Military Officer - April 2007 - (Page 17) EXCLUSIVE MOAA Monthly Rates MEDIPLUS TRICARE Standard Retiree Supplement Monthly Rates ® MEDIPLUS® Retired TRICARE Prime Supplement Member or Spouse Age Nonsmoker Smoker $7.72 11.78 13.90 17.79 $7.35 Under 50 50-54 11.22 55-59 13.25 60-64 16.94 Each Child — $9.56 Under 45 Inpatient and Outpatient Plan —$300 Per Person Deductible 45-49 $13.33 $14.81 $20.00 $22.22 50-54 $18.52 $20.00 $24.44 $27.40 50-54 $33.93 $36.64 $44.78 $50.21 55-59 $25.19 $26.66 $27.40 $31.11 55-59 $46.14 $48.85 $50.21 $56.99 60-64 $29.62 $32.59 $31.11 $34.81 60-64 $54.28 $59.71 $56.99 $63.78 Each Child Member (or Auxiliary Member) Spouse Nonsmoker Smoker Nonsmoker Smoker $11.85 $12.59 $16.30 $18.52 $11.11 Inpatient and Outpatient Plan —$150 Per Person Deductible Member (or Auxiliary Member) Spouse Nonsmoker Smoker Nonsmoker Smoker Under 45 45-49 $21.71 $24.43 $23.07 $29.85 $33.93 $27.14 $36.64 $40.71 Each Child $20.36 You classify as a nonsmoker if you have not smoked cigarettes, cigars, or used a pipe, chewing tobacco, nicotine chewing gum or snuff in the past 12 months. Other MEDIPLUS TRICARE Standard Supplement Plans are available. For more information, call TOLL FREE 1-800-247-2192. Premiums are based on each person’s age when coverage becomes effective, and increase on January 1 after the next highest age bracket is reached. Premiums may be increased or decreased on a class-wide basis. For your convenience, you will be billed quarterly. Take Up To 30 Days To Examine At No Risk: If for any are covered); breast implants except when covered by during any period of 12 consecutive months. In addition, for reason you are not completely satisfied with your MEDIPLUS TRICARE for reconstructive surgery due to cancer; hearing Mental Illness we will pay up to 150 days of inpatient care for Certificate of Insurance after you have examined it for up to 30 aids; orthopedic footwear; care for the mentally covered expenses for a covered dependent child up to age 21. days, you may cancel it with no questions asked. Simply write incapacitated or physically handicapped if a) the care is Pre-Existing Conditions Limitation: If you or your covered “Cancel” on your Certificate and return it within 30 days to required because of the mental incapacitation or physical dependents received medical treatment or advice for a health MOAA Insurance Plans. handicap; or b) the care is received by an Active Duty condition (including pregnancy) during the six months before Important Information You Should Know: Your MEDIPLUS Member’s child who is covered by the “Program for the date the coverage takes effect, that health condition won’t be coverage begins on the first day of the month following receipt Persons with Disabilities” under TRICARE; nursing covered until the person has been enrolled in the plan for six of your Enrollment Form and first premium payment, provided service, unless it is for the full-time service of a registered months. We urge you to consider this limitation before you are an MOAA member. graduate nurse or a licensed practical nurse; purchase of dropping any other health insurance you may have. Qualified Hospital: A hospital must be engaged primarily in a wheelchair, Hospital type bed, iron lung or other durable Important Information Regarding Veterans’ medical care and treatment of sick and injured persons on an equipment unless approved by TRICARE (the rental of Administration (VA) Hospitals: TRICARE Supplement inpatient basis, have full surgical facilities, be under the such equipment is covered); ambulance service in excess insurance policies pay benefits only after TRICARE has first supervision of legally qualified physicians and provide 24-hour of $100 per trip unless approved by TRICARE; any reviewed and approved the expense. A review by TRICARE nursing services by R.N.s to qualify. A sanitarium operated by expenses paid in full by TRICARE; drugs which do not results in a TRICARE Explanation of Benefits (“EOB”). Many VA or certified by the First Church of Christ Scientist, Boston, require a prescription (except that insulin is covered); Hospitals currently do not submit their claims through TRICARE. Massachusetts, also qualifies. A convalescent home; skilled dental care, except that it is covered when it is needed to Only claims TRICARE processes, resulting in an EOB, are subject nursing facility; a place for rest, custodial care or care for the treat another (not dental) injury or sickness; any to benefits under The Hartford’s TRICARE Supplement insurance aged; or a place primarily caring for mental illness, drug confinement, service, or supply that is not covered under policies. If you use VA facilities for your care, please be aware of addiction or alcoholism does not qualify. In certain situations, TRICARE; any expense applied to the TRICARE Outpatient this TRICARE Supplement policy requirement. VA Hospitals also an institution for the treatment of nervous, mental or emotional Deductible or the TRICARE Prime Point of Service can charge the veteran a Category C copayment based on a disorders is considered a hospital under the MEDIPLUS Deductible; any expense applied to the Retiree Inpatient means test, per Public Law 99 Section 272. This law specifically TRICARE Standard Supplements. Confined or Confinement Only Supplement $200 Deductible; any expense applied applies only to the veteran and not the insurance company. The means being an inpatient in a Hospital or Skilled Nursing to the Retiree Inpatient/Outpatient Supplement $300/$150 Hartford is not liable for payment of these charges. Facility due to sickness or injury. per person Deductibles; any portion of the cost-share This brochure explains the general purpose of the insurance described, but Termination: Your coverage, as well as your dependents’ amount which the Insured Person is not legally obligated in no way changes or affects the Master Policy (Policy # AGP-1134; Policy coverage, will terminate only if the Master Group Policy is to pay because of payment by a TRICARE alternative Form 7318-5 [3rd Rev][HLA][1134]) as actually issued. In the event of a canceled, your premiums are not paid or you discontinue your program; expenses for which TRICARE makes full discrepancy between this brochure and the policy, the terms of the policy MOAA membership. Your dependent children’s coverage will payment for the TRICARE allowed amount (this exclusion apply. All benefits are subject to the terms and conditions of the policy. Life and Insurance continue as long as they maintain TRICARE eligibility, are does not apply to coverage expressly provided for Policies underwritten by the Hartford reduction ofAccident and terms Company detail exclusions, limitations, benefits unmarried and are under age 21 (23 if full-time student). expenses in excess of the TRICARE allowable amount); under which the policies may be continued in full or discontinued. Spouse coverage will continue as long as he/she remains any portion of a TRICARE cost-share which we determine Complete details are in the Certificate of Insurance issued to the insured married to the MOAA member. is payable by TRICARE because the TRICARE cap has individual and the Master Policy issued to the policyholder, MOAA. This General Exclusions and Limitations: These TRICARE been met; under the Inpatient Only Plans, outpatient program may vary and may not be available to residents of all states. Supplements do not cover: injury or sickness resulting from war surgical benefits are limited to $500 a year. Marsh Affinity Group Services, a service of Seabury & Smith, receives or acts of war, whether declared or undeclared; intentionally Nervous, Mental, Emotional Disorders, Alcoholism, compensation for services to provide this program; these services may self-inflicted injury; suicide or attempted suicide, whether sane and Drug Addiction Limitations: The coverage include enrollments, on-going servicing, billing, marketing, brokerage, or insane; the following services: a) routine physical exams, provided under the TRICARE Supplement does not cover customer administrative and claim servicing and communications. Refer to https://www.personal-plans.com/disclosure and enter in the security except when such services are rendered to a child who is less inpatient treatment for mental, nervous, or emotional code i674009 or call us at 1-888-206-5088 for specific details. than 6 years of age or when required for school enrollment (but disorders in excess of 45 days if under age 19, or in not sports physicals) for a covered child ages 5 through 11; b) excess of 30 days if age 19 or older (or 90 days if Your association shares a financial interest in this program which benefits the entire membership. routine or well baby care and immunizations, except that these approved by TRICARE Standard) in any one calendar year. Underwritten by: Hartford Life and Accident Insurance Company services are covered when rendered to a child who is less than Outpatient benefits for such disorders are limited to $500 Simsbury, CT 06089 6 years of age; hospital nursery charges for a well Switching To MEDIPLUS From Other Plans newborn; domiciliary or custodial care; eye refractions you are still an eligible participant, the six-month waiting and routine eye exams, unless required for school; Employer Plans: You won’t have to satisfy a waiting period period for current health conditions will apply. eyeglasses and contact lenses (except that surgically on current health conditions if you sign up for MEDIPLUS Active Duty: Officers who enroll within 30 days of the date implanted contact lenses ar e covered if approved by within 30 days after your employer-sponsored protection TRICARE); prosthesis (except that artificial limbs and ends because you are no longer an eligible participant in that their active duty medical coverage ends or within 30 days of their initial eligibility for TRICARE benefits are also covered for eyes, and devices which must be implanted by surgery, program (if you https://www.personal-plans.com/disclosure
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