Supplemental Limited Benefit Medical Expense Insurance MEDlink IV Proposal Proposal for: Presented by: Date: Livingston Independent School District Combined Benefits Group 4/1/2014 Policy provisions apply only to TX. Proposal based on information provided to American Public Life Insurance Company (APL) and is valid for 60 days from the date proposed. The certificate issued is not a policy of Workers Compensation Insurance. Final rates and benefits are subject to verification of data.
Employer Name: Livingston Independent School District Major Medical Deductible: $2,400 Summary of Benefits Option 2 - Enhanced Plus Base Policy Maximum In Hospital Benefits In Hospital Ambulance Benefit In Hospital Deductible $2,500 per Covered Person per Confinement Up to $350 per trip for ground transportation or up to $1,000 per trip for air transportation where a Covered Person is Confined as an Inpatient. Limited to one trip per day. $0 per Covered Person per Confinement Outpatient Benefit Rider Maximum Outpatient Benefits Outpatient Ambulance Benefit Outpatient Deductible $200 per Covered Person Per Occurrence for Covered Outpatient Services Up to $350 per trip for ground transportation or up to $1,000 per trip for air transportation where a Covered Person resides less than 18 hours. Limited to one trip per day. $0 per Covered Person Per Occurrence Covered Outpatient Services Hospital Emergency Room Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above. Urgent Care Facility Maximum of 3 Urgent Care visits per Covered Personper Calendar Year. Maximum of 6 Urgent Care visits per Calendar Year for all Covered Persons combined. Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Outpatient Surgery Diagnostic Testing Outpatient Treatment for a Serious a Mental Mental or Emotional Illness in a Hospital Disorder Outpatient in a Hospital Facility Outpatient Facility Cancer Treatment Facility Physical Therapy Facility Outpatient Surgery in Hospital Outpatient Facility or Freestanding Outpatient Surgery Center. Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above. Diagnostic Testing in ahospital Outpatient Facility or MRI Facility. Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Maximum of of 30 60 days of of treatment per per Covered Person per per Calendar Year. Payable up up to to the the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shownabove. above. Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit 2 P
Optional Benefit Rider Physician Outpatient Treatment Benefit Rider $25 per visit; Maximum of fourvisits per CoveredPerson per Calendar Year and eightvisits per Calendar Year for all Covered Persons combined for treatment in a: Hospital Outpatient Facility Freestanding Emergency Care Clinic Urgent Care Facility/Clinic Physician Office Premiums* Ages 18-54 Ages 55+ Monthly Premiums by Plan* Spouse Child Family $20.46 $47.05 $34.78 $61.37 $30.69 $70.58 $52.16 $92.06 Ages 18+ Spouse Child Family Ages 18-54 Ages 55+ Spouse Child Family *The premium and amount of benefits vary dependent upon Plan selected at time of application. **Total premium includes the Plan selected and the Physician Outpatient Treatment Benefit Rider premium. 3 WV-201308-1 SIC-8211 P
Base Policy In Hospital Benefit Ambulance Benefit THIS IS NOT A POLICY OF WORKERS COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A SUBSCRIBER TO THE WORKERS COMPENSATION SYSTEM BY PURCHASING THIS POLICY AND IF THE EMPLOYER IS A NON SUBSCRIBER, THE EMPLOYEE LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS COMPENSATION LAW AS IT PERTAINS TO NON SUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED. Pays for Covered Charges incurred, after satisfaction of any applicable deductible, when a Covered Person is Confined in a Hospital as an Inpatient for at least 18 continuous hours and is covered by the Insured s Other Medical Plan. Benefits are payable subject to the Maximum In Hospital Benefit and, if applicable, the Maximum Combined In Hospital and Outpatient Benefits. Benefits payable under this policy are limited to any out of pocket deductible amount incurred under the Insured s Other Medical Plan; any out of pocket co payment or coinsurance amounts the Covered Person actually incurs under the Insured s Other Medical Plan; and any out ofpocket amount the Covered Person actually incurs under the Insured s Other Medical Plan for treatment of a Serious Mental Illness. The treatment of a Serious Mental Illness is limited to 45 days per Covered Person, per Calendar Year. Pays the out of pocket amount up to $350 pertrip for ground transportation or up to $1,000 per trip for air transportation, of a Covered Person by ambulance to a Hospital or from one medical facility to another where a Covered Person is Confined as an Inpatient. This benefit is limited to one trip per day. A licensed ambulance company must provide the ambulance service. If air and ground ambulance service are both required in the same day, APL will only pay the highest benefit amount. This amount is subject to the Maximum In Hospital Benefit and, if applicable, the Maximum Combined In Hospital and Outpatient Benefits. The In Hospital deductible does not apply to this benefit. Important Policy Provisions Limitations and Exclusions No benefits will be payable for expenses incurred during any period the Covered Person does not have coverage under the Insured s Other Medical Plan, except as provided in the Absence of the Insured s Other Medical Plan provision, described in the Policy. Pre Existing Condition Limitation Exclusions No benefits are payable during the Pre Existing Condition Exclusion Period following the Covered Person s Effective Date for any loss resulting from a Pre Existing Condition. The Pre Existing Condition Exclusion Period is shown on the Policy Schedule. The Pre Existing Condition Limitation will apply only if the Covered Person is subject to a Pre Existing Condition Limitation under the Other Medical Plan. Therefore, any Pre Existing Condition Limitation applied to the Major Medical plan would, in effect, limit coverage under this plan. No benefits are payable for any loss resulting from or caused, whether directly or indirectly, by: war or any act of war, whether declared or undeclared, or active service in the armed forces; (This exclusion includes Accident sustained or Sickness contracted while in the service of any military, naval, or air force of any country engaged in war. If coverage is suspended for any Covered Person during a period of military service, APL will refund the pro rata portion of any premium paid for any such Covered Person upon receipt of the Insured s written request.) an intentionally self inflicted Injury or Sickness; suicide or attempted suicide, while sane or insane; rest care or rehabilitative care and treatment; routine newborn care, including routine nursery charges; voluntary abortion except, with respect to the Insured or covered Eligible Dependent spouse: where the Insured or Dependent spouse's life would be endangered if the fetus were carried to term; or where medical complications have arisen from abortion; pregnancy of a Eligible Dependent child; 4
participating in a riot, insurrection, rebellion, civil commotion, civil disobedience or unlawful assembly; (This does not include a loss which occurs while acting in a lawful manner within the scope of authority.) committing, or attempting to commit, an illegal act that is defined as a felony; (Felony is as defined by the law of the jurisdiction in which the act takes place.) participation in a contest of speed in power driven vehicles, parachuting or hang gliding; air travel, except: as a fare paying passenger on a commercial airline on a regularly scheduled route; or as a passenger for transportation only and not as a pilot or crew member; being intoxicated or under the influence of any narcotic unless administered by a Physician or taken according to the Physician s instructions; (Intoxication means that which is determined and defined by the laws and jurisdiction of the geographical area in which the event that caused the loss occurred.) alcoholism or drug addiction; sex changes; experimental treatment, drugs or surgery; Accident or Sickness arising out of, and in the course of, any occupation for compensation, wage or profit; (This does not apply to those sole proprietors or partners not covered by Workers' Compensation.) dental or vision services, including treatment, surgery, extractions or x rays, unless: resulting from an Accident occurring while the Covered Person's coverage is in force and if performed within 12 months of the date of such Accident; or due to congenital disease or anomaly of a covered newborn child. routine examinations, such as health exams, periodic check ups or routine physicals; elective cosmetic surgery; drugs (prescription and non prescription for use outside of a covered facility as defined in this Policy or any attached rider); sterilization and reversal of sterilization; an expense that does not meet the definition of Covered Charges; an expense or service that exceeds any of the Maximum Benefits, as shown in the Schedule of Benefits; or any expense for which benefits are not payable under the Insured s Other Medical Plan. Premium Changes Termination of Policy The premium rates may be changed by APL at the first anniversary date of this Policy or any premium due date thereafter. APL or the Policyholder may terminate this Policy on any premium due date after the first Policy anniversary date. Insurance coverage under this Policy will end on the earliest of these dates: the end of the grace period if the premium for all Certificates in force remains unpaid; the date all Certificates under this Policy terminate; the end of the Policy Month in which the Company receives a written request from the Policyholder to terminate this Policy; or the end of the Policy Month in which APL has terminated this Policy, subject to a 60 day written notice. In addition, APL may end the coverage of a Policyholder if: fewer persons are insured than the Policyholder s application requires; the Policyholder does not promptly provide APL with information that is reasonably required; or the Policyholder fails to perform any of its obligations that relate to this Policy. Cobra Continuation of Coverage This plan may be continued in accordancewith the Consolidated Omnibus Reconciliation Act of 1986. 5
Outpatient Benefit Rider Outpatient Benefits Pays, after satisfaction of any Deductible, for Covered Charges incurred by a Covered Person, if the Covered Person is covered by the Other Medical Plan, at the time the Covered Charges are incurred. If the Deductible is on a Per Occurrence basis, and the Covered Person receives more than one Covered Outpatient Service on the same calendar day, only one Deductible will be required to be met. Per Occurrence means treatment for the same or related condition, unless separated by a period of 90 days. Treatment for the same or related condition separated by 90 days, or an unrelated condition will be considered a new Per Occurrence. The 90 day period of separation begins on the date treatment was received for which an outpatient benefit was paid that resulted in the Per Occurrence Benefit Maximum being met. Benefits payable under this rider are limited to any out of pocket deductible, copayment, and coinsurance amounts the Covered Person incurs under the Other Medical Plan for: outpatient treatment in a Hospital Emergency Room without subsequently being considered an Inpatient; and outpatient treatment in an Urgent Care Facility; and outpatient surgery performed in a Hospital Outpatient Facility or a Freestanding Outpatient Surgery Center; and outpatient diagnostic testing performed in a Hospital Outpatient Facility or a Magnetic Resonance Imaging (MRI) Facility; and outpatient treatment of a Serious Mental Illness performed in a Hospital Outpatient Facility; and Benefits for treatment in an Urgent Care Facility are limited to 3 Urgent Care visits per Covered Person per Calendar Year. Maximum of 6 Urgent Care visits for all Covered Persons combined. Benefits for outpatient treatment of a Serious Mental Illness performed in a Hospital Outpatient Facility are limited to a maximum of 60 days of treatment per Covered Person, per Calendar Year. Cancer Treatment performed in a Cancer Treatment Facility; and Physical Therapy performed in a Physical Therapy Facility. Ambulance Benefit Pays the out of pocket amount up to $350 per trip for ground transportation or up to $1,000 per trip for air transportation, of a Covered Person by ambulance to a Hospital or from one medical facility to another where a Covered Person resides less than 18 hours. If the Covered Person is Confined to a Hospital for 18 hours or more, this benefit will be payable under the In Hospital Benefit in the base policy. This benefit is limited to one trip per day. A licensed ambulance company must provide the ambulance service. If air and ground ambulance service are both required in the same day, APL will only pay the highest benefit amount. This amount is subject to the Maximum Outpatient Benefit and, if applicable, the Maximum Combined In Hospital and Outpatient Benefits. The Outpatient Deductible does not apply to this benefit. Optional Rider Physician Outpatient Treatment Benefit Rider Pays $25 per visit per calendar year for the professional fee of a Physician incurred by a Covered Person in a Hospital Outpatient Facility, Freestanding Emergency Care Clinic, Urgent Care Facility or Physician s Office, as the result of treatment due to a Sickness; or care for an Injury due to an Accident. The Covered Person must be covered by the Other Medical Plan and not be confined as an Inpatient when such Covered Charges are incurred. Benefits are limited to a Maximum of four visits per Covered Person, per Calendar Year and eight visits per Calendar Year for all Covered Persons combined. Benefits for treatment in a Hospital Emergency Room are excluded under the terms of this rider. 6 GMLIV11APL Series
Supplemental Limited Benefit Medical Expense Insurance MEDlink IV - Enhanced Plus Option 2 [Var. - Enhanced 9] Plus Summary of Benefits Livingston Independent School District Base Policy Maximum In Hospital Benefits $2,500 per Covered Person per Confinement In Hospital Ambulance Benefit In Hospital Deductible Up to $350 per trip for ground transportation or up to $1,000 per trip for air transportation where a Covered Person is Confined as an Inpatient. Limited to one trip per day. $0 per Covered Person per Confinement Pre Existing Period Outpatient Benefit Rider Maximum Outpatient Benefits The Pre Existing Period is 12 months prior to the effective date of coverage.this product has a Pre Existing Condition Limitation. The Pre Existing Condition Limitation will apply only if the Covered Person is subject to a Pre Existing Condition Limitation under the Other Medical Plan. Therefore, any Pre Existing Condition Limitation applied to the Major Medical plan would, in effect, limit coverage under this plan. $200 per Covered Person Per Occurrence for Covered Outpatient Services Outpatient Ambulance Benefit Outpatient Deductible Up to $350 per trip for ground transportation or up to $1,000 per trip for air transportation where a Covered Person resides less than 18 hours. Limited to one trip per day. $0 per Covered Person Per Occurrence Covered Outpatient Services Hospital Emergency Room Urgent Care Facility Outpatient Surgery Diagnostic Testing Payable up tothe Maximum Outpatient Benefit, subject to the Outpatient Benefit Maximum of 3Urgent Care visits per Covered Person per Calendar Year. Maximum of 6 Urgent Care visits per Calendar Year for all Covered Persons combined. Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above. Outpatient Surgery in Hospital Outpatient Facility or Freestanding Outpatient Surgery Center. Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Diagnostic Testing in a Hospital Outpatient Facility or MRI Facility. Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above. Must be used in conjunction with brochure APSB 22133 APSB-22133 series Series APSB 22136 APSB-22136(TX)-0912
Supplemental Limited Benefit Medical Expense Insurance MEDlink IV - Enhanced Plus Outpatient Treatment for Mental or Outpatient Treatment for a Serious Mental Emotional Illness Disorder in a Hospital in a Hospital Outpatient Facility Outpatient Facility Cancer Treatment Facility Physical Therapy Facility Maximum Maximum of of 60 30 days days of of treatment treatment per per Covered Covered Person Person per per Calendar Calendar Year. Year. Payable Payable up up to to the the Maximum Maximum Outpatient Outpatient Benefit, Benefit, subject subject to to the the Outpatient Outpatient Benefit Benefit Deductible, Deductible, as as shown above. Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Ages 18-54 Ages 55+ Premiums* Monthly Premiums by Plan* Spouse Child Family $20.46 $47.05 $34.78 $61.37 $30.69 $70.58 $52.16 $92.06 *The premium and amount of benefits vary dependent upon the plan selected. This premium includes the Additional Services Benefit Rider premium. **Total premium includes the Plan selected and the Physician Outpatient Treatment Benefit Rider premium. Must be used in conjunction with brochure APSB 22133 APSB-22133 series Series APSB 22136 APSB-22136(TX)-0912 WV-201308-1 SIC-8211 Underwritten by: