MEDICAL FEATURES

Deductible
Single deductible: this is the amount of eligible expenses that the insured must incur each year before the plan pays benefits.

Family deductible: this is the amount of eligible expenses that all the insured family members must incur each year before the plan pays benefits. Federal guidelines require that covered expenses for all insured family members be added together and applied toward the family deductible before benefits are paid. When the family deductible applies, the single deductible does not apply. The family deductible is an aggregate amount that can be satisfied by one or any combination of family members incurring expenses toward this yearly amount.

Coinsurance
Individual coinsurance: after the deductible is satisfied, the plan pays a percentage of the eligible expenses up to the coinsurance limit (the insured also shares in this expense up to the out-of-pocket maximum). Then the plan pays 100% of eligible expenses for the balance of that calendar year.

Family coinsurance: the coinsurance limit for all family members combined is two times the individual coinsurance maximum. Then the plan pays 100% of eligible expenses for the rest of that calendar year.

Maximum Benefit
As of April 1, 2006, on all new business cases, the lifetime maximum benefit for all injuries, sicknesses or pregnancies is unlimited.  It is also unlimited on all groups renewing after April 1, 2006 as well as any group having a plan change after April 1, 2006.  Psychiatric and alcohol and drug abuse benefits are limited. See Eligible Expenses.

Eligible Expenses
Eligible expenses include medical expenses incurred as a result of an injury, sickness or pregnancy for the following supplies and services received while insured under the plan.

• Hospital expenses:
• Hospital room and board up to the semi-private room rate.
• Hospital supplies and services.
• Intensive care.
• Services of a licensed doctor, anesthetist, or a licensed or board certified psychologist. In-hospital doctors' visits are limited to four visits per two days.
  
• Services of a licensed physiotherapist or licensed occupational therapist, but only to restore or improve lost function following an injury or sickness.
  
• Services of a licensed physical therapist.
• Services of a qualified speech therapist for certain conditions.
• Services of a certified nurse-midwife under qualified medical direction, affiliated or practicing in conjunction with a facility licensed pursuant to Article 28 of the New York Public Health Law.
• Private duty nursing services. The maximum eligible expense is limited to $125 per day. And such services provided by a person who is also an employee of or affiliated with the Hospital or similar place in which the insured is an in-patient will not be an Eligible Expense.
• Services provided as a hospital out-patient in connection with an injury or sickness in a medical emergency.
• Services and medications used for non-experimental cancer chemotherapy and cancer hormone therapy.
• Preadmission tests performed as a hospital outpatient prior to scheduled surgery.
• Treatment of correctable medical conditions causing infertility, except for in vitro fertilization, gamete intrafallopian tube transfers (GIFT) or zygote intrafallopian tube transfers (ZIFT), reversal of elective sterilizations; sex change procedures; cloning; or medical or surgical services or procedures deemed experimental by the guidelines and standards established by the New York Superintendent of Insurance and Commissioner of Health.
• Second surgical opinion by a qualified doctor on the need for surgery.
• Equipment and supplies for the treatment of diabetes, if recommended or prescribed by a doctor or other licensed health care provider.
• Diabetes self-management education, including education relating to proper diets.
• Nutritional supplements (formula) as medically necessary for the treatment of phenylketonuria, branched-chain ketonuria, galactosemia, and homocystinuria when administered under the care of a doctor.
• Allergy tests for diagnosing disease.
• Lab tests.
• Mastectomy or lymph node dissection, on the same basis as any other surgical procedure. Eligible Expenses include in-patient care and reconstructive surgery.
• For pregnancy on the same basis as an illness, including in-patient care and post-discharge care.
• Adult Preventive Care services for doctors' office visits for routine physical exams, including routine injections, inoculations, immunizations, routine x-rays, laboratory tests and multiphasic screening.
• Mammography screening
  - Upon the recommendation of a physician, a mammogram at any age for women having a prior history of breast cancer or who have a first degree relative with a prior history of breast cancer; and
  - a baseline mammogram for women age 35 but under 40 years; and
  - a mammogram once a year for women 40 years of age or older.
• An annual cervical cytology screening for women age 18 or older.
• An annual colorectal cancer screening starting at age 50.
• Preventive and Primary Care Services from birth up to age 19 for an initial hospital checkup and well child visits in accordance with the recommendations of the American Academy of Pediatrics. The visits include a medical history, a complete physical examination, development assessment, anticipatory guidance, and appropriate immunizations and laboratory tests. Necessary immunizations as follows: diphtheria, pertussis, tetanus, polio, measles, rubella, mumps, hemophilus influenza type b, and hepatitis b. are also covered. The plan pays 100%. No deductible or Coinsurance Percent applies to any of these services.
• Bone density tests, drugs and devices approved by the Federal Food and Drug Administration for the detection of osteoporosis for women at significant risk of osteoporosis.
• Diagnostic x-ray exams.
• X-ray, radium and radioactive isotope therapy.
• Prescription drugs and prescription medicines.
• Artificial limbs and eyes, and their repair or (at our option) replacement.
• Casts, splints and surgical dressings.
• Orthopedic appliances (such as trusses, crutches and braces).
• Rental or purchase (at our option) of medical appliances and durable medical equipment up to $10,000 during the insured’ s lifetime.
• Whole blood or blood plasma, unless it is replaced by or for the insured.
• Oxygen and the rental of equipment for giving it.
• Anesthesia and fluids needed for surgery.
• Local ambulance services.
• Transportation by rail, ambulance, or plane to the nearest hospital for specialized treatment up to $2,500 per confinement.
• Services provided by an Ambulatory Surgical Center.
• Services provided by a Birthing Center.
• Home Health Care if a doctor prescribes home care in lieu of a hospital confinement.
• Convalescent Facility Care for up to 90 days, and limited to 50% of the daily semi-private room rate of the Hospital in which the insured was previously confined. This care is eligible if the admission is within 14 days of a 3-day minimum hospital confinement, and the insured continues to remain under the doctor’ s care.
• Hospice Care benefits for a maximum of 210 days for inpatient and outpatient care, and up to 5 visits for all family members combined for bereavement counseling.
• Psychiatric Care.
  - Inpatient Care for 30 days per year. Each day of covered inpatient care may be exchanged for 2 days of intensive, outpatient psychiatric care.
  - Outpatient Care for up to 52 visits per year. We pay $40 or the actual charge, if less, for each visit.
  - Out-patient crisis intervention services for up to 3 emergency visits per year. We pay $60 or the actual charge, if less, for each visit.
• Alcoholism and Drug Abuse.
  - Inpatient Care for 30 days plus 7 days detoxification per year.
  - Outpatient Care for 60 visits per year. 20 of the visits may be for family members.
• Foot Care up to $2,000 per year for an open cutting operation to treat weak, strained, flat, unstable or unbalanced feet, metatarsalgia or bunions, and/or the removal of nail roots, and the treatment of corns, calluses or toenails in connection with a systemic disease.

Extension of Benefits
If a person is totally disabled when insurance terminates, he or she remains protected for the illness or injury causing the total disability while the disability continues up to a period of 12 months.

Coverage Continuation
The continuation of coverage required by New York law is provided for groups not subject to the requirements of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). The continuation of coverage required by COBRA is provided for all other groups.

Conversion privilege: A conversion privilege is available for insured employees and dependents except on plan termination when the plan is replaced by similar group coverage.

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