GROUP HOSPITAL INCOME INSURANCE PLAN ENROLLMENT FORM

Transcription

1 E American Association of Critical-Care Nurses GROUP HOSPITAL INCOME INSURANCE PLAN ENROLLMENT FORM AGP-1961 (Please make any corrections to your full name and address printed below.) Name: Last First MI Add 1: TO ENROLL: Send this completed form with your premium check payable to: ADMINISTRATOR AACN GROUP INSURANCE PROGRAM P.O. Box Des Moines, IA QUESTIONS? Call: Add 2: City, St., Zip: Hartford Life Insurance Company Hartford, CT Member Information Phone Numbers: Home Date of Birth (MM/DD/YYYY) Sex q M q F Work Address Indicate your chosen Per Day Benefit Amount $ ($50 to $200 in multiples of $10) Indicate the waiting period of your choice (when you want benefits to begin): q 1 st Day q 4 th Day When the member attains age 65, coverage reduces to a $50 per day plan. Indicate how you wish to be billed: q Automatic Monthly Check Withdrawal q Quarterly Direct Bill (If you select Automatic Monthly Check Withdrawal, please complete the Automatic Check Withdrawal Request form.) Please complete if insuring family members Name Birth Date Spouse/Domestic Partner Child Child Child The Hartford is The Hartford Financial Services Group, Inc., and its subsidiaries including issuing companies Hartford Life Insurance Company. BE SURE TO COMPLETE ALL PAGES AND SIGN LAST PAGE /27451/ 1018/52247

2 I hereby certify that the above statements are complete and true to the best of my knowledge. I understand that the insurance applied for, when combined with all other Hospital Income Insurance in force for me may not exceed $250 per day in total benefits and that benefits under this group policy will be reduced by the excess and premiums paid for the excess will be returned. I understand that this insurance shall become effective on the date specified by the Hartford Life Insurance Company. I understand that this program will not cover Pre-Existing Conditions (conditions for which I received medical advice or treatment within 12 months of this coverage) until 12 treatment free months have passed (ending on or after my effective date) or until the coverage has been in effect for 2 years. I attest that I am covered under a health benefits plan, contract or policy (also known as a "primary healthcare plan"), which satisfies minimum essential coverage of the Affordable Care Act. THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES. Member's Signature Date Underwritten by: Hartford Life Insurance Company Hartford, CT Hospital Indemnity Form Series includes SRP-1151, or state equivalent. Policy Number AGP-1961 HI648E April

3 Domestic Partnership Affidavit Name of Applicant Name of Domestic Partner The undersigned member and domestic partner, being of sound mind, hereby state the following: 1. That the undersigned member and domestic partner have an exclusive mutual commitment to share responsibility for each other s welfare and financial obligations and that this commitment is of at least six months duration and is expected to continue indefinitely. 2. That the undersigned member and domestic partner share a single permanent residence (attach one copy of evidence such as driver s license). 3. That the undersigned member and domestic partner are financially interdependent as demonstrated by at least two of the following (check all that apply and attach copy of evidence): q Common ownership of a motor vehicle. q Joint bank or credit accounts. q Assignment of durable power of attorney in favor of one another. q Common ownership of real estate or common leasehold interest in property. q Joint ownership or holding of stocks, bonds, or other investments. q Execution of will naming each other as executor and/or beneficiary. q Designation as beneficiary under the other s retirement or pension benefits account. 4. That the undersigned member and domestic partner (check one): q have filed a domestic partner declaration with the (City/Council/Borough) of and that such domestic partner declaration remains in effect (attach copy of declaration). q do not reside in a jurisdiction which provides for the registration of domestic partnership declarations. 5. That neither the undersigned member nor domestic partner would be able to affirm questions 1 through 4 above with respect to any person except the other. 6. That neither the undersigned member nor domestic partner has executed or filed a declaration or affidavit of domestic partner status with any other person within the past 12 months. 7. That the undersigned member and domestic partner are each no less than 18 years of age, and are under no legal disability which would prevent them from making this affidavit. 8. That neither the undersigned member nor domestic partner are now, or have been within the past six months, married to any other person, including common law marriage. 9. That the undersigned member and domestic partner are not related by blood in any degree which would prevent their marriage to each other. The undersigned member and domestic partner represent that the statements made herein are true and correct to the best of their knowledge, information and belief. Member and domestic partner understand that these statements are given for the purpose of establishing their eligibility and understand that any misrepresentation, whether or not made with intent to deceive, may result in the ineligibility of the domestic partner for coverage under such policy, and in the voiding of such coverage. The member and domestic partner agree to furnish upon the Company s request evidence to substantiate any statement made herein, and that the Company may require the member and/or domestic partner, if living, to reaffirm all statements made herein periodically and/or when a claim is submitted. In the event any coverage is voided due to any misrepresentation herein, the Company s liability shall be limited to a return of any premiums paid on behalf of the domestic partner for any period of ineligibility. Applicant s Signature Date Domestic Partner s Signature Date

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5 Important Notice to Persons on Medicare This Insurance Duplicates Some Medicare Benefits This is not Medicare Supplement Insurance This insurance pays a fixed dollar amount, regardless of your expenses, for each day you meet the policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement Insurance. This insurance duplicates Medicare benefits when: any expenses or services covered by the policy are also covered by Medicare. Medicare generally pays for most or all of these expenses. Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include: hospitalization physician services hospice other approved items and services. BEFORE YOU BUY THIS INSURANCE Check the coverage in all health insurance policies you already have. For more information about Medicare and Medicare Supplement Insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company. For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program. Form PA-9055 Printed in U.S.A.

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7 AUTOMATIC CHECK WITHDRAWAL REQUEST: By selecting Automatic Check Withdrawal, your premium will automatically be withdrawn from your checking account. Please provide the information requested below. Checking Account Routing #: Account #: I request that you pay and charge my account debits drawn from my account by the Plan Administrator to its order. This authorization will stay in effect until I revoke it in writing. Until you receive such notice, I agree that you shall be fully protected in honoring any such debits. I also agree that you may, at any time, end this agreement by giving 30 days advanced written notice to me and to the Plan Administrator. You are to treat such debit as if it were signed by me. If you dishonor such debit with or without cause, I will not hold you liable even if it results in loss of my insurance. Signature of Premium Payer: Date:

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9 P Association Sponsored Hospital Income Insurance Plan FOR AACN MEMBERS Coverage to help you keep in step with today s increasing cost of Hospitalization. Questions and Answers Q: Why would I need additional Hospitalization protection? A: The Hospital Income Insurance Plan is designed to help provide the benefits you may need to keep up with inflationary health costs. Benefits are paid directly to you or you may assign benefits to be paid directly to the Hospital or any other health care facility in which you receive care. Q: How much additional protection could I get? A: Tailor the Hospital Income Insurance Plan to help fit your basic Hospital and medical insurance plan. Members under age 65 may select a daily benefit in units of $10 ranging from $50 to $200**. If you are under age 65 and Hospital Confined for Cancer, the Plan would pay DOUBLE your chosen benefit. And, if you're under age 65 and are Confined to an Intensive Care Unit, you also receive DOUBLE your benefit. (The Intensive Care benefit does not apply to Cancer patients.) Coverage is limited to $165/day to New York residents under age 65. The increase in payments up to two times for the Cancer benefits is not available to New York residents. ** Benefit reduce to a $50 maximum daily benefit at age 65 with an appropriate adjustment in premium. Q: When would I start collecting my benefits? A: You may choose to collect benefits on either the 1 st day of necessary Hospitalization or select a Plan with benefits starting on the 4 th day of Hospitalization (subject to the Pre-Existing Conditions Limitation). Either way, you would be paid for days you are Confined after your benefits begin for up to 2 years for all covered Hospitalization. Here's how the Plans work: If you are Hospitalized for a covered Injury or Sickness and are insured under the $100 Per Day/1 st Day Plan, you receive $100 for each day you are Hospitalized for up to 2 years. If you are insured under the $100 Per Day/4 th Day Plan, you receive $100 for each day starting on the 4 th day of Hospitalization for up to 2 years. Q: What if my Sickness recurs? A: Repeat claims for the same Injury or Sickness will be honored as a new claim if the end of the first and the start of the second are separated by 180 consecutive non-hospitalized days. If the separation is less than 180 days, the remaining benefits for the first claim (if any) are still available. Q: Are premiums affordable? A: The group buying power of your association, combined with centralized administration, helps keep your cost reasonable. You pay economical group rates which are billed in convenient quarterly premiums. Q: How do I file a claim? A: You simply request a claim form from the Insurance Administrator. You and your doctor complete the form stating why and how long you were Hospitalized. Return the form to the Insurance Administrator and they will expedite your payment. Q: When does my coverage begin? A: Your Hospital Income Insurance Plan coverage will take effect on the first day of the month following receipt of your enrollment form and the required premium. Q: When does coverage end? A: Your coverage ends if premiums are not paid or you cease to be an AACN member. Coverage for all insureds ends in the event that the Master Policy is cancelled, the AACN ceases to sponsor the coverage or an entire class of insured persons is cancelled. Dependent coverage ends; for your Spouse/Domestic Partner, the date you become legally separated or divorced, premiums are not paid, your coverage is no longer in force, or for child coverage, the date the covered child no longer qualifies as an Eligible Child, premiums are not paid, your coverage is no longer in force. Q: What if I'm over age 65? A: Medicare may not cover all your bills when Hospitalized. The $50 Per Day Plan for members age 65 and over pays benefits regardless of any other insurance you carry. 1

10 Q: Are there any limitations for Pre-Existing Conditions? A: During the first two years of coverage, losses incurred for Pre-Existing Conditions are not covered. Pre-Existing Condition means any Injury or Sickness including pregnancy; diagnosed or undiagnosed, for which you have received medical care within the 12-month period prior to your coverage effective date or the date of an increase in coverage. During that time, benefits for all other accidents or illnesses will be paid under the policy provisions. You are urged to consider this limitation before dropping any coverage you may have until the waiting period is over. Q: Are there any exclusions? A: The Policy does not cover: intentionally self-inflicted Injuries, suicide or attempted suicide, whether sane or insane (in Missouri while sane); any loss caused or contributed by war or act of war, whether war is declared or not; any loss which occurs while the Covered Person is in any of the armed forces, whether land, water, or air of any country or international authority; pregnancy or childbirth, except Complication of Pregnancy; Confinement in a Veterans Administration or any other National Government owned or operated Hospital; Elective or cosmetic surgery. (This does not apply to surgery to repair damage to the natural body caused only by Injury). Q: What are my payment options? A: You are able to choose between two premium payment options, whichever one best suits your needs: Option 1: Pay through Automatic Monthly Check Withdrawal. This saves you the time spent writing checks and remembering due dates. Option 2: Pay through quarterly direct billing. GUARANTEED ACCEPTANCE! You can t be turned down. All Association members, regardless of age, are eligible. Members under age 65 may select up to $200 per day in coverage. PLUS members may choose when their benefits begin on the 1 st day or on the 4 th day of necessary Hospitalization. Members over age 65 are eligible for the $50 Per Day Plans beginning the 1 st or the 4 th day of Hospitalization. Guaranteed Acceptance means that insurance benefits payable are subject to your policy s Pre-Existing Conditions Limitation. NOTE: The insurance applied for, when combined with all other Hospital Income insurance in force for you, may not exceed $250 per day in total benefits paid. Benefits under this group policy will be reduced by the excess and premiums paid for the excess amount will be returned. Important satisfaction guarantee! When you receive your Certificate of Insurance, read it over carefully. If it is less than what you had expected, just mail it back to the Insurance Administrator within 30 days of receipt and any paid premium will be promptly refunded, minus any claims paid. No questions asked! Protection you can depend on... Your choice of daily benefits from $50, up to $200 per day! Pays from 1 st day or 4 th day of Hospitalization YOUR CHOICE! Group rates help save you money payable in convenient quarterly premiums. Family coverage available. Pays DOUBLE benefits for Intensive Care and Cancer Confinements. Benefits paid directly to you or you may assign benefits to be paid directly to the Hospital or any other health care facility in which you receive care. Designed to help pay out-of-pocket expenses related to basic medical insurance including Medicare. Satisfaction guaranteed! To Figure Your Cost: All premiums are based on member s age at the time of enrollment and at renewal dates. Multiply the premium listed on the next page under the desired waiting (elimination) period by the number of $10 daily units you wish to enroll for. (Example: For coverage of a member for $150 Per Day/1 st Day at age 37, multiply $1.44 x 15 = $21.60). If you elect to pay through quarterly direct bill, using the same example, multiply $1.44 x 3 = $4.32. Multiply $4.32 x 15 = $64.80 This coverage is available only for residents of the United States excluding AZ, ID, MD, MN, MT, NM, OR, SC, SD, TX, VT, WA and WV. 2

11 Benefits Begin Monthly Premiums for Each $10 Per Day Unit of Coverage Member's Age Member Only Member & Spouse/ Domestic Partner Member Spouse/ Domestic Partner & Children* Member & Children* 1 st Day Under $50 Per Day 65** th Day Under $50 Per Day 65+** *Children are eligible for 50% of the member s benefit. **Members age 65 and over may enroll in the $50 Per Day Plans only. At the renewal date following the member s 65th birthday, all coverage reduces to a maximum of $50 Per Day. You cannot be singled out for a rate increase because of your health or age. Rates and/or benefits may be changed for all members of your insurance classification only. Rates are based on the attained age of the Insured Person and increase as you enter each new age category. If applicable, an additional $2 billing fee will be included on your billing notice payable to the administrator. To save the fee, select Electronic Funds Transfer (EFT) as a safe and secure payment option. Eligibility: All members of the sponsoring association and their Spouses/Domestic Partners who are not already insured in the program are eligible to enroll with guaranteed acceptance regardless of age. This means that insurance benefits payable are subject to your policy's Pre-Existing Conditions Limitation. Unmarried dependent children under 21 years of age (23 if a full-time student) are eligible for 50% of the member's benefit. Members age 65 and over are eligible for any of the $50 Per Day Plans. All Hospital Income benefits when combined cannot exceed $250 per day, per insured. Remember, one premium covers all eligible children! General Limitation: The Hospital Confinement Benefits of the Policy will be limited as follows: 1. We will not pay benefits for more than a Maximum Benefit Period of 730 days per Period of Confinement, and 2. We will not pay more than two times the Daily Benefit Amount for any one day of Hospital Confinement. Coverage is limited to $165/day to New York residents. Double Cancer benefits are not available to New York residents. How to enroll: 1. Complete the Enrollment Form. 2. Indicate your Per Day Benefit Amount and your Waiting Period selections. 3. See chart to compute your premium. NOTE: The premiums are based on the member's age. 4. Indicate your billing preference. If you are paying through automatic monthly check withdrawal, you must also include a check for your first monthly premium and a blank voided check. If you are paying through quarterly direct bill, just include your first quarterly check. 5. Mail the Enrollment Form with your monthly or quarterly check (and a blank voided check if you select automatic check withdrawal) payable to: Mercer Consumer, a service of Mercer Health & Benefits Administration LLC P.O. Box Des Moines, IA Administered by: Mercer Consumer, a service of Mercer Health & Benefits Administration LLC P.O. Box Des Moines, IA AR Insurance License # CA Insurance License #0G39709 In CA d/b/a Mercer Health & Benefits Insurance Services LLC 3

12 Underwritten by: Hartford Life Insurance Company Hartford, CT The Hartford is The Hartford Financial Services Group, Inc., and its subsidiaries, including issuing company Hartford Life Insurance Company. This brochure explains the general purpose of the insurance described, but in no way changes or affects the Master Policy as actually issued. In the event of a discrepancy between this brochure and the policy, the terms of the policy apply. All benefits are subject to the terms and conditions of the policy. Policies underwritten by the Hartford Life Insurance Company detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in full or discontinued. Complete details are in the Certificate of Insurance issued to each insured individual and the Master Policy issued to the policyholder. THIS IS A HOSPITAL CONFINEMENT INDEMNITY POLICY. THE POLICY PROVIDES LIMITED BENEFITS. This limited health benefit plan (1) does not constitute major medical coverage, and (2) does not satisfy the individual mandate of the Affordable Care Act (ACA) because the coverage does not meet the requirements of minimum essential coverage. This policy provides limited benefits health insurance only. It does NOT provide basic hospital, basic medical or major medical insurance as defined by the New York State Department of Financial Services. Definitions A Hospital as used in this brochure is defined as a facility which has available 24-hour nursing services and has facilities for major surgery. Hospital does not mean a nursing home, convalescent home, or Skilled Nursing Facility; a place for rest, custodial care, or for the aged; a clinic; a place for the treatment of mental illness, alcoholism, or drug addiction. A place for the treatment of Mental, Nervous or Emotional Disorders will be regarded as a Hospital if it is part of an institution that meets the above requirements and it is listed in the American Hospital Association Guide as a general Hospital. Confined or Confinement means being an Inpatient in a Hospital. Injury means bodily injury of a person resulting directly and independently of all other causes from an accident. However, injury that occurred prior to a Covered Person's effective date of coverage will be subject to the Policy's Pre-Existing Condition Limitation. Sickness means Sickness or disease or complications of pregnancy sustained by a covered person. However, Sickness first manifested before a Covered Person's effective date of coverage will be subject to the Policy's Pre-Existing Condition Limitation. Intensive Care Unit means a Hospital unit in which patients are grouped in an area where facilities and staff are tailored to the special needs of the seriously ill, where 24-hour-a-day care by registered nurses is provided and where life-saving drugs and equipment are always at hand. Such units must render care more intensive than that rendered in the general surgical or medical nursing units treating the majority of the Hospital's inpatients. Cancer means a malignant neoplastic disorder commonly known as cancerous, including Leukemia, Lymphoma, Hodgkin's Disease and mixed tumors of the Parotid Gland. Hospital Indemnity Form Series includes SRP-1151, or state equivalent. 4/18 ed. Policy Number AGP-1961 HI648P-27203P 30316HART Copyright 2018 Mercer LLC. All rights reserved. 4