co nversion without g iving medica l evide nce of
in s urabilit y.
Th e Covered Person mus t :
a) make writte n application for co nve rs ion ; and
b) pa y the initi a l premium;
wit hi n 31 da ys after he o r s he ceas es to be cove red under the Poli cy.
The conve rs ion po lic y:
a ) will ha ve the provi s io ns, limitations and exc lu sio ns on the fo rm we are iss u ing for thi s pu rp ose at the time
of convers ion;
b) wi ll base premiu ms on o ur rates in effec t for new app lic ants of the Cove red Pers on's Age, sex and
geograph ic location at th e time of conve rs ion.
The Cove red Pe rson will be give n a c ho ice to e le ct con ve rs ion coverage whi c h:
a) provide s s imi la r benefi ts to t he Senior Medical Ins urance Plan he or s he had under th e Policy; or
b) provide s the minimum benefit s required by law for a Medicare Supp lement policy .
Conve rs ion coverage iss ued to the Covered Pers on und e r th e Conve rs ion Pri vilege beco mes effect ive on the date of
hi s or her termi na tion a nd w ill be in li e u of a ll o ther be ne fit s under the Policy.
7
SEN IO R MEDI CAL INSU RA NCE PL AN BENE FITS
HOS PITAL C O N FI NEMENT BENEFIT
No te : The Sch edule o f Ben efits a nd Am o un ts will indi ca t e th e Be nefits a pplicable t o each Cove r ed Pe r son
w hil e c ove r ed unde r the Po li cy.
Wh e n a Covere d Pe rso n is cove red un de r thi s Benefi t a nd is Co nfin ed in a Hos pita l, we wi ll pay the bene fi t sta ted
be low . Th e Con fi nement mu st be a Medi care A pp roved Co nfin e ment. A Covered Pe rso n mus t Incu r ex pe nses for
th e Co nfi neme nt whi le he or s he is cove red by th is be ne fi t.
I st t o 60th Day of Hos pita l Confinem ent: For th e fi rs t 60 Days of appr oved Confine men t during a Med ica re Pa rt
A Be ne fit Per iod , Me dica re pays a ll Hos pit al Ex penses exce pt the Med ica re Pa rt A Ded uct ib le.
We cover th e Med icare Part A Deductib le if it is in d icate d o n the Cove red Pe rson 's Sche dule of Bene fi ts and
Amo unts.
6 1st to 90th Day o f Hos pital Co nfin em ent : From the 6 1 s t to 90th Day of a pproved Co n fi neme nt du ri ng a
Me di care Part A Be nefit Per iod, Medi ca re pays a ll Hospi ta l Expe nses except a dail y Coinsu rance Cha rge eq ual to
25% of th e Med ica re Part A Dedu ctib le.
If a Covered Perso n's Sc hedu le of Benefi ts and Amounts ind ica tes cove rage for th is po rti on o f th e Benefi t, We pay
th e Medicare Part A Coi ns ur an ce C harges the Covered Pe rson Inc urs fro m th e 61 s t to 90th Day o f Con fin ement .
Lifetime Rese rv e Pe riod : Regu lar Medi ca re Hos pita l bene fit s end on t he 90th Day of Co n fi neme nt du rin g a
Med icare Part A Be nefit Peri od . Afte r th e 90th day , Me dica re gra nt s a 60 day Lifetim e Rese rve Pe ri od . These 60
a dditi ona l days ca n be used only o nce in a li fet im e. Med ica re a ll ows a pe rson the cho ice o f usin g th e days or
sa vi ng th e m fo r th e fu ture. If he or she uses the days, Med icare pays all Hos pita l Ex penses Incurred durin g the
Life tim e Reserve Period exce pt a da il y Co in surance C harge eq ual to 50% o f th e Medicar e Part A Deduc tib le.
We pay th e Med icare Part A Coi ns ur ance C harges durin g t he Life tim e Reserve Per iod. If t he Covered Person
saves the days for fut ure use , we lim it our da il y payment to 50% of the Medi ca re Pa rt A Ded uctib le.
Aft e r th e Lifetim e Re se rv e P e ri od : After the Li fet im e Rese rve Period ends (or wo ul d have e nded if used), we
will pay the pe rce ntage s hown o n You r Sc hedu le of Be ne fi ts and Amo unts o f Hosp ital Expenses In curred for each
Day of Co nfin eme nt during a Med icare Part A Benefit Pe ri od. Ou r pay ment pe ri od wi ll be li mit ed to an addit ional
365 Days of Co nfi ne ment per perso n per li fe tim e .
8
SEN IOR MEDI C AL IN SURANCE PLAN BENEFITS (Continued)
S KILLED NUR l NG FACILITY BENEFIT
No te: The Sc hedule o f Benefits and Amounts will indic a te the Benefits applica ble to eac h Covered Person
whi le covered under the Po lic y .
When a Covered Pe rso n is covered for thi s Benefit and Confined in a Skilled Nu rsing Facility, we wi ll pay the
be nefit stated below. T he Confi nement mu s t be a Medicare App roved Co nfinement. A Cove red Person must Incu r
expenses for the Confinemen t while he or she is cove red by this benefit.
1st to 20th Day of Sk illed N ursin g Facility C o nfin e ment: For the fi rs t 20 Day s of App roved Confinemen t
dur ing a Medica re Part A Be nefit Period , Medicare Part A pays a ll Skilled Nursing Facil ity Expenses.
We pay nothing fro m the I st to 20 th Day of Confinemen t.
21 s t t o I OOth Da y of killed Nursin g Facility Confinement : From the 21 st to I OOth Day of Approved
Confineme nt during a Medicare Part A Benefit Period, Medicare pays all Sk illed Nursing Facility Expenses excep t
a daily Coinsura nce Cha rge equa l to 12 1/2% of th e Med icare Part A Deductible.
If a Cove red Person's Schedu le of Benefits and Amount s indica tes cove rage fo r this portion of the Benefit,
We pay the Medicare Part A Coins urance Charges the Cove red Per son Incurs from the 21st to I OOth Day of
Confineme nt.
EXTEND E D S KILLED NU RS I NG FACILITY BEN E FIT
No te: The Sc hedule of Benefits a nd A mo unts will indicate th e Benefits appli cable to eac h Cove red P e r son
while cov e r ed under th e Po lic y.
JOi st to 365th Da y of S killed Nursin g Facility Co nfin e m ent : Afte r th e I OOt h Day of Co nfine ment during a
Medicare Part A Benefit Period, Medicare benefits for Ski ll ed Nu rsing Facility Confinements e nd . If a Covered
Perso n 's Schedule of Benefits and Amounts ind icates coverage for thi s port ion of th e Be nefit , We pay the lesse r of:
a) the daily amo unt stated in the Schedu le; or
b) the room and board ex pe nse Inc ur red;
from the 10 I st to the 365th Day of Confinement.
Medicare Approved Confin e ment : Medica re only approves Skilled Nurs ing Facility Confi nemen t that provides
ski ll ed, medically necessa ry care:
a) at a level mee ting Medicare sta ndards; and
b) commencing within 30 day s of di sc harge from a Hospital Confinement of at least 3 co nsecutive days.
Ou r benefit under this plan is li mited to those Da ys of Co nfinement which Medicare approves, or wou ld have
approved had Me d ica re benefit s fo r t he Co n finement not bee n exha usted.
9
SEN IOR M E DI CAL I NSU RA NCE PLA N BENEFITS (Continue d )
M E DI CAL CA R E B ENEF IT
Note : The S chedule of B e n e fi t s and A m o unts will indica t e th e Be ne fi ts a pplica ble t o each Cover ed P e r son
w hile c over e d under t h e P o lic y.
Aft e r the Medicare Part B Ded uct ible , M edicare p ays the percentage shown in Your Sc hedu le of Benefi ts a nd
A mo unts of Medicare Pa rt B El ig ib le Ex pe nses. T he po rt io n of a n ex pe nse whic h is more tha n M edicare con s id e rs
reasona bl e:
a) is not a M ed icare Pa rt B E lig i ble Expe nse;
b) is no t covered by Me di care; an d
c) is not covered un de r t h is benefi t.
If a Covered Person 's Sc hedu le of Benefit s and A mo unts ind icates coverage fo r thi s po r ti o n of th e Be nefi t, We w il l
pay the percentage s hown i n Your S chedule o f Benefi ts a nd Amou nts of the Me dicare Part B Eligi b le Expenses
after the M e dicar e Pa rt B De d uctibl e is me t eac h Calendar Year. T he expe n ses m ust be In curred by a Covered
Pe rso n w h ile c overed by t hi s benefi t. Expe nses a ppl ie d toward th e Med icare Pa rt B Deductible ar e not covered
unde r thi s be nefi t.
M E DI CARE P A R T B EXCESS C H A RGES BENE FIT
Note: The Schedule of Ben efit s and A mounts w ill indica t e the B e n e fits a pplicable t o each Cover e d P e r son
while c ov e red under th e P o licy .
If a Cove red Pe rson 's Sc hedul e of B e ne fit s and Amounts ind icates coverage for th is Be nefit, We wi ll pay a
pe rcentage o f t he di ffe re nce between :
a) the a ct ua l Med icare Pa rt B c ha rge a s b ill ed; a nd
b) the M e di car e a p pro ved Part B c harge;
after t he M e d ic ar e Pa rt B De duc tibl e is me t each Cale ndar Year. Ho weve r, our paymen t w il l no t exceed any
c harge li mita t io n esta b li shed by M ed icare or sta te law . The expe nses m us t be In c ur red by a Covered Perso n w h il e
cove red u nd e r th is be ne fi t.
We w ill not pay thi s benefi t if:
a) the p ro vide r of the Med ical Care acc epts Medicare assignment; o r
b) the servi ce o r su ppl y is not covere d by M ed ica re Pa t1 B.
T he Out-of Pocke t Ex pe nse A mount is :
a) s tat e d i n t he Schedul e of Bene fi ts and Amo un ts; a nd
b) a ppli es to each Covered Person each Cale ndar Year.
O nl y Out-o f-P ocket Ex p enses can be used t o me et the Out-of-Pocke t Expense A mount.
Out-of-Pocke t Ex penses means:
a) the portion o f a ny expense, covere d u nde r M edicare Pa rt B, whi c h is mo re tha n M edi care cons iders
reasonab le, up to th e Us ua l an d Customa ry C ha rg e; plus
b) expe nses used t o meet the M e di care Part B Deducti b le to t he extent t he M ed icare Pa rt B Ded uctib le is no t
covere d u nde r th e Po licy.
O ut-o f -Poc ke t Expe nses do not i nclude expe nses that a re excluded o r limi te d under t he Polic y.
Exp e nses Inc urre d During L ast 3 Mo nths of a Ca le nda r Year: If:
a) a Covered Pe rs o n Incurs Out-of-P ocket Expenses du ring the last 3 mo nt hs of a Calend ar Yea r; an d
b) tho se expe n ses are a pp li ed to h is or he r O ut-of-Pocket Ex pe nse A mo unt d uri ng the Calendar Year;
t he n, a Covere d Pe rson 's O ut-of-P ocket Exp ense A mo unt fo r the next Calendar Year w i ll be reduced by th e
a mo unt of th ose expe n ses. If a Covered Pe r son's Sc hed ule of Be ne fit s a nd A mo unts indi cat es coverage for thi s
Be ne fit, t he pe rcentage paya bl e w ill be stat ed in th e Sc hed ul e.
10
SEN IOR MEDICAL IN SURANCE PLA N BENEFITS (Continued)
PRIVATE D TY NURSING BENEF IT
During Hos pital Co nfin eme nt
Note: The Sc hedule of Benefits and Amounts wi ll indicate th e Benefits applicab le to each Cover ed Person
while cove red under th e Polic y.
If a Covered Pers on's Schedu le of Benefit s and Amount s indicates cove rage for thi s Ben e fit, We will pa y the le sser
of:
a) th e expe ns e Incurre d; or
b) the Pri vate Dut y urs ing Maximum Benefit Amount ;
for each sh ift of private duty nursi ng servi ce, up to the Ma x imum Nu mbe r of Sh ift s per Ca lendar Year.
The priv ate duty nursin g service mu s t be pr ovided to a pe rson while he or s he is:
a) cove red under th is benefit ; and
b) Confined in a Hos pita l.
The privat e duty nu rs ing services mu s t be cha rged directl y to a Covered Per son by th e N urse and not charged by
the Ho spita l.
Nurse mean s :
a) a Regi s tered Graduate Nurse (R.N.); or
b) a Licen sed Practical urs e (L.P .. );
who is not a member of a Covered Pers on's Famil y.
Famil y mea ns a Cove red Per so n's :
a) children , paren ts, s pouse, brother or s is ter ; or
b) pouse 's ch il dren, parent s, brother , or s is ter.
We will not pay for more than 3 s hift s of private dut y nur s ing se rv ice s per day . A shift co nsists of at lea st 3
consecutive hours of nurs in g ca re. Shift s of more than 3 hour s but le ss than 8 hours wi ll be paid on a pro-rata
ba s is .
The Max imum Be nefit Amou nt and t he Ma x imum umbe r of Shift s a re stated in the Schedule , if a Covered
Person 's Sc hedule of Be nefits and Amou nts indicat es cove rage fo r th is Ben efit.
M E DICARE PART B DED UC TIBL E BEN EF IT
Note: The Schedu le of Benefits and Amounts will indicate the Be n efit s applicable to each Covere d Person
while covered under the Policy.
If a Covered Pe rs on 's Schedule of Benefit s a nd Am o unt s indicate s coverage for thi s Benefit, We will pa y the
Med ica re Part B Eli gible Ex pe nses incur red by a Cove red Person us ed to sati s fy th e Medicare Part B Deduct ibl e
each Calendar Year.
The Medicare Part B Eligib le Expe nses mus t be in curred by a Cove red Pers on while he or she is covered under thi s
benefit.
11
SEN IOR MEDI CA L I NSU RA NCE PLAN BENE FITS (Co ntinu ed)
FO RE IGN T RAVE L EME RGENCY B ENEF IT
No t e: Th e Sch edule of Bene fi ts a nd Amo un ts w ill indic a te t he Be ne fit s a pplicab le to each Cove r ed Pe r so n
whil e covered un de r th e Po lic y.
Fo r e ign Trave l Em ergency Be n efit : We will pa y a perce nt age of th e expenses Incurred by a Covered Person for
Foreign Travel Eme rgency Medi ca l Treat men t if:
a) the Cove red Perso n has satis fi ed the Ca lenda r Yea r Deductible ; and
b) the fir st ex pense was Incurred within th e fir st 60 da ys of tr avel Out si de of the Un ited States.
Payment under this benefi t wi ll be limi ted to the Lifetime Max imum Benefit Amou nt.
T he Perce nt age Payab le, Deductible Amount and Lifetime Maximum Benefi t Amount are sho wn in the Sc hed u le
of Ben efi ts and Amounts if a Covered Perso n 's Schedule of Benefits a nd Amoun ts ind icates coverage for this
Bene fit.
T hi s benefit will not cove r Foreign T rave l Emerge ncy Medical Treatment if a Covered Perso n :
a) leaves th e Unit ed States primaril y to see k Forei gn T ravel Emerge ncy Medical Treatment fo r a Sickness or
Injury;
b) ha s no legal obligation to pay fo r the trea tm ent; or
c) receives the treatment du ri ng a Cale nd ar Year in which he or she travel s or res id es Out sid e of th e United
States for 6 co nsec uti ve mon th s o r lo nger.
In additi o n, thi s benefit will not cover Foreign Travel Emergency Medical Trea tm ent if Medicare app roves th e
trea tm en t (in whi ch event, the other benefits of the Plan apply).
Wh en thi s benefit is payable , no oth er benefits of th e Pol icy will be provided for any expense wh ic h is covered
under thi s Fo reign Tra ve l Emergency Medical Be nefit.
Fo re ign Travel Eme r ge n cy Medi ca l T r eat me n t mean s any medica ll y nece ss ary Con finement , serv ic e, or su pply
needed immediatel y d ue to an Injury o r Sickness of s udden and un expected onset while the Cove red Person is
O ut side of th e Un it ed States pro vide d t he sa me medical t rea tm ent, if re ceived in the United States:
a) wou ld be cons ider ed reim bu rsa bl e tr eatme nt und e r Med icare ;
b) wou ld be cons idered in ge neral use and of de monstrated va lue in th e di agnos is and treatm ent of Sickness or
Inj ury by United States Ph ys ic ians; and
c) wou ld not be cons idere d in a researc h o r ex perim ental s ta ge by United Sta tes Ph ys icia ns.
O u tsi d e o f t he United St a t es mean s o utside th e territo rial limits of:
a) th e 50 Unite d States and the Di str ict of Col umbi a; and
b) Puerto Rico , th e Virgin Is lands , Guam and Ame rican Samoa.
12
SEN IOR MEDICAL I NSURANCE PLAN BENEFITS (Continued)
FOREIGN MEDICAL TREATMENT BENEFIT
No t e: The Sc h ed ul e of Benefits and Amou nts will indicate the Benefits appli cable to eac h Covered Perso n
while covered unde r the Policy.
Fo r e ig n Medical Treatment Ben efit: We will pa y the rea so nabl e expe nse Incurred by a Cove red Perso n for
Fo reign Medical Treatmen t provided he or s he rece ive s th e firs t Foreign Medical Treatment :
a) wh ile cove red by thi s be ne fi t; an d
b) wit hi n the fir s t 180 days of trave l Outs id e of the United Sta tes per Ca lenda r Year.
Thi s bene fit wi ll be lim ited to treatment rec e ived durin g a Forei gn Medical Treatment Ben efi t period. The Foreign
Medical Trea tm ent Bene fit Period:
a) begins on th e date of the firs t Fore ig n Medical Trea tm ent; and
b) ends 90 consecutive day s later.
Th is benefit will not cover any part of a Confine me nt tha t ex ten ds beyo nd that 90 day benefit pe riod or any se rvice
or s uppl y received afte r that 90 day be nefit pe riod.
Thi s benefi t will not cover Foreign Medical Treat ment if a Cove red Perso n:
a) leaves the United Stat es prim ar il y to see k Fo re ig n Med ica l Treat ment fo r a S ickn ess or Injury;
b) has no lega l obligation to pay for th e tre atment ; or
c) receive s the treatm e nt during a Calendar Year in which he or she travel s o r res ide s Outside of the Un tied
States fo r 6 co ns ecutive mo nth s or long er.
In additio n, th is be nefit w ill not cove r Foreign Medical Trea tm en t if Medicare approves th e treatment (i n which
eve nt , the regu lar benefit s of the Sen ior Medica l Insurance Pl a n Be nefi ts app ly).
Howeve r, if:
a) a Cove red Per son mu s t re mai n Out side of the United State s more than 6 mont hs beca use of a n In jury or
Sickness that preven ts re turn to the Un ited States; a nd
b) he or s he ha s estab li s hed a Fo reign Med ica l Trea tm e nt Ben efi t Pe ri od for that Si ckn ess or Injury with in th e
fir st I 80 days o f tr ave l, as s tated abo ve;
th en , we wil l con tinue thi s be nefit for t hat Sickness or Injury unt il th e e nd of th e Fore ig n Medical Trea tm en t
Benefit Peri od.
Fo r e ig n Medical Treatment mean s any medi cally necessa ry Co nfin e ment , se rvice o r s upply received Out s id e of
the Un it ed States provided the same medical treatment , if rece ive d in th e United State s:
a) wou ld be cons idered re imbu rsable tr ea tm ent und er Medicare;
b) would be consi dered in ge ne ra l use and of demons trated va lu e in th e di ag nos is and treatment of S ickne ss or
Inj ury by United States Phys icia ns; and
c) wo uld not be considered in a research or expe ri me nt a l s tage by Un ited States Ph ys ician s .
Outside of the United St ates means outs id e th e te rritorial li mi ts of:
a) the 50 United States and the Di s tri ct of Co lumb ia; and
b) Puerto Rico, the Virg in Is lands, Guam and Amer ica Samoa.
Wh e n this benefi t is paya ble, no oth e r benefi ts of th e Pol icy w ill be provided fo r any expe nse which is cove red
under thi s Fo re ign Med ical Treatm e nt Benefit.
13
SEN IO R ME DI CA L INSU RANCE P LAN BENEFITS (Co nt inu ed)
AT HO M E RECOVERY BENEFIT
No te : The Sch e dule of Ben efit s a nd A m o unts w ill indi cate the Ben efits app li cab le to each Covered Person
w hile covere d und e r th e Poli cy.
If a Covere d Person's Physician cert ifi es t hat th e Covered Pe rson req uires the ser vices of a Care Pr ovid er for Home
re c overy f rom a S ickness, Injury or su rger y for which a Ho m e Care Pl a n of T reatm ent was app roved by M edicare,
t he n if a Cove re d Person 's Schedule of Benefits a nd A mo unts indicates coverage fo r t h is Be nefi t, w e w i ll pay the
lesser of:
a) th e expe nse Inc u rre d ; o r
b) th e A t -Ho m e Recovery M axi mum Amou nt per visit;
fo r s ho rt term A t -Ho m e R ecovery V is it s, up to the Maxi m u m Benefit Amount pe r Calendar Year.
The At-Hom e Re c overy V is its m us t be:
a) prov ide d to a pe rson wh ile he or she is covere d un der this benefit;
b) prima ril y to p rov id e services w hich assist in A cti vities of Daily Livi ng;
c) provide d o n a v is it i ng bas is in the Covered Person's H o m e; and
d) provid e d w hi le the Covered P erson is rece iv ing Medi care -approved home care services or within 8
weeks afte r t he service date of the last Medi care ho m e health care visit.
The Cove red Perso n's a tte nd ing Phys ic ian mu st cert ify that the s pec ific type and f req uency of A t-Home Recovery
s ervices a re nec essary because of a cond iti o n for wh ic h a home care p lan of treatment was a p proved by Medicare.
Thi s be ne fit w ill not pay fo r :
a) At-Home Recovery Visi ts paid fo r by Medicare o r other gove rn men t programs;
b) At-Ho me Recovery Visit s provided by fam ily me m bers, un paid vol un teers or providers w ho are no t
Care Prov id ers, as defined;
c) m o re th an the n um ber o f Med icare a p proved ho m e healt h care v isits u nd er a Medicare approved
home care p la n of treatm ent; o r
d) m o re tha n 7 vis its in a ny o ne week.
T he Maximum Amou nt per visit, the Max imum visits per week and the Maximum Benefit A m o un t a re shown in
th e Sche dule of Be ne fi ts a nd A moun ts if You a re covered for th is Be nefit.
Act iv it ies o f Dail y Livi ng mean s those dai ly acti v it ies necessa ry for a person to perfo rm i n order to fu nc ti o n
i nd epe ndently, inc luding, but not limi t ed t o, bathing, d ress in g, pe rson a l hygiene, transferri ng, eating, ambul a ti ng,
assis ta nce w ith d ru gs t hat are no rm ally self-a d m i niste red a nd c hangin g bandage s or othe r d re ss ings.
At-Ho m e Recovery V is it means the period of a vis it requ ired to provide at-ho m e recovery care, w ithout lim it o n
the duration of t he v is it, exc e pt e ach conse cutive 4 hours i n a 24 hour period of se rv ices p rovided by a care
provid e r is co ns idered o ne v is it.
Ca re P rovid er m ean s a duly qua lifi ed or licensed ho me health a ide or homemaker, personal care a id e o r nurse
prov ided t hro ugh a licensed home health care age ncy o r refe rred by a l ice nsed referral agency o r li censed nurses
regis try.
14
SEN IOR MEDICAL I NSURANCE PLAN BENEFITS (Conti nu ed)
AT HOM E R EC OVERY BENEFIT (Continued)
Ho me means a place used by the Covered Person as a pl ace of reside nce. It may be the Cove red Pe rso n's ow n
dwelling, an apartment, a relative's home , a home fo r the aged or so me ot her type of inst itu ti on, prov ided that suc h
a place wou ld qualify as a reside nce for Home Hea lth Care services covered by Medica re. A Hospital o r Skilled
ursing Facility is not considered th e Covered Pe rso n's home.
PREVENTIVE MEDI C AL C ARE BENEFIT
Note: The Sc hedule of Benefits and Amounts will indicate the Benefits applicable to each Covered Person
while covered under th e Policy.
If a Covered Person's Schedu le of Ben efits and Amounts indicates cove rage for th is Benefit, We wi ll pay the act ual
cha rges up to the Medicare approved amount for expe nses In curred by the Covered Per so n fo r:
a) an annua l c li nical preventive medica l hi story and physica l examination (which may incl ude Preventive
Screening Tests or Services) and patient education to address preventive health measures; and
b) Preventive Screening Te sts and Services, as defined; and
c) influe nza vacc in e administered at any appropriate time during the yea r; and
d) Tetanu s and Diphtheria boos ter every I 0 years; and
e) any other te sts or preventive measures determined to be app ropriate by the attending Phy sicia n .
The ex pe nses mu st be In cu rred by a Covered Per so n whil e covered by th is be nefit.
Our paymen t will be limited to th e Maximum Be nefit Amou nt per Ca lenda r Year shown in th e Schedule of
Benefit s a nd Amount s, if a Covered Perso n 's Schedu le of Benefits and Amounts indicate s coverage fo r this
Benefit.
Preventive creening Tests and Preve nti ve crvic es mean s one or more of the following, the frequency of whi c h
is cons idered med ica ll y appropriate:
a) fecal occu lt blood te st and /or di g ita l rectal exam ination ;
b) mammogram;
c) dip stick urinalysis fo r hem aturia, bacteriuria and proteinauria;
d) pure tone (a ir only) hearing sc reenin g tests, administered or ordered by a physician;
e) se rum c holestero l sc reening (every 5 yea rs);
f) th yro id fun ct ion te s t; and
g) d iabe tes sc reeni ng.
15
SEN IOR MEDICAL INSURANCE PLAN BENEFITS (Co ntinued)
HO SPICE CARE BENEFIT
APPLICABLE TO ALL PLAN S
Unde r Med icare, a terminall y ill person may elect to receive Hosp ice Care benefits instead of most regular
Medicare Part A and Part B benefits. T hen, Medicare pays all approved Hospice Care cha rges except coin surance
charges for In patient respite care, d r ugs and biologicals.
When a Covered Pe rso n elects to receive Hospice Care, we wi ll pay th e Medicare Coinsurance Charges which he
o r she Incurs.
The Hospice Care must:
a ) be approved by Medicare; and
b) be received whil e covered by thi s benefit.
When thi s benefit is payable, no o th er benefits of the Policy will be provided for any expense which is covered
under thi s Hos pice Care Benefit.
16
SE NIOR MEDI CA L I NSU RA NCE PL AN B ENE FITS (Co ntinu ed )
TH E SC HEDU L E OF BEN EFITS AND A MO UN T S WILL INDI C ATE TH E B ENE FITS APPLICA BL E
TO EACH C OV E R E D P E R SON WHIL E C OVE RED UN DE R TH E POLI C Y.
ST AT E MA N DA T E D BENE FITS
With r es pects t o in s ure d s of th e foll owin g s tates, th e fo ll owin g b e n efit s a r e add e d t o t h e P o licy and
Certifica t e:
C alifornia:
Ca ncer S creenin gs Be n e fit
W e wil l pay the Usual and C ustomary charges not cove red by M edicare fo r mammography and cervica l
ca ncer screenings Incurred by a Covered Person each Ca l enda r Y ear.
17
S ENIOR MEDICA L INSU RANCE PL AN A DDITION AL B ENEFI TS (Conti n u ed)
T HE S CH ED ULE O F B ENEFI TS A N D AMOUNTS WILL IN DI CAT E TH E B ENEFITS APPLICA BLE
T O EACH COVER ED P E R SO N WHIL E C O VERE D UN D ER TH E POLIC Y.
B LOOD D E DUCTIBL E B ENEFIT
A PPLI CA B LE TO A LL PLANS
M e dicare does not cover the first 3 pints of blood rece ived u nder Medicare Part A o r M ed icare Part B each
Cale nda r Year.
We pay the expenses a Covered Perso n I ncurs for th ese firs t 3 p ints o f blood, o r equi valent q uan t ities of packed red
b lood cell s, as defi ne d un der federa l reg u lati o ns:
a) under Me d icare P art A , exc e pt to t he exte nt be nefit s fo r the Pa rt B Bl ood De ducti b le have been pa id; o r
b) unde r M e di care Pa rt B, except to the ext ent bene fi ts for th e Part A Bl ood De duc ti b le have been pai d .
The e x pe nses m us t be Incurred whil e a Covered Perso n is covered by t hi s be n e fit.
EXT ENS ION OF B ENEFITS
A PPLI CABLE TO ALL P LANS
If a Covere d Pe rson is T otall y D isable d o n th e da te h is o r her coverage te rm i nates, we w ill e xtend the Polic y
Be nefit Pe ri o d fo r expe nses In curre d as the re su lt of t ha t d isabili ty, subj ect to a ll Po licy benefit p rovis io ns,
exclus ions, a nd li mitatio ns.
Fo r Me d ica re Part A Eli gible Expe nses: A Policy Benefi t Pe ri od for M ed icare Part A E li gible Expenses which
is esta b lis hed prio r to te r minatio n extend s un t il th e firs t to occur of:
a) the da te t he Covere d Pe rson has no t been Confined in a Hospit a l o r Skill e d Nurs ing Facility for a period of
60 co nsecut ive days; or
b) t he 365 th d ay a ft e r te r m inat io n.
If a Covered P e rson's cove rage termi nates whi le he or she is rece ivi ng a pproved Hospice Care, the Hospice Care
be nefits of t he Po licy wi ll conti n ue until t he end of the Hospice Care benefit pe ri od, as d e fined by Med icare.
Fo r Medica re Pa rt B Eli gible Expe nses: T he Pol icy Benefit Period f o r Med ica re Part B E ligi bl e Expense s
e xte nd s until th e e nd of t he Cale nda r Y ear qua rt er fo ll owi ng te rm inat io n as shown below:
T ermin ation Month
January, Fe b rua ry, M arc h
A pri l, M ay, J u ne
Jul y, A ugus t, Sep te mb e r
Oc tobe r, Novem be r, Decemb er
Exte ns ion Da te
June 30 of sa m e year
Sept em be r 30 o f sam e year
December 3 I of sa m e year
Ma rc h 3 I of next year.
GENE RAL LI MITATIONS
A P P LICABL E TO ALL PLANS
Limitatio n : If a Covered Pe rson has not e nrol led in bo th Medicare Part A a nd Pa rt B, we w ill pay the benefi ts
u nde r the Po licy as if he o r s he had e nro ll ed in both pa rts of Medi care.
1 8
EN IOR MEDICAL I NSU RANCE PLAN A DDITIO NAL BEN EFITS (Continued)
THE SC HEDULE OF BENEFITS AND AMOUNTS WILL I NDI CATE TH E B ENEFITS APPLICABLE
TO EAC H COVE R E D P E RSO N WHILE COVE RED UN DER THE POLI CY.
PRE-EX ISTING COND ITIO N LIMITAT IO N
APPLICABLE TO ALL PLAN S
Pre-existing Co nditio n mea ns any Injury or Sic kn ess for which a Cove red Pe rso n received medi ca l advice or
tr ea t men t w it hi n th e 6 mo nth peri od imm e d ia te ly befo re:
a) hi s or her effec ti ve dat e of cove rage; or
b) th e effect ive da te of an inc rease in coverage:
whic hever is app li cable.
Co nditions Prior to Effective Date : Du ring the fi rs t 6 mo nth s fr o m a Cove re d Pers on 's effective date of
in s ur ance , ex pe nses In cu rr ed fo r Pr e -ex is ting Co nd itions are not cove red.
C h a nge from a Related Policy: If a Cove red Perso n's cove rage has co nverted wi th o ut int e rruptio n:
a) fr om the Re late d Poli cy;
b) to thi s Po li cy;
we will c red it toward sati sfact ion of t he above Pr e-Ex is ting Co ndition Limitati o n the pe ri od th at he or s he was
con tin uou s ly covered by t he Re lat ed Po li cy imm ed ia tely be fo re th e co nve rs ion.
An y ex penses In c urred whi c h are payab le unde r an Exten s ion o f Bene fit s prov is io n of th e Re lated Pol icy will not
be payab le under this Pol icy.
Rep lace m e nt Cover age : If th e Cove red Person:
a) has pu rchased cove rage unde r t hi s Policy in order to re p lace coverage un de r a pr ior Med ica re
S up p le ment poli cy o r Se n ior Med ica l In s urance Pl an; an d
b) he o r s he pro vid es pro of of cove rage unde r s uch pri or Seni o r Me di ca l In s urance Pl an poli cy;
we w ill c redi t toward sa ti sfac ti o n of th is Po licy's Pre-ex isting Co ndi ti on Limit ati on the per iod th at he or s he was
co nt inuo us ly covere d by the prior Med icare upp leme nt or Se nior Me di ca l In s ur ance Pl an po li cy im med iate ly
be fore h is or her e ffec ti ve date und e r th is Po li cy.
Howeve r, i f benefi t s under t his Po li cy are greate r tha n t hose provided by the pr ior policy , t he 6 mo nth Pr e -exis ting
Co nd itio n Limi tation of th is Policy w ill a ppl y o nl y to the increased benefi ts.
Co nditions Prio r to E ffective Da t e o f In c r ea s e in Cove r age : Duri ng th e fi rs t 6 mo nths foll ow in g th e date a
Cove red Pe rso n makes a c ha nge in coverage that inc reases be nefits, t he increased po rti on of the be ne fit w ill no t be
payab le for expe nses In cu rre d du e to Pr e-existin g Condi tion s.
Thi s Limit a ti on w ill not a pply to any inc rease in cove rage due to c hanges in Me d ica re be ne fit s.
19
SE NIOR MEDI CAL INSU RA NCE PLA N BENE FIT S (Continu e d)
T he Pol icy d oes no t cover:
I. a ny e x pe nse that is:
GE NERAL EXC LUS IO NS
A PPLI CABL E TO AL L PL ANS
a) no t a M edicare Eligible Expense; o r
b) beyond the li mits imposed by Med icare fo r such expense; or
c) exc luded by na me o r specifi c descripti on by Med icare;
except as s pecifi call y prov id ed unde r t he Po l icy;
2. any portio n of a covere d expense to th e extent paid by Me dicare;
I . any be ne fits payable u nder o ne benefi t of th e Po licy to t he extent payable under a nother benefit of the
Po licy; and
4. covered expenses Incurred after coverage te rm in ates except as s ta ted in th e Extension of Benefi t s provision.
20
C LAIM PROV I IO NS
APPLI C ABL E TO AL L PLANS
Notice of C la im : The person who has the ri gh t to claim ben efits must give us written notice of a claim with in 20
days after a covered loss begins. If notice cannot be given within that time, it must be given as soon as reasonab ly
possible. Th e notice shou ld include your name and the Polic y number. Send it to the Hartford's approved Cla im s
Administrator.
C la im Forms: When we receive the notice of claim, we will send forms to the claimant for giv ing us proof of lo ss.
The forms will be sen t within 15 day s after we receive the notic e of c laim. If the fo rms are not received, the
claimant wi II satisfy the proof of loss requirement if written pr oof of the occurrence, characte r and extent of the
loss is se nt to us.
Proof of Lo ss: Proof of lo ss mu s t be se nt to us in writing wi thin 90 days after:
a) the end of each month of our liability for periodic payment claims; or
b) the date of the loss for all other claims.
If the claimant is not ab le to send it withi n th at time, it may be sen t as soo n as reasonab ly possible without affecting
the claim. The additional time allowed cannot exceed one year unless the cla imant is lega ll y incapacita ted.
Time of C la im Pay ment: We will pay any benefit due:
a) on a monthl y basis, a fte r we receive the proof o f loss, wh ile the lo ss and ou r liability continue; o r
b) immediatel y after we receive the proof of lo ss fo ll owing the end of our liability.
We will pay any other benefit due immediately after we receive the proof of loss.
Pay me nt of C laim s: We will pay any benefits due and not assigned, to you, if livin g. Otherwise, we will pay:
a) any benefits due for a lo ss which occurred prior to your death to you r estate;
b) any ben efi ts due to a Covered De pendent 's loss to the Dependent.
!fa benefi t due is payable to a minor, it wi ll be paid to hi s or her guard ian. If a benefit due is payable to your
Dependent and he or s he dies, it will be paid to the Depend ent 's estate. If a benefi t due is payable to:
a) the Depend e nt's estate;
b) to a minor; or
c) to a person not co mpetent to give va lid release for pa ymen t;
we ma y pay up to $1,0 00 of the benefit due to some other person.
The other person will be someone re lated to you by blood or marriage who we believe is entitled to t he payment.
We will be rel ieved of further responsibility to the extent of a ny payment made in good fai th.
21
CLAIM PROVISIONS (Continued)
If you provide us with a Writte n Rel ease to do so, we ma y, at our option , pay be nefits directly to the in stitution or
person rendering:
a) Hospital serv ices; or
b) nursing, medical , or s urgical service s;
un less you or the person to whom th e benefit is pay able requ es ts oth erwi se in writing no lat er th a n th e time t he
proof ofloss is filed with us .
Written Release means an y wr itten direction from you to pay benefits to the insti t ution or person rendering the
service. We will not require that the servi ces be rende re d by a part icular in stit uti on or pe rson.
Assignment : You ma y ass ign the benefits of th e Polic y to the in stit ution , or person re ndering se rvice as a llowed in
the Payment of Cla ims pr o vi sion . You may not ass ign th e Polic y in an y oth er way or to any other person.
Physical Exam ina tio ns: While a claim is pe nd in g we have the ri ght at our expe nse to hav e the pe rson who has a
loss examined by a Ph ysician when and a s oft en as we feel is nece ssary.
Legal Actions : Lega l action cannot be taken aga inst us:
a) befo re 60 days follow in g the date proof of lo ss is sent to us ;
b) afte r 3 years following the dat e proof of loss is due .
Changes to Medicare: Ben efit s are adju sted annuall y to reflect changes in the fed era l gov e rnment 's Medicare
program . These changes ma y cause increases or de creases in be nefit amounts pay ab le under the Polic y .
The amou nt of Med icare Eligib le Expen se s cov ered as the re s ult of an inc rea se in our benefits can not be used to
sat isfy any deductible under the Seni o r Medica l In s ura nce Pl an Benefi ts .
However, thi s increase in benefits due to a reduct ion in Medicare pay ments will not appl y if the pro vider accept s
Med icare Ass ignment for the Medica l Care .
2 2
HARTFORD LIFE AND ACCIDENT I NSURANCE COMPANY
Hartfo rd, Connecticut
(A stock in suranc e compa ny)
will pay benefi ts according to the conditions o f thi s Policy.
Signed for the Company
Lisa levi n, Secretary Michael Concannon, President
HIE HARTFORD GROUP R E TIR EE I URANCE POLICY (S M)
OTIC E TO B YER: This Policy may not cover all of the costs a ssociated with medical treatment and services prov ided
to the bu ye r during the period of coverage. The buyer is advised to review carefully all Policy limi tations.
This is not a s tandardized Medicare Supplement Plan .
This is a upplemental Policy on ly.
Policy holder Name : County of Fresno Policy Number: AGP-3829
Policyholder Add r ess : 2200 Tulare Street, uite 14 00
Fresno, CA 93 721
Policy Effecti ve Date: January I. 20 I I
Policy Renewal Date: Januar; 111117-12/31 /17 unless mutually agreed upon between th e Policyholder and Us.
RE EWABILITY : Except for material misrepresentation, coverage under th is Pol icy wi ll continue by timely payment of
premium until the first to occur of:
a) the date the Policy is cance lled ; or
b) the date the Covered Person ceases to qualify within a class of persons eligible for coverage under this Policy.
Accepted by
Pol icy holder
Fo rm GBD -1500 A.l
Table of Contents
c hedulc
Contract P rovisions
Incorporation Provision
1.4
Countersigned by
Licensed Resident Agent
AGP-3829
SCH EDULE -E LI G IBI L I TY
T H E SCH E D ULE OF BENEFITS S H OWS T H E BENEF ITS FOR WHI CH T H E ELIG IB LE P E R SON(S) ARE
COVE R E D. T HIS P O LI CY MAY D ESCRIB E B ENEFITS NOT I NCLU D ED I N ALL P LANS. P LEASE C H ECK TH E
SCH E D U LE OF BENEFITS T O D ETE R M I E SPECI FI C C OVE R AGE UN D E R T HJ S P O LI CY.
E li g ible P e r son : El igible Per sons a r e descr ibed be lo w.
C l ass Descr iptio n o f E li g ib le Pe r so n s
I A ll Reti rees Employees of the Policyholder who are entitled to Medicare.
2 A ll R etirees who a re covered under thi s Policy ho lder's group health plan and w ho are under age 65. Retirees in thi s
c lass are not eligible for coverage under this policy but may en roll their El igible Depend e nts
3 widow/w idowers of a deceased spouse who was a n acti ve employee o r Retiree of the Policyholder and who i s entitled to
Medicare.
E li g ible Dep e nde nts : Class I and C lass 2 El igible Persons may ap pl y fo r Depen dent's Coverage. E l ig ible Dependents are
described b elow:
Desc riptio n o f E li g i b l e S p ouse
T h e E l igible Person's Spouse w ho is enti tled to Medicare, provided the spo u se is not legally separated o r divorced from the
Eligible Person .
Spouse wi ll include the El igible Perso n 's domes ti c p artner, provided he o r s he h as executed a Domestic P artner Affidavit
satisfactory to Us, establi s h i ng that t h e E li g ible Person a nd h is or her partner are domestic partners fo r purposes of th is P olicy.
The Eligible Person and s u ch domes ti c partn er wi ll continue to be considered dom estic partners p rovided th ey continue to
meet th e requirements described in t h e Do mes ti c Partner Affidavit.
E l igi bility R estrictio n s : The E li gible Person mu s t enroll fo r coverage under e ith er thi s Policy o r th e Related Policy in order to
enrol l for Depe ndent 's Cover age.
I f a hu s b and a nd wife are both E ligible Persons, only one may apply for Insured Person Coverage with the other covered as a
Dependent o nl y. A Dependent's Pl an Benefits must be the same as, or less th an, the El igible Person's Benefit P lan. However, thi s
lim itation w ill not apply i f the E l igible Person is covered by the Related Pol icy.
In no event wi ll a person be eligible fo r coverage under th is Pol icy if he or she:
a) is engaged in acti ve employm ent or is the Dependent of a person e ngaged in active employment, and is covered by an
employer's health plan w hich is primary payor to Medicare; or
b) is covered by Medicaid; o r
c) has other coverage in force th a t sup p lements Medicare or which provides coverage for h is o r her hospit al or medical
exp ense; or
d ) is not covered by Medicare.
E nro llment Per io d : Each E ligible Person must enroll fo r cover age under this Po l icy during an enrollment period.
The in iti al e n rollment period w i ll be a 30 consecuti ve day peri od, establis hed by mutual agreement with the Policyholder. We m ay
establis h la ter period s of open en ro llm ent by mut ual agreement wi th the Policyholder, but not more often than once in a 12 mont h
period .
Persons who become eligible for coverage after t he enrollment period must e nroll for coverage during the 30 consecutive days
fo ll owing the d ate th ey fir s t become Eligible Persons.
Form GBD-1500 B. I 2
SC H E D LE-B E EF ITS AN D A MOUN T S
TH E C H E D U L E O F B ENEF I T S SHOWS H I E BENEFI TS FOR WHI C H TH E ELI G I BLE PE RSO N(S) AR E
C OV E R E D . TH I S POLI C Y MAY DE SC RIBE B E EFITS 'OT I C L O ED 11 A LL PLAN . PLEASE C H EC K THE
SC H E D LE O F B ENE F ITS TO DETE RMI E SPECIFI C C O VE RA G E D ER T I-l l S POLI CY.
Be n e fi t s a nd A m o unts : A Covered Person ·s plan \\ill be the one plan that the E l igible Person elected from the Schedule as
shown below and on t he follow ing page(s). The election must be in accordance with the Eligibility provisions and a ll othe r terms
of thi s Policy.
B E EFI T
Hospital Confinement Bene fi t
Day of Confinement
I " to 60'h Day
6 1 '' to 90'h D ay
91 "-150'h D ays ( Li fet imc R eserve Period)
A fl c r Li fctime Reser ve Pe ri od
killed ursing Facility Benefi t
Day of Confinement
21 " to IOO'h Day
Outpat ie nt Medical Expenses per Calendar
Year
Medicare Part B Deducti ble B enefit
Medical Care Coi nsurance (20% Medicare
Part B Eligible Expenses)
Form G I)D-1 500 C.2
PLAN B E EFI T S
A MOU NT PAYABL E
I 00% of the Medicare Part A Deductible
I 00% of the Medicare Part A Coinsurance charge per day (Coinsurance
charge is equal to 25% of Medicare Part A Deductible)
I 00% of' the Medicare Part A Coinsurance charge per day (Coinsuran ce
charge is equal to 50% of Medicare Part A Deductible)
I 00% of ll osp ital Expenses Incurred for each Day of Confi neme nt for a n
additional 365 Days of Confi nement per lifet ime
I 00% of the Medicare Part A Coinsurance charge (Coin surance charge is
equal to 12 !h % of Medicare Part A Deductible)
I 00% of Med icare Pa rt B Deductible
I 00% of Med icare Part B 20% Coinsurance
J
BENEFIT
Fo re ign T r avel E mergency
Outpati ent Medical Care Excess
Hos pi ce Care Bene fit
B lood D educt ibl e B enefi t
State Situ s M a nd ate Benefi t s
Fo rm G BD-1500 C.3
SC HED UL E -BENEFITS AN D AMOUNTS (Con tinued)
Additi o nal Plan Benefits
AMOUNT PAYA BL E
80% of t he Foreign T ravel Emergency Medical Treatment Expense
Deductible Amount: $250
Li fetime Max imum Benefit A m ount: $5 0 ,000
100% of the di ffe re nce between the act ua l Med icare Part B charge a s b illed and
the Medicare a p proved Part B charge.
T he coins urance fo r In patie nt respite care, drugs, and b iologicals fo r a ll Med icare
ap p roved Hos pice c ha rges
Firs t 3 pints of b lood u nder M edi care Part A and Medicare Part B
See Benefi ts in the G RI P A ll State R ider PA-9243
4
SC H E D U LE -PR E MI U M S
Indiv idu a l Premiums: P remiu m s fo r each Covered Person arc stated below.
The premiums stated in t h is section are for month I) periods of coverage. cmi -annual premiums are 6 ti mes and annual premiums
are 12 times those stated. I f a p remium becomes due fo r a different period of time. it will be determined pro rata.
Individua l Plan Be n e fit Mo nthly Pre miums
$239.95
*A $13.95 per person per mon th administrative fee for services which include but are not limited to bil ling, enrollment, claims
payment and customer ser vice is included in the per per son per month premium.
Covered Person Premium Du e Dates : T he first premium for each Covered Person is due on the date he o r she becomes covered
unde r this Policy. Each P remium after the initial premium is due at t he e nd of the period fo r w h ich his or her p receding premium
was paid.
Grace Period : Aficr t he initial premi um . a g race per iod of3 1 days from the Covered Pe rson's Premium D ue Date is allowed each
Ins u red Per son for payment of each p r emium due afier his or her initial premi um. A Covered Person's coverage w ill be contin ued
du r ing the g race period. I f he or she Incurs a covered loss during the g race per iod, the I nsured Person will be liable to Us for
payment of any premium accruing during the period We continued coverage in force under this provision. The grace per iod will
not continue coverage beyond a date stated in a Termination provision.
Po li cy Premium : The premium for th is Policy is the sum of Ind ividual Premiums for each Covered Pe rson .
Policy Premium Due Dates: Th is Policy Premium is payable on:
a) the Po l icy Effective Date; and
b) the I" day of each month thcrcaflcr, with respect to each Cover ed Person \\hose premium becomes due on such date.
subject to the Grace Period provision.
Each Policy Pre m ium is due on o r in advance of the date it becomes payable. This Policy terminates on the last day of the period
for wh ic h premiu m is paid. s u bject to the grace period.
Form GB D-1 500 D . I 5.4
SC H ED ULE-PR EMIUM S (Continued)
Po lic y P re mium P ay ment: The Pol icy Premiums are to be paid to Us by the Pol icyholder. However, they may be paid to Us by
any o ther perso n accord ing to a mut ual agreem e n t among t he o t her person, th e Pol icy holder and Us.
C hange of Polic y P re miums : We hav e t he right o n any premium due date to change the rate at which futu re premi ums w i ll be
calculated . T his includes t he r ight to change premium rates for a benefit that applies to all indi viduals of the same class a nd
geographi c location .
Rates may be changed based o n :
a) changes in Medicare;
b ) the c la ims experience of thi s Policy;
c) state or fed eral legis lation affecting h ealth in s urance coverage with w hi c h t his Policy must comply; or
d) t he ex p erience of a ll g roups o n which We write group reti ree medical coverage providing simi la r Plan B e nefits.
We wi ll g ive the Pol icyhold er advan ce w r itten notice of any c hange in prem ium rates a t least 30 da ys prior to the Prem ium Due
Date o n wh ich the c h ange is to become effecti ve.
Policy ho lder Grace Pe ri od P rovis io n : A grace period of 3 1 days is allowed for payment o f each premium due after the fi rst
un less th e Pol ic y is cancell ed o n or before the due dat e. This Policy wi ll continue in force during t he grace period. The
Pol icyholder is li a b le to Us for the payment of premium acc r uing for t he period this Po li cy continues in force .
Form GB D-1500 D.2 6
CO TRACT P R OV IS IONS
E ntire C ont ract : The enti re contract between the Po li cyholder a nd Us consists of this Policy and any forms made a part of this
Policy at issue.
All statements made by the Policyh older o r the Covered Person will be deemed represen ta t ions and not warra nties. No statement
made to effect this in s urance wi ll:
a) 'oid the in s urance; or
b) reduce benefits unless it is in writing and signed b) the Policyholder or the Covered Person .
C h a n ges : We reserve the right to m ake c ha nges in th is Policy. We w ill give the Poli cyhold e r 30 days advance w ri tte n notice of
any c h an ge.
No agent has authority to c h ange or waive any part of this Policy. To be valid. any change o r waiver must be in w ri ting. approved
by one of Our officers and made a part of thi s Pol icy .
T im e P e rio d s : A II periods begin and end at 12 :0 I A.M .. Standard Time at the place w here t his Po li cy is delivered.
Certifi cat es : We wil l give indi v idual Cert ifi cates to:
a) the Policyholder; o r
b) any o th er person according to a mutual agreement among the other pe r son, the Policyholder a nd Us;
for delivery to each In sured Person.
The Certificate s will s tate the fea tures of this Policy that a re important to each Covered Pe rson .
30 Day Ri g ht t o Exa mine Certificat e : The Insured Person ha s a 30 day right to examine his or her Ce rtifica te. I f the Insured
Pe rso n is no t sati sfied , h e o r she may re t urn it to Us w ithin 30 days of the date of its delivery. In that event, We w ill consider it
void from the Certificate effective d ate a nd a ny p remium p a id wi ll be refunded to ei t he r the Pol icyho lder or Insured Person . Any
claims paid will be deduc ted from the refund .
Da t a F u r nish ed b y Po li cyh o ld er: The Po lic) holder. or any other person designated by the Po licy holder. may keep the important
insurance reco rd s on all Covered Persons. The Polic) holder o r it s designee mus t gi ve Us info rmation. when and in the manner We
ask. to admin is ter th e insurance provided by thi s Po licy.
The Pol icyholder o r designee will, upon Our reques t , give Us:
a) t he names o f a ll pe rsons init ial ly e li gible;
b ) th e name of all add iti onal person s who become eligible;
c) the names of all Covered Persons;
d ) the names of all persons whose benefit is to be changed;
e) the names of a ll persons whose ins urance is cancelled; and
f) any data necessary to calculate p remiums.
The Po licyholder's failure to:
a) gi ve Us the name of any Covered Person w ill not in valida te such person's in surance; or
b) report a Covere d Person's te rmination of in s urance wi ll not continue coverage beyond the date of term inatio n .
The Policyholder's ins urance records will be open for Our inspection at a ny reasonable time.
Form G BD-15 00 G. I 7
C O N TRA C T PROVISIONS (Co ntinued )
C lerical Error: Clerical erro r (whether by the Polic y ho lder, t he Third Party Administrato r, o r Us) in keep in g t he records hav ing
to d o wit h this Po lic y, o r del ays in makin g entries o n the re cords, wi ll not vo id the insura nce o f any person if th at in sura nce wo ul d
othe rwise ha ve been in effect. Such clerica l error will not extend the in sur a nce of a ny person if that in surance would oth erwise
ha ve ended or bee n reduced as pro vided by this Poli cy.
When a clerical er ror is found , p remium s an d benefits will be adj usted ba se d on the true fa c ts and t his Policy.
Policy C ancellation : otice of Pol icy cancellati o n ma y be provided at any tim e by wr it ten no ti ce sent by Us to the Policyholder
or by the Pol icyho ld er to Us. I f We can cel , We will del ive r the no tice to the Po li cy ho lde r at its las t ad d ress s hown in Our records.
If We ca ncel, it becomes effec tive on the lat er of:
a) the date stated in t he noti ce ; o r
b) the 31 st day aft e r We mai l or deliver the noti ce (6 0 da ys in New Jers ey).
If the Po licy ho ld er ca ncel s, it becomes effective o n th e later of:
a) the date We rece ive the no ti ce ;
b) the date stated in t he noti ce; o r
c) t he 3 1s t d ay afte r the noti ce is del ive red.
In either event:
a) We wil l promptly return any unearned premium paid; o r
b) th e Po li cy holder w ill promptly pay any earned premium that has no t been paid .
Any earned or une arn ed premium wi ll be d etermined on a pro rata basis.
Cancellation wil l be with o ut preju dice to any cla im t hat or igi nated prior to the effectiv e d a te o f th e cancellat io n.
Not in Lieu of Worker's Co mpensation : Thi s Policy does not sa tisfy any requ irement for worke r's compe nsatio n insuran ce.
Conformity with Law : I f a ny prov isio n of t his Po li cy is co ntrary to the law o f the jurisdicti o n in whic h it is delivered , s uch
pro vis io n is he reby a me nded to con form to that la w.
Form GBD -1 500 0.2 8
I NCORPORATION PROVISIO
The Certificate(s) of In surance and Riders listed below are attached to , incorporated in and made a part of th is Policy.
Certificate of In surance Applicable to: Effective Date of Incorporation
GBD-1500 CRT All Eligible Persons January I. 20 I I
The p rov is ion s listed below are shown in the Ccrtificate(s) of In surance and are hereby incorporated int o and made a part of this
Policy.
r:orm GBD -1 500 II. I
General Definitions
Insured Person Period of Co verage
Covered Dependent Period of Coverage
Conversion Privilege
Ben efits
tate Mandates and Exceptions Provision
Eligibility for Payment of Benefits
Extension of Benefits
General Limitation
Pre-existing Conditions Limitation
General Exclusion
Claims Provisions
Riders (if any)
9
THE POLIC Y UNDER WHICH THIS CERTIFICA TE IS ISSUED IS
N OT A STANDARDIZED MEDICA RE SUPPLEMENT PLAN.
THE HARTFORD GROUP R ETIREE I NSURANCE PLA N (s m )
CERTIFI CAT E OF PLA N B ENEF ITS
Hartford Life and Accident Ins urance Company
H a rtfo rd, Conn ecticut
Policy holder Name: County of Fre n o
Policy Number: AGP-3829
30 Day Ri g ht to Exa mine Ce rtifica t e: W e urge you t o examin e this Ce rtifica t e closely. If yo u a re not satis fied ,
return it to Us within 30 days of the date of it s delivery. In that event, We will consider it void fro m the
Certificate effective date and any premium paid will be r efund e d to th e P olic y holder. Any claims paid will be
deducte d from the refund.
Notice to buyer: The Policy may not c over a ll of the costs associat ed with m edical care Incurred by yo u during
the perio d o f coverage. Yo u are advised to review carefull y a ll Policy limitatio n s contained in this certificate.
RENEWABILITY : Exce pt fo r m a te ria l m is rep re se n tation, coverage un der t he Poli cy w ill cont in ue by time ly
paym e nt of pre mi um u ntil th e firs t to occur o f :
a) th e da te th e Po li cy is ca ncell ed; o r
b) th e d ate the you o r your d e pende nt s ceas e to qualify wi thi n a class o f perso ns e ligib le for coverage unde r th e
Po li c y .
We have is sued a Po li cy to the Poli cyho lde r. The provis ions of the Po li cy wh ich a re im p orta nt to you are s ummar ized
in this C ertific ate; cons is tin g of thi s fo rm , the Sched ul e of Bene fit s an d Amo un ts w ith t he most recent effe c tive da te
a nd a ny add iti o na l fo rms w hi c h have bee n made a part of th is Cert i fi cate. This Certi fi cate replaces a ny certifi cates that
m ay have be e n g iven to you earlie r fo r t he Po li c y . T he Po li cy alone is the onl y contract under w h ich payme nt w ill be
made . Any differe nce be tween the P o li cy a nd th is Cert ifica te w ill be settled accordi ng to th e provisions of the Po li c y .
The Po li cy may be i ns pected at the o ffi ce of t he Policyho lder.
S ig n e d fo r the Compa n y
Lisa Levin , Secre tory Mic h a el Co ncannon , President
Form GBD-1500 C RT A. I
YOUR SCHEDULE OF BENEFITS AND AMOUNTS SHOWS THE B ENEFITS FO R WHIC H YOU AND/
OR YOUR C OVE RE D DEP EN DEN T ARE COVER E D. THIS CE RTIFI CATE MAY DESC RIB E B ENEF ITS
NOT I NCLUDED I N YOU R PARTICU L A R PLAN. PLEASE C H ECK YO UR SCHE DU LE OF BENEFITS
AND AMOUNTS TO DETERMI NE SPEC I F I C COVERAGE UN DER T H E POLICY.
Fo rm GBD-1500 B. I
TABLE OF CONTENTS
Gene ra l De finiti o ns
Ins ured Perso n Pe ri od of Cove rage
Covered Dependent Period of Coverage
State Man dates a nd Except io ns Provisions
Eli gib il ity fo r Pa yme nt of Be nefits
Exte nsio n o f Be ne fi ts
Genera l Li mita ti on
Pre-existing Co nditi ons Limit ation
Ge nera l Ex cl us ion
Cla im s Pr ov isions
2
GENERAL DEFINITIONS
NOT ALL DEFI N ITIONS ARE APPLICABLE TO A COVER E D PERSON'S COVERAG E UN DE R THE
POLI C Y. PLEA SE C H EC K THE SC H EDULE OF BENEFITS.
Age mea ns a Covered Perso n 's attained age o n any premium due date.
Calendar Year mea ns a period of 12 co nsecutive month s, s tarting on January I a nd endi ng on December 31 of th e
sa me year.
Calendar Year Deductib le mean s the amou nt of Eligible Expe nses th at eac h Covered Person must In cu r before any
be ne fit s are paid by Us during a Ca le nd ar Yea r. Expen ses In curred to sati sfy th e Medicare Part A Deduct ibl e a nd
Coinsurance do not apply to th e Calenda r Year Deductible. T he Ca lendar Year Deductible is shown in the Schedule of
Benefit s and Amount s.
C hild , C hildre n means Your unmarried children, step chi ldren . and legall y adop ted ch il d ren w ho, are primaril y
dependent on You for su pport and ma int enance and who are entit led to Medicare by reaso n o f disability.
Th e term Children will a lso include any ot her ch il dren re lated to You by b lood or marr iage or dom est ic partne rship
and who:
a) li ved with You in a regul a r paren t-ch ild re lationship; and
b) we re e li gib le to be claimed as dependent s on Your federa l income tax return.
Confined, Confi nes, or Co nfine m ent means being an Inpatient in:
a) a Hosp it a l; or
b) a Skilled N ur s in g Facili ty wi t h respect to Skilled Nurs ing Faci lity cove rage, if a ny;
due to Sic kne ss or In jury.
Cove re d P e rson mean s an Eli g ible Person or El ig ible Dependent wh ile cove red under the Po li cy.
Day of Confin e me nt me a ns a day of Inpatient Confinemen t in:
a) a Hosp it a l; or
b) a Skilled ursing Fac ility with respect to Ski ll ed N ursing Facility coverage, if a ny;
for which a daily room and board charge is made for a full Day of Confine men t.
Hos pice Care mea ns Med icare approved medical and s uppor1 se rvices needed to manage symp toms and re lieve the
pain of a terminal illn ess. T he services mu s t be provided through a Medi ca re ap pr oved Hospice Care Program.
Hosp ice Care in c ludes but is not limi ted to:
a) nursing ca re, therapie s, medical s upplies a nd ap pli ances;
b) s hort-t erm Inp ati ent respite ca re; and
c) Ph ysic ian, home health a ide and cou nse ling serv ices.
Form GBD-15 00 CRT C. I 3
GENERAL DEF INIT IONS (C ontinu ed)
NO T ALL DEF INIT IONS ARE AP PLICABLE TO A COVERED PERSON'S COVERAGE UN DER THE
PO LICY . PL EASE CHECK T HE SCHEDULE OF BENEFITS .
Hosp ita l mean s an institution whi ch:
a) is approved by Medicare and ha s ag reed to parti ci pate in Medic are;
b) operates purs uant to Jaw ;
c) primari ly and co ntin uo usly pr ovi de s medi ca l care and trea tm ent on an Inpatient basis for sick and
injured pe rsons at the patient's expense ;
d) operates diagnostic and major s ur g ical facilities eith er:
I) on its premi ses; o r
2) in faci litie s ava il able to the Hospital on a prearrange d basis;
3) operates und er the sup ervi sion of a staff of Ph ys ician s; and
e) pro vid es 24-hour nurs ing serv ic e by or under th e su pervision of regi s tered grad uate nurses (R.N.).
Ho spita l do es not mea n any in stitution o r part the reo f that is used primaril y as:
a) a nu rsi ng hom e, convale sce nt home, or Skilled N ur si ng Facility;
b) a place for res t, custodial , educational or rehabilitor y care;
c) a place for the age d ; or
d) a pl ace for alco holi sm or drug addiction.
Hospita l Ex p e nses mean s:
a) Medicare Part A Eli gible Exp en ses for tr eatme nt provided and bi ll ed by the Hospital;
b) after th e Lifetim e Reserve Peri od, Ho spital Ex penses of the kin d th at would have bee n cove red by Medica re had
Medicare Part A Be nefit s not been ex hau sted .
In c u r re d mean s th e date a Covered Person rece ived the parti c ular treatmen t, serv ice , or su ppl y th at gave ri se to an
expe nse.
Inj ury me ans bodil y Inju ry res ul ting:
a) directly from an accident ; and
b) indep endent ly of a ll o th er ca use s;
which occurs whil e Yo u or Your Dependents are covered under the Poli cy.
Loss re s ulting fr om:
a) Sickness or disease, exce pt a pu s-forming in fect ion tha t occ ur s through an accide nt al wo un d; or
b) medical or s ur gica l tre atme nt of a Sickness or di seas e ;
is not cons idered as resulting fr om Injury.
Inpatie n t mea ns Co nfi nement in :
a) a Hos pita l; or
b) a Skilled Nursing Facili ty with re s pect to Skilled N urs ing Facil ity coverage, if any;
fo r which a room a nd board charge is mad e.
In s ured Pe rson means an Eligibl e Person wh il e he or s he is cove red by t he Pol icy.
Medica l Care mean s any profess iona l or outpatien t treatm ent , serv ice, or supply th at is cove red by Medicare Part B.
Medica re means Titl e XVIII of the Social Secu rit y Act of 1965, as amended.
Medicare Eligi bl e Expenses means hea lth care expe nse s covered by Medi care to t he extent recogni ze d as reasona ble
by Medicare .
Form GBD-1 500 CRT C .2 4
GENE RAL DEFI NITIONS (Cont in ued)
NO T ALL DEFINITIO NS ARE AP PLI C ABLE TO A COVERED P E RSON'S C OVERAGE UN DE R THE
POLICY. PLEASE C HEC K TH E SC H EDULE OF BENEF IT .
Medicare P art A Benefit Period me ans a period of time du ring which a Medicare benefic iary is Hospi tal or Skilled
N urs in g Fa c ilit y Confined. A Medicare Part A Benefit Period:
a) begin s w hen a Medicare benefi c ia ry is adm itted to a Hosp ital as an Inp a tient; and
b) ends when he or s he has not been Co nfin ed in a Hosp ita l or Skil led Nu rs in g Facili ty for 60 co nsecutive days .
Medicare Pa rt A Ded uctible means th e deduc tible amou nt that a Cove red Person is required to pay under Medicare for
the expenses In c urred at th e beginning of a Medicare Part A Ben e fit Period.
Medicare Part B De ductible mean s th e deductib le amo unt th at a Covered Person is required to pa y under Medicare Part
Beach Ca lendar Year for Medicare Eligib le Expenses.
Mental and Nervou s Di sorders mea ns any neurosis, psyc honeu ros is, psyc hopath y, psychosis, or menta l or e motional
di sease or di sorder of any kind.
Ph ys ici a n means a perso n who is:
a) a doctor of med ic ine , osteopath y, psychology, or other le ga ll y qualified practit ione r of a healing arts th at We
recognize or are required to rec ognize;
b) licensed to pract ice in the j uri sd icti o n where care is being given;
c) pract ic in g with in the sco pe of that licen se; and
d) not related to an In s ured Perso n by b lood or marriage or a dome stic partner o f a Covered Pe rson.
Policy Benefit P e ri od for Medic a r e Pa rt A Eli g ibl e Expe nses means a Medi care Part A Benefit Period as defined, but
does not include:
a) any Day of Co nfinement before the Covered Pe rso n· s effect ive date ; or
b) any Day of Confineme nt aft er the Covered Pe rson 's termination date, except as s tated in the Ex tensio n of Benefi ts
provi sion.
Polic y Benefit Pe riod fo r M edicare Part B E li g ible Ex pe nses mean s a Calendar Ye a r, bu t does not in clude any period
of time:
a) before the Covered Perso n 's e ffe c tive da te; or
b) a fter t he Cove red Person 's termin at ion da te, except as sta ted in the Extension of Benefit s prov isio n.
Related Polic y mean s th e Po li cy ho ld e r 's Employee Hea lth Plan.
Request mean s written request made on the form s We furni s h fo r making the req uest.
Retiree mean s a forme r employee of the Poli cy holde r: a) who is participating in a n Emp loye r-sponsored pe nsion plan.
Form GBD-150 0 CRT C.4 5
GENERAL DEFINITIONS (Continued)
NOT ALL DEFINITIONS ARE A PPLICABLE TO A COVERE D P E RSON'S COVERAGE UNDE R THE
POLICY. PL EASE C H ECK THE SCHEDULE OF BENEFITS.
S ickness means a perso n's sickness o r disease . Ho weve r, s ickness first manifested before a Covered Pe rson 's effective
date wi ll be s u bject to th e Pol icy's Pre-ex isting Condition Limitation.
Skilled Nursing Facility mean s an ins titution that:
a) o perates pursuant to law;
b) in addition to room and board accommodatio ns, is pr ima ril y engaged in provid in g skill ed nurs ing
care under th e s upervi s ion of a Phys ician;
c) provides continuous 24 hour a day nurs ing se rvi ce by o r under the supervis ion of a registered
graduat e nurse (R.N.); and
d) ma intains a daily medical record of each pat ie nt.
Ski ll ed Nursi ng Facility does not mean any in stitution or part thereof that is used ma in ly as a ho me o r place:
a) for the aged, o r for rest , custodia l or educat ional care;
b) fo r a lcoholism and drug addiction;
c) for the treatment of Mental and Nervous Di sorders .
S killed Nursing Facility Expe n ses means Medicare Part A E li gible Expe nses fo r se r vices provided a nd bill ed by a
Skilled N ur s in g Facility.
S pouse means Your wife or husband w ho was not legall y separated or divorced fr om You. Spouse wil l incl u de Your
domesti c partner, provided You have executed a Domes t ic Partner Affidavit acceptable to Us , establishing the You a nd
Your partner a re domestic partners for purposes of the Policy. You will continue to be cons idered domestic partners
provid e d You continu e to me et the re q u irements described in th e Domestic Partner Affidavit.
Totally Di sa bl ed means:
a) di sabled by a n Injury o r Sickness th at continuous ly Co nfine s a Covered Pe rson in a Hos pital o r Skilled Nursi ng
Faci li ty ; or
b) if not Confined, continuously di sabled by an Injury o r Sickness which a Covered Person's Phys ician certifie s
prevents h im o r her fro m engagin g in the normal activities of a person of like age a nd gender in good health.
Us ual and C u s tomary C harge mean s the prevaili ng cha rge made by most provid ers of a given service in the geograph ic
a r ea whe re the service is received . In no event will the Usual a nd Customary C harge exceed the actua l amount c harged.
We, Us, or Our means the ins ura nce company named o n the face page of this P olicy .
Fo rm GBD-1 500 CRT C .4 6
I NSU R ED PER ON PER IO D OF COVERAG E
In s ured Person Effec ti ve Da t e : An Eligible Person will become covered by the Policy o n the later to occur of:
a) the Policy Effective Date, if he or s he e nr olled prior to the Policy Effec tive Da te; or
b) the Pol icy Effec ti ve Date if We receive his or her Reque st for coverage prior to the Policy Effective Date; or
c) the fi rs t day of the month on or next fo ll owing the da te he or s he becomes an Eligible Person; o r
d) the first day of the mo nth after We rece ive the Reques t, if it is received at any other time ; or
e) with respect to a n Eligible Pe rson who attained Age 65 whi le cove red by the Re lated Policy, the date stated in
th at Policy's Convers io n provisio n;
subjec t to pa yme nt of the required pr emiu m.
Requ es t fo r C ha nge in In s ured P er so n 's Cove r age (if ava il able unde r this Po li cy): If th e Insured Person Req uests to
make a cha nge in coverage , the cha nge will become effective on the first day of th e mo nth after We receive the Request
prov id ed:
a)
b)
the Ins ured Perso n is eligible for the change reque s ted ; and
the requ ired premium is paid.
If the Request increases cove rage , the amount of the increase wi ll be subject to the Pre-exi sting Condition Limitat io n
prov ision.
In s ured Pe r so n Te rmin a ti o n : The Insured Person's coverage und e r the Policy wil l cea se on the first to occu r of:
a) th e date t he Pol icy is cancelled ; or
b) th e premium due date th at the required premium for hi s or her cove rage is not paid , s ubject to the Grace Pe ri od
pr ov is ion ; o r
c)
Howeve r i f th e Ins ured Pe rso n is e ligible for coverage under the Po li cy because he or she is the wid ow/w id owe r of an
ac tive employee of the Pol icyholder. The In s ur ed Person 's coverage will cease o n the Pre miu m Due Date on o r next
follow in g th e date he or s he remarries.
G r ace Pe ri od : A grace pe ri od of 31 day s is al lowed for payment of each premium du e after the first premi um . We will
continue th e in s urance during the grace period. If an In s ured Pe rson Inc urs a covered lo ss during the Grace Period , the
Policyholder wi ll be li able to Us for payment of any prem ium accruing dur ing the period We cont inu ed coverage in fo rce
under th e provi sion. The Grace Pe r iod will not continue coverage beyond a date stated in the Insured Person Te rm inat ion
Provi s ion.
Form GBD-1 50 0 CRT D.l 7
COVERED DEPENDENT PERIOD OF COVE R AGE
DEPENDENT COVERAGE WILL BE I ND ICATED ON THE SCH EDULE OF B ENE FITS, IF APPLICAB L E. IF
THE SCH E D ULE DOES NOT S HOW AN E FF ECTIVE DATE FOR COVERAGE FOR THE DEPENDENT,
THEN HE OR S H E IS NOT COVER E D UNDE R THIS POLICY.
Cover ed Depend e nt E ffective Date: An El igible Pe rson's Dependent w ill become covered by the Po licy o n:
a) the Policy Effective Date, if We receive the El ig i ble Person's Request fo r the Dependent 's coverage prior to the
Policy Effecti ve Date;
b) the firs t day of the month afte r We rece ive the Eli g ib le Pe rson's Request for the Depe nd ent's coverage if it is
rece i ved at a ny o the r time; or
c) w ith respect to a De pendent w ho attai ned Age 65 whi le covered by the Related Policy, the date stated in that
Policy's Conversion provis ion;
s ubject to payment of the requ ired prem ium .
However, in no event will a Depe ndent become covered under the Policy:
a) before the date he o r s he qualifies as an Eligible Depende nt; or
b) before the Eligi ble Person's effective date of coverage under either the Poli cy or th e Re lat ed Policy.
Req uest for C hange in Depe ndent Coverage : If the Ins ured Person Requests to make a change in Dependent 's
coverage, the c hange will become effecti ve on the first day of the month after We receive the Request provided:
a) the Dependent is eligible fo r the change requested; and
b) the required premium is paid .
If the Request in creases coverage, the amount of the increase will be subject to the Pre-ex isting Condition Limitation
provision.
Depende nt Termination : Dependent cove rage unde r the Policy w ill cease on th e fir st to occur of:
a) th e date the Pol icy is cancelled;
b) th e Premium Due Date that the required premium for his o r her coverage is not paid, s ubject to th e Grace
Period prov is ion; o r
c) with respect to a Covered Dependent who is a n eligible Spouse, the premium due date on or next following the
date he or s he is Divorced from the Eli gible Person, un less continued in accordance with the Spouse
Continuation provi s ion .
S po use Co ntinuatio n : If a covered spouse is Divorced while covered under the Policy, he o r s he may continue his or her
coverage under the Policy. We must receive the Request and required premium to continue coverage under the Policy
within 3 1 days of th e date coverage termi nates. Solely for the pu rpose of continuing the coverage under the Policy, the
Spouse will be considered the In sured Pe rson. However, this wi ll not continue the coverage beyond a date the coverage
would norma ll y cease un de r a De pendent Termi nation prov is ion of the Policy. Any coverage cont inued by this provision
w ill termi nate o n the Premium Due Date on o r next followi ng the date the Spouse remarries o r executes another Domest ic
Partner Affidavit.
Divorce/Di vo rce d means annu lm ent, dissol ut ion of marriage, or legal separation from th e In sured Person.
Covered Depe nde nt Grace Perio d : A grace period of 31 days is allowed for pay ment of each premium due after the
first. We will continue the in surance duri ng the grace period. If a Covered Dependent In c urs a covered loss during the
G race Period, the Policyholder will be li able to Us for payment of any pre mium accruing during the period We continued
coverage in fo rce under thi s provi s ion. The grace period will not continue coverage beyond a date stated in the Dependent
Terminatio n provi s ion.
Form GBD-1500 CRT E. I 8
PLAN BEN E FITS
THE SC H E DULE OF BENEF ITS AND AMOUNT WILL I NDICATE TH E BENEFITS APPLICABLE TO
EAC H COVERE D P E RSON WHILE COVERED UN DER THE POLI C Y.
HOSPITAL C ONF INEMENT BE NE FIT
When a Covered Person is Co nfi ned in a Hospital , We wi ll pay the bene fi ts stated below. The Confinement must be a
Medicare approved Confine ment. A Cove red Person must Incur ex penses for the Confineme nt wh il e he or s he is cove red
by this benefit.
l st to 60t h Day of Hosp ital Confin e ment : Fo r the fir st 60 Day s of approved Confine ment during a Medicare Part A
Be ne fit Period , Medi ca re pays all Hospital Ex pen ses except for the Medica re Part A Deduct ible.
If a be nefit is indicated as payable for Hospita l Confinemen t on the Schedule of Benefi ts and Amounts, We will pay a
benefit equa l to the percentage of the Medicare Par t A Deductible and fo r the spec ified pe ri od of time as s hown on such
Schedule.
6 1 st t o 90th Da y of Ho s pita l Confin e ment : From the 61 st to 90th Day of app roved Con finement during a Medicare Part
A Benefit Period , Medicare pays all Hosp it al Expenses exce pt a daily Coinsu rance Charge equa l to 25% of the Medicare
Pa rt A Deductible.
If a benefi t is indicated as pa yab le for Hosp ital Confinement on th e Schedule of Benefits a nd Amou nts, We will a pay
be nefit equal to the percentage of the Med icare Part A Coinsurance charge show n on s uch Schedule.
91 " to I SO'h Da y of Hospital Co nfin ement (Lifetim e Rese rv e Peri od): Regular Medicare Hospital benefits end on the
90th Da y of Confinement during a Medicare Part A Benefit Pe riod. After the 90th day, Medicare grants a 60 da y Lifetime
Re se rve Period. T hese 60 addit ional da ys can be used only once in a life ti me . Medicare allows a person the choice of
us ing the days or saving them for th e futu re. If he o r s he uses the days, Medicare pays all Ho spi tal Expenses Incurred
during th e Life tim e Rese rve Pe ri od excep t a dai ly Coinsurance Charge eq ual to 50% of the Medicare Part A Deductible.
If a benefit is ind icated as payable for Hospital Confinement on the Schedule of Benefits a nd Amount, We will pay a
benefit eq ual to the pe rcentage of the Med icare Part A Co in suran ce Charge s hown on s uch Schedu le.
After th e Lifetim e Reserve Period : Afte r the Li fetime Re se rv e Period e nd s (or would have ended if used), We will pa y
the percentage s hown o n the Schedule of Benefits and Amou nts for Usual and Customary Ho spi tal Expenses Incurred for
each Day of Confinement during a Medicare Part A Benefit Per iod . Our payme nt period will be limited to an additiona l
365 Da ys of Confinement per pe rso n per lifetime.
If a benefit is indicated a s payable for Hos pital Confinement on th e Sc hed ule of Benefits a nd Amoun t, We wil l pa y a
bene fit equa l to the percentage of th e Ho spital Expenses Incurred and for the s pecified pe ri od of time as s hown on such
Sc hedule.
FormG BD-1500CRT G.l 9
PLAN BENEF IT S (Continued)
TH E SCHED ULE O F BENEF IT S AND AM O UNTS WI LL IN DI CATE T H E B ENE FIT S A PPLI CA BL E TO
EAC H COV ERED PE R SO N WHI LE CO VE RED UN DER TH E PO LI CY.
SK ILLE D NU RS ING FAC ILIT Y BENE FI T
When a Covered Pe rson is Confi ned in a Skilled Nursing Facility , We will pay the benefit stated below. The Confi nemen t
must be a Medicare Approved Confi nement. A Covered Person mu st Incu r expenses for t he Confinement wh ile he or she
is cove red by th is benefit.
l st to 20th Da y of S kill e d Nur s in g Fac ili ty Co nfin e me nt : For the fir st 20 Da ys of Med icare App roved Co nfi nement
d uri ng a Med icare Part A Benefit Period , Medicare Part A pays all Skilled Nursing Facility Expenses.
We pay not h ing from t he I st to 20t h Day of Confinement.
21 st to tOOth Day of Skill ed N ur s in g Faci li ty Co nfin eme nt: From the 21st to tOOth Da y of Med icare App roved
Confi nemen t du ring a Medicare Part A Benefit Peri od, Med icare pays all Skilled Nurs ing Faci lity Expenses except a da il y
Coinsurance C harge equa l to 12 1/2% of the Medicare Part A Deduc tible .
If a Cove red Pe rson 's Schedu le of Benefits and Amounts indicat es cove rage for th is portion ofthe Ben efit , We wi ll pay a
be nefit equal to the percentage of the Medicare Part A Coi ns urance Charges that the Covered Person Incurs from the 2 1st
to I OOth Day of Confinement as show n in s uch Sc hedule.
EX T EN DED S KILLED NU RS ING FAC ILITY BENE FI T
JOi st to 365th Da y o f S kill ed Nursin g Fac ili ty Co nfin e ment: Afte r the I OOth Day of Co nfin ement in a Sk i lled N ur sing
Faci lity dur ing a Medicare Part A Benefit Period , Medicare benefits for Sk ill ed Nurs ing Facility Co nfinement s en d.
If a Covered Perso n's Schedu le of Be nefit s and Amounts indi ca tes coverage for thi s porti on of the Benefit, We pa y th e
lesser of:
a) the da ily amo unt stated in th e Schedule ; or
b) the room and board ex pen se Incurred show n in s uch Sched ule;
f rom the I 0 I st to the 365 th Day of Co nfinement.
Medica re Approved C onfin e me nt: Med icare o nly ap prove s Skil led Nursing Fac ility Confine ment that provides ski ll ed,
med ically necessary care:
a) at a leve l meeti ng Med icare standards; and
b) com mencing within 30 day s of discharge from a Ho spita l Confineme nt of at least 3 consecutive da ys; and
c) is recommended by the Covered Pe rso n's Ph ys ician.
Our benefi t un der th is plan is limited to tho se Day s of Confi nement that Medicare ap proves, or would have app roved had
Medicare benefits for t he Co nfinem ent not been ex hausted.
Form GBD-1500 CRT H.1 10
ADDITIONAL PLA N BE NEF ITS (Continued)
THE SCHEDULE OF BEN E FITS AND AMOUNTS WILL INDICATE THE BEN EFITS APPLICABLE TO
EAC H COV E R E D PE RSO N WHIL E COVE RE D UN D ER THE POLICY.
OUTPATIENT MEDICAL EXPENSE BEN E FIT
Medicare Part B Deductible Portion : If a benefit is ind icated as pa yable for the Medicare Part B Deductible on the
Schedu le of Benefits and Amount, We will pay a benefit equal to th e percentage ofthe Medicare Part B Deductible s hown
in the Schedule of Benefit s a nd Amounts.
The portion of an expense that is more than Medicare considers reasonable:
a) is not a Medicare Part B Eligible Expense;
b) is not covered by Medicare; and
c) is not covered under this benefit.
The Expenses mu st be Incurred by a Cove red Person while covered by the benefit.
Medical Care Coin s urance Portion : During a Ca lendar Yea r, afte r the Medicare Part B Deductible is met, Medicare
pays 80% of Medicare Part B Eligible Expenses. The Covered Person pays the remaining 20% of the Medicare Eligible
Expenses. If a Covered Person's Schedule of Benefits and Amounts indicates coverage for that portion of the Benefit,
We wi ll pay a benefit equal to the percentage shown in th e Schedu le of Be nefits and Amounts for the coinsurance amount
of Medicare Part B Eligible Expe nses.
The balance of the Eligible Expenses after We and Medicare pay are pa yab le by th e Covered Person. These are referred
to as out-o f-p oc ket expenses. When a Cove red Perso n 's out-of-pocket expen ses equal the amount s hown in the Sc hedule
of Benefit s and Amounts, We will pay the I 00% of th e Medicare Part B Coi ns urance amount for a Cove red Per so n he or
she must then sa ti sfy the co rridor deductible. This amou nt is shown in the Schedule of Benefits a nd Amounts a nd is
payable by the Cove red Person directly. When the corridor deductible is sat isfied, We will th en pay I 00% of the
Medicare Part B Coinsu rance amount for a Cove red Perso n.
T he portion of an expense that is mo re than Medicare considers reasonable:
a) is not a Medicare Part B Eligible Ex pense;
b) is no t covered by Medicare; and
c) is not covered under this benefit.
The Expenses must be Incurred by a Covered Person while cove red by the benefit.
Form GBD-1 500 CRT 1.1 I I
ADDI TIONAL PLAN BENEF ITS (Continued)
TH E SC HEDULE OF BENEF IT S AN D AMO UNT S WIL L INDI CATE T HE BENEFITS APPLI CA BL E TO
EAC H COVE RED PERSON WHIL E COVERE D UNDE R TH E PO LI CY.
O UT PATI EN T ME DI CAL CA RE EXCE SS CHA RGE S BENEF IT
If a Cove red Perso n 's Schedu le of Benefi ts an d Amount s indicate s coverage for th is Be nefit , We will pay a perce ntage
of t he di ffere nce betwee n:
a) the ac tua l Medi care Pa rt B c harg e as bill e d; and
b) t he Med icare approve d Part B ch arge ;
after the Medic are Pa rt B Ded uc tib le is met eac h Ca le nda r Year. However, Ou r pay men t wi ll not exceed any ch a rge limit
ac ti on es tabli s hed by Medic are o r state law. The ex penses must be Inc urr ed by a Cove red Person whil e covered un der
thi s benefit.
However, We will not pa y thi s benefit if :
a) the prov id er of t he Med ica l Ca re acc epts Medi care ass ignm ent ; or
b) the servi ce or s upp ly is not covered by Medi care Part B.
T he O ut -of-Poc ket Ex pe nse Amou nt is :
a) stated in t he Sc hed ul e of Benefit s and Amou nts; and
b) appli es to eac h Cove red Perso n each Calendar Year.
Onl y Out-of-Pocket Ex penses c an be used to mee t the Out-of-Pocket Expe nse Amo un t.
Ou t-o f-Pocket Ex pe n ses mea ns:
a) the po rt io n of an ex pe nse, cove re d un der Med icare Part B, whic h is more than Med ic are co nsiders reasona bl e, up to
the Usual and C ustomary Charge ; plu s
b) expenses use d to mee t th e Me di care Pa rt B Deduct ible to th e ex tent the Med ica re Part B De duc ti ble is no t cove red
und er th e Po li cy.
Out-o f-P ocket Ex penses do not inc lud e ex pe nse s th at are exc lu ded or li mited und er th e Policy .
Expe nses In c urre d During La st 3 Months of a Calend a r Yea r: If :
a) a Covered Person In c ur s O ut-of-P ocke t Expen ses d uri ng th e las t 3 mon ths of a Cale nda r Year ; and
b) th ose ex pen ses are appli ed to his o r he r Ou t-of-Pock et Ex pense Amoun t d urin g th e Calenda r Yea r;
then , a Cove red Pe rson's Out-of-P oc ket Expen se Amount for th e ne xt Ca lendar Year wi ll be reduced by the am ou nt of
th ose expe nses.
Form G BD-1 500 CRT J . I 12
ADD IT IO NAL PLA N BENE F IT S (Con ti nue d)
TH E SC H E DUL E OF BENE FITS AN D AMO UN T S W I LL I NDIC AT E TH E B ENEF ITS APPLI C ABL E TO
EACH C OVERED P E RSON WH I L E C OVE R E D UN DE R TH E POLICY.
FO R E IGN M E DIC AL TREATM E NT BENEF IT
Be nefits provided only if shown as covered on the Sc hedu le of Benefits and Amo unts.
Fo r e ign Med ica l Treat me nt Be n e fi t : We wil l pay the reasona bl e ex pense Incu rr ed by a Covered Pe rso n fo r Foreign
Me di ca l Treatme nt provided he o r s he receives th e fi rst Foreig n Medica l Trea t men t:
a) while cove red by this bene fi t; and
b) within t he fi rst 180 days of travel Outside of the Un ited States duri ng a Ca lendar Year.
T his be ne fi t will be li mit ed to trea tm en t rece ived dur ing a Fore ign Med ica l Trea tm e nt Be nefit Per iod. The Foreign
Me di ca l Treatm en t Bene fi t Peri od:
a) begins on the date of the first Fore ign Medical Treatment; and
b) ends 90 co nsecutive days la ter.
This bene fi t wi ll not cove r a ny pa rt of a Confin ement that ex tends beyond tha t 90 day be nefi t per iod or a ny service or
su pp ly rece ive d after tha t 90 -day be nefi t pe riod.
Th is be nefi t will not cove r Fore ign Medical T reatment i f a Covered Pe rson:
a) leaves t he United Sta tes primari ly to see k Foreign Medical Treatment fo r a Sickness or Inj ury;
b) has no le ga l ob i igat io n to pay fo r the tr eatme nt; or
c) receives the treatm e nt d ur in g a Ca le nda r Year in whic h he or s he travels o r res ides O uts ide o f t he United Sta tes for
more than 180 consecut ive days.
In addit ion, this be nefit will not cover Fo re ign Medical Treatment if Med ica re ap proves the t reatmen t (i n wh ich event, the
reg ul ar be nefi ts of th e Co un t r y of F res no Insurance Plan Benefits apply).
However, if:
a) a Covered Perso n must re main Outside of the Uni ted States mo re than 180 days because of an Inj ury or Sickness
tha t preve nts retu rn to the Un ited S ta tes; and
b) he or s he has estab li s hed a Foreig n Med ica l T reatment Be nefi t Pe riod for that Sic kness or Injury wi th in the fi rst
180 days of trave l, as state d above;
th en , We wi ll con ti nue thi s be ne fi t for th at Sickness or Injury until the end of the Fore ign Me dical T reatme nt Be nefi t
Period.
Foreig n Med ical T r ea t men t mea ns any med ica ll y necessary Confinement, service or su pply received Outs ide of the
United States pr ov ided th e sa me medi ca l tr eatme nt , i f rece ived in the United States:
a) would be considered re im bu rsab le treat ment under Med icare Part A and Part B;
b) would be co nsidered in gene ral use and of de monstra ted va lue in the d iagnosis and trea tme nt of Sickness or Injury
by Unite d Sta tes Physic ians; and
c) woul d no t be considered in a research or experimen ta l stage by Un ited Sta tes Ph ysic ians .
Outside of the United Sta tes means o uts ide the te rr itor ial li mi ts of:
a) th e 50 Uni ted Sta tes and th e Distr ict of Columbia; and
b) Puerto Rico, the Vi rgin Islands, Guam and America Samoa.
Wh e n thi s be nefi t is payab le, no othe r be ne fit s of the Policy will be prov ided for any expense that is cove red under th is
Fo re ign Med ica l Trea t men t Be nefit.
Form GBD-1500 CRT K .l 13
ADDI T IONAL PLAN BENEF ITS (Con ti nued)
TH E SC HEDULE OF BENEF IT S AN D AMO UN TS WIL L INDI CATE TH E BENEF ITS AP P LI CA BL E TO
EAC H COVERE D PE RSON WHIL E COVERED UNDER THE POLI CY.
FOREI GN TRA VE L EME RGENCY ME DI CA L T REA T MENT BENEF IT
F o rei g n Travel Emergency M edical Treatme nt Benefi t : We will pay the perce ntage of th e expe nses Inc urr ed by a
Covered Person for Fo re ign Travel Eme rge ncy Med ica l Treatme nt if :
a) the Covered Perso n has sati sfie d th e Ca lendar Yea r Deduc tible; and
b) th e fi rst expense was Inc urred with in th e fi rst 60 day s of trave l Out side of th e Un ited States.
Pay me nt un de r the bene fit will be limite d to th e Lifeti me Max im um Be nefi t Amo unt.
The Perce ntage Paya ble , Ded uc ti b le Am ount an d Lifet im e Max imum Bene fit Amou nts are shown in t he Sc hedu le of
Ben efit s and Amo unts if a Cove red Pe rso n 's Schedule of Bene fit s a nd A mou nts in dica tes coverages for th is Be nefit.
Th is be nefit will not cove r Foreign Trave l Eme rge ncy Me di ca l Trea tm ent if a Cove red Per son :
a) leaves the Uni ted St at es pri maril y to see k Fo re ig n Trave l Emergenc y Med ica l Trea tmen t fo r a Si ck ness or Inj ur y ;
b) has no lega l o bl igat io n to pay fo r the treatm ent ; or
c) receives the tr ea tm ent duri ng a Ca le nd a r Year in wh ich he or she tr ave ls or res id es O utside of th e United States for
6 co nsecut ive mo nths o r lo nger.
In addi ti on , th is bene fit will not cove r Fo re ig n T ravel Emerge ncy Med ica l Treatm en t if Med icare app roves the treatm en t
(in which e ve nt, th e other benefi ts of the Plan ap pl y .)
When thi s benefit is pay ab le, no other bene fit s of the Po licy will be provid ed fo r a ny ex pe nse tha t is covered unde r t his
Fore ign Trave l Eme rgency Me di ca l Treatmen t Be nefit.
Foreig n Travel Emergency Medical T rea tm e nt means any medica ll y necessary Con fi neme nt , se rvice, or suppl y needed
immediate ly du e to Injury or S ickness of s udden a nd un ex pec ted on set wh il e t he Cove red Perso n is O ut side of the Unit ed
State s prov ided th e sam e med ica l treatmen t, if rece ive d in the United States :
a) wo uld be cons ider ed re im bursa bl e treat ment under Medi care;
b) wo uld be co ns id e red in general use an d of demo nstrate d va lue in t he diag n os is a nd tr eat me nt of Sickness or Injury
by United St ates Phys ic ia ns; a nd
c) would not be co ns id e re d in a researc h or ex perim ental s tage by Un it ed States Phys ic ian s.
Outs id e o f th e Unit ed S tates mean s outs ide th e te rri tor ial lim its of:
a) the 50 Uni te d States and the Di s tri ct of Co lumbia; a nd
b) Puerto Rico , th e Virgi n Is lan ds, G uam and Am erica n Samoa .
Fo rm GB D-1500 CRT L.l 14
ADDITIONAL PLAN BE NEF ITS (Co ntinued)
THE SCHEDULE OF B ENEFITS AND AMOUNTS WILL I N DI C ATE TH E BENEFITS APPLI CABLE TO
EAC H COVE RED PERSON WHILE COVE RED UNDE R TH E POLIC Y .
PRIVATE DUTY NU R SI NG BENEFIT
D U RI NG H OS PITAL CONFI NEMENT
If a Covered Person's Sc hed ul e of Benefits and Amounts indicates coverage for this Benefit, We wi ll pay the Pri vate Duty
Nursing Maximum Be nefit for eac h 8 hou r s hift. In no event will We pay more than the ac tu al amount charged fo r such
Private Duty Nursing sh ift nor will We pay more than the maximum number of sh ifts per Calendar Year.
The private duty nursing se rvice mu st be provided to a Covered Person wh ile he or she is:
a) covered under thi s benefit; and
b) Confined in a Hosp ital.
The private duty nursing services must be charged directly to a Covered Person by th e Nurse and not charged by the
Hospital.
N urse means:
a) a Re g iste red Graduate Nurse (R.N. or A.P.R.N); or
b) a Li ce nsed Practical Nurse (L.P .. );
who is not related to a person by blood or marriage or a domestic partner of a Covered Person.
We wi ll not pay for more than 3 s hift s of pr ivate duty nursing services per day. A s hi ft cons ists of at lea s t 3 consecutive
hours of nursing care. Shifts of more th an 3 hours but less than 8 hours wil l be paid on a pro-rata basis.
The Maximum Benefit Amount and th e Maximum Number of Shifts are stated in the Schedule, if a Covered Person's
Schedule of Benefit s and Amounts indi ca te s coverage for this Benefit.
Form GBD-1 500 CRT M.l I S
ADDITIONAL PLAN B ENEFITS (Continued)
THE SCHEDULE OF BENEFITS AND AMOUNTS WILL INDICATE THE B ENEFITS APPLICABLE TO
EACH COVERED PERSON WHILE COVERED UNDER THE POLI C Y.
AT HOME RECOV E RY B ENEFIT
If a Covered Pe rso n 's Phys ic ian certifies that th e Covered Person requires the se rvice s of a Care Provider for Home
recovery from a Sickness, Injury or surge ry for whi c h a Home Ca re Pl a n of Treatment was app roved by Medicare, and if a
Covered P erson 's Schedule of Benefit s and Amounts indicates coverage for thi s Benefit, then We w ill pay t he lesse r of:
a) the expense Incurred; or
b) the At-Home Recovery Maximum Amou nt per vis it ;
for short term At-Home Recovery Vi s it s, up to the Maximum Benefit Amo unt per Cale nd a r Year.
The At -H ome Recovery Visits must be:
a) provid ed to a person whil e he o r s he is cove red under th is benefit;
b) primaril y to provide s ervices whic h ass ist in Activities of Daily Livi ng;
c) prov id ed on a visiting basis in the Cove red Person 's Home; and
d) prov ided wh ile the Cove red Pe rso n is receiving Med icare -approved home hea lth ca re services or within 8 weeks
after th e se rvice date of the last Medicare home health care v is it.
The Covered Pe rson 's atten ding Ph ys ic ian mu st ce rti fy that the s pecific type and freq uency of At-Home Recove ry
serv ices a re necessary because of a co ndition for wh ich a home health ca re plan of treatme nt was ap proved by Medicare.
Thi s bene fit w ill not pay for :
a) At-Home Reco ve ry Vis it s pa id for by Medicare or othe r gove rnm ent programs;
b) At -Home Recovery V isits provided by fami ly membe rs, unpa id volunteers or providers who are not Care
Providers , as defined ;
c) more than th e numb er of Medicare approved home hea lt h care vis it s under a Medicare ap proved home ca re plan of
treatment; o r
d) mo re th an 7 visits in any one week.
The Max imum Amou nt per v isi t, the Max imum vis it s pe r week a nd th e Maximum Benefit A mou nt are s hown in the
Sc hedu le of Benefi ts and Amounts if th e Covered Person is cove red for this Benefi t.
Activities of Dail y Living means tho se daily act ivit ies necessary for a person to perform in order to function
ind epe ndentl y, including, but not limit ed to , bathing, dre ss ing , personal hygiene, transferri ng, eatin g , amb ul at ing,
assistance with drugs th at are no rm a ll y s e lf-admini stered and changin g ba nda ges o r other dress in gs.
At-Home Recovery Visit means the period of a vis it required to prov ide a t-home recovery care , wit hout limit on th e
durati on of the visit, except each consecutive 4 hour s in a 24 hour period of services provided by a Care Pro vi der is
cons id ered one visit.
Care Provider means a duly qualified or lice nse d home health aide or homemaker, personal care aide or nurse provided
through a lice nse d home hea lt h care agency or referred by a licen sed referral agency or licen sed nurses reg istry.
Home mea ns a pl ace used by the Covered Pe rson as a place of res ide nce. It may be the Covered Pe rson 's ow n dwe lli ng ,
an apartment, a re la ti ve 's home, a home for the aged or some oth er type of institut ion, provided that s uch a place wou ld
qua li fy as a re s idence for Ho me Health Care se rv ices cove red by Med icare . A Hos pi tal or Skill ed Nurs in g Fac ility is not
cons id ered the Covered Person 's home .
Fo rm GB D-1500 CRT N.1 16
AD DITI ONAL PLAN BENEF ITS (Cont inued )
TH E SC H E DULE OF BENEF ITS AN D AMOUNTS WILL IN DI C ATE THE B ENEFITS A PPLICA BLE TO
EAC H C OV E RED PERSON WHILE COVERED UN DE R T H E POLICY.
PREVENTIV E M E DI CAL CA RE BENEFIT
If a Covered Person 's Schedule of Benefit s and Amounts indi ca tes cove rage for th is Benefit , We wi ll pay the actual
cha rges up to the Medica re approved amount for ex pen ses Incurr ed by the Covered Perso n for:
a) an annua l clinical prevent ive medical his tory and ph ys ica l exa minatio n (w hich may inc lude Pre ven ti ve Screening
Tests or Se rvices) and pat ient education to address preventive hea lth meas ure s; and
b) Preve ntive Screeni ng Tests a nd Pre vent iv e Service s, as defined; a nd
c) influenza vacc in e ad mini ste red at a ny app ropria te tim e during t he year; and
d) Tetanus and Diphtheria booster ev e ry I 0 yea rs; a nd
e) a ny oth e r tes ts or preventive meas ur es de termin ed to be a ppropri ate by the atte ndin g Physician.
The expenses mu st be Incu rred by a Covered Perso n wh il e covered by th is bene fit.
Our pa yment w ill be limi ted to the Maximum Be ne fit Amount per Cale nd ar Year s hown in the Schedule of Benefits a nd
Amounts , if a Cove red Perso n 's Schedu le of Ben e fi ts and Amounts indicate s coverage fo r th is Benefit.
Preventive Screenin g Tes ts a nd Preventive Se rvices me ans o ne or more of th e fo ll owing, the freq uenc y of which is
conside re d med ically appro priat e:
a) dipstick urina lys is for hematuria, bac teriuri a and prote in a uri a;
b) pu re to ne (air on ly) he arin g sc reenin g te sts, admini s tered or ordered by a Ph ys ic ian ;
c) se rum cho leste ro l sc reenin g (every 5 yea rs);
d) thyroid fu nctio n test; and
e) di a bet es screeni ng.
Subject to a ll othe r co ndit ion s and limitations of th e polic y, the follo wi ng Pr eventi ve Screenin g Test s are covered
regardle ss of wheth er the Covered Per so n is covered for othe r Preve ntive Medi cal Ca re benefits as s how n in the Schedule
of Bene fit s a nd Amo unt s .
Ca ncer Screenin g Ben efit
If a ny of th e following te sts is no t covered by Medi ca re, We wi ll pa y th e Us ual a nd Cu s tomary c harges Incurred by the
Cove red Perso n for:
a) one mammography sc ree nin g each Calendar Yea r o rdered by a Ph ys ician;
b) one ce rv ical cancer sc ree nin g each Ca le nd ar Yea r or more frequ e ntly if certifi ed by a Ph ys ician that s uch
ce rvical cancer screening is medi c ally necessa ry; a nd
c) one prostate sc ree n ing eac h Ca len da r Yea r fo r the early de tec tion of prostate cancer for men over 50 yea rs of
age. The screenin g may be perfo rmed by any qualified medi cal professional, including a uro log is t, interni st,
genera l pract iti oner, doctor of os teopa th y, nurse pr ac titioner or phys ician ass ista nt. The sc ree nin g must
include at least the foll ow in g tests: a prostate-s pec ifi c antigen (PSA ) blood test and/o r a digital recta l
exam ination.
Form GI30-1500 C RT 0 .1 17
ADDITIONAL PLAN BEN EF ITS (Continued)
THE SCHEDULE OF BENEFITS AND AMOUNTS WILL INDICATE TH E BENE FITS APPLICABLE TO
EACH COVERED PER SON WHILE COVERED UN DER THE POLICY .
HO S PI CE CA RE BENEFIT
Under Medicare, a terminally ill perso n may elect to receive Hospice Care be nefits instead of most regular Medicare Part
A and Part B benefits . Then, Medicare pays all approved Ho s pice Car e charges except coinsurance charges for Inpatient
re s pite care, drugs a nd biologicals.
When a Covered Perso n elects to recei ve Hos pice Care, We wi ll pa y the Medicare Coinsurance Charges th at he or she
Incurs.
The H ospice Care mus t:
a) be approved by Med icare; and
b) be received while covered by thi s benefit.
Whe n thi s benefit is paya ble, no other bene fit s o f the Policy wi ll be provided fo r any expense that is other wise covered
under thi s Hospi ce Care benefit.
Form GBD-1 500 C RT P.l 18
ADDITIONAL PLAN BENEFITS (Continued)
THE SCHEDULE OF BENEFITS AND AMOUNTS WILL INDICATE THE BEN EFJTS APPLICABLE TO
EACH COVERED PERSON WHILE COVERED UNDER THE POLICY .
BLOOD DEDU CTIBLE BENEF IT
Medicare does not cover the first 3 pints of blood rece ived under Medicare Part A or Medicare Pa rt Beach Calendar Year.
We pay the expenses a Covered Person In curs for these firs t 3 pints of blood, or equi valent quantities of packed red b lood
cell s, a s defined under federal regulations :
a) u nder Medicare Part A , except to th e extent benefi ts fo r the Part B Blood Deductible have be en paid; or
b) und e r Medicare Part B , except to th e extent be ne fits for the Part A B lood Deductibl e have been paid.
The expens es must be Incurred whi le a Covered Perso n is covered by th is benefit.
Fo rm GBD-1500 CRT Q.1 19
ELI GIBILI TY FOR PAYMENT OF BENEF ITS
We w ill pay the benefit of the Policy only whe n the following requirements a re met:
a) the expense In curred is a Medicare El igible Expense, as defined;
b) if the Covered Person is Confined in a H ospital, the Confinement is a Medicare approved Confinement;
c) We have verified that the Covered Person 's coverage is in force on the date th e expense is Incurred ;
d) the Covered Perso n has sati sfied any deductible that applies; and
e) the Covered Perso n has not exhausted the Calendar Year or Lifetime Maximum Benefits.
The Schedule of Benefits and Amounts s hows the applicab le deductibles and Ma x im um Be nefit Amounts.
Form GBD-1 500 CRT S.l 20
EXT ENS IO N OF BE NE FIT S
If a Covered Person is Total ly D isabled on the date h is or her coverage terminates, We w ill extend the Poli cy Benefit
Pe r iod fo r expenses Inc u rred a s t he result of that disabil ity, s ubject to a ll Po li cy benefit provis ions, excl us io ns , a nd
limitatio ns.
Fo r Medic a re Pa rt A Eli gibl e Exp e nses: A Policy Benefi t Pe riod fo r Medicare Part A E li gible Expenses w hi ch is
established prior to termination extends u ntil the firs t to occur of:
a) the date t he Covered Person has not bee n Confi ned in a Hospital or Ski ll ed Nursing Facility fo r a period of 60
cons ecutive days; o r
b) the 365th day after terminat io n .
If a Covered Person 's coverage terminates while he or s he is rece i vi ng approve d Ho sp ice Care, t he Hospice Care be nefits
of the Policy will contin ue u ntil the e nd of the Hospi ce Care benefit period, as defined by Medicare.
For Medicare Pa rt B Eli gibl e Exp e nses: The Poli cy Benefit Period for M ed icare Part B Eligible Expenses extends unti l
the end of the Calendar Year qua rt er following term i nation as shown below:
Te rmination Month
Janu ary, February, March
April, May, J u ne
July, August, Septe mber
October, November, December
Ex tension Da te
June 30 of same year
S e ptem be r 30 of same year
December 3 I of same year
M arc h 3 l of nex t year.
GENE RAL LIMIT ATIO NS
Limitation : !fa Covered Pers on ha s no t enroll ed in bot h Medicare Part A and Part B , We w ill pay the be nefits u nder the
Policy as if he o r s he had e nrolled i n both parts of Medicare .
Form GBD -150 0 CRT T. I 2 1
PRE-EXISTING CON DI T ION LIMITATION
Pre-existing Condition means any I njury o r Sickness for which a Covered Person received medical advice or treatment
within the 6 month pe ri od immediate ly befo re :
a) h is or her effective date of coverage; or
b) the effective date of a n i ncrease in coverage ;
wh ichever is applicable.
Conditions Prior to E ffective Date: During the fir s t 6 mo nths from a Cove red Person 's effecti ve date of ins urance,
expenses In curred for Pre-existin g Conditions are not covered.
Change from a Related Policy: If a Covered Pe rson's coverage ha s conve rted without interruption:
a) from th e Re lated Poli cy;
b) to th is Po licy ;
We wi ll credit toward satisfactio n of th e abo ve Pre-existing Condition Li mita ti on the period that he or she was
continuo us ly covered by the Related Policy imm e diate ly before th e convers ion. Any expenses In curred which a re payable
under an Extens ion of Benefits provi s io n of the Re lated Policy wi ll not be payable unde r thi s Po lic y .
Replacement Coverage: If the Covered Pe rson:
a) has purchased cove rage unde r th is Policy in order to re place coverage under a prior Reti ree group healt h
poli c y; and
b) he or s he prov ide s proof of cove rage und er such prior policy ;
We will c redit toward satis fact io n of thi s Pol icy's Pre-existi ng Conditi on Limita ti o n the period that he or s he was
continuous ly covered by the prior po li cy imme diatel y before h is or he r effective date un der th is Po li cy.
Howeve r, if benefits under thi s Policy are g reate r th an those provided by the prior policy, th e 6 mont h Pr e -ex is ting
Condi tion Lim itatio n of thi s Polic y wi ll ap pl y o nl y to the in creased benefits.
Conditions Prior to E ffecti ve Date of Increase in Coverage: During the first 6 months fo ll owin g the date a Covered
Perso n makes a c hange in cove rage that i ncreases benefits, the in creased po rti o n of t he be n efit w ill not be payab le for
expenses In c urre d d ue to P re-existing Conditio ns .
T his Pre-ex is tin g Conditions Limitation w ill not apply to any increase in coverage due to c ha nges in M edicare bene fi ts.
For m GB D-1500 C RT U.l 22
The Policy does not cove r :
a) any expense that is:
GENE RAL EXC LUS IO NS
APPLI CABL E TO A LL PLA NS
I. not a Medicare Eli gible Expense; or
2. beyond the limits imposed by Medicare for such expense; or
3. excluded by na me or specific desc r ipt ion by Medicare ;
except as spec ifically provid ed unde r the Policy ;
b) a ny portion of a covered expense to the extent paid by Medicare;
c) any benefi ts payable under one benefit of the Polic y to the exte nt payab le under anothe r benefit of the Policy ; and
d) covered expenses Incurred after coverage term inates except as stated in the Extens ion of Benefit s prov ision.
Fo rm GBD-1500 CRT V.l 23
CLAIM PROVISIONS
Notice of Claim: The Covered Person mu st give Us, or Our representative , wr itten notice of a claim within 20
days after a covered loss begins. If Cove red Perso n cannot g ive notice with in tha t time, it must be g iven to Us as
soon as reaso nab ly possib le. Such notice mu st include the Covered Person's name , Cove red Person 's addr ess,
Covered Person's lD number and the Policy num ber.
C laim Forms: Our representative or We will send fo rm s to the Covered Person to provide proof of loss within 15
days after We receive a notice of clai m. If We do not send the form s within 15 day s, the Cove red Person may
sub mit any other writt en proof that fu ll y de sc rib es the natu re and extent of a Covered Person 's claim.
Sending Proof of Loss: Written proof of lo ss mu st be sent to Us with in 90 day s afte r:
a) the end of each month of Our liability for periodic payment cla im s; or
b) the date of the los s for all o th er claim s.
If proof is not give n by the tim e it is due , it will not affect the claim if:
a) it wa s not poss ible to gi ve proof wit hi n the required time ; and
b) proof is given as soo n as po ss ib le; but
c) not later th an I year after it is due, unless the Covered Person is not leg a lly compete nt.
C laim Payment: When we determine that the Cove red Person is eligible to receive benefits, We wi ll pay a ll
bene fit s due:
a) on a month ly basis , after We rece ive the proof of lo ss, whi le the loss and Our liabil ity conti nue; or
b) immed iate ly afte r We receive th e proof of loss following the end of Our liability .
We will pay any other benefit due immediately after We re ce ive the proof of loss .
Pay ment of C laim : We will pay an y benefits du e and no t as sign ed, to the Covered Per son , if living . Otherwi se,
We wi ll pay any be nefits du e fo r a loss th at occurred pr ior to the Co ve red Per son's death to h is or her e state.
If a benefit due is payab le to a mi nor, it will be paid to his o r her guardian. If a benefit due is payab le to:
a) the Dependent's e state ;
b) a minor; or
c) a person not compete nt to give valid relea se for payment;
We may pay up to $1 ,000 of the benefit due to some othe r per son.
The other pe rso n will be someone re lated to the Cov ered Person by blood or marriage who We believe is entit led to
the payment. We will be re lieved of further re spon sibility to the extent of any payment made in good fa ith .
If the Cove red Person provides Us with a Written Re lease to do so, We may , at Ou r option , pay be nefi ts direc tly to
the institution or person rendering :
a) Hospital services; or
b) nu rs ing, medical , or surg ica l services ;
unless the Cove red Person or the person to whom the be nefit is payable req uests otherwi se in writing no later than
th e time the proof of loss is filed wit h Us.
Written Re lease means any wr itt en direct io n from the Covered Person to pay benefits to th e institution or pe rson
rendering the serv ice. We will no t require that the se rvice s be rendered by a parti cu lar in stitution or person.
Fo rm GBD-1500 C RT W .l 24
C LAIM PROVI S IO NS (Cont inued)
Assi gnm e nt: T he Covered Pe rso n may as sign the benefits of this Pol icy to the in s ti t ut io n, or person rendering
service as allowed in the Payment of Claim s provi sio n. The Cov ered Pe rso n may not a ss ig n the Po li cy in any other
way or to any ot her pe rso n.
Le gal Action s: Legal act ion cannot be taken again st Us:
a) soone r than 60 days after the date proof of lo ss is give n; or
b) 3 years afte r the date written proof of loss is required to be g iven acco rding to the te rms ofthe Policy.
C hanges to Medicare : Be nefi ts are adj us ted a nnually or upon the effective date es tab lis hed by Medicare to re fl ect
changes in the federal gove rn me nt's Medicare program. These changes ma y cause incre ases or decreases in benefi t
amou nts payable under th e Po lic y .
In s ur anc e Fraud: Insurance Fra ud occ urs when a Cov ered Person and/or Covered Person 's Employer prov ide s
Us with fal se , incomple te o r mislead ing information wit h the intent to inju re, defraud , or deceive Us. It is a cri me
if t he Covered Person and/or Cove red Person 's Employer comm it Ins urance Fraud. We will use all mean s
ava ilable to Us to detect, investigate , dete r, and prosecute tho se who comm it In s uran ce Fra ud. We will pu rsue a ll
available remedies if the Cove red Perso n and/or Covered Pe rso n 's Employer perpetra te In s urance Fra ud.
Form GBD-1500 CRT W.2 25
IN WITNESS WHEREOF, the parties hereto have executed this Agreement (Hartford-
Plan Year 2017).
COUNTY OF FRESNO
Chairman , Board of Supervisors
DATE : ----~3--~~~~~-\~) ____________ _
\
REV~J E ~PROVAL
Paul Nerland , Director of Human Resources
APPROVEDASTOLEGALFORM
/1 I ~'~ / /' 1.4 ~ 1!/\,dl-L /r_ bud!<'}
Daniel C . cel%org, County Counsel ,..,..-
~ t-/'
APPROVED AS TO ACCOUNTING FORM
Oscar arcia ,
Auditor-ControllerfTreas
FOR ACCOUNTING USE ONLY:
Fund No :
Subclass:
ORG No :
Account No :
1060
10000
89250200
7185
(
ATIEST:
BERNICE E . SEIDEL, Clerk
Board of Supervisors
B y ~50.M_ &sb?t>
Deputy