That s why supplemental health insurance like the TRICARE Reserve Select Supplement Plan may be so important for you and your family.

Transcription

1 Information Request For AFA Member: Here s the TRICARE Reserve Select Supplement Insurance Plan information you requested. Dear AFA Member, Thank you for requesting more information about the Air Force Association s TRICARE Reserve Select (TRS) Supplement Insurance Plan, underwritten by Transamerica Premier Life Insurance Company, Cedar Rapids, IA. Enclosed you will find everything you need to make a decision for you and your family. As you may already know, your out-of-pocket medical expenses may add up quickly, especially when you receive care outside of the military health system. That s why supplemental health insurance like the TRICARE Reserve Select Supplement Plan may be so important for you and your family. With this insurance coverage, you and your family may be better protected against the high cost of medical expenses you might face each year in the event of an illness or injury. Plus, this plan includes these features: May help pay your TRICARE Reserve Select cost-shares for covered inpatient and outpatient care. Pays 100% of covered expenses in excess of the TRICARE-allowed amount, not to exceed the legal limit. Covers your eligible spouse and dependent children. You qualify for competitive group rates thanks your AFA membership. Please review the enclosed Benefits Summary for your rates and other important details about this plan. Then to enroll, complete and return the enclosed Enrollment Form. Send no money now. Coverage is available for your TRICARE eligible spouse under age 65, and dependent, unmarried children under age 21 (23 if a full-time college student). Once your form is received, we will send you a Certificate of Insurance. You ll have 30 days to look over the plan benefits. If you decide to continue with this coverage, pay the bill accompanying your Certificate. If you decide it s not what you had in mind, simply let us know. You re under no obligation. (Over, please) AFATRL 1

2 Thank you again for considering this valuable plan. We look forward to your participation. Sincerely, Sincerely, Janeé Williams Manager, Member Relations Air Force Association Timothy R. Weber, Partner Mercer Health & Benefits Administration LLC AFA Insurance Plans Administrator License # P.S. As an eligible TRICARE Reserve Select member of the Air Force Association, you have a guaranteed right to this supplemental plan. And it s easy to enroll today. Just complete and return the enclosed Enrollment Form. Underwritten by: Transamerica Premier Life Insurance Company, Cedar Rapids, IA (TPLIC) Policy# MZ H0000A Copyright 2017 Mercer LLC. All rights reserved. AFATRL 2 AT#

3 Check the appropriate block: n New enrollment n Add dependent(s) n Change coverage Transamerica Premier Life Insurance Company Administrative Office: Cedar Rapids, Iowa Member s Information Group TRICARE Reserve Select Supplement Plan TR-Q POLICY HOLDER: AIR FORCE ASSOCIATION VETERAN BENEFITS ASSOCIATION ORGANIZATION: AIR FORCE ASSOCIATION VETERAN BENEFITS ASSOCIATION ENROLLMENT FORM (n Mr. n Mrs. n Ms.) LAST FIRST INITIAL STREET ADDRESS CITY STATE ZIP CODE ( ) ( ) TELEPHONE NO: HOME OFFICE nnnn n nnn n Date of Birth: / / Rank/Grade: Dependent Information Name of each dependent for whom coverage is desired: Spouse Name: Child Name: Child's Sex: Child Name: Child's Sex: Child Name: Child's Sex: (Complete additional sheet if necessary.) Date of Birth: / / Date of Birth: / / Date of Birth: / / Date of Birth: / / Coverage Requested Select the coverage you want: (Check the reverse side for the appropriate premium schedule.) Note: the TRS member must be covered for the Spouse and/or Dependents to be enrolled. Selected Reserve Member Spouse of Selected Reserve Member Each Child of Selected Reserve Member n Member Only (TS21) n Add Spouse (TS25) n Add Child(ren) (TS27) Answer the question below: Enter the date your TRICARE Reserve Select coverage began: Member: / / / Spouse: / / / I hereby enroll myself and/or my dependents with the Transamerica Premier Life Insurance Company for coverage under AFAVBA supplemental insurance plan. I understand that I must be a member of AFAVBA to be eligible for coverage and that my coverage will become effective on the first day of the month following receipt of this enrollment form and premium. I understand that any injury or sickness, whether diagnosed or undiagnosed, for which any person proposed for coverage has received medical treatment or care within the 6 months immediately preceding their effective date will not be covered until that person has not received medical treatment or care for that condition during a period of 6 consecutive months ending on or after his or her effective date. After 6 months from that person's effective date, he or she will become covered regardless of any preexisting conditions he or she may have. I further understand that new conditions will be covered immediately. AR, CO, KY, LA, NM, OH, OK, and TN Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of a claim or an application containing any false, incomplete or misleading information is guilty of a crime and may be subject to fines or confinement in prison. DC and RI Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. FL Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurer, files a statement of a claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree. NJ Residents: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. MD Residents: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. PA Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such a person to criminal and civil penalties. Member s Signature (X): Date: Spouse s Signature (X): Date: MLTRC1000GE (If Enrolling) 1 MZ H0000A AT# AFATRA

4 Age Monthly Premium Rates Retirees Under 65 Member $8 Under 65 Spouse $8 Each Child $7 TRICARE Reserve Select Plan Rates and/or benefits may be changed on a class basis. Rates are based on the attained age of the insured person and increase as you enter each new age category. SEND NO MONEY NOW After completion, sign and date the form where indicated. Keep a copy for your records and return the original to: Mercer Consumer, P.O. Box 14464, Des Moines, IA Questions Call Toll-Free (7:00a.m.-5:00p.m. Central). Or, afa.service@mercer.com AFAVBA 204-9/10 MLTRC1000GE AFATRA 2

5 TRICARE Reserve Select Supplement Insurance Plan Benefits Summary Guaranteed Issue You are guaranteed issue provided you are a member of the Select Reserve or the Ready Reserve and enrolled in TRICARE Reserve Select (TRS) and under age 65. You cannot be eligible for or enrolled in the Federal Employees Health Benefits Program (FEHBP) or currently covered under FEHBP (either under your own eligibility or through a family member with FEHBP). Coverage is also available for your TRS eligible spouse under age 65, and dependent, unmarried children under age 21 (23 if a full-time college student). Coverage is extended to adult dependent children who are under age 26 and enrolled in the TRICARE Young Adult (TYA) program. You, the member, must be enrolled in order for spouse/dependent children to enroll. Please note: A pre-existing condition may initially limit the extent of your coverage. Helps Pay Expenses TRICARE Doesn t TRICARE Reserve Select provides excellent health care coverage. However, it was never designed to cover all expenses. This Supplement Insurance Plan works with TRICARE may help pay the expenses TRICARE doesn t cover. Specifically, once you meet any TRICARE and plan deductibles, it pays: 100% of your cost-shares for doctor visits, hospital stays, surgeries and more. Pays 100% of your prescription drug copays. Pays 100% of the difference between what your doctor bills you and the amount TRICARE allows (excess charges). Please see the benefit chart below for how it works with TRICARE to pay your medical expenses: How this Plan works to Pay After TRICARE Reserve Select Pays Care Required TRICARE Reserve Select Pays Your TRICARE Reserve Select Pays Government Hospital All TRICARE Reserve Select Allowed Amounts except Current daily subsistence charge. the daily subsistence fee. Civilian Hospital or Skilled Nursing Facility Outpatient Visit All TRICARE Reserve Select allowed amounts except the daily subsistence fee or $25, whichever is greater. TRICARE Network Provider 85% of the TRICARE allowable charge after the annual deductible is met. TRICARE Authorized, Non-Network Provider 80% of the TRICARE allowable charge after the annual deductible is met. The greater of 1) Current daily subsistence charge for each day of confinement; or 2) $25 for all confinements which are due to the same or related sickness or injury and separated by less than 60 days; until the TRICARE Cap* is met. TRICARE Network Provider Your 15% cost share for covered expenses until the TRICARE Cap is met. TRICARE Authorized, Non-Network Provider Your 20% cost share PLUS 100% of the covered excess charges up to the legal limit. Prescription Drug Charges Home Delivery Network Retail (up to 30-day supply) All but the copayments of $13 brand name or $43 non-formulary. All but the copayments of $5 generic, $17 brand name or $44 non-formulary. Copayments of $13 brand name or $43 non-formulary. Copayments of $5 generic, $17 brand name or $44 non-formulary. Non-Network Pharmacy All but $17 or 20% of the total cost for generic/brand name or $44 or 20% for non-formulary (whichever is greater) after the fiscal year deductible. Copayments of $17 or 20% of the total cost for generic/brand name or $44 or 20% for non-formulary (whichever is greater) after the fiscal year deductible. *TRICARE Catastrophic Cap-Maximum out-of-pocket expense=$1,000 per family, per fiscal year. Monthly premium payments do not apply toward meeting the catastrophic cap. **TRICARE Annual Outpatient Deductible Member-Only Plan Family Plan E-4 and Below $50.00 $100 E-5 and Above $ $300 AFATRB 1 (Over, please)

6 The TRICARE Reserve Select Supplement Plan will not pay for expenses used to satisfy the annual deductible charged by TRICARE. Legal Limit means the maximum amount that a non-participating provider can legally charge. This amount is up to the 115% of the TRICARE Allowed Amount. All outpatient Covered Expenses will be deemed incurred on the date the Covered Person received the treatment, service or supply that gave rise to the expense. Competitive Group Rates As a member, you benefit from your Air Force Association membership. The result: these group rates to fit your budget. (Note: MONTHLY rates shown below.) Under Age 65 Member: $8 Spouse: $8 Each Child:* $7 Premiums shown are per person. *Newborn children and adopted children not named in your enrollment form are automatically covered for the first 60 days. You must notify the Plan Administrator in writing and pay the additional premium due within 60 days of birth for coverage to continue beyond this period. Each dependent child s insurance terminates on the premium due date following the date he or she is no longer a dependent. It s easy to enroll Just complete the enclosed Enrollment Form making sure to provide all information requested and return it. Send no money now. After your completed Enrollment Form is received, you ll be sent a certificate of insurance, which you can examine for 30 days risk-free. Effective Date Your coverage begins on the first day of the first or second month (whichever you select on the TRS Supplement Request Form) following the postmark of our TRS Supplement Request Form. For example, if your form is postmarked in March, you may choose for your coverage to begin on the first day of the next month, April, or on the first day of the second month, May. Limitations Routine newborn and well baby care, hospital nursery charges for a well newborn, dental care, treatment for prevention or cure of alcoholism or drug addiction, and prosthetic devices are limited to expenses covered by TRICARE. INPATIENT treatment for mental, nervous or emotional disorders in excess of 45 days if under age of 19, or 30 days if age 19 or older, is limited to 90 days (if approved by TRICARE) in a Fiscal Year. OUTPATIENT benefits for mental, nervous or emotional disorders, drug addiction or alcoholism are limited to a maximum of $500 in a Fiscal Year. Pre-Existing Conditions Limitations If a member enrolls in TRICARE Reserve Select and requests coverage under the TRICARE Reserve Select Supplement within 30 days of the date his or her TRICARE Reserve Select coverage begins, we will waive the Pre-Existing Conditions Limitation. A pre-existing condition provision means any injury or sickness whether diagnosed or undiagnosed, for which a covered person received medical care or treatment within the 6 month period preceding the effective date of his or her insurance and will not be covered until the coverage has been in effect for 6 months. However, new conditions will be covered immediately. Exclusions The Policy does not cover: 1. injury or sickness resulting from war or act of war, whether war is declared or undeclared; 2. intentionally self-inflicted injury; 3. suicide or attempted suicide, whether sane or insane (in Colorado and Missouri while sane); 4. routine physical exams and immunizations, except when: a) rendered to a child up to 6 years from his or her birth; or b) ordered by a Uniformed Service: (1) for a Covered Spouse or Child of an Active Duty Member; (2) for such spouse or child s travel out of the United States due to the Member s assignment; 5. domiciliary or custodial care; 6. eye refractions and routine eye exams except when rendered to a child up to 6 years from the child s birth; 7. eyeglasses and contact lenses; 8. prosthetic devices, except those covered by TRICARE; 9. cosmetic procedures, except those resulting from Sickness or Injury while a Covered Person; 10. hearing aids; 11. orthopedic footwear; 12. care for the mentally incapacitated or physically handicapped if: a) the care is required because of the mental incapacitation or physical handicap; or b) the care is received by an Active Duty Member s child who is covered by the Program for the Handicapped under TRICARE; 13. drugs which do not require a prescription, except insulin; 14. dental care unless such care is covered by TRICARE, and then only to the extent that TRICARE covers such care; 15. any AFATRB 2

7 confinement, service, or supply that is not covered under TRICARE; 16. Hospital nursery charges for a well newborn, except as specifically provided under TRICARE; 17. any routine newborn care except Well Baby Care, as defined, for a child up to 6 years from his or her birth; 18. expenses in excess of the TRICARE Cap; 19. expenses which are paid in full by TRICARE; 20. any expense or portion thereof applied to the TRICARE Outpatient Deductible; 21 treatment for the prevention or cure of alcoholism or drug addiction except as specifically provided under TRICARE and the Policy; 22. any part of a covered expense which the Covered Person is not legally obligated to pay because of payment by a TRICARE alternative program; and 23. any claim under more than one of the TRICARE Supplement Plans, or under more than one Inpatient Benefit or more than one Outpatient Benefit of the TRICARE Supplement Plans. If a claim is payable under more than one of the stated Plans or Benefits, payment will only be made under the one that provides the highest coverage, subject to the Pre Existing Condition Limitation. Nervous, Mental, Emotional Disorder, Alcoholism and Drug Addiction Limits The coverage provided under the Inpatient Benefit of the TRICARE Supplement Plan for nervous, mental and emotional disorders, including alcoholism and drug addiction, is limited to: a) 30 Inpatient treatment days for a Covered Person age 19 or older; or b) 45 Inpatient treatment days for a Covered Person under age 19; per Fiscal Year. This Inpatient limit is based on the number of days TRICARE normally provides each Fiscal Year for such confinements. In rare instances, TRICARE extends these daily limits. If this occurs, we will limit the number of days that we provide for such confinement to the lesser of: a) the number of days TRICARE pays for such Inpatient treatment during the Fiscal Year; or b) 90 Inpatient days per Fiscal Year. The coverage provided under the Outpatient Benefit of the TRICARE Supplement plan for: a) nervous, mental, and emotional disorders; and b) alcoholism and drug addiction; is limited to $500 during any Fiscal Year for all such disorders. Termination Your coverage under the Policy will cease on the first to occur of: 1. the date the Policy terminates; 2. the date the required premium is not paid, subject to the Grace Period provision; 3. the first day of the month on or next following the date you cease to be a member of the Policyholder; 4. the first day of the month on or next following the date you cease to be eligible for the Plan under which you are covered; 5. the date we or the Policyholder cancel coverage for a Class of Eligible Person to which you belong; 6. the date you attain age 65; 7. the date you cease to be covered under TRICARE; 8. the date you become eligible for Medicare unless you reside in an area where Medicare is not available, in which case coverage will not terminate until you return to residency in an area where Medicare is available. Termination of coverage will be without prejudice to any claim which originated before the effective date of termination. Definition Confined or Confinement means being an Inpatient in a Hospital (or Skilled Nursing Facility) due to Sickness or Injury. Skilled Nursing Facility means one which: (a) is approved by Medicare or is qualified to receive approval by Medicare if so required; (b) operates pursuant to law; (c) primarily and continuously provides skilled nursing care and related services to persons convalescing from Sickness or Injury on an Inpatient basis for which a charge is made; (d) provides 24-hour-a-day nursing service by or under the supervision of registered nurses (R.N.); (e) provides adequate procedures for the administration of drugs; (f) maintains daily medical records of each patient; and (g) provides each patient with a planned program of medical care and treatment by or under the supervision of a Physician. Non-Duplication of Coverage under Employer Health Program If a claim payable under the Policy is also payable under an Employer Health Program with TRICARE as the secondary payor, we will limit our payment to an amount which, when added to the amounts paid by the Employer Health Program and TRICARE, will not exceed 100% of TRICARE Covered Expenses. Change of Policy Premiums We have the right on each Premium Due Date to change the rate at which premiums will be calculated. This includes the right to change premium rates for a benefit that applies to all individuals of the same class, age, plan and effective date. Rates may be changed based on claims experience of the Policy. We will give the Policyholder or Organization notice of any change at least 45 days before the Premium Due Date on which it is to become effective. AFATRB 3

8 QUESTIONS? Call: This brochure explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In the event of any discrepancy between this brochure and the contract, the terms of the contract will apply. Complete details are found in the certificate of insurance issued to each insured individual. Coverage may not be available in all states; you will be advised. This is a supplemental health insurance plan that requires you to have major medical coverage, Medicare, or other health coverage that meets minimum essential coverage as defined by the Affordable Care Act. Administered by: Underwritten by: Transamerica Premier Life Insurance Company, Cedar Rapids, IA (TPLIC) 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 AFATRB 4 AT#