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DOCUMENT RESUME
ED 024 149 EA 001 802
Group Health Insurance Plans for Public-School Personnel, 1964-65.National Education Association, Washington, D.C.Repor t No- RR- 1966-R10Pub Date Jul 66Note- 82p.Available from-National Education Association, 1201 Sixteenth St., N.W., Washington, D.C. 20036 (Stock No.435-13282, S1.50).
EDRS Price MF-S0.50 HC Not Available from EDRS.Descriptors-Employer Employee Relationship, Frin9e Benefits, Health Insurance, Insurance Companies.Insurance Programs, *Public School Systems, School Personnel, Tables (Data), Teachers
This report explains the major considerations in developing group healthinsurance coverage for public school personnel. A general overview is given of (1)group heAlfh insurance coverage. (2) patterns of group health insurance. (3) grouphealth i ince organizations. (4) eligibility and enrollment practices. and (5)continuout: .alth insurance coverage. Developing specifications for group healthinsurance it.1iscussed in terms of (1) hospital insurance. (2) medical insurance. (3)surgical ir ur..Ince. (4) major medical insurance. (5) generai exclusions and limitations.and (6) group health insurance premiums. Sample contracts of representative groupinsurance plans are included and maximum allowances and benefits of these plans arepresented by State and school district. A short bibliography lists relevant backgroundmaterial. A related document is EA 001 801. (TT)
RESEARCH REPORT 1966-R10
PROCESS WITH MICROFICHE ANDPUBLISHER'S PRICES. MICRO-FICHE REPRODUCTION ONLY.
Group Health InsurancePlans for Public-SchoolPersonnel, 1964-65
RESEARCH DIVISION NATIONAL EDUCATION ASSOCIATIONJuly 1966
PROCESS WITH MICROFICHE ANDPUBLISHER'S PRICES. MICRO-FICHE REPRODUCTION ONLY.
U.S. DEPARTMENT OF HEALTH, EDUCATION & WELFARE
OFFICE OF EDUCATION
THIS DOCUMENT HAS BEEN REPRODUCED EXACTLY AS RECEIVED FROM THE
PERSON OR ORGANIZATION ORIGINAlING IT. POINTS OF VIEW OR OPINIONS
STATED DO NOT NECESSARILY REPRESENT OFFICIAL OFFICE OF EDUCATION
POSITION OR POLICY.
RESEARCH REPORT 1966-R10
Group Health InsurancePlans for Public-SchoolPersonnel, 1964-65
Permission to reproduce this copyrighted work has beengranted to the Educational Resources Information Center(ERIC) and to the organization operating under contractwith the Office to Education to reproduce documents in-cluded in the ERIC system by means of microfiche only,but this right is not conferred to any users of the micro-fiche received from the ERIC Document ReproductionService. Further reproduction of any part requires per-mission of the copyright owner.
RESEARCH DIVISION NATIONAL EDUCATION ASSOCIATION
Copyright © 1966 by theNational Education Association
All Rights Reserved
NATIONAL EDUCATION ASSOCIATION
President: Irvamae ApplegateExecutive Secretary: William G. CarrAssistant Executive Secretary for Information
Services: Sam M. Lambert
DIRECTORHazel Davis
ASSOrIATE DIRECTORGlen Robinson
ASSISTANT DIRECTORSMartha L. WareJean M. FlaniganJack H. KleinmannSimeon P. Taylor IIIWilliam S. Graybeal
RESEARCH ASSOCIATESFrieda S. ShapiroGertrude N. StieberNettie S. Shapiro
ADMINISTRATTVE ASSISTANTValdeane Rice
RESEARCH DIVISION
PUBLICATIONS EDITORBeatrice Crump Lee
RESEARCH ASSISTANTSDonald P, WalkerMarsha A. ReamSheila Martin
CHIEFS OF SECTIONSGrace Brubaker, InformationWally Anne Sliter, TypingFrances H. Reynolds, LibrarySimeon P. Taylor III, Statistics
ASSOCIATE CHIEFRichard E. Scott, Statistics
ASSISTANT CHIEFSHelen Kolodziey, InformationLilian C. Yang, Typing
Research Report 1966-R9: GROUP HEALTH INSURANCE PLANS FOR PUBLIC-SCHOOL PERSONNEL, 1964-65
Project Directors: JACK H. KLEINMANN, Assistant DirectorDONALD P. WALKER, Research Assistant
Price of Report: Single copy, $1.50. Stock #435-13282. Discounts onquantity orders: 2-9 copies, 1070; 10 or more copies, 207.. Ordersamounting to $2 or less must be prepaid. Orders aver $2 may be billedbut shipping charges will be added. Make checks payable to the Na-tional Education Association, 1201 Sixteenth Street, N. W., Washing-ton, D. C. 20036.
Subscription Rate: One-year subscription to the NEA Research DivisionReports, $10; send inquiries to NEA Records Division.
Reproduction of Material: Address communications to the PublicationsEditor, Research Division, National Education Association, 1201 Six-teenth Street, N. W., Washington, D. C. 20036.
NEA Departments and affiliated associations may reproduce excerptsfrom this Report in their official publications without authorizationother than this notice. However, when quotations are used in publica-tions sold commercially by individuals, organizations, or corporations,written permission must be obtained. In all cases, reproduction ofthe Rescarch Report materials must include the usual credit line andthe copyright notice.
CONTENTS
oreword 4
I. Introduction 5
Scope of the Report 5
Tabulation Resume 5
Analysis of ReSumes Returned 6
Summary of School Employer Coopera-tion in Group Health Insurance 6
Competitive Position of School Systems 8
II.- Overview of Group Health Insurance 9
Group Health Insurance Coverage 9
Patterns of Group Health Insurance 9
Group Health Insurance Organizations 9
Eligibility and Enrollment Practices 10
Continuous Health Insurance Coverage 10
III. Considerations in Developing GroupHealth Insurance Specifications 12
Hospital Insurance 12
Medical Insurance 13Surgical Insurance 13
Major Medical Insurance 13
General Exclusions and Limitations 14
Group Health Insurance Premiums 14
IV. Representative Examples of GroupHealth Isurance Plans 16
V. Digests of Group Insurance Plans forPublic-School Personnel, 1964-65,Maximum Allowances and Benefits 46
VI. Selected References on Group HealthInsurance 81
FOREWORD
Group health insurance provides protection from the financial burden ofhealth care for the teacher and his family. More public school systems areaccepting the responsibility of providing and paying part of the cost ofgroup health insurance, which may be an incentive in attracting and retainingthe finest personnel. The needs and desires of school personnel, combinedwith a competitive premium rate, should be the basic considerations in theselection and maintenance of a group health insurance plan. These two fac-tors will tend to stimulate full participation and acceptance of the grouphealth insurance plan by all members of the group to be served.
This report is designed to simplify and explain the major complexitiesand considerations in developing group health insurance coverage. The ap-proach is based on actual experience in public school systems and insuranceorganizations in providing hospital, medical, and surgical protection. Theappeal is to public-school insurance administratols and local education asso-ciation committees for a proper understanding and knowledge of group healthinsurance to protect adequately both the school system and the teacher.
This study has been tabulated and reported under the direction of JackH. Kleinmann, Assistant Director, and Donald P. Walker, Research Assistant.The staff of the Statistics Section and Typing Production Unit were of in-valuable assistance in gathering and producing the digest of group healthinsurance plans.
The Division is most grateful to the many central-office personnel andinsurance officials who supplied the flyers, brochures, and policies, andwho later checked the accuracy of the reported digests.
HAZEL DAVISDirector, Research Divisi6n
I. INTRODUCTION
In 1964, 79 percent of the civilian popula-tion had some protection against hospital carecosts; 75 percent had some surgical expenseprotection; and 57 percent were protected tosome extent against the cost of in-hospitalmedical visits, according to ;he Health Insur-ance Association of America..lf A survey con-ducted by the NEA Research Division during the1964-65 school year shows that a majority ofschool systems cooperate in providing thesegroup health insurance benefits for theirstaffs.2/ This report, which contains descrip-tions of group health insurance plans, is oneof two reports based on the original, compre-hensive study. The other report will containdetailed information on group life insuranceprovisions.
Scope of the Report
This report, in addition to the introduc-tion, contains five parts:
II. Overview of Group Health Insurance
III. Considerations in Developing GroupHealth Insurance Specifications
IV. Representative Examples of GroupHealth Insurance Plans
V. Digests of Group Insurance Plans forPublic-School Personnel, 1964-65,Maximum Allowances and Benefits
VI. Selected References on Group HealthInsurance
Tabulation Re 'mine
The questionnaire on school system groupinsurance cooperation for 1964-65 contained arequest for printed material or brochures de-smdadng the various insurance plans in effect.A wide variety of plans and printed materialon group health insurance was remitted by therespondents.
5
A group health insurance tabulation re/ sumewas prepared to gather information on specifichealt4 care coverage. Information recorded onthe resumes included specific coverage for hos-pitalization, medical, surgical, and major med-ical insurance, all of which was taken from thegroupthealth insurance brochures. Separateresumes were used for those school systemswhich cooperated in more than one group health
TAELE 1. ----ANALYSIS OF RESUMES RETURNED,1964-65
Enrollmentstratifi-cation
Numberof us-
Number able refof sys- Number plies as
Total terns of sys- percentnumber cooper- tens of sys-of op- ating report- teus co-erating in pro- ed (us- operat-systeus, viding able ing in1964-65 health re- provid-
insur- plies) ingance health
insur-ance
1 2 3 4 5
Stratum 1--100,000 ormore 21 21 19 90.57.
Stratum 2--50,000-99,999. 48 45 35 77.8
Stratum 3--25,000-49,999. 73 57 56 98.2
Total,Strata 1-3 . 142 123 110 89.47.
Selected sys-tems--below25;000 enroll-ment 72 72
1/ Reed, Louis S. "Private Health Insurance in the United States: An Overview." Social Secur-ity Bulletin 28: 3-21, 48; December 1965.
2/ National Education Association, Research Division. Employer Cooperation in Gruup InsuranceCoverage for Public-School Personnel, 1964-65. Research Report 1966-R4. Washington, D. C.: theAssociation, March 1966. p. 7:
6
TABLE 2.--EXTENT OF EMPLOYER COOPERATIONBY TYPE OF GROUP HEALTH INSURANCE
COVERAGE, 1964-65
Enrollment Hospitali- Medical Majorstratifi- zation surgical medicalcation Num- Per- Num- Per- Num- Per-
1
Stratum 1--100,000 ormore (totalrespond-ents--21) ....
Stratum 2--50,000-99,999.(total re-spondents--48)
Stratum 3--25,000-49,999(total re-spondents--65)
Stratum 4--12,000-24,999(total re-spondents-2*
Total,Strata 1-4(total re-spondents--390)
Selected sub-urban systems--
enrollment be-low 12,000 (to.-
tal respond-ents-193) ...
ber cent ber cent ber cent
2 3 4 5 6 7
20 95.2% 20 95.2% 16 76.2%
44 91.7 42 87.5 33 68.8
54 83.1 53 81.5 43 66.2
214 83.6 208 81.3 154 60.2
332 85.17. 323 82.8% 246 63.17.
179 92.7% 174 90.1% 133 68.9%
insurance plan.' Some group health plans of-fered varying levels of coverage under the samebasic plan, graded according to amount or op-tion desired, annual income, or age; these wererecorded at the highest option level, $6,700annual income and age 40, respectively.
I
Resumes were then returned to the school sys-tems for any additions, corrections, or dele-tions, and, also, to furnish certain informationnot available from the brodhures. Since therewas a time lapse between thi original requestand the completion of the resumes, school sp-tems were reminded not to update the resumesbut to make necessary changes that were in ef-fect for the 1964-65 school year.
3/ Ibid., p.
Analysis of Resumes Returned
Table 1 furnishes information on the numberof resumes sent and the number of resumes re-turned. All operating school systems cooperat-ing in group health insurance programs in Stra-ta 1-3 (pupil egrollment of 25,000 or more)were sent resumes, as were 72 selected urbanand suburban systems with enrollments below25,000. The 72 systems were selected as repre-sentatives in terns of size, geographical loca-tion, and variation in health insurance cover-age.
Summary of School Employer Cooperationin Group Health Insurance
Group health :Insurance provides some measureof protection from the financial burdens ofhealth care. Basically, health care may bebroken down into three categories: hospitalcare, medical treatment, and surgical proce-dures. For each of these categories, manykinds of forms and coverage are availablethrough insurance companies, nonprofit healthservice organizations, and group-practice asso-ciations.
Some health insurance plans distinguishbetween "basic" health insurance coverage andmajor medical insurance coverage. In thoseinstances, basic health insurance coverage isgenerally limited to short-term health care,after which supplementary major medical cover-age provides for the prolonged, expensive in-jury or illness. Recent developments in healthinsurance have led to the provision of compre-hensive major medical insurance plans, whichreplace basic health insurance plans. Also,the trend is to extend basic health insurancecoverage to provide up to two years of hospitalcare and greater allowances for medical-surg-ical procedures.
There are two basic advantages in partici-pating in group health insurance coverage:(a) minimum cost in relation to coverage, and(b) .coverage for individuals who otherwise wouldbe considered "poor risks."
The summary Tables 2, 3, and 4 on school sys-tem cooperation in providing group health insur-ance were computed from the questionnaire forEmployer Cooperation in Group Insurance Cover-site for Public-School Personnel, 1964-65. Alloperating school systems in Strata 1-4 (pupilenrollment of 12,000 or more) were sent ques-tionnaires, as were 203 selected suburban sys-tems with enrollments below 12,000. Usable re-plies totaled 88.0 percent of the Strata 1-4systems and 95.1 percent of the suburbansystems...1/
TABLE 3.--PERCENT OF SCHOOL SYSTEMS WHICH COOPERATE,BY COMBINATIONSOF GROUP HEALTH INSURANCE PROVITED, 1964-65
--.'
7
Enrollment stratification
Number ofsystemsreporting
Hospitaliza-tion, medical-surgical,major medical
Hospitaliza-tion, medical-surgical (only) Other
Total--some typeof healthinsurance
1 2 3 4 5 6
Stratum 1--100,000 or more 21 71.47. 23.8% 4.8% 100.0%
Stratum 2--50,000-99,999 48 64.6 22.9 6.3 93.8
Stratum 3--25,000-49,999 65 58.5 21.5 7.7 87.7
Stratum 4-12,000-.24,999 256 53.9 26.6 7.0 87.1
Total, Strata 1-4 390 56.9% 25.1% 6.9% 88.7%
Selected suburban systems--below12,000 enrollment 193 65.87 24.47. 4.1% 94.1%
TABLE 4.--SCHOOL SYSTEMS WHICH PAY ALL OR PART OFGROUP HEALTH INSURANCE COST, 1964-65
Type of insurance
Total systems reporting 12,000and over in enrollment
Selected suburban systems, lessthan 12,000 in eprollment
Cooperate Pay all or part Cooperate Pay all or_part
Number Percent Number Percent Number Percent Number Percent
1 2 3 4 5 6 7 8 9
Hospitalization 332 85.1% 131 33.6% 179 92.7% 77 39.97.
Medical-surgical 323 82.8 128 32.8 174 90.1 74 38.3
Supplemental or comprehen-sive major medical 246 63.1 115 29.5 133 68.9 86 44.6
Total school systemsreporting 390 100.0% 390 100.0% 193 100.0% 193 100.0%
8
School systems may cooperate in one or more
ways: by sponsoring, making payroll deductions,
or paying all or part of the premium cost of
group health insurance. Table 2 shows that ofthe different types of group health insurance,
school systems cooperate in providing hospitali-
zation most frequently, but medical-surgical
is very close behind. Far fewer school systems
cooperate in providing major medical insurance.
This is to be expected, since major medical
coverage is a relatively recent development in
health insurance.
Table 3 shows that 88.7 percent of the Stra-
ta 1-4 systems and 94.3 percent of the subur-bmisystens cooperate in providing one or more
types of group health insurance--hospitaliza-tion, medical-surgical, or major medical. Over
half of the Strata 1-4 systems and 65.8 percent
of the suburban systems make available all
three types of group health insuranm. In ad-
dition, approximately one-fourth of the Stra-
ta 1-4 and the suburban systems have available
basic health insurance coverage consisting of
hospitalization and medical-surgical insurance.
Table 4 shows that about a third of Stra-
ta 1-4 systems pay all or part of the cost of
insurance coverage; the percentage of selected
suburban systems which participate in financing
group health coverage is somewhat higher for
each type of insurance listed.
Competitive Position of School Systems
A survey of approximately 690 reporting
companies conducted in 1963 by the U.S. Bureau
of Labor Statistics revealed that 97 percent
of all industries cooperate in providing
hospitalization, surgical, and medical plans,
and sickness and accident insurance for their
white-coliar employees (clerical, technical,
professional, administrative, and executive po-
sitions). Included in the survey were 289 firms
with 250 to 999 employees, and 401 firms with
1,000 or more employees. Of these companies,
74 percent indicated that they paid all or part
of the expenditures for these Osurance plans;
30 percult paid all the cost.A1
While the percentage of school employers pay-
ing part or all of the premium for employee
health insurance has increased somewhat in the
past decade, the extent of employer cooperation
is by no means as great as is found in privace
and governmental employment. According to
Allen:
Although the major benefit from a hospital
medical plan accrues to the employee, there
are specific advantages to the school dis-
trict. Through better means of preventivehealth care or early and adequate treatmentwhen illness occurs, employees lose less
time due to sickness. This is of particularimportance, considering the present high
costs for illness-leave payments and the ex-
pense of employing substitutes, especially
in the teaching services. An adequate planof hospital-medical coverage tends to im-
prove morale, particularly if the district
sponsors the program and contributes toward
the cost. An adequate hospital-medicalprogram is an effective tool in meeting com-
petition in a tight labor market. In the
vecruitment and holding of good personnel,
a broad and well-administered hospital-med-ical plan is of much greater effect than
a similar amount of expenditure added to
the salary scale.51
4/ U.S. Department of Labor, Bureau of Labor Statistics.
duction Workers, 1963. Bulletin No. 1470. Washington, D.0
1965. Tables 6 and 9, p. 24 and 27.
5/ Allen, Clifford H. School Insurance Administration.
Supplementarx Compensation for Nonpr27
.: Government Printing Office, December
New York: Macmillan Co., 1965. p. 104.
IL OVERVIEW OF GROUP HEALTHINSURANCE
National health expenditures stood at $36.8billion in 1964, 5.8 percent of the Gross Na-tional Product, Almost 68 percent ($24.8 bil-lion) of all health expenditures were made byprivate consumers or health insurance organi-sations on their behalf. One-third of the to-
tal consumer expenditures for personal healthcare, $7.8 billion, was met by health insur-
ance and the balance, $15.9 billion, represent-ed direct out-of-pocket payments for cared./
Group Health Insurance Coverage
Hospital care expenditures constituted thelargest single item of national health expendi-tures and in 1964 accounted for almost 35 per-cent ($12.7 billion) of the total. Expendi-
6 tures for the services of physicians in private
practice, the next largest component of health
expenditures, amounted to $7.3 billion (20 per-
cent). Health insurance coverage provides theprotection which more readily enables indivi-duals to meet rising costs in these two majorhealth expenditure areas.
Patterns of Group Health Insurance
Private health insurance organizations pro-vide group health insurance protection for
their members in two basic patterns: reimburse-
ment and service.
The common feature of reimbursement, c in-
demnity, health insurance is the application
of maximum amounts. Generally, maximum amounts
are applied in two ways:
1. Scheduled maximum amounts for specificitems or procedures
2. Over-all maximum amounts limited to aspecific illness, number of years, orsome other form of time measurement.
The reimbursement payments may be made tothe insured individua O. for health expense in-
9
curred, or assigned directly to the hospital orphysician for benefits provided.
Service plans provided the insured with spe-cific scheduled or nonscheduled benfits orhealth care offered through service plans isprovided either by prearranged agreements withparticipating hospitals and physicians (BlueCross-Blue Shield) or through group practicemedical facilities and staff physicians.
Various combinations of reimbursement andservice insurance patterns have been developedto provide a wide variety of coverage.
Gimmip Health Insurance Orgamizadons
Group health insurance organizations havebeen grouped into three different types: in-
surance companies, nonprofit health service or-ganizations (Blue Cross-Blue Shield), and group-
practice associations. Some individuals may beenrolled in more than one of the three types oforganizations. Of the total enrollment in in-surance organizations at the end of 1964, ap-
proximately 60 percent of the persons were cov-ered by insurance companies, 36 percent by BlueCross-Blue Shield, and 4 percent in group-prac-tice associations.21
Insurance CompaniesThe group health insurance policy is contract-
ed between the insurance company and the mem-ber's organization. The policy will specifythe amount of reimbursement and conditions forwhich.payment will be made under the group cov-erage. The insurance company will reimbursethe insured individual directly for approvedclaims, or, if preferred, the individual may as-sign payment to the hospital and doctor. Mem-bers covered under the group health insurancecarrier's policy can usually recieve medicaltreatment in any accredited hospital or by anylicensed doctor. Insurance carrier's policiesgenerally follow the indemnity pattern in in-surance coverage. Over 1,000.insurance com-panies wrote group insurance policies in 1963.
---17Keed, Louis 3., and Hanft, Ruth S. "National Health Expenditures, 1950-64." Social security
Bulletin 29: 3-19; January 1966. p. a and 6.----TEteed,Lotiis S. "Private Health Insurance in the United States: An Overview." Social Security
Bulletin 28: 3-21, 48; December 1965. p. 10.
10
Nonprofit Health Service Organisations
Blue Cross and Blue Shield are by far thelargest nonprofit health service organizations.At present, there are 76 Blue Cross associa-tions and 74 Blue Shield associations in theUnited States. Generally, these associationsare independent, locally governed, nonprofitcorporations serving the general geographicalarea in which they are situated.
Although most associations are iiidependentand sometimes in competition with each other,they are coordinated by their respective na-tional associations. The national associationscoordinate interplan arrangements for transferof membership, without loss of status, for amember who moves or receives service benefitsin another association's area.
Blue Cross and Blue Shield offer numerousindividual or group plans through participatingmember hospitals and doctors. Almost all ofthe accredited hospitals and licensed physi-cians in a covered area are participants andunder contract with the Blue Cross or BlueShield association.
The group plan usually requires a certainpercentage of enrollment. Plans vary accord-ing to types of services and benefits, amountsand schedules of aliowances and specified pro-cedures and treatment. These service plansmay also incorporate an indemnity type feature,whereby the plan pays only a specific amountand the member is responsible for additionalcharges. This feature is usually based on an-nual income; within specified annual incomelevels, the physicians agree to accept theschedule of allowances as payment in full.
Group Practice Associations
Group-practice plans are established on acooperative prepaid basis. The larger plansgenerally provide, in addition to needed hos-pital, medical, and surgical care, diagnosticand preventive care in their own clini;s orhospitals with salaried medical staffs; otherplans provide their own medical care and con-tract out for hospital care. Even thoughhealth coverage is much broader under group-practice plans, the physical facilities andstaff members are the limiting factors. Incases of emergency, some plans provide minimumcoverage outside the service area until thepatient can be moved to their own facilities.Another feature in some plans is a slightcharge for certain services, such as doctor'soffice and home calls and full maternity bene-fits. Group-practice plans have been organizedby community-consumer groups, employer-employeegroups, and private medical societies. Theyare presently available only in the large pop-ulation centers. The major group-practice
plans are the four Kaiser Health Plans (inNorthern California, Southern California, Ore-gon, and Hawaii); Group Health Association ofPuget Sound; Health Insurance Plan of GreaterNew York; Group Health Association of Washing-ton, D.C.; and Community Health Association ofDetroit.
Eligibility and Enrollment Practices
Some state statutes govern the minimum numberof individuals who must participate in groupinsurance before a policy may be issued. Also,many insurance organizations require a certainpercentage of eligible employees to maintainenrollment under a group policy, along withother standards which must be met before an in-dividual may be eligible for group enrollment.Within these limitations, it is usually thepurchasing organization which determines theemployees who will be offered the opportunityto participate in the group plan.
Eligibility and enrollment procedures arevery closely allied. The initial enrollmentperiod is usually immediately or within 30 daysof employment for eligible employees. If anemployee waives his initial enrollment opportu-nity, he may have to wait from three months toa year and provide evidence of "good health"to obtain group coverage.
Continuous Health Insurance Coverage
Membership in the group health insuranceplan usually terminates when the individualterminates his employment. However, if thegroup plan contains conversion privileges,theindividual may maintain continuous health in-surance coverage. A conversion privilege clausepermits the individual to change to an individ-ual contract upon termination of employment.Some group plans make special provisions whichallow retired employees and their dependentsto remain members in the group plan. Applica-tion for the individual policy must be madewithin a specific time period, and rates areadjusted according to age, dependents, health,and choice of plan.
Special attention on the part of many inter-ests has been given to provide health protectionfor elderly persons. The most significant de-velopment was the Social Security Amendments of1965 which provide for "medicare." BeginningJuly 1, 1966, all eligible persons 65 and overwho have enrolled will receive hospital insur-ance protection. In addition, voluntary medi-cal insurance is provided at a low premium ($3monthly) with the federal government matching
this amount. Groups developing health insur-ance programs should be aware of these servicescurrently available to retired individuals.
Hospitalization is provided for up to 90days in a "spell of illness." After a $40 de-ductible, the first 60 days of hospital expenseis covered in full; thereafter, 30 of such careis provided except for $10 daily which must bepaid by the patient. The medical insurance
11
program pays 80 percent of the reasonablecharges for covered expense, except for thefirst $50 in a calendar year.
Some items and services not covered byeither plan are routine physical checkups, eye-glasses, hearing aids, private duty nursing,custodial care, and personal services. Drugs
are covered only in the hospital or if adminis-tered by a physician.
12
III. CONSIDERATIONS IN DEVELOPING GROUPHEALTH INSURANCE SPECIFICATIONS
Specifications should be clear, concise, andas comprehensive as possible. Allowable limita-tions and restrictions should be completely cov-ered along with the areas of protection desired.When specifications are complete and reflectfully the coverage desired by the group, littleor no deviation should be permitted while re-ceiving bids or during negotiations, withouta full explanation by the prospective company.The reason for this caution is that changes inspecifications make it exceedingly difficultto evaluate the different types of protectionoffered by various companies.
While under present health plan arrangements,amounts and types of benefits vary considerably,there are specific provisions that can be com-pared for both reimbursement and service plans.A preliminary investigation is necessary todetermine the most desirable type of grouphealth coverage available (see Section IV).
Actual benefits should be compared ratherthan maximum amounts, along with specified ex-clusions and restrictions. The ultimate deter-mination will depend on the group's desiredcoverage consistent with a competitive premiumlevel.
One important question to be considered isthat of dependent coverage--how much and forwhom? Most group plans provide the same healthcoverage for dependents as for employees.Children are usually covered from birth orfrom 14 days after birth. Recent trends havebeen to.expand the upper age limit from 19 to23, so long as the child is single and goingto school. The immediate family unit is stillthe most common guideline in considering whois a dependent.
Hospital Insurance
The group health insurance organizationdetermines the hospital or other medicalfacilities that the member may use, e.g., anyaccredited hospital, member accredited hos-pital, nursing home, and clinic. Following arefactors (and comments) which should be consid-ered in developing specifications for hospitalinsurance:
1. Conditions or causes excluded from hospitaladmission coverage. (See general exclu-sions, page 14.
2. Minimum confinement before hospital cow...ragegoes into effect. Generally, the minimumconfinement is not more than 18 hours beforecoverage commences.
3. Scope of daily benefits and service. Mostoften room and meals, general nursing care,and special diets are included.
4. Maximum allowance for hospital room. Allow-ances are generally provided on an "up to"basis. This means that the patient will bereimbursed for charges up to the allowanceshown in the digest.
5. Type of accommodation. Accommodations varyfrom private to ward; these should be de-fined in the policy according to bed capac-ity.
6. Flexibility of daily allowance or accommoda-tions. If the physician prescribes betteraccommodations for the patient than coveredunder the plan, is the cost of daily cover-age applied toward these better accommoda-tions.
7. Maximum number of days allowed for each hos-pital confinement. Consec-,Ave days of cov-erage for each confinement are usually notless than 21 days, and may be as high as twoyears.
8. Waiting period before maximum benefits maybe renewed. Some maximum hospital confine-ment benefits are available once each con-tract term. Others are renewable after anappropriate out-of-hospital waiting periodof 30 to 90 days.
9. Other hospital services, including cash al-lowances or services provided in additionto daily benefits. Services vary consider-ably from full coverage, maximum amounts,and specific lists of items covered foreach hospital confinement (e.g., drugs,supplies and medications, laboratory examina-tions, and the use of operating room).
10. Emergency outpatient care in case of acci-dent. Treatment must usually be obtainedwithin a specific number of hours after theaccident occurs.
11. Diagnostic treatment or examination. Gen-eralliapplicable after the illness has
been determined, except under group-prac-tice plans which provide full diagnosticcoverage.
12. Maternity and newborn child care. If pro-vided, consider carefully as these areusually handled separately from other hos-pital confinements, and usually are not pro-vided under individual coverage.
Medical Insurance
Medical insurance covers medical treatmentby a physician in the hospital for surgical ornonsurgical confinement, in the doctor's of-fice, or at the patient's home. Medical careis most often provided in the hospital for non-surgical conditions. Additionally, if coverageis available in all three situations, allowancesare usually much greater for in-hospital treat-ment. When home and office calls are covered,they are generally limited to the employee,with some plans charging a minimum fee forservice. Following are factors (and comments)which should be considered in developing speci-fications for medical insurance:
1. Number of days or visits allowed for eachplace. Visits are usually limited to oneper day. The number of days allowed forin-hospital medical treatment may differfrom the hospital confinement period.
2. Allowance for each day or visit, and maximumamount allowed for each location. Allow.
ances are usually more liberal for in-hospi.tal medical care than for care provided inthe home or doctor's office.
3. Waiting period before medical coverage goes
into effect. May vary for illnesses not re-quiring hospitalization as opposed to thoserequiring hospital admission.
4. Waiting period before maximum benefits maybe renewed. May nOt be the same as pro-vided under hospital insurance.
5. Maternity and child care. Prenatal andpostnatal care is usually not providedexcept under group practice plans.
6. Consulting physicians and specialists asneeded. Allowances vary considerably butgenerally must be requested by anotherphysician.
7. Diagnostic treatment and examination. Gen-erally applicable after the illness hasbeen determined except under group-prac-tice plans which provide full coverage.
8. Preventive care and medical check-up. Notprovided except under group practice plans.
9. Psychiatric treatment of mental or nervous
disorders. Generally not covered exceptunder major medical provisions.
13
Surgical Insurance
Whether surgical procedures are scheduled ornonscheduled, amounts are usually provided forunder a "reasonable" charge clause in the policy.The "reasonable" charge is a charge not out ofline with charges.for the same or similar typesurgical procedures in the general area. Al-though the following factors are considerationsfor a scheduled listing of surgical operations,they may also be the basis for the "reasonable"charge allowance:
1. Amount and types of surgical operationslisted. Some provision should be made fornonscheduled operations and minor surgerynot requiring hospitalization.
2. Maximum allowance for a single operation.The higher the maximum, the less restric-tion on unexpected, complex procedures.Single operation maximums range from $200to over $1,000.
3. Multiple surgical procedures. Allowancesfor multiple procedures depend on theirrelationship to the original operation.Generally, the highest amount is allowed,with various arrangements for the otherprocedures.
4. Covera e for anesthesia and anestheist.Coverage is provided in various ways: bythe number of hours of service required, asa percentage of operation cost, separateamounts for each operation, or as part ofthe total surgical procedure allowance.
$. Obstetrical procedures. Benefits describedin Section IV are for normal delivery.Scheduled obstetrical procedures usuallyprovide higher benefits in those cases whereobstetrical complications arise. Othermethods of providing obstetrical proceduresare covered by lump-sum or fee-for-servicearrangements which include other maternitybenefits covered under a single amount.
6. Surgical assistants and consultants. Thisitem may be specifically included, specif .
ically excluded, or not mentioned in thepolicy.
Major Medical Insurance
Some major medical insurance plans listspecific benefits and allowances similar tothose designated above, which limit the chargescovered within the over-all maximum amount.Generally, actual expense reimbursement is pro-vided on a coinsurance basis after a deductibleis paid by the member.
Major medical insurance is applied in twoways--supplementary and comprehensive.
14
$upplementary major medical insurance extendsthe basic health coverage; comprehensive planshave tended to replace basic health coverage.Following are factors (and comments) whichshould be considered in developing specifica-tions for major medical insurance.
1. Conditions and causes excluded from main.medical insurance. See general exclusions,below.
2. Amount of deductible paid by member.Various amounts or one mmximum amount maybe applied to different types of healthcare, before expenses are covered. Out-of-pocket deductibles vary from $25 to over$500 but most often will be about $100.
3. &slicatiorictible:inicorricuThaIti-cte.tised incomprehensive major medical plans and areap?lied before any payments by coinsurancefor a particular type of covered expense.Corridor deductibles pertain to supplemen-tary major medical plans and are appliedafter basic plan benefits are ekhaustedand before supplementary major medicalpayments commence on a coinsurance basis.
4. Time allotted for payment of deductible.Varies from 90 days, 6 months, 1 year, orin relation to a particular illness.
5. Coinsurance provisions. Percentage ofshared covered.expense; 80 percent paid byinsurance company, 20 percent paid by mem-ber is typical, but numerous other arrange-ments are available.
6. Maximum amount or upper limit. fianges from$5,000 to $40,000 with most plans providingup to $10,000.
7. Time limit on payment of maximum amount.Some measure of time is generally attachedto the payment of the maximum amount,whether it be per illness, number of years,or life.
8. Reinstatement of maximum amount. Themaximum amount is usually reinstated after$1,000 in benefits has been paid. Some-times reinstatement is automatic, but moreoften it occurs after proof of good healthis furnished.
9. Common family accident deductible. Thisprovides one deductible rather than indi-vidual deductibles in case of a commonfamily accident.
10. Outpatient psychiatric care. If covered,outpatient psychiatric care is sometimesreimbursed on a lower coinsurance basis(e.g., 50-50) than other types of cover-age.
General Exclusions and Limitations
All types of health insurance plans generallycontain some exclusions. The most common ex-clusions are dental care, cosmetic surgery,alcoholism, drug addiction, venereal disease,attempts at suicide or other intentionally self-inflicttd injuries or illnesses, tuberculosis,conditions covered by Workman's Compensationlaws, military service-connected conditions,service rendered by government hospitals, andconditions caused by war. Still other healthinsurance plans exclude health examinations,normal eye and ear examinations, glasses orhearing aids, corrective appliances andartificial aids and blood or blood plasma.Provisions for maternity care, appendectomy,tonsillectomy or hernia coverage may require awaiting period before they can be consideredcovered expenses. These exclusions.are enumer-ated in the group policy. Other limitations,not specifically included in the insurancepolicy, are the scope of facilities and varietyof professional personnel made availabe by theinsurance organization from which a subscribermay choose, by desire or necessity, to receivehealth care.
Group Health Insurance Premiums
The cost of providing the same benefitsmay vary considerably from one group toanother depending on differences in composi-tion of the group. Premiums are determinedby a number of factors:
1. The scope of benefits desired.
2. The occupations of the members of thegroup: i.e., the element of riskinherent in the occupations of thegroup members affects the cost ofcertain benefits.
3. The numbers of men and women in thegroup: experience indicates that,on the average, women make moreclaims for certain benefits than domen.
4. The ages of the group.members.
5. The size of the group: generally,the larger the group and the greaterthe volume of premiums, the lower theinitial and ultimate cost of the plan.(This is known as a "premium-volumediscount.")
6. The number of group members who havedependents: the cost of benefitsfor dependents varies in direct pro-portion to the number of dependentscovered.
The first year's premium is determinedon the basis of the foregoing factors. Thepremiums for following years are determinedby experience-rating, or by what is knownas the "cost-plus" basis, the "cost" beingthe actual claim payments made by the in-surance company during the preceding yearand the "plus" being the amount the insur-ance company retains for its operating ex-penses and profit. If the claim experienceis greater than anticipated, the premium,of course, is raised; conversely, if the
15
claim experience is less than anticipated,the premium is lowered.1/
Health service organizations,such as BlueCross and Blue Shieldpused to determine theirpremiums on a "community-rated" basis but re-cent trends, due to competition from insurancecowanies, have caused them to change to theIII experience-rated" basis. Under the community-rating approach, the entire service plan areawas considered a group and the premium for bas-ic coverage was the same for all participants.
1/ Jack H. Kleinmann. Fringe Benefits for Public School Personnel. (New York: Bureau of Pub-lications, Teachers College, Columbia University, 1962), pp. 18:19. Quoted with permission.
16
IV. REPRESENTATIVE EXAMPLES OF GROUPHEALTH INSURANCE PLANS
The examples of group health insurance poli-cies included in this section were selected toillustrate the types of plans different organi-zations provide for local school systems togive some protection against the expenses ofhospital care, medical treatment, and surgicalprocedures. Many variations of these basictypes of coverage are available; each group tobe insured must determine the group health planwhich best fulfills its particular needs.
Example 1 is a basic health insurance planwith supplementary major medical insurance pro-vided by nonprofit health service organizations(Hospital Service Corporation of Rhode Islandand Rhode Island Medical Society PhysiciansService--Blue Cross and Blue Shield). There
are three separate contracts provided: hospi-
tal care (Blue Cross), surgical-medical care(Blue Shield), and supplementary major medicalcare (issued jointly by Blue Cross and BlueShield). The basic health insurance can becontracted for separately from supplementarymajor medical care. In some instances, supple-mentary major medical care is underwrittenseparately by either Blue Cross or Blue Shieldand in other instances by an independent insur-ance company. The plans in this example areavailable only in the Rhode Island Blue Cross
and Blue Shield service area, but similarplans are available elsewhere.
Example 2 is a comprehensive major medicalcare plan provided by an independent insurancecompany (The Equitable Life Assurance Societyof the United States). This group health planillustrates several features: (a) conditionsfor deductible amount, (b) scheduled allowancesalong with the maximum amount, (c) special pro-visions which limit the extent of maternityand psychiatric treatment. Variations of com-prehensive major medical insurance are avail-able through the addition or deletion of spe-cial provisions.
Example 3 is a basic health insurance planprovided by a group-practice association(Kaiser Foundation Health Plan, Inc.). TheKaiser plan, like other group-practice plans,provides diagnostic services on a preventivebasis as well as medical treatment after anillness or disability occurs. The Kaiser Foun-dation follows a policy of dual choice, whichmeans that at least two organizations must beavailable to provide health care; each employeethus may choose between the Kaiser plan and theother plan, depending upon which comes closestto meeting his individual needs. The Kaiserplans are available only to groups within theirspecific service area.
BL
UE
CR
OSS
CO
NT
RA
CT
for
Hos
pita
l Car
e
RH
OD
E IS
LAN
D B
LUE
CR
OS
SP
RO
VID
EN
CE
, RH
OD
E IS
LAN
D
A N
on-P
rofit
Com
mun
ity S
ervi
ce,
Inco
rpor
ated
Und
er th
e La
ws
of R
hode
Isla
nd.
eApp
rove
d by
Am
eric
an H
ospi
tal A
ssoc
iatio
n
31I
3101
0113
1010
101M
OM
MO
ME
NC
1101
0163
1011
311
Of
*4 44
Thi
s co
ntra
ct is
mad
e be
twee
n th
e H
ospi
tal
Ser
vice
Cor
pora
tion
of R
hode
Isla
nd (
here
-in
afte
r ca
lled
the
Cor
pora
tion)
and
the
App
li-ca
nt n
amed
in th
e ap
plic
atio
n to
rec
eive
the
bene
fits
prov
ided
her
ein
and
who
se n
ame
and
iden
tific
atio
n nu
mbe
r ap
pear
on
the
mem
bers
hip
card
furn
ishe
d to
sai
dA
pplic
ant.
In c
onsi
dera
tion
of th
e ap
plic
atio
n an
d up
onpa
ymen
t in
adva
nce
of th
e su
bscr
iptio
nch
arge
s, th
e C
OR
PO
RA
TIO
N a
gree
s to
fur-
nish
and
pro
vide
to s
aid
App
lican
t and
eac
hS
ubsc
riber
". if
any
, lis
ted
on th
e ap
plic
atio
nor
rec
lass
ifica
tion
ther
eof,
hosp
ital c
are
acco
rdin
g to
the
Blu
e C
ross
Pla
n de
scrib
edon
the
follo
win
g pa
ges
whi
ch is
par
t of t
his
cont
ract
.In
Witn
ess
Whe
reof
, the
HO
SP
ITA
L S
ER
V-
ICE
CO
RP
OR
AT
ION
OF
RH
OD
E IS
LAN
D h
asex
ecut
ed th
is C
ontr
act.
HO
SP
ITA
L S
ER
VIC
E C
OR
PO
RA
TIO
NO
F R
HO
DE
ISLA
ND
By:
Atte
st:
Cou
nter
sign
ed:
aree
..e.4
r/S
erie
s(7
-145
)
3101
0101
0101
=31
0001
01M
MO
NIM
ION
NO
N
Exe
cutiv
e D
irect
or
TH
E B
LUE
CR
OS
S P
LAN
FO
R
HO
SP
ITA
L C
AR
E
PA
RT
I- H
OS
PIT
AL
BE
NE
FIT
S P
RO
VID
ED
Eac
h su
bscr
iber
in g
ood
stan
ding
, if i
n ne
ed o
f car
ein
an
appr
oved
hos
pita
l for
illn
ess,
or
inju
ry, u
pon
adm
issi
on to
a h
ospi
tal a
s a
bed
patie
nt, o
n an
d af
ter
the
effe
ctiv
e da
te o
f thi
s ag
reem
ent,
shal
l be
entit
led
to c
redi
ts fo
r ho
spita
l ser
vice
s an
d su
pplie
s w
hile
suc
hca
re is
med
ical
ly n
eces
sary
, sub
ject
to th
e te
rms
and
cond
ition
s of
this
agr
eem
ent,
for
the
leng
th o
f tim
esp
ecifi
ed in
Par
t II o
f thi
s ag
reem
ent,
as fo
llow
s:
(a)
FO
R M
ED
ICA
L A
ND
SU
RG
ICA
L C
AS
ES
(i)If
the
subs
crib
er is
hos
pita
lized
in a
ME
MB
ER
HO
SP
ITA
L or
SE
RV
ICE
BE
NE
FIT
HO
SP
ITA
L, u
p to
the
amou
nt p
er d
ay in
dica
ted
on th
e m
embe
rshi
p ca
rd(u
nder
"R
& B
"), a
s a
cred
it to
war
ds th
e us
ual h
ospi
tal
char
ges
for
(1)
room
acc
omm
odat
ions
, (2)
die
tary
ser
v-ic
e an
d m
eals
, and
(3)
gen
eral
nur
sing
car
e (it
ems
(1)
thro
ugh
(3)
bein
g he
rein
afte
r re
ferr
ed to
as
RO
UT
INE
SE
RV
ICE
S)
and,
IF IN
A M
EM
BE
R H
OS
PIT
AL
OR
SE
RV
--IC
E-B
EN
EF
IT H
OS
PIT
AL,
the
full
amou
nt o
f the
'hos
-pi
tal's
usu
al c
harg
es fo
r (4
) us
e of
ope
ratin
g ro
om, (
5)m
edic
al a
nd s
urgi
cal s
uppl
ies,
and
dru
gs a
nd m
edic
a-tio
ns a
s m
ost c
urre
ntly
list
ed in
eith
er th
e "U
. S. P
har-
mac
opei
a" o
r "N
ew a
nd N
on-O
ffici
al R
emed
ies"
, (6)
labo
rato
ry e
xam
inat
iods
, (7)
bas
al m
etab
olis
m te
sts,
(8)
oxyg
en th
erap
y an
d (9
) ph
ysic
al th
erap
y (it
ems
(4)
thro
ugh
(9)
bein
g he
rein
afte
r re
ferr
ed to
as
SP
EC
IAL
SE
RV
ICE
S).
(ii)
If a
subs
crib
er is
hos
pita
lized
in c
oope
ratin
gm
embe
r ho
spita
l of a
noth
er B
lue
Cro
ss P
lan
with
whi
chth
e C
orpo
ratio
n ha
s a
reci
proc
al a
gree
men
t, su
ch s
ub-
scrib
er s
hall
rece
ive
cred
its fo
r al
l ben
efits
pro
vide
d bY
the
Rec
ipro
catin
g P
lan
unde
r su
ch a
gree
men
t. If
the
tota
l of t
he c
redi
ts r
ecei
ved
from
the
Rec
ipro
catin
g P
lan
is le
ss th
an th
e su
bscr
iber
wou
ld h
ave
rece
ived
in a
ME
MB
ER
HO
SP
ITA
L, th
e su
bscr
iber
sha
ll, u
pon
writ
ten
requ
est,
be e
ntitl
ed to
cre
dit f
rom
the
Cor
pora
tion
for
the
diffe
renc
e; p
rovi
ded
that
if h
is c
ontr
act i
s fo
r se
mi-
priv
ate
cove
rage
, he
shal
l be
entit
led
to c
redi
t fro
m th
eC
orpo
ratio
n fo
r th
e di
ffere
nce
betw
een
the
cred
its r
e-ce
ived
for
RO
UT
INE
SE
RV
ICE
S fr
om th
e R
ecip
roca
ting
Pla
n an
d, if
mor
e, th
e av
erag
e co
st o
f sem
i-priv
ate
room
sin
Rho
de Is
land
Mem
ber
Hos
pita
ls.
(iii)
If a
subs
crib
er is
hos
pita
lized
in a
mem
ber
hos-
pita
l of a
noth
er B
lue
Cro
ss P
lan
with
whi
ch th
e C
orpo
ra-
tion
does
not
hav
e a
reci
proc
al a
gree
men
t, su
ch s
ub-
scrib
er s
hall
rece
ive
cred
its fo
r R
OU
TIN
E S
ER
VIC
ES
as d
escr
ibed
for
a M
embe
r H
ospi
tal,
and
for
the
SP
E-
CIA
L S
ER
VIC
ES
ref
erre
d to
abo
ve, 9
0% o
f the
hos
pita
l'sus
ual c
harg
es, a
s a
cred
it to
war
ds $
he c
harg
es fo
rsu
ch s
ervi
ces.
(iv)
If th
e su
bscr
iber
is h
ospi
taliz
ed in
a n
on-m
embe
rho
spita
l, su
ch s
ubsc
riber
shal
lre
ceiv
e cr
edits
for
RO
UT
INE
SE
RV
ICE
S a
s de
scrib
ed fo
r a
Mem
ber
Hos
-pi
tal,
and
for
the
SP
EC
IAL
SE
RV
ICE
S r
efer
red
to a
bove
,90
% o
f the
hos
pita
l's u
sual
cha
rges
, as
acr
edit
tow
ards
the
char
ges
for
such
ser
vice
s.
(v)
Eac
h of
the
abov
e su
bpar
agra
phs
are
subj
ect t
osp
ecia
l pro
visi
ons,
if a
ny, s
how
n on
par
ticul
arm
embe
r-sh
ip c
ards
.
(b)
FO
R M
AT
ER
NIT
Y C
AS
ES
Up
to $
110
for
each
pre
gnan
cy a
s a
cred
it to
war
dus
ual h
ospi
tal c
harg
es to
the
subs
crib
er fo
r bo
th R
OU
-T
INE
SE
RV
ICE
S A
ND
SP
EC
IAL
SE
RV
ICE
S d
urin
g a
hosp
ital a
dmis
sion
for
deliv
ery,
or
such
oth
er a
mou
ntas
may
be
show
n on
the
mem
bers
hip
card
.
If ca
re b
eyon
d th
e 5t
h da
y of
hos
pita
lizat
ion
durin
gan
y ad
mis
sion
res
ultin
g in
del
iver
y is
med
ical
ly n
eces
-sa
ry, t
he s
ubsc
riber
sha
ll al
so b
e en
title
d to
the
cred
itsse
t for
th fo
r M
ED
ICA
L A
ND
SU
RG
ICA
L C
AS
ES
in p
ara-
grap
h (a
) ab
ove
begi
nnin
g on
the
6th
day
of h
ospi
tal-
izat
ion.
Adm
issi
ons
for
fals
e la
bor
will
be
entit
led
only
to th
ecr
edits
set
fort
h in
par
agra
ph (
a) a
bove
.S
ubsc
riber
s re
quiri
ng a
esar
ean
deliv
ery
or o
ther
maj
or s
urgi
cal p
roce
dure
s re
latin
g to
mat
erni
ty w
ill b
een
title
d to
the
cred
its s
et fo
rth
for
ME
DIC
AL
AN
D S
UR
-G
ICA
L C
AS
ES
in p
arag
raph
(a)
abo
ve, o
r to
cre
dits
for
MA
TE
RN
ITY
CA
SE
S a
s se
t for
th in
this
par
agra
ph (
b),
whi
chev
er a
re g
reat
er.
In c
ases
rec
eivi
ng b
enef
its u
nder
par
agra
ph (
a) n
ocr
edit
is a
vaila
ble
for
serv
ices
ren
dere
d th
e ne
wbo
rnch
ild u
ntil
he o
r sh
e sh
all b
ecom
e a
subs
crib
er (
exce
ptas
oth
erw
ise
indi
cate
d on
the
mem
bers
hip
card
). E
ach
new
born
chi
ld s
hall
beco
me
a su
bscr
iber
ent
itled
to a
llbe
nefit
s of
mem
bers
hip
(i) w
hen
a m
ajor
sur
gica
l pro
-ce
dure
is p
erfo
rmed
on
the
child
, (ii)
whe
n th
e m
othe
ror
chi
ld is
dis
char
ged
from
the
hosp
ital,
or (
iii)
whe
n th
ech
ild h
as a
ttain
ed th
e ag
e of
14
days
, whi
chev
er e
vent
shal
lfir
st o
ccur
. The
abo
ve m
ater
nity
cas
e cr
edits
(whe
ther
allo
wed
und
er p
arag
raph
s (a
) or
(b)
abo
ve)
are
avai
labl
e on
ly if
the
patie
nt a
nd h
er h
usba
nd h
ave
both
been
sub
scrib
ers
unde
r th
e sa
me
subs
crip
tion
agre
e-m
ent f
or a
wai
ting
perio
d of
7 m
onth
s im
med
iate
lypr
ior
to a
dmis
sion
. (T
he 7
mon
ths'
wai
ting
perio
d is
wai
ved
for
subs
crib
ers
unde
r th
e C
ompr
ehen
sive
Pla
n.)
Cas
es in
volv
ing
any
of th
e fo
llow
ing
com
plic
atio
ns o
fpr
egna
ncy,
whi
ch d
o no
t res
ult i
n de
liver
y, w
ill b
e en
ti-tle
d to
the
cred
its s
et fo
rth
for
ME
DIC
AL
AN
D S
UR
-G
ICA
L C
AS
ES
in p
arag
raph
ta)
abov
e w
ithou
t a w
aitin
gpe
riod,
pro
vide
d th
e pa
tient
and
her
hus
band
are
bot
hsu
bscr
iber
s un
der
the
sam
e su
bscr
iptio
n ag
reem
ent,
othe
rwis
e su
ch c
ases
will
be
entit
led
to n
o cr
edits
:
Any
pre
gnan
cy te
rmin
atin
g be
fore
exp
iratio
n of
26
wee
ks, e
ctop
ic p
regn
ancy
, mis
carr
iage
, or
abor
tion
Pla
cent
a pr
evia
or
plac
enta
abr
uptio
.
Agg
rava
tion
of a
hea
rt c
ondi
tion
or o
fdi
abet
es.
Hyp
erem
esis
gra
vida
rum
.
Tox
emia
.
Pre
mat
ure
rupt
ure
of m
embr
anes
.
Thr
eate
ned
mis
carr
iage
.
Cas
es w
hich
res
ult
inde
liver
y, in
volv
ing
any
ofth
e ab
ove
com
plic
atio
ns o
f pre
gnan
cy, s
hall,
from
the
date
of a
dmis
sion
to a
nd e
xclu
ding
dat
e of
del
iver
y, b
een
title
d to
the
cred
its s
et fo
rth
for
ME
DIC
AL
AN
DS
UR
GIC
AL
CA
SE
S in
par
agra
ph (
a) a
bove
. Upo
n an
daf
ter
the
date
of d
eliv
ery,
suc
h ca
ses
shal
l be
entit
led
to th
e cr
edits
set
fort
h In
the
first
sub
para
grap
h of
Par
tI (
b) a
bove
, but
if c
are
Is m
edic
ally
nec
essa
ry b
eyon
dth
e 5t
h da
y of
hos
pita
lizat
ion
from
and
incl
udin
g th
eda
y of
del
iver
y, th
e cr
edits
set
fort
h iri
the
seco
nd s
ub-
para
grap
h of
Par
t I (
b) w
ill a
pply
.
PA
RT
HO
SP
ITA
L B
EN
EF
ITS
con
tinue
d
(c)
FO
R O
UT
-PA
TIE
NT
SU
RG
ICA
L C
AS
ES
Up
to $
7.50
, or
such
larg
er a
mou
nt a
s m
ay b
e sh
own
on th
e m
embe
rshi
p ca
rd, a
s a
cred
it to
war
ds th
e ho
s-pi
tal's
usu
al c
harg
es fo
r S
PE
CIA
L S
ER
VIC
ES
ren
dere
da
subs
crib
er w
ho, a
s an
out
-pat
ient
of t
he h
ospi
tal,
requ
ires
the
use
of a
n op
erat
ing
room
for
an o
pera
tion
invo
lvin
g (i)
a c
uttin
g pr
oced
ure,
(ii)
the
adm
inis
trat
ion
of a
gen
eral
ane
sthe
sia,
or
(iii)
the
redu
ctio
n of
a fr
ac-
ture
or
disl
ocat
ion.
,
(d)
AC
CID
EN
T R
OO
M C
AS
ES
Up
to $
7.50
or
such
larg
er a
mou
nt a
s m
ay b
e sh
own
on th
e m
embe
rshi
p ca
rd, a
s a
cred
it to
war
ds th
e ho
s-pi
tal's
usu
al c
harg
es fo
r th
e us
e of
its
Acc
iden
t Roo
mfa
cilit
ies
and
SP
EC
IAL
SE
RV
ICE
S r
ende
red
a su
bscr
iber
durin
g th
e in
itial
visi
t with
in 2
4 ho
urs
follo
win
g a
trau
mat
ic o
r po
ison
ing
acci
dent
.
(e)
CO
VE
RA
GE
UN
DE
R M
OR
E T
HA
NO
NE
AG
RE
EM
EN
T
A s
ubsc
riber
ent
itled
to b
enef
its u
nder
mor
e th
an o
nesu
bscr
iptio
n ag
reem
ent o
f the
Cor
pora
tion
shal
l be
enti-
tled
to th
e ag
greg
ate
cf th
e cr
edits
pro
vide
d un
der
whi
chev
er o
f par
agra
phs
(a)
thro
ugh
(d)
of P
art I
of
the
seve
ral a
gree
men
ts m
ay b
e ap
plic
able
, but
not
exce
edin
g th
e to
tal c
harg
e fo
r th
e se
rvic
es r
ende
red
unde
r th
ose
para
grap
hs, n
or s
hall
such
add
ition
al c
ov-
erag
e in
crea
se th
e du
ratio
n of
ben
efits
spe
cifie
d in
this
agre
emen
t. A
sub
scrib
er e
ntitl
ed to
ben
efits
und
er s
ub-
scrip
tion
agre
emen
ts o
f the
Cor
pora
tion
and
of a
noth
erB
lue
Cro
ss P
lan
shal
l be
entit
led
to r
ecei
ve c
redi
ts fo
ral
l of t
he .b
enef
its p
rovi
ded
by b
oth
plan
s, b
ut n
otex
ceed
ing
the
tota
l cha
rges
for
hosp
ital s
ervi
ces
ren-
Jere
d to
the
subs
crib
er n
or to
ben
efits
from
the
Cor
pora
-tio
n lo
nger
in d
urat
ion
than
spe
cifie
d in
this
agr
eem
ent..
Sub
stitu
tion
of s
ubsc
riptio
n ag
reem
ents
und
er w
hich
asu
bscr
iber
is e
ntitl
ed to
ben
efits
, or
term
inat
ion
of o
neag
reem
ent a
nd e
ntry
into
ano
ther
agr
eem
ent,
shal
l not
incr
ease
the
dura
tion
of b
enef
its s
peci
fied
inth
isag
reem
ent.
(f)
Any
hos
pita
l cha
rges
in e
xces
s of
the
max
imum
cred
its s
peci
fied
abov
e sh
all b
e th
e ob
ligat
ion
of th
esu
bscr
iber
and
not
the
Cor
pora
tion.
Cre
dits
acc
ruin
g to
a su
bscr
iber
und
er th
is a
gree
men
t may
be
used
onl
yfo
r pa
ymen
t dire
ctly
from
the
Cor
pora
tion
to th
e ho
s-pi
tal o
f out
stan
ding
cha
rges
giv
ing
rise
to s
uch
cred
its,
and
a su
bscr
iber
sha
ll no
t be
entit
led
to a
. cas
h pa
y-m
ent i
n lie
u of
hav
ing
such
cre
dits
so
appl
ied,
exc
ept
that
the
Cor
pora
tion
may
ele
ct to
mak
e su
ch p
aym
ent
to th
e su
bscr
iber
whe
re s
ervi
ces
are
rend
ered
by
aN
ON
-ME
MB
ER
HO
SP
ITA
L.
PA
RT
II-E
XT
EN
T-
AN
D D
UR
AT
ION
OF
HO
SP
ITA
L C
AR
E
(a)
Whe
n ad
mis
sion
is to
a M
EM
BE
R H
OS
PIT
AL,
SE
RV
ICE
-BE
NE
FIT
HO
SP
ITA
L, o
r an
y ot
her
HO
SP
ITA
Lcl
assi
fied
as a
SH
OR
T-T
ER
M G
EN
ER
AL
HO
SP
ITA
L by
the
Am
eric
an H
osoi
tal A
ssoc
iatio
n an
d/or
acc
epta
ble
to th
e C
orpo
ratio
n as
suc
h (e
xcep
t as
prov
ided
in P
art
II (b
)), e
ach
subs
crib
er is
ent
itled
to r
ecei
ve c
redi
ts fo
rho
spita
l ser
vice
s as
spe
cifie
d in
Par
t I o
f thi
s ag
reem
ent
for
each
per
iod
of h
ospi
taliz
atio
n up
to 1
20 d
ays,
or
such
othe
r nu
mbe
r of
day
s as
may
be
show
n on
the
mem
ber-
ship
car
d, e
xcep
t tha
t eac
h ad
mis
sion
, if a
ppro
ved,
sha
llbe
for
a pe
riod
of 1
5 da
ys o
f car
e. A
ppro
vals
of a
dditi
onal
perio
ds o
f 15
days
eac
h w
ill b
e gi
ven
if th
e at
tend
ing
phys
icia
n ce
rtifi
es a
s to
the
med
ical
nec
essi
ty o
f eac
hsu
ch a
dditi
onal
per
iod
and
the
med
ical
adv
isor
(S)
of th
eC
orpo
ratio
n co
ncur
ther
ein.
Suc
cess
ive
perio
ds o
f hos
pita
lizat
ion
in a
ny ty
pe o
rty
pes
of h
ospi
tal d
urin
g a
perio
d in
whi
ch th
is a
gree
-m
ent o
r an
y ea
rlier
agr
eem
ent i
s or
was
in fo
rce
shal
lbe
dee
med
to b
e co
ntin
uous
and
to c
onst
itute
a s
ingl
epe
riod
of h
ospi
taliz
altio
n if
disc
harg
e fr
om a
nd s
ubse
-qu
ent a
dmis
sion
to a
ny h
ospi
tal o
r ho
spita
ls o
ccur
with
in a
90
day
perio
d, p
rovi
ded
that
if e
ither
suc
h di
s-ch
arge
or
subs
eque
nt a
dmis
sion
with
in s
uch
90 d
aype
riod
shal
l be
for
mat
erni
ty c
are
or c
ompl
icat
ions
of
preg
nanc
y or
trea
tmen
t of b
odily
inju
ry to
whi
ch e
ither
the
cond
ition
at t
he r
espe
ctiv
e pr
ior
disc
harg
e or
sub
se-
quen
t adm
issi
on is
unr
elat
ed, t
hen
such
sub
sequ
ent
adm
issi
on s
hall
be d
eem
ed fo
r a
sepa
rate
per
iod
ofho
spita
lizat
ion.
(b)
Whe
n ad
mis
sion
is to
a h
ospi
tal o
pera
ted
by th
eS
tate
of R
hode
Isla
nd o
r is
to a
ny h
ospi
tal o
ther
than
thos
e re
ferr
ed to
in P
art I
I (a)
,.eac
h su
bscr
iber
is e
nti-
tled
to r
ecei
ve c
redi
ts fo
r ho
spita
l ser
vice
as
spec
ified
in P
art I
of t
his
agre
emen
t for
eac
h pe
riod
of h
ospi
tal-
izat
ion
up to
45
days
, or
such
oth
er n
umbe
r of
day
s as
may
be
show
n on
the
mem
bers
hip
card
, exc
ept t
hat
each
adm
issi
on, i
f app
rove
d, s
hall
be fo
r a
perio
d of
15
days
of c
are.
App
rova
ls o
f add
ition
al p
erio
ds o
f 15
days
each
will
be
give
n if
the
atte
ndin
g ph
ysic
ian
cert
ifies
as to
the
med
ical
nec
essi
ty o
f eac
h su
ch a
dditi
onal
perio
d an
d th
e m
edic
al a
dvis
or(s
) of
the
Cor
pora
tion
conc
ur th
erei
n, p
royi
ded
that
:
(i) N
o su
bscr
iber
sha
ll be
ent
itled
to r
ecei
ve s
uch
cred
its u
nder
this
Par
t II (
b) fo
r m
ore
than
45
days
inth
e ag
greg
ate
in e
ach
cale
ndar
yea
r.
(ii)
If di
scha
rge
from
a h
ospi
tal o
f the
type
spe
cifie
din
Par
t II (
a) o
r P
art I
I (b)
, res
pect
ivel
y, a
nd s
ubse
quen
tad
mis
sion
to a
hos
pita
l of t
he ty
pe s
peci
fied
in P
art I
I(b
) or
Par
t II (
a), r
espe
ctiv
ely,
sha
ll oc
cur
with
in a
90
day
perio
d, th
e sa
me
shal
l be
deem
ed to
te c
ontin
uous
and
to c
onst
itute
a s
ingl
e pe
riod
of h
ospi
taliz
atio
n fo
rth
e pu
rpos
e of
com
putin
g th
e 12
0 da
y lim
itatio
n pr
e-sc
ribed
in P
art I
I (a)
; and
in n
o ca
se s
hall
furt
her
cred
itsbe
yond
120
day
s be
giv
en u
nder
Par
t II (
b) a
nd/o
r P
art
II (a
) un
less
a 9
0 da
y pe
riod
follo
win
g di
scha
rge
shal
lin
terv
ene
befo
re r
eadm
issi
on.
(iii)
If a
subs
crib
er is
adm
itted
to a
hos
pita
l of t
hety
pe s
peci
fied
in th
is P
art I
I(b
) an
d ha
s du
ring
the
sam
e ca
lend
ar y
ear
been
dis
char
ged
as a
pat
ient
from
such
a h
ospi
tal m
ore
than
90
days
prio
r to
suc
h ad
mis
-si
on, t
he s
ubsc
riber
sha
ll be
ent
itled
to (
a) c
redi
t for
so m
any
of th
e 45
day
s du
ring
the
cale
ndar
yea
r as
hav
eno
t the
reto
fore
bee
n us
ed, a
nd (
b) if
suc
h ad
mis
sion
on
or a
fter
Nov
embe
r 17
th in
any
yea
r co
ntin
ues
into
the
next
cal
enda
r ye
ar a
nd c
redi
ts fo
r 45
day
s du
ring
the
cale
ndar
yea
r of
adm
issi
on a
re n
ot e
xhau
sted
dur
ing
the
cale
ndar
yea
r of
adm
issi
on, t
he s
ubsc
riber
sha
ll re
ceiv
ecr
edits
dur
ing
the
next
cal
enda
r ye
ar o
n th
at s
ame
adm
issi
on fo
r so
man
y of
the
45 d
ays
as h
ave
not b
een
used
in th
e ca
lend
ar-y
ear
of a
dmis
sion
.
(iv)
A s
ubsc
riber
will
be
entit
led,
to r
ecei
ve c
redi
tsup
on a
dmis
sion
to a
hos
pita
l of t
he ty
pe s
peci
fied
inP
art I
I (b)
onl
y if
in n
eed
of m
edic
al c
are
of th
e ty
pepr
ovid
ed b
y su
ch h
ospi
tal.
(c)
In c
ompu
ting
the
num
ber
of d
ays
for
whi
ch c
redi
ts'fo
r ho
spita
l ser
vice
s ar
e av
aila
ble,
the
day
of a
dmis
sion
shal
l be
coun
ted,
taut
not
the
day
of d
isch
arge
. Ben
efits
shal
l end
on
the
day
prio
r to
the
day
of d
isch
arge
, or,
ifea
rlier
, on
the
day
prio
r to
that
on
whi
ch c
are
in a
nac
ute
gene
ral h
ospi
tal (
as to
adm
issi
ons
unde
r P
art I
I(e
)) o
r in
a h
ospi
tal o
f the
type
spe
cifie
d in
Par
t II (
b)(a
s to
adm
issi
ons
to s
uch
hosp
itals
) is
no
long
er m
ed-
ical
ly n
eces
sary
.
PA
RT
III-B
EN
EF
ITS
NO
T P
RO
VID
ED
Thi
s ag
reem
ent d
oes
not i
nclu
de th
e fo
llow
ing
serv
-ic
es e
xcep
t as
spec
ifica
lly n
oted
on
the
mem
bers
hip
card
:(a
) H
ospi
tal a
dmis
sion
s so
lely
for
diag
nost
ic e
xam
ina-
tions
not
inci
dent
al to
car
e an
d tr
eatm
ent a
s a
bed
patie
nt; n
or h
ospi
tal s
ervi
ces
not s
peci
fical
ly m
entio
ned
in P
art I
, as
by w
ay o
f exa
mpl
e an
d no
t by
way
of l
imi-
tatio
n , X
-ray
,.X-r
ay o
r ra
dium
trea
tmen
t, el
ectr
ocar
di-
ogra
phy,
ele
ctro
ence
phal
ogra
phy,
am
bula
nce
serv
ices
,in
tens
ive
nurs
ing
care
ser
vice
s, p
rivat
e nu
rses
and
thei
rbo
ard;
nor
ser
vice
s of
blo
od d
onor
s an
d te
stin
g or
typi
ngth
eir
bloo
d; n
or fo
r bl
ood
or b
lood
pla
sma
or c
harg
esfo
r its
adm
inis
trat
ion;
nor
pay
men
t for
an
atte
ndin
g ph
y-si
cian
in r
ende
ring
any
surg
ical
or
med
ical
trea
tmen
t.
(b)
Hos
pita
l car
e (i)
for
any
pers
onal
inju
ry (
incl
udin
gan
y oc
cupa
tiona
l dis
ease
or
cond
ition
as
defin
ed in
Wor
kmen
's C
ompe
nsat
ion
law
s) a
risin
g ou
t of a
nd in
the
cour
se o
f em
ploy
men
t, co
nnec
ted
ther
ewith
and
refe
rabl
e th
eret
o, e
xcep
t in
the
case
of a
sel
f-em
ploy
edpe
rson
; or
(ii)
prov
ided
by,
or
paid
for
by th
e U
nite
dS
tate
s or
any
of i
ts a
genc
ies.
(c)
Car
e w
hich
is n
ot n
eces
sary
in a
n ac
ute
gene
ral
hosp
ital (
as to
an
adm
issi
on u
nder
Par
t II (
b)),
or
ina
hosp
ital o
f the
type
spe
cifie
d in
Par
t II (
b) (
as to
adm
is-
sion
to s
uch
a ho
spita
l), a
nd s
ervi
ces
and
supp
lies
not
med
ical
ly n
eces
sary
for
diag
nosi
s or
trea
tmen
t of a
nill
ness
, inj
ury,
or
bodi
ly m
alfu
nctio
n.(d
) C
usto
dial
car
e, r
est c
ures
, or
care
in c
onva
lesc
ent
or n
ursi
ng h
omes
or
hom
es fo
r th
e ag
ed.
(e)
Hos
pita
l car
e fo
r an
y co
nditi
on, d
isea
se o
r in
jury
whi
ct e
xist
ed o
n or
bef
ore
the
effe
ctiv
e da
te o
f thi
sag
reem
ent.
(Thi
s pa
ragr
aph
(d)
does
not
app
ly to
hos
-pi
tal a
dmis
sion
s oc
curr
ing
afte
r 7
mon
ths
cont
inuo
usm
embe
rshi
p no
r at
all
unde
r th
o C
omor
ehen
sive
Pla
n.)
(f)
Ser
vice
s ch
arge
d fo
r oy
the
hosp
ital f
or a
ny d
ayon
whi
ch th
e su
bscr
iber
leav
es th
e ho
spita
l pre
mis
esfo
r al
l or
any
port
ion
of th
e da
y, e
xcep
t for
pur
pose
s of
trea
tmen
t els
ewhe
re.
(5)
Ser
vice
s an
d su
pplie
s fo
r pe
rson
al c
omfo
rt, s
uch
as r
adio
, tel
epho
ne, t
elev
isio
n, a
ir co
nditi
oner
, bea
uty
and
barb
er s
ervi
ces.
(h)
Cha
rges
, if a
ny, m
ade
by th
e ho
spita
l on
acco
unt
of a
del
ay in
dep
artu
re b
eyon
d th
e re
gula
r di
scha
rge
time.
PA
RT
IV-C
HA
NG
ES
An
appl
ican
t who
doe
s no
t inc
lude
his
spo
use
and/
orch
ildre
n on
his
app
licat
ion
may
add
suc
h fa
mily
mem
-be
rs o
nly
on th
e an
nive
rsar
y of
the
effe
ctiv
e da
te o
f his
Dire
ct P
aym
ent m
embe
rshi
p or
of t
he G
roup
of w
hich
he
is a
mem
ber,
whi
chev
er is
app
licab
le. A
n ap
plic
ant w
hola
ter-
mar
ries
may
, with
in 6
0 da
ys o
f suc
h m
arria
ge, a
ddhs
spo
use
to h
is m
embe
rshi
p by
app
licat
ion
to th
eC
orpo
ratio
n if
a D
irect
Pay
men
t mem
bers
hip,
or,
if a
Gro
up m
embe
rshi
p, b
y ap
plic
atio
n to
the
pers
on w
hore
mits
pay
men
ts fo
r th
e G
roup
; afte
r 60
day
s he
may
add
his
spou
se o
n th
e an
nive
rsar
y da
te a
s in
dica
ted
abov
e. A
n ap
plic
ant w
ho in
clud
ed h
is s
pous
e an
d/or
child
ren
may
rem
ove
such
fam
ily m
embe
rs fr
om h
ism
embe
rshi
p on
ly a
s of
a d
ate
subs
eque
nt to
the
requ
est
for
rem
oval
whe
n su
bscr
iptio
n ch
arge
s ar
e pa
yabl
e.
PA
RT
V-TE
RM
INA
TIO
N A
ND
RE
FU
ND
(a)
If a
Dire
ct P
aym
ent m
embe
rshi
p, th
is a
gree
men
tsh
all c
ontin
ue in
forc
e un
til a
def
ault
shal
l exi
st fo
r 15
days
in th
e pa
ymen
t of s
ubsc
riptio
n ch
arge
s, o
r un
til th
eef
fect
ive
date
, dur
ing
such
per
iod
of d
efau
lt, o
f any
new
agre
emen
t the
app
lican
t may
ent
er in
to w
ith th
e C
orpo
ra-
tion,
in e
ither
of w
hich
cas
es th
is a
gree
men
t sha
ll au
to-
mat
ical
ly te
rmin
ate.
The
Cor
pora
tion
may
rei
nsta
te th
isag
reem
ent a
t its
sol
e di
scre
tion,
but
onl
y to
cov
er a
nyill
ness
or
inju
ry fi
rst m
anife
stin
g its
elf m
ore
than
15
days
afte
r re
inst
atem
ent,
exce
pt th
at s
uch
limita
tion
will
exp
ire a
t the
end
of 7
mon
ths
of c
ontin
uous
mem
-be
rshi
p fo
llow
ing
rein
stat
emen
t.
(b)
An
appl
ican
t sub
scrib
er h
oldi
ng a
Dire
ct P
aym
ent
mem
bers
hip
who
join
s a
grou
p at
his
pla
ce o
f em
ploy
-m
ent m
ay c
ontin
ue to
mai
ntai
n hi
s D
irect
Pay
men
t mem
-be
rshi
p in
depe
nden
tly o
f his
new
gro
up m
embe
rshi
ppr
ovid
ed h
e m
akes
writ
ten
requ
est t
o th
e C
orpo
ratio
n,pr
ior
to th
e ef
fect
ive
date
of h
is n
ew G
roup
mem
bers
hip,
or in
dica
tes
his
inte
nt in
the
spac
e pr
ovid
ed o
n th
eG
roup
app
licat
ion
card
. In
the
abse
nce
of s
uch
requ
est
this
agr
eem
ent w
ill a
utom
atic
ally
term
inat
e on
the
effe
ctiv
e da
te o
f the
new
Gro
up m
embe
rshi
p. In
suc
hca
ses
the
appl
ican
t will
be
elig
ible
for
a re
fund
of t
hat
port
ion
of th
e D
irect
Pay
men
t sub
scrip
tion
char
ges
paid
beyo
nd th
e ef
fect
ive
date
of t
he n
ew G
roup
mem
bers
hip
and
any
subs
eque
nt p
aym
ent o
f Dire
ct P
aym
ent s
ub-
scrip
tion
char
ges
whe
n du
e w
ill b
e ac
cept
ed a
s a
requ
est
for
rein
stat
emen
t of t
he D
irect
Pay
men
t mem
bers
hip
asof
suc
h du
e da
te. A
cha
nge
or tr
ansf
er fr
om D
irect
Pay
-m
ent m
embe
rshi
p to
new
Gro
up m
embe
rshi
p w
ill n
otad
vers
ely
affe
ct e
ligib
ility
for
bene
fits
base
d on
con
tinu-
ity o
f mem
bers
hip.
(c)
If a
Gro
up m
embe
rshi
p, th
is a
gree
men
t sha
ll co
n-tin
ue in
forc
e un
til a
def
ault
shal
l exi
st fo
r 30
day
s in
the
paym
ent o
f sub
scrip
tion
char
ges,
or
until
the
effe
ctiv
eda
te, d
urin
g su
ch p
erio
d of
def
ault,
of a
ny n
ew a
gree
-m
ent t
he a
pplic
ant m
ay e
nter
into
with
the
Cor
pora
tion,
in e
ither
of w
hich
cas
es th
is a
gree
men
t sha
ll au
tom
ati-
cally
term
inat
e. A
ny a
pplic
ant w
ho le
aves
his
pla
ce o
fem
ploy
men
t may
join
a g
roup
at h
is n
ew p
lace
of e
m-
ploy
men
t or
enro
ll on
a D
irect
Pay
men
t bas
is in
acc
ord-
ance
with
the
Enr
ollm
ent R
egul
atio
ns o
f the
Cor
pora
tion.
(d)
The
Cor
pora
tion
rese
rves
the
right
to te
rmin
ate
this
agr
eem
ent a
t any
tim
e up
on g
ivin
g 15
day
s pr
ior
writ
ten
notic
e to
the
App
lican
t. It
may
als
o, u
pon
like
notic
e at
any
tim
e an
d fr
om ti
me
to ti
me,
am
end
this
agre
emen
t or
any
port
ion
ther
eof a
nd r
edet
erm
ine
and
fix th
e am
ount
of s
ubsc
riptio
n ch
arge
s as
it m
ay d
eem
nece
ssar
y; p
rovi
ded,
how
ever
, tha
t eac
h su
ch a
men
d-m
ent o
r.ch
ange
of s
ubsc
riptio
n oh
arge
s sh
all b
e ef
fect
ive
as to
this
agr
eem
ent o
nly
upon
the
expi
ratio
n of
the
term
for
whi
ch th
e su
bscr
iptio
n ch
arge
s ha
ve b
een
paid
.N
otic
e sh
all b
e de
emed
to h
ave
been
giv
en to
eac
h su
b-sc
riber
ent
itled
to b
enef
its h
ereu
nder
whe
n m
aile
d to
the
appl
ican
t at h
is a
ddre
ss w
hich
app
ears
upo
n th
e re
cord
sof
the
Cor
pora
tion,
or
whe
n m
aile
d to
the
appl
ican
t'sag
ent,
or w
hen
publ
ishe
d in
a d
aily
new
spap
er p
ublis
hed
in th
e S
tate
of R
hode
Isla
nd. P
aym
ent o
f sub
scrip
tion
char
ges
afte
r th
e gi
ving
of n
otic
e of
an
amen
dmen
t or
chan
ge in
subs
crip
tion
char
ges
shal
l con
stitu
te a
nac
cept
ance
ther
eof i
n be
half
of a
ll su
bscr
iber
s en
title
dto
ben
efits
her
eund
er.
(e)
The
Cor
pora
tion
shal
l be
relie
ved
of a
ll lia
bilit
y to
prov
ide
cred
its fo
r ho
spita
l ser
vice
s af
ter
the
date
of
term
inat
ion,
exc
ept t
hat i
f suc
h te
rmin
atio
n oc
curs
whi
lea
subs
crib
er is
con
fined
as
a be
d pa
tient
in a
hos
pita
lsu
ch s
ubsc
riber
sha
ll be
ent
itled
to b
enef
its in
acc
ord-
ance
with
this
agr
eem
ent d
urin
g su
ch h
ospi
tal s
tay.
(f)
In th
e ev
ent o
f ter
min
atio
n of
this
agr
eem
ent w
ith-
in 8
mon
ths
prio
r to
the
birt
h of
a c
hild
to a
ny s
ubsc
riber
who
wou
ld o
ther
wis
e be
ent
itled
to m
ater
nity
ben
efits
spec
ified
in P
art I
(b)
of t
his
agre
emen
t and
whe
n su
chsu
bscr
iber
mai
ntai
ns c
ontin
uous
mem
bers
hip
by e
nter
-in
g in
to a
new
agr
eem
ent w
ith th
e C
orpo
ratio
n, w
hich
isin
effe
ct a
t the
tim
e of
the
child
's b
irth,
sha
ll be
ent
itled
to th
e m
ater
nity
ben
efits
und
er w
hich
ever
of t
he a
gree
-m
ents
pro
vide
s th
e gr
eate
r be
nefit
s, b
ut n
ot to
the
bene
fits
of b
oth.
(g)
An
appl
ican
t who
term
inat
es h
is m
embe
rshi
p,ot
her
than
as
prov
ided
in P
art V
(b)
abo
ve, m
ay d
o so
effe
ctiv
e as
of t
he la
st d
ay o
f the
mon
th in
whi
ch th
eC
orpo
ratio
n re
ceiv
es a
pplic
ant's
writ
ten
requ
est t
o te
r-m
inat
e. H
e sh
all b
e en
title
d to
a r
efun
d of
any
pre
paid
subs
crip
tion
char
ges
appl
icab
le to
per
iods
follo
win
gsu
ch e
ffect
ive
date
of t
erm
inat
ion.
PA
RT
VI
GE
NE
RA
L C
ON
DIT
ION
S
(a)
The
effe
ctiv
e da
te o
f thi
s ag
reem
ent s
hall
be th
atin
dica
ted
on th
e ap
plic
atio
n on
file
with
the
Cor
pora
tion.
(b)
All
clai
ms
unde
r th
e su
bscr
iptio
n ag
reem
ent m
ust
be fi
led
with
the
Cor
pora
tion
with
in 6
0 da
ys a
fter
the
serv
ices
sha
ll ha
ve b
een
rend
ered
. The
max
imum
lia-
bilit
y of
the
Cor
pora
tion
here
unde
r fo
r ho
spita
l ser
vice
sre
nder
ed to
any
and
all
part
ies
for
any
part
icul
ar d
is-
abili
ty s
hall
not e
xcee
d th
at s
peci
fied
in P
arts
I an
d II.
The
ben
efits
of t
his
subs
crip
tion
agre
emen
t are
non
-as
sign
able
.
(c)
Thi
s ag
reem
ent i
s m
ade
upon
the
expr
ess
cond
i-tio
n th
at a
ny h
ospi
tal o
r ph
ysic
ian
is a
utho
rized
todi
sclo
se to
the
Cor
pora
tion
any
info
rmat
ion
rega
rdin
g or
acqu
ired
in c
onne
ctio
n w
ith th
e at
tend
ance
, car
e or
trea
tmen
t of a
ny s
ubsc
riber
her
eund
er a
nd th
at a
ll pr
o-vi
sion
s of
law
or
prof
essi
onal
eth
ics
forb
iddi
ng s
uch
dis-
clos
ures
are
wai
ved
by o
r in
beh
alf o
f eac
h su
bscr
iber
here
unde
r.
(d)
The
app
lican
t agr
ees
that
the
appl
ican
t's a
gent
may
mak
e av
aila
ble
to th
e C
orpo
ratio
n fo
r in
spec
tion
any
empl
oym
ent a
nd o
ther
per
sonn
el r
ecor
ds w
hich
hav
ea
bear
ing
upon
the
elig
ibili
ty o
f the
Enr
olle
d G
roup
, the
appl
ican
t or
any
subs
crib
er.
(e)
The
ben
efits
ava
ilabl
e he
reun
der
may
be
exte
nded
by a
ctio
n of
the
Boa
rd o
f Dire
ctor
s of
the
Cor
pora
tion,
but n
o su
bscr
iber
sha
ll be
ent
itled
to s
hare
in a
nyas
sets
, res
erve
s, o
r ot
her
fund
s or
pro
pert
y no
w o
r he
re-
afte
r ow
ned,
acq
uire
d, o
r ac
cum
ulat
ed b
y th
e C
orpo
ra-
tion. (f
) T
he C
orpo
ratio
n is
und
er n
o ob
ligat
ion
to p
rovi
deho
spita
l acc
omm
odat
ions
and
nei
ther
the
Cor
pora
tion
nor
any
of it
s D
irect
ors,
offi
cers
or
empl
oyee
s sh
all b
elia
ble
for
any
act,
omis
sion
or
negl
ect o
f any
hos
pita
l,its
ser
vant
s, a
gent
s or
. em
ploy
ees,
or
of a
ny p
hysi
cian
or
su r
geon
.
(g)
No
actio
n or
sui
t at l
aw o
r in
equ
ity s
hall
be c
om-
men
ced
unde
r th
e su
bscr
iptio
n ag
reem
ent u
ntil
30 d
ays
afte
r w
ritte
n no
tice
of c
laim
has
bee
n gi
ven
by th
e su
b-sc
riber
to th
e C
orpo
ratio
n, n
or s
hall
such
act
ion
bebr
ough
t at a
ll la
ter
than
one
yea
r af
ter
the
serv
ices
on
whi
ch s
uch
clai
m is
bas
ed s
hall
have
bee
n re
nder
ed.
(h)
In th
e ev
ent a
ny h
ospi
tal s
ervi
ce o
r be
nefit
is p
ro-
vide
d fo
r, o
r an
y pa
ymen
t is
mad
e or
cre
dit e
xten
ded
to,
a su
bscr
iber
und
er th
is a
gree
men
t, th
e C
orpo
ratio
n sh
all
be s
ubro
gate
d an
d sh
all s
ucce
ed to
the
subs
crib
er's
right
of r
ecov
ery
ther
efor
aga
inst
any
per
son
or o
rgan
i-za
tion,
exc
ept i
nsur
ers
on p
olic
ies
of in
sura
nce
issu
ed to
and
in th
e na
me
of th
e su
bscr
iber
. The
sub
scrib
er s
hall
pay
over
to th
e C
orpo
ratio
n al
l sum
s re
cove
red
by s
uit,
settl
emen
t or
othe
rwis
e, o
n ac
coun
t of s
uch
hosp
ital
serv
ice
or b
enef
it. T
he s
ubsc
riber
sha
ll ta
ke s
uch
actio
n,fu
rnis
h su
ch in
form
atio
n an
d as
sist
ance
, and
exe
cute
such
ass
ignm
ents
and
oth
er in
stru
men
ts a
s th
e C
or-
pora
tion
may
req
uire
to fa
cilit
ate
enfo
rcem
ent o
f its
right
s he
reun
der,
and
sha
ll ta
ke n
o ac
tion
prej
udic
ing
the
right
s an
d in
tere
sts
of th
e C
orpo
ratio
n he
reun
der.
(i) A
men
dmen
ts o
f thi
s co
ntra
ct a
nd c
hang
es in
the
amou
nts
or ty
pes
of c
over
age
or in
the
pers
ons
cove
red,
as a
pplie
d fo
r or
dire
cted
by
appl
ican
t, sh
all b
e ap
plic
a-bl
e on
ly a
s to
hos
pita
l adm
issi
ons
occu
rrin
g on
or
afte
rth
e ef
fect
ive
date
of s
uch
amen
dmen
t or
chan
ge.
PA
RT
VII
DE
FIN
ITIO
NS
(a)
Cor
pora
tion
The
term
"C
orpo
ratio
n" s
hall
mea
nth
e H
ospi
tal S
ervi
ce C
orpo
ratio
n of
Rho
de Is
land
, 31
Can
al S
tree
t, P
rovi
denc
e, R
hode
Isla
nd.
(b)
App
lican
t The
term
"A
pplic
ant"
sha
ll m
ean
any
indi
vidu
al w
ith w
hom
the
Cor
pora
tion
has
ente
red
into
a su
bscr
iptio
n ag
reem
ent.
(c)
Sub
scrib
er T
he te
rm "
Sub
scrib
er"
shal
l inc
lude
the
appl
ican
t and
eac
h pe
rson
list
ed o
n th
e ap
plic
atio
nso
long
as
such
per
sons
rem
ain
elig
ible
for
incl
usio
n in
acco
rdan
ce w
ith th
e C
orpo
ratio
n's
Enr
ollm
ent R
egul
a-tio
ns. U
nmar
ried
subs
crib
ers
liste
d on
the
appl
icat
ion
will
cea
se to
be
mem
bers
at t
he e
nd o
f thz
: cal
enda
r ye
ardu
ring
whi
ch th
ey a
ttain
age
19.
A m
inor
sub
scrib
erlis
ted
on th
e ap
plic
atio
n w
ho m
arrie
s be
fore
the
end
of
PA
RT
VII
DE
FIN
ITIO
NS
cont
inua
l
the
cale
ndar
yea
r in
whi
ch h
e or
she
atta
ins
age
19 w
illce
ase
to b
e a
subs
crib
er o
n th
e fir
st o
f the
mon
th fo
llow
-in
g m
arria
ge. A
min
or s
ubsc
riber
who
se m
embe
rshi
pce
ases
follo
win
g m
arria
ge o
r at
tain
men
t of a
ge 1
9 as
afor
esai
d, m
ay e
nrol
l und
er h
is o
r he
r ow
n m
embe
rshi
pby
app
licat
ion
to th
e C
orpo
ratio
n in
writ
ing.
A h
andi
-ca
pped
chi
ld, r
egar
dles
s of
age
, may
be
reta
ined
as
asu
bscr
iber
on
the
appl
ican
t's fa
mily
mem
bers
hip
pro-
vide
d a
spec
ial s
uppl
emen
tal a
pplic
atio
n fo
r su
ch c
hild
has
been
file
d w
ith a
nd a
ccep
ted
by th
e C
orpo
ratio
n.
(d)
Sub
scrip
tion
Agr
eem
ent
The
term
"S
ubsc
rip-
tion
Agr
eem
ent"
sha
ll m
ean
the
agre
emen
t ent
ered
into
betw
een
the
Cor
pora
tion
and
the
appl
ican
t and
sha
llco
nsis
t of t
he a
pplic
atio
n, in
clud
ing
any
supp
lem
enta
lap
plic
atio
n, a
nd th
e ap
prop
riate
Blu
e C
ross
Con
trac
t for
HoS
pita
l Car
e th
en in
forc
e an
d fil
ed w
ith th
e S
tate
of
Rho
de Is
land
Insu
ranc
e D
ivis
ion
of th
e D
epar
tmen
t of
Bus
ines
S R
egul
atio
n, th
e m
embe
rshi
p ca
rd e
vide
ncin
gth
e ac
cept
ance
of t
he a
pplic
atio
n an
d an
y am
endm
ents
mad
e un
der
Per
t V (
d) h
ereo
f.
(e)
App
lican
t's A
gent
The
term
"A
pplic
ant's
Age
nt"
shal
l mea
n an
y In
divi
dual
who
, or
firm
, ass
ocia
tion
orco
rpor
atio
n w
hich
pay
s fo
r ap
plic
ant,
in w
hole
or
inpa
rt, o
r w
hich
as
agen
t for
the
appl
ican
t has
agr
eed
toco
llect
and
rem
it, in
who
le o
r in
part
, sub
scrip
tion
char
ges
paya
ble
unde
r th
is a
gree
men
t. S
uch
appl
ican
t'Sag
ent s
hall
not b
e co
nstr
ued
to b
e th
e ag
ent o
f the
Cor
pora
tion.
(f)
Hos
pita
lT
he te
rm "
Hos
pita
l" (e
xcep
t whe
re th
eco
ntex
t oth
erw
ise
requ
ires)
sha
ll m
ean
any
inst
itutio
nlis
ted
as s
uch
by th
e A
mer
ican
Hos
pita
l Ass
ocia
tion
and
appr
oved
by
the
Cor
pora
tion,
or
any
inst
itutio
n op
erat
edex
clus
ivel
y fo
r th
e ca
re a
s be
d pa
tient
s of
med
ical
and
surg
ical
cas
es in
volv
ing
acut
e ill
ness
or
inju
ry a
ppro
ved
by th
e C
orpo
ratio
n. It
sha
ll no
t inc
lude
con
vale
scen
tho
mes
, res
t hom
es, n
ursi
ng h
omes
, hom
es fo
r th
e ag
ed,
scho
ol in
firm
arie
s, o
r pr
ivat
e sa
nita
ria.
(I)
Mem
ber
Hos
pita
l_
The
term
"M
embe
r H
ospi
tal"
shal
l mea
n an
y ho
spita
l in
the
Sta
te o
f Rho
de Is
land
(exc
ludi
ng h
ospi
tals
ope
rate
d by
the
Sta
te o
f Rho
deIs
land
) w
ith w
hich
the
Cor
pora
tion
has
a pa
rtic
ipat
ing
mem
ber
hosp
ital c
ontr
act f
or th
e re
nder
ing
of h
ospi
tal-
izat
ion
prov
ided
by
the
subs
crip
tion
agre
emen
t.
(h)
Ser
vice
-Ben
efit
Hos
pita
l _ T
he te
rm "
Ser
vice
-B
enef
it H
ospi
taiii
sha
ll m
ean
any
hosp
ital o
utsi
de o
f the
Sta
te o
f Rho
de Is
land
with
whi
ch th
e C
orpo
ratio
n ha
sa
cont
ract
for
the
rend
erin
g of
hos
pita
lizat
ion
prov
ided
for
by th
e su
bscr
iptio
n ag
reem
ent.
(I)
Non
-Mem
ber
Hos
pita
lT
he te
rm "
Non
-Mem
ber
Hos
pita
iii s
haii
mea
n an
y ho
spita
l with
whi
ch th
e C
orpo
-ra
tion
does
not
hav
e a
cont
ract
for
the
rend
erin
g of
hosp
italiz
atio
n pr
ovid
ed fo
r by
the
subs
crip
tion
agre
e-m
en*.
(i) C
ompr
ehen
sive
Pla
n _
The
term
"C
ompr
ehen
sive
Pla
n" s
hall
mea
n th
e pl
an in
effe
ct w
ith a
ny G
roup
whe
re th
e C
orpo
ratio
n's
appr
opria
te E
nrol
lmen
t Reg
u-la
tions
hav
e be
en m
et, a
nd w
here
mem
bers
hip
in s
uch
plan
is in
dica
ted
by th
e sy
mbo
l "C
", "
F",
or
"J",
on
the
subs
crib
er's
mem
bers
hip
card
.
TH
E M
AT
ER
IAL
BE
LOW
IS F
OR
EX
PLA
NA
TIO
NO
NLY
AN
D IS
NO
T P
AR
T O
F T
HIS
CO
NT
RA
CT
.
Kee
p yo
ur B
lue
Cro
ss C
ontr
act i
na
safe
pla
ce,
alon
g w
ith y
our
othe
r va
luab
le p
aper
s.
You
r M
embe
rshi
p N
umbe
r an
d da
ily h
ospi
tal
room
allo
wan
ce a
re s
how
n on
you
r m
embe
rshi
pca
rd.
If yo
u sh
ould
hav
e a
ques
tion
abou
t you
r m
em-
bers
hip,
or
your
ben
efits
, you
mig
ht w
ant t
o re
fer
to th
is c
ontr
act.
Or,
cal
l or
writ
e th
e B
lue
Cro
ssof
fice.
Our
mos
t im
port
ant j
ob is
to p
rovi
deyo
u w
ithth
e ve
ry b
est s
ervi
ce p
ossi
ble.
How
To
Get
You
r B
enef
its
Whe
n yo
u go
to th
e ho
spita
l for
car
e, b
e su
re to
have
you
r m
embe
rshi
p ca
rd w
ith y
ou. I
t des
crib
esyo
ur h
ospi
tal r
oom
pla
n an
d is
you
r "c
redi
t car
d"fo
r ho
spita
l car
e. M
erel
y pr
esen
t you
r B
lue
Cro
ssca
rd a
t the
hos
pita
l...
and
they
'll d
o th
e re
st. I
t'sas
sim
ple
as th
at.
Car
e A
way
Fro
m H
ome
You
r m
embe
rshi
p ca
rd is
rec
ogni
zed
by o
ver
6,00
0 B
lue
Cro
ss m
embe
r ho
spita
ls a
cros
s th
ena
tion.
If y
ou n
eed
care
aw
ay fr
om h
ome,
mer
ely
pres
ent y
our
Rho
de Is
land
Blu
e C
ross
car
d to
the
hosp
ital.
Whe
n yo
u ar
e di
scha
rged
, you
r be
nefit
sw
ill b
e cr
edite
d to
you
r bi
ll, a
nd y
ou w
ill b
e bi
lled
only
for
exce
ss c
harg
es, i
f any
.
Rem
embe
r, if
you
hav
e a
ques
tion
abou
tyo
urbe
nefit
s or
you
r m
embe
rshi
p, th
e be
stw
ay to
get
accu
rate
ans
wer
s is
to c
all o
r w
rite
Blu
e C
ross
.
PLE
AS
E G
IVE
YO
UR
ME
MB
ER
SH
IP N
UM
BE
RW
HE
NE
VE
R Y
OU
CA
LL O
R W
RIT
E B
LUE
CR
OS
S.
Hos
pita
lS
ervi
ceC
orpo
ratio
nof
Rho
deIs
land
31 C
anal
Str
eet,
Pro
vide
nce,
Rho
de Is
land
029
01T
elep
hone
831
-730
0
04 4+ 0,4 .4 04 P. 04 04 14 04 04 04 04
1100
8100
1NE
NO
1010
1618
1810
1011
3113
1111
001
NE
PHY
SIC
IAN
S SE
RV
ICE
CO
NT
RA
CT
for
Surg
ical
-Med
ical
Car
e
run
Rho
de Is
land
Med
ical
Soc
iety
Phy
sici
ans
Ser
vice
Pro
vide
nce,
Rho
de Is
land
A n
on-p
rofit
com
mun
ity s
ervi
ce, i
ncor
pora
ted
unde
rth
e la
ws
of R
hode
Isla
nd in
194
9.
3113
1010
1131
0113
1810
1131
8101
1310
1010
1131
8113
IOW
N
Thi
s co
ntra
ct is
mad
e be
twee
n th
e R
hode
Isla
nd M
edic
al S
ocie
ty P
hysi
cian
s S
ervi
ce(h
erei
nafte
r .c
alle
d th
e C
orpo
ratio
n) a
nd th
eA
pplic
ant n
amed
in th
e ap
plic
atio
n to
re-
ceiv
e th
e be
nefit
s pr
ovid
edhe
rein
and
who
se n
ame
and
iden
tific
atio
nnu
mbe
rap
pear
on
the
mem
bers
hip
card
furn
ishe
dto
sai
d A
pplic
ant.
In c
onsi
dera
tion
of th
e ap
plic
atio
n an
d up
onpa
ymen
t in
adva
nce
of th
e su
bscr
iptio
nch
arge
s, th
e C
OR
PO
RA
TIO
N a
gree
s to
pro
-vi
de to
sai
d A
pplic
ant a
nd e
ach
Sub
scrib
er,
if an
y, li
sted
on
the
appl
icat
ion
or r
e-cl
assi
-fic
atio
n th
ereo
f, th
e su
rgic
al-m
edic
al b
ene-
fits
acco
rdin
g to
the
PH
YS
ICIA
NS
SE
RV
ICE
PLA
N d
escr
ibed
on
the
follo
win
g pa
ges,
whi
ch is
a p
art o
f thi
s co
ntra
ct.
In W
itnes
s W
here
of, t
he R
HO
DE
ISLA
ND
ME
DIC
AL
SO
CIE
TY
PH
YS
ICIA
NS
SE
RV
ICE
has
exec
uted
this
con
trac
t.R
HO
DE
ISLA
ND
ME
DIC
AL
SO
CIE
TY
PH
YS
ICIA
NS
SE
RV
ICE
By: Atte
st:
Cou
nter
sign
ed:
Pre
side
nt
r Sec
reta
ry
ava.
c.4
3C/
Exe
cutiv
e D
irect
or
Sur
gica
l-Med
ical
. Ser
ies
6 (7
445)
1101
0101
0101
1110
1011
310N
3101
1311
3113
IDIO
NN
ON
IN
TH
E P
HY
SIC
IAN
S S
ER
VIC
E P
LAN
FO
R
SU
RG
ICA
L-M
ED
ICA
L C
AR
E
PA
RT
I- P
HY
SIC
IAN
S S
ER
VIC
E
BE
NE
FIT
S P
RO
VID
ED
:
The
Cor
pora
tion
will
pay
, exc
ept a
s pr
ovid
ed in
PA
RT
III b
elow
, for
the
follo
win
g su
rgic
al a
nd m
edic
al s
ervi
ces
whe
n re
nder
ed tr
y a
phys
icia
n en
title
d by
taw
to p
erfo
rmsu
ch s
ervi
ce to
an
elig
ible
sub
scrib
er in
goo
d st
andi
ngan
am
ount
equ
al to
the
fees
act
ually
, cha
rged
to th
esu
bscr
iber
up
to th
e m
axim
um a
mou
nt s
peci
fied
unde
rw
hich
ever
of P
lan
A o
r P
lan
B c
over
age
he ia
ent
itled
to in
the
Sch
edul
e of
Allo
wan
ces
(PA
RT
VIII
), (
or s
uch
othe
r m
axim
um a
mou
nts
as m
ay b
e sh
own
on th
esu
bscr
iber
's m
embe
rshi
p ca
rd)
such
pay
men
ts to
be
mad
e to
the
phys
icia
n if
he is
a p
artic
ipat
ing
Phy
sici
an,
and
othe
rwis
e to
the
appl
ican
t:
(a)
Sur
gica
l Ser
vice
s (o
ther
than
thos
e se
rvic
es d
e-sc
ribed
in P
AR
T II
I bel
ow)
rend
ered
by
a ph
ysic
ian
ofth
e su
bscr
iber
's c
hoic
e in
a h
ospi
tal,
in a
phy
sici
an's
offic
e, o
r at
hom
e.
(b)
Ser
vice
s of
an
assi
stin
g ph
ysic
ian
in c
onne
ctio
nw
ith a
n op
erat
ive
proc
edur
e w
hen
the
natu
re o
f suc
hpr
oced
ure
is s
uch
that
his
ser
vice
s ar
e ne
cssa
ry.
(c)
Ser
vice
s of
a p
hysi
cian
-ane
sthe
tist i
f oth
er th
anth
e su
rgeo
n or
ass
istin
g ph
ysic
ian.
(d)
Mat
erni
ty S
ervi
ces,
(bu
t not
incl
udin
g pr
e-na
tal
and
post
-nat
al c
are
in th
e ho
me
or in
the
phys
icia
n's
offic
e) r
ende
red
by a
phy
sici
an in
con
nect
ion
with
chi
ld-
birt
h, in
clud
ing
a .s
urgi
cal d
eliv
ery
such
as
Cae
sare
anS
ectio
n, if
the
patie
nt a
nd h
er h
usba
nd h
ave
both
bee
nsu
bscr
iber
s un
der
the
sam
e su
bscr
iptio
n ag
reem
ent f
orat
leas
t 7 c
ontin
uous
mon
ths
prio
r to
the
oper
atio
n. (
The
7 m
onth
s' w
aitin
g pe
riod
is w
aive
d fo
r su
bscr
iber
s un
der
the
Com
preh
ensi
ve P
lan.
)
(s)
Med
ical
Ser
vice
s (e
xcep
t as
prov
ided
in P
AR
T II
Ibe
low
) w
hen
rend
ered
by
a ph
ysic
ian
to a
sub
scrib
er,
only
whi
le a
bed
pat
ient
in a
hos
pita
l for
trea
tmen
t of
an a
cute
illn
ess
or in
jury
, and
onl
y if
no s
urgi
cal s
ervi
ces
are
perf
orm
ed d
urin
g th
e sa
me
cont
inuo
us p
erio
d of
disa
bilit
y.(f
) X
-ray
and
Ele
ctro
card
iogr
am S
ervi
ces
to th
e ex
tent
prov
ided
in P
AR
T V
III b
elow
.
(g)
CO
VE
RA
GE
UN
DE
R M
OR
E T
HA
N O
NE
AG
RE
E-
ME
NT
: A s
ubsc
riber
, ent
itled
to b
enef
its u
nder
mar
eth
an o
ne s
ubsc
riptio
n ag
reem
ent o
f the
Cor
pora
tion,
shal
l be
entit
led
to th
e ag
greg
ate
of th
e cr
edits
pro
vide
dun
der
whi
chev
er o
f par
agra
phs
(a)
thro
ugh
(f)
of P
AR
T I
of th
e se
vera
l agr
eem
ents
may
be
appl
icab
le, b
ut n
otxc
eedi
ng th
e ph
ysic
ians
' cha
rges
for
serv
ices
ren
dere
dun
der
thos
e pa
ragr
aphs
, nor
sha
ll su
ch a
dditi
onal
cov
-ra
ge in
crea
se th
e du
ratio
n of
ben
efits
spe
cifie
d in
this
agre
emen
t. A
sub
scrib
er e
ntitl
ed te
ben
efits
und
er s
ub-
scria
tion
agre
emen
ts o
f the
Cor
pora
tion
and
of a
noth
erB
lue
Shi
eld
plan
' sha
ll be
ent
itled
to r
ecei
ve c
redi
ts fo
ral
l of t
he b
enef
its p
rovi
ded
by b
oth
plan
s, b
ut n
ot e
x-
caw
ing
the
phys
icia
ns' d
owse
s fo
r se
rvic
es r
ende
red
nor
for
bene
fits
hem
the
Cor
pora
tion
long
er k
e du
ratio
nth
an s
peci
fied
in th
is a
gree
men
t Sub
stitu
tion
of s
ub-
scrip
tion
agre
emen
ts u
nder
whi
ch a
sub
scrib
er is
gad
-de
d to
ben
efits
or
berm
inet
ion
of o
ne a
gree
men
t and
e nt
ry in
to a
noth
er a
gree
men
t, sh
ell n
ot in
crea
se th
edu
ratio
n of
ben
efits
spe
cifie
d in
this
agr
eem
ent.
PA
RT
II -
SE
RV
ICE
BE
NE
FIT
PR
OV
ISIO
NS
:
Par
tpeU
ng p
hysi
cian
s ho
ve a
gree
d w
ith th
e C
or-
pora
tion
that
thei
r ch
arge
s fo
r se
rvic
es w
ill n
ot m
used
the
bene
fits
prov
ided
in P
AR
T V
III (
A, B
, C, D
, and
E.;)
prov
ided
the
subs
crib
er's
rat
e of
inco
me
does
not
at t
hetim
e of
dis
abili
ty e
xcee
d th
e lim
it ol
the
appr
opria
tes
ELI
GIB
LE IN
CO
ME
GR
OU
P s
how
n W
ow:
PLA
N A
PLA
N 1
11
$4,0
00.0
0$6
,000
.00
$2,8
00.0
0$4
,000
.00
For
sub
scrib
er w
ho h
as e
nrol
led
one
or m
ore
fam
ily m
embe
rs.
For
sub
scrib
er w
ho h
as e
nrcl
ied
him
esif
only
.
For
the
purp
ose
of d
eter
min
ing
inco
me
elig
ibili
ty, a
subs
crib
er's
inco
me
shal
l be
deem
ed to
be
the
com
bine
dan
nual
inco
me
of s
ubsc
riber
and
spc
xree
.
Any
sub
scrib
er w
ho, e
xcep
t upo
n th
e or
der
of h
rsph
ysic
ian,
occ
upie
s ho
spita
l acc
omm
odat
ions
in a
pri-
vate
roo
m th
ereb
y re
mov
es h
imse
lf or
her
self
from
the
elig
ible
inco
me
grou
p.F
or a
ny s
ubsc
riber
who
se r
ats
of in
com
e is
in m
imes
of th
at o
f the
elig
ibie
inco
me
grou
p, o
r w
ho is
ent
itled
to r
ecei
ve b
enef
its fo
r th
e sa
me
or s
imila
r se
rvic
es fr
omso
me
othe
r so
urce
, the
ben
efits
pro
vide
d un
der
this
cont
ract
sha
ll ap
ply
as a
n in
dem
nity
, and
if th
e fe
e of
the
phys
icia
n ex
ceed
s th
at a
mou
nt, s
uch
char
ges
shal
lbe
the
liabi
lity
of th
e su
bscr
iber
.
PA
RT
BE
NE
FIT
S N
OT
PR
OV
IDE
D:
Thi
s ag
reem
ent d
oes
NO
T in
clud
es
(a)
Pay
men
t for
any
Sur
gica
l_ o
r M
edic
al S
ervi
ces
not
perf
orm
ed b
y a
lega
lly q
uene
ed p
hysi
cian
of s
urge
on.
(a)
PaY
men
t for
any
Sur
ikai
or
Med
ical
Ser
vice
s no
tW
ecifi
ed in
PA
RT
I or
in th
e S
ched
ule
of A
llow
ance
s(P
AR
T V
III),
exc
ept a
s pr
ovid
ed in
(f)
bel
ow.
(e)
Pay
men
t for
any
Sur
gica
l or
Med
ical
Ser
vice
s g)
in c
onne
ctio
n w
ith a
ny p
erso
nal i
niur
y (in
clud
ing
any
occu
patio
nal d
isee
se o
r co
nditi
on a
s de
fined
in W
ork-
men
's C
ompe
nsat
ion
law
s) a
risin
g ou
t of a
nd ir
r th
eco
urse
of e
mpi
oym
ent,
conn
ecte
d th
erew
ith a
nd r
efer
-ab
le th
eret
o, e
xcep
t in
the
case
of s
set
t em
pioy
ed p
er-
son;
or
(ii)
prov
ided
or
paid
for
by th
e U
nite
d S
teen
s or
any
of it
s ag
encl
eer
or (
iii)
to th
e ex
tent
that
the
cost
ef
such
Sur
gica
l or
Med
ical
Ser
vice
s m
ay b
e re
cove
rabl
eby
ar
on b
ehal
f of t
he s
ubsc
riber
in a
ny a
ctio
n at
kw
or in
set
tlem
ent o
f com
prom
ise
of s
ny c
laim
age
inet
any
part
y ot
her
than
an
insu
rer
of th
e su
bscr
iber
.
(d)
Pay
men
t for
Sur
gica
l ar
Med
ical
Ser
vice
s fo
rco
rrec
tion
of c
osm
etic
def
ects
exi
stin
g pr
ice
to th
eef
fect
ive
date
cf t
he s
ubsc
riptio
n ag
reem
ent.
Whe
re
ther
e is
ass
ocia
ted
impa
irmen
t of f
unct
ion,
ben
efits
may
be p
rovi
ded,
und
er th
e C
ompr
ehen
sive
Pla
n on
ly, f
or th
ere
med
y of
suc
h im
pairm
ent,
but t
he s
ubsc
riber
sha
ll be
pers
onal
ly r
espo
nsib
le fo
r ch
arge
s at
trib
utab
le to
cor
rec-
tion
of th
e co
smet
ic d
efec
t.
(e)
Pay
men
t for
Sur
gica
l or
Med
ical
Ser
vice
s fo
r an
yco
nditi
on, d
isea
se o
r in
jury
whi
ch e
xist
ed o
n or
bef
ore
the
effe
ctiv
e da
te o
f thi
s ag
reem
ent.
(Thi
s pa
ragr
aph
(e)
does
not
app
ly fo
r se
rvic
es r
ende
red
afte
r 7
mon
ths
cont
inuo
us m
embe
rshi
p no
r at
all
unde
r th
e C
ompr
ehen
-si
ve P
lan.
)
(f)
Pay
men
t for
unl
iste
d pr
oced
ures
exc
ept i
n am
ount
sde
term
ined
by
the
Cor
pora
tion
and
cons
iste
nt w
ith th
ose
liste
d in
the
Sch
edul
e of
Allo
wan
ces,
PA
RT
VIII
.
(g)
Pay
men
t to
the
phys
icia
n fo
r S
urgi
cal o
r M
edic
alS
ervi
ces
rend
ered
by
such
phy
sici
an e
mpl
oyed
or
re-
tain
ed b
y a
hosp
ital,
the
empl
oyer
or
any
othe
r pa
rty,
to p
rovi
de w
ithou
t fee
the
serv
ices
per
form
ed.
PA
RT
IV-
CH
AN
GE
S:
An
appl
ican
t who
doe
s no
t inc
lude
his
spo
use
and/
orch
ildre
n on
his
app
licat
ion
may
add
suc
h fa
mily
mem
-be
rs o
nly
on th
e an
nive
rsar
y of
the
effe
ctiv
e da
te o
f his
Dire
ct P
aym
ent m
embe
rshi
p or
of t
he G
roup
of w
hich
he is
a m
embe
r, w
hich
ever
is a
pplic
able
. An
appl
ican
tw
ho la
ter
mar
ries
may
, with
in 6
0 da
ys o
f suc
h m
arria
ge,
add
his
spou
se to
his
mem
bers
hip
by a
pplic
atio
n to
the
Cor
pora
tion
if a
Dire
ct P
aym
ent m
embe
rshi
p, o
r if
aG
roup
mem
bers
hip,
by
appl
icat
ion
to th
e pe
rson
who
rem
its p
aym
ents
for
the
Gro
up; a
fter
60 d
ays
he m
ayad
d hi
s sp
ouse
on
the
anni
vers
ary
date
as
indi
cate
dab
ove.
An
appl
ican
t who
incl
uded
his
spo
use
and/
orch
ildre
n m
ay r
emov
e su
ch fa
mily
mem
bers
from
hi-
mem
bers
hip
only
as
of a
dat
e su
bseq
uent
to th
e re
ques
..fo
r re
mov
al w
hen
subs
crip
tion
char
ges
are
paya
ble.
PA
RT
V-
TE
RM
INA
TIO
N A
ND
RE
FU
ND
:
(a)
If a
Dire
ct P
aym
ent m
embe
rshi
p, th
is a
gree
men
tsh
all c
ontin
ue in
forc
e un
til a
def
ault
shal
l exi
st fo
r 15
days
in th
e pa
ymen
t of s
ubsc
riptio
n ch
arge
s, o
r un
tilth
e ef
fect
ive
date
, dur
ing
such
per
iod
of d
efau
lt of
any
new
agr
eem
ent t
he a
pplic
ant m
ay e
nter
into
with
the
Cor
pora
tion,
in e
ither
of w
hich
cas
es th
is a
gree
men
tsh
all a
utom
atic
ally
term
inat
e. T
he C
orpo
ratio
n m
ay r
e-in
stat
e th
is a
gree
men
t at i
ts s
ole
disc
retio
n, b
ut o
nly
toco
ver
any
illne
ss o
r in
jury
firs
t man
ifest
ing
itsel
f mor
eth
an 1
5 da
ys a
fter
rein
stat
emen
t, ex
cept
that
suc
hlim
itatio
n w
ill e
xpire
at t
he e
nd o
f 7 m
onth
s of
con
tinu-
ous
mem
bers
hip
follo
win
g re
inst
atem
ent.
(b)
An
appl
ican
t sub
scrib
er h
oldi
ng a
Dire
ct P
aym
ent
mem
bers
hip
who
join
s a
Gro
up a
t his
pla
ce o
f em
ploy
-m
ent m
ay c
ontin
ue to
mai
ntai
n hi
s D
irect
Pay
men
tm
embe
rshi
p in
depe
nden
tly o
f his
new
Gro
up m
embe
r-sh
ip p
rovi
ded
he m
akes
writ
ten
requ
est t
o th
e C
orpo
ra-
tion,
prio
r to
the
effe
ctiv
e da
te o
f his
new
Gro
up m
em-
bers
hip,
or
indi
cate
s hi
s in
tent
in th
e sp
ace
prov
ided
on
the
Gro
up a
pplic
atio
n ca
rd. I
n th
e ab
senc
e of
suc
hre
ques
t thi
s ag
reem
ent w
ill a
utom
atic
ally
term
inat
e on
the
effe
ctiv
e da
te 0
the
new
Gro
up m
embe
rshi
p. In
suc
hca
ses
the
appl
ican
t will
be
elig
ible
for
a re
fund
of t
hat
port
ion
of th
e D
irect
Pay
men
t sub
scrip
tion
char
ges
paid
beyo
nd th
e ef
fect
ive
date
of t
he n
ew G
roup
mem
bers
hip
and
any
subs
eque
nt p
aym
ent o
f Dire
ct P
aym
ent s
ub-
scrip
tion
char
ges
whe
n du
e w
ill b
e ac
cept
ed a
s a
requ
est
for
rein
stat
emen
t of t
he D
irect
Pay
men
t mem
bers
hip
asof
suc
h du
e da
te. A
cha
nge
or tr
ansf
er fr
om D
irect
Pay
men
t mem
bers
hip
to n
ew G
roup
mem
bers
hip
will
not a
dver
sely
affe
ct e
ligib
ility
for
bene
fits
base
d on
cont
inui
ty o
f mem
bers
hip.
(c)
If a
Gro
up m
embe
rshi
p, th
is a
gree
men
t sha
ll co
n-tin
ue in
forc
e un
til a
def
ault
shal
l exi
st fo
r 30
day
s in
the
paym
ent o
f sub
scrip
tion
char
ges,
or
until
the
effe
c-tiv
e da
te, d
urin
g su
ch p
erio
d of
def
ault,
of a
ny n
ewag
reem
ent t
he a
pplic
ant m
ay e
nter
into
with
the
Cor
-po
ratio
n, in
eith
er o
f whi
ch c
ases
this
agr
eem
ent s
hall
auto
mat
ical
ly te
rmin
ate.
Any
app
lican
t who
leav
es h
ispl
ace
of e
mpl
oym
ent m
ay jo
in a
Gro
up a
t his
new
pla
ceof
em
ploy
men
t or
enro
ll on
a D
irect
Pay
men
t bas
is in
acco
rdan
ce w
ith th
e E
nrol
lmen
t Reg
ulat
ions
of t
heC
orpo
ratio
n.
(d)
The
Cor
pora
tion
rese
rves
the
right
to te
rmin
ate
this
agr
eem
ent a
t any
tim
e up
on g
ivin
g 15
day
s pr
ior
writ
ten
notic
e to
the
App
lican
t. It
may
als
o, u
pon
like
notic
e at
any
tim
e an
d fr
om ti
me
to ti
me,
am
end
this
agre
emen
t or
any
port
ion
ther
eof a
nd r
edet
erm
ine
and
fix th
e am
ount
of s
ubsc
riptio
n ch
arge
s as
it m
ay d
eem
nece
ssar
y; p
rovi
ded,
how
ever
, tha
t eac
h su
ch a
men
d-m
ent o
r ch
ange
of s
ubsc
riptio
n ch
arge
s sh
all b
e ef
fect
ive
as to
this
agr
eem
ent o
nly
upon
the
expi
ratio
n of
the
term
for
whi
ch th
e su
bscr
iptio
n ch
arge
s ha
ve b
een
paid
.N
otirl
sha
ll be
dee
med
to h
ave
been
giv
en to
eac
h su
b-sc
riber
ent
itled
to b
enef
its h
ereu
nder
whe
n m
aile
d to
the
appl
ican
t at h
is a
ddre
ss w
hich
app
ears
upo
n th
e re
cord
sof
the
Cor
pora
tion,
or
whe
n m
aile
d to
the
appl
ican
t'sag
ent,
or w
hen
publ
ishe
d in
a d
aily
new
spap
er p
ublis
hed
in th
e S
tate
of R
hode
Isla
nd. P
aym
ent o
f sub
scrip
tion
char
ges
afte
r th
e gi
ving
of n
otic
e of
an
amen
dmen
t or
chan
ge in
subs
crip
tion
char
ges
shal
l con
stitu
te a
nac
cept
ance
ther
eof i
n be
half
of a
ll su
bscr
iber
s en
title
dto
ben
efits
her
eund
-r.
(e)
The
Cor
pora
tion
shal
l be
relie
ved
of a
ll lia
bilit
y to
prov
ide
cred
its fo
r S
urgi
cal o
r M
edic
al S
ervi
ces
afte
rth
e da
te o
f ter
min
atio
n, e
xcep
t tha
t if s
uch
term
inat
ion
occu
rs w
hile
a s
ubsc
riber
is c
onfin
ed a
s a
bed
patie
ntin
a h
ospi
tal s
uch
subs
crib
er s
hall
be e
ntitl
ed to
ben
efits
in a
ccor
danc
e w
ith th
is a
gree
men
t dur
ing
such
hos
pita
lst
ay.
(f)
In th
e ev
ent o
f ter
min
atio
n of
this
agr
eem
ent
with
in 8
mon
ths
prio
r to
the
birt
h of
a c
hild
toan
ysu
bscr
iber
who
wou
ld o
ther
wis
e be
ent
itled
to m
ater
nity
bene
fits
spec
ified
in P
AR
T I
(d)
of th
is a
gree
men
t and
whe
n su
ch s
ubsc
riber
mai
ntai
ns c
ontin
uous
mem
ber-
ship
by
ente
ring
into
a n
ew a
gree
men
t with
the
Cor
pora
-tio
n, w
hich
is in
effe
ct a
t the
tim
e of
the
child
's b
irth,
shal
l be
entit
led
to th
e m
ater
nity
ben
efits
und
er w
hich
-ev
er o
f the
agr
eem
ents
pro
vide
s th
e gr
eate
r be
nefit
s,bu
t not
to th
e be
nefit
s of
bot
h.
(g)
An
appl
ican
t who
term
inat
es h
is m
embe
rshi
p,ot
her
than
as
prov
ided
in P
AR
T V
(b)
abo
ve, m
ay d
o so
effe
ctiv
e as
of t
he la
st d
ay o
f the
mon
th in
whi
ch th
eC
orpo
ratio
n re
ceiv
es a
pplic
ant's
writ
ten
requ
est t
o te
r-m
inat
e. H
e sh
all b
e en
.title
d to
a r
efun
d of
any
pre
paid
subs
crip
tion
char
ges
appl
icab
le to
per
iods
follo
win
gsu
ch e
ffect
ive
date
of t
erm
inat
ion.
PA
RT
VI-
GE
NE
RA
L C
ON
DIT
ION
S:
(a)
The
effe
ctiv
e da
te o
f thi
s ag
reem
ent s
hall
be th
atin
dica
ted
on th
e ap
plic
atio
n on
file
with
the
Cor
pora
tion.
Ben
efits
her
eund
er s
hall
be p
ayab
le w
ith r
espe
ct to
Sur
gica
l or
Med
ical
Ser
vice
s re
nder
ed o
n an
d af
ter,
but
not b
efor
e, th
e ef
fect
ive
date
, pro
vide
d, h
owev
er, t
het
bene
fits
will
not
be
avai
labl
e he
reun
der
to a
ny s
ub-
scrib
er in
the
hosp
ital o
n an
d pr
ior
to th
e ef
fect
ive
dela
in th
e tr
ea'a
ient
of t
he p
artic
ular
con
ditio
n ca
t.sin
gsu
ch h
ospi
taliz
atio
n.
(b)
All
clai
ms
here
unde
r m
ust b
e fil
ed w
ith th
eC
orpo
ratio
n w
ithin
60
days
afte
r th
e se
rvic
es s
hall
have
been
ren
dere
d. T
he m
axim
um a
rnot
int p
ayab
le b
y th
eC
orpo
ratio
n to
any
and
all
part
ies
in ir
tere
st fo
r ar
ypa
rtic
ular
dis
abili
ty s
hall
not e
xcee
d th
e m
axim
umam
ount
pro
vide
d by
the
Sch
edul
e of
Allo
wan
ces,
exe
mpt
as p
rovi
ded
in P
AR
T I
(f)
and
PA
RT
VIII
A 1
0 . S
uch
paym
ent s
hall
cons
titut
e a
full
and
final
dis
ch.ir
ge o
fal
l obl
igat
ions
of t
he C
orpo
ratio
n fo
r su
ch b
enef
its.
(c)
Thi
s ag
reem
ent i
s m
ade
upon
the
expr
ess
cond
i-tio
n th
at a
ny p
hysi
cian
or
hosp
ital i
s au
thor
ized
todi
sclo
se to
the
Cor
pora
tion
any
info
rmat
ion
rega
rdin
gor
acq
uire
d in
con
nect
ion
with
atte
ndan
ce, c
are
or tr
eat-
men
t of a
ny s
ubsc
riber
her
eund
er, a
nd th
at a
ll pr
ovi-
sion
s of
law
or
prof
essi
onal
eth
ics
forb
iddi
ng s
uch
dis-
clos
ures
are
wai
ved
by o
r in
beh
alf o
f eac
h su
bscr
iber
here
unde
r.
(d)
The
app
lican
t agr
ees
that
the
appl
ican
t's a
gent
may
mak
e av
aila
ble
to th
e C
orpo
ratio
n fo
r in
spec
t.on
any
empl
oym
ent a
nd o
ther
per
sonn
el r
ecor
ds w
hich
hav
ea
bear
ing
upon
the
elig
ibili
ty o
f the
Enr
olle
d G
roup
, the
appl
ican
t or
any
subs
crib
er.
(e)
The
ben
efits
ava
ilabl
e he
reun
der
may
be
exte
nded
by a
ctio
n of
the
Boa
rd o
f Dire
ctor
s of
the
Cor
pora
tion,
but n
o su
bscr
iber
s sh
all b
e nt
itled
to s
hare
in a
nyas
sets
, res
erve
s, o
r ot
her
fund
s or
pro
pert
y no
w o
r he
re-
afte
r ow
ned,
acq
uire
d, o
r ac
cum
ulat
ed b
y th
eC
orpo
ratio
n.(1
) N
othi
ng in
this
agr
eem
ent i
s in
tend
ed to
affe
ct th
ere
latio
nshi
p be
twee
n th
e su
bscr
iber
and
his
phy
sici
an.
The
Cor
pora
tion
is u
nder
no
oblig
atio
n to
sec
ure
a ph
y-si
cian
for
the
subs
crib
er, n
or d
oes
it as
sum
e an
y lia
-bi
lity
aris
ing
out o
f the
phy
sici
an-p
atie
nt r
elat
ions
hip,
and
neith
er th
e C
orpo
ratio
n no
r an
y of
its
Dire
ctor
s or
empl
oyee
s sh
all b
e lia
ble
for
any
act,
omis
sion
, or
negl
ect o
f any
phy
sici
an.
(g)
No
actio
n or
sui
t at l
aw o
r in
equ
ity s
hall
beco
mm
ence
d un
til 3
0 da
ys a
fter
writ
ten
notic
e of
cla
imha
s be
en g
iven
by
the
subs
crib
er to
the
Cor
pora
tion,
nor
shal
l suc
h ac
tion
be b
roug
ht a
t all
late
r th
an o
neye
ar a
fter
the
serv
ices
on
whi
ch s
uch
clai
m is
boi
led
shal
l hav
e be
en r
ende
red.
(h)
Ben
efits
of t
his
agre
emen
t are
per
sona
l to
the
subs
crib
er a
nd a
re n
ot a
ssig
nabi
e, e
xcep
t und
er te
rms
and
cond
ition
s de
term
ined
by
the
Cor
pora
tion.
(i) In
the
even
t any
Sur
gica
l or
Med
ical
Ser
vice
or
bene
fit is
pro
vide
d fo
r, o
r an
y pa
ymen
t is
mad
e or
cre
dit
exte
nded
to, a
sub
scrib
er u
nder
this
agr
eem
ent,
the
Cor
pora
tion
shal
l be
subr
ogat
ed a
nd s
hall
succ
eed
toth
e su
bscr
iber
's r
ight
of r
ecov
ery
ther
efor
aga
inst
arg
ype
rson
or
orga
niza
tion,
exc
ept i
nsur
ers
on p
olic
ies
ofin
sura
nce
issu
ed to
and
in th
e na
me
of th
e su
bscr
iber
.T
he s
ubsc
riber
sha
ll pa
y ov
er to
the
Cor
pora
tion
all
sum
s re
cove
red
by s
uit,
settl
emen
t or
othe
rwis
e, o
nac
coun
t of s
uch
Sur
gica
l or
Med
ical
Ser
vice
or
bene
fit.
The
sub
scrib
er s
hall
take
suc
h ac
tion,
furn
ish
such
in-
form
atio
n an
d as
sist
ance
, and
exe
cute
suc
has
sign
-m
ents
and
oth
er in
stru
men
ts a
s th
e C
orpo
ratio
n m
ayre
quire
to fa
cilit
ate
enfo
rcem
ent o
f its
rig
hts
here
unde
r,an
d sh
all t
ake
no a
ctio
n pr
ejud
icin
g th
erig
hts
and
inte
rest
s of
the
Cor
pora
tion
here
unde
r.
(i) A
men
dmen
ts o
f thi
s co
ntra
ct a
ndch
ange
s in
the
amou
nts
or ty
pes
of c
over
age
or in
the
pers
ons
cove
red,
as a
pplie
d fo
r or
dire
cted
by
appl
ican
t,sh
all b
e ap
plic
a-bl
e on
ly a
s to
ser
vice
s lis
ted
in P
AR
T V
IIIw
hich
are
rend
ered
on
and
afte
r th
e ef
fect
ive
date
of s
uch
amen
d-m
nt o
r ch
ange
exc
ept f
or In
-Hos
pita
lM
edic
al C
are
(PA
RT
VIII
(f)
), w
hich
sha
ll be
onl
y fo
r ad
mis
sion
sto
aho
spita
l on
and
afte
r th
e ef
fect
ive
date
of s
uch
amen
d-m
ent o
r ch
ange
.
PA
RT
VII
- D
EF
INIT
ION
S:
As
used
in th
is a
gree
men
t:
(a)
Cor
pora
tion
The
term
"Cor
pora
tion"
sha
ll m
ean
the
Rho
de Is
land
Med
ical
Soc
iety
Phy
sici
ans
Ser
vice
.
(b)
App
lican
t The
term
"App
lican
t" s
hall
mea
n an
yin
divi
dual
with
who
m th
e C
orpo
ratio
n ha
sen
tere
d in
toa
subs
crip
tion
agre
emen
t.
(c)
Sub
scrib
erT
he te
rm "
Sub
scrib
er"
shal
l in-
clud
e th
e ap
plic
ant a
nd e
ach
pers
onlis
ted
on th
eap
plic
atio
n so
long
as
such
per
sons
rem
ain
elig
ible
for
incl
usio
n in
acc
orda
nce
with
the
Cor
pora
tion'
sE
nrol
l-m
ent R
egul
atio
ns. E
ach
new
born
chi
ldsh
all b
ecom
ea
subs
crib
er e
ntitl
ed to
all
bene
fits
of m
embe
rshi
p (i)
whe
n a
maj
or s
urgi
cal p
roce
dure
ispe
rfor
med
on
the
child
, (ii)
whe
n th
e m
othe
r or
chi
ld is
disc
harg
ed fr
omth
e ho
spita
l, or
(iii
) w
hen
the
child
has
atta
ined
the
age
of 1
4 da
ys, w
hich
ever
eve
nt s
hall
first
occ
ur.
Unm
arrie
dsu
bscr
iber
s lis
ted
on th
e ap
plic
atio
n w
ill c
ease
to b
em
embe
rs a
t the
end
of t
he c
alen
dar
year
dur
ing
whi
chth
ey a
ttain
age
19.
A m
inor
sub
scrib
er li
sted
on
the
appl
icat
ion
who
mar
ries
befo
re th
e en
d of
the
cale
ndar
year
in w
hich
he
or s
he a
ttain
s ag
e 19
will
cea
se to
be
a su
bscr
iber
on
the
first
of t
hem
onth
follo
win
g m
ar-
riage
. A m
inor
sub
scrib
er w
hose
mem
bers
hip
ceas
esfo
llow
ing
mar
riage
or
atta
inm
ent o
f age
19
as a
fore
said
,m
ay tr
ansf
er h
is o
r he
r m
embe
rshi
pto
a G
roup
at t
heir
plac
e of
erip
loym
ent o
r m
ay m
ake
writ
ten
requ
est t
oth
e C
orpo
ratio
n fo
r a
Dire
ct P
aym
ent m
embe
rshi
p.A
hand
icap
ped
child
, reg
ardl
ess
of a
ge m
ay b
e re
tain
edas
a s
ubsc
riber
on
the
appl
ican
t's fa
mily
mem
bers
hip
prov
ided
a s
peci
al s
uppl
emen
tal
appl
icat
ion
for
such
child
has
bee
n fil
ed w
ith a
nd a
ccep
ted
byth
e C
orpo
ra-
tion. (d
) S
ubsc
riptio
n A
gree
men
t _ T
he te
rm "
Sub
scrip
-tio
n A
gree
men
t" s
hall
mea
n th
e ag
reem
ent
ente
red
into
betw
een
the
Cor
pora
tion
and
the
appl
ican
tan
d sh
all
cons
ist o
f the
app
licat
ion,
incl
udin
g an
ysu
pple
men
tal
appl
icat
ion,
and
the
appr
opria
te P
hysi
cian
s S
ervi
ceC
on-
trac
t for
Sur
gica
l-Med
ical
Ben
efits
then
in fo
rce
and
filed
with
the
Sta
te o
f Rho
de Is
land
Insu
ranc
eD
ivis
ion
of th
e D
epar
tmen
t of B
usin
ess
Reg
ulat
ion,
and
the
mem
bers
hip
card
evi
denc
ing
the
acce
ptan
ce o
fth
eap
plic
atio
n an
d an
y am
endm
ents
mad
e un
der
PA
RT
V(d
) he
reof
.(e
) A
pplic
ant's
Age
nt_
The
term
"A
pplic
ant's
Age
nt"
shal
l mea
n an
y in
divi
dual
who
, or
firm
,as
soci
atio
n or
corp
orat
ion
whi
ch p
ays
for
appl
ican
t, in
who
le o
r in
par
t,or
whi
ch a
s 'g
ent f
or th
eap
plic
ant h
as a
gree
d to
col
lect
and
rem
it, in
who
le o
r in
per
t,S
ubsc
riptio
n ch
arge
spa
yabl
e un
der
this
agr
eem
ent.
Suc
h ap
plic
ant's
agen
tsh
all n
ot b
e co
nstr
ued
to b
e th
e ag
ent o
f the
Cor
pora
tion.
(f)
Hos
pita
l The
term
"H
ospi
tal"
(exc
ept w
here
the
cont
ext o
ther
wis
e re
quire
s) s
hall
mea
n an
yin
stitu
tion
liste
d as
suc
h by
the
Am
eric
an H
ospi
tal A
ssoc
iatio
nan
dap
prov
ed b
y th
e C
orpo
ratio
n, o
r an
y in
stitu
tion
appr
oved
by th
e C
orpo
ratio
n w
hich
is o
pera
ted
excl
usiv
ely
for
the
care
as
bed
patie
nts
of m
edic
al a
ndsu
rgic
al c
ases
in-
volv
ing
acut
e ill
ness
or
inju
ry.
It sh
all n
ot in
clud
eco
nval
esce
nt h
omes
, res
t hom
es, n
ursi
ng h
omes
, hom
esfo
r th
e ag
ed, s
choo
l inf
irmar
ies,
or
priv
ate
sani
taria
.(g
) S
ched
ule
of A
llow
ance
s_ T
he te
rm ',
sche
dule
ut
Allo
wan
ces"
sha
ll m
ean
the
Sch
edul
e of
Allo
wan
ces
spec
ified
in P
AR
T V
III.
(h)
Phy
sici
an T
he te
rm "
Phy
sici
an"
shal
l mea
n an
ype
rson
dul
y lic
ense
d an
d re
gist
ered
ti.. p
ract
ice
surg
ery
and/
or m
edic
ine
unde
r an
y of
the
follo
win
gC
hapt
er5-
37, 5
-36,
5-3
1 or
5-2
9 of
the
Gen
eral
Law
sof
Rho
deIs
land
, 195
6, a
s am
ende
d, o
r un
der
equi
vale
nt la
ws
ofot
her
stat
es a
nd c
ount
ries.
(i) P
artic
ipat
ing
Phy
sici
an T
he te
rm "
Par
ticip
atin
gP
hysi
cian
" sh
all m
ean
any
phys
icia
n w
ho h
as s
igne
d an
agre
emen
t with
the
Cor
pora
tion
for
rend
erin
g ca
reun
der
the
term
s en
d co
nditi
ons
of th
is c
ontr
act,
and
with
in th
esc
ope
he m
ay r
ende
r un
der
his
licen
se.
(j) C
ompr
ehen
sive
Pla
nT
he te
rm "
Com
preh
ensi
veP
lan"
sha
ll m
ean
the
plan
in e
ffect
with
any
Gro
upw
here
the
Cor
pora
tion'
s ap
prop
riate
Enr
ollm
ent
Reg
ula-
tions
hav
e be
en m
et, a
nd w
here
mem
bers
hip
in s
uch
plan
is in
dica
ted
by th
e sy
mbo
l "C
", "
F",
or"
J" w
ithin
the
mem
bers
hip
num
ber
show
n on
the
subs
crib
er's
mem
bers
hip
card
.
PA
RT
VIII
- S
CH
ED
ULE
OF
ALL
OW
AN
CE
S:
1. T
he fo
llow
ing
abrid
ged
Sch
edul
es li
st s
ome
of th
eal
low
ance
s pr
ovid
ed u
nder
this
Con
trac
t for
Sur
gery
,A
ssis
tanc
.rt S
urge
ry, A
dmin
istr
atio
n of
Ane
sthe
sia,
Dia
gnos
tic P
roce
dure
s, O
ral S
urge
ry, I
n-H
ospi
tal M
ed-
ical
Car
e, M
ater
nity
Car
e, D
iagn
ostic
Xra
y, a
nd E
lect
ro-
card
iogr
ams.
A c
ompl
ete
listin
g of
the
sche
dule
d al
low
ance
sfo
r pr
o-ce
dure
s co
ntai
ned
in th
e va
rious
Sch
edul
es is
ava
ilabl
efo
r in
spec
tion
at th
e of
fices
of t
he C
orpo
ratio
n, th
e S
tate
of R
hode
Isla
nd In
sura
nce
Div
isio
n of
the
Dep
artm
ent
of B
usin
ess
Reg
ulat
ion,
or
at m
ost p
hysi
cian
s'of
fices
in th
e S
tate
of R
hode
Isla
nd.
2. T
he a
mou
nts
of a
llow
ance
s lis
ted
are
not i
nten
ded
tofix
the
char
ges
for
the
serv
ices
of t
he p
hysi
cian
,ex
cept
as p
rovi
ded
in P
AR
T II
,re
latin
g to
"S
ervi
ce B
enef
itP
rovi
sion
s".
3. P
aym
ent f
or s
ervi
ces
not p
rovi
ded
by th
is C
ontr
act,
or (
whe
n no
t con
trar
y to
the
term
s of
PA
RT
II, r
elat
ing
to"S
ervi
ce B
enef
it P
rovi
sion
s")
of c
harg
es in
exc
ess
ofth
eA
llow
ance
s pr
ovid
ed b
y th
is C
ontr
act,
ars
the
sole
resp
onsi
bilit
y of
the
subs
crib
er.
A. S
CH
ED
ULE
OF
ALL
OW
AN
CE
S F
OR
SU
RG
ER
Y:
1. P
r, a
nd P
ost-
Ope
rativ
e C
are:
The
allo
wan
ces
for
surg
ical
pro
cedu
res
shal
l inc
lude
pre
and
pos
t-op
erat
ive
care
in th
e ho
spita
l onl
y.
2. M
axim
um S
lugf
est L
iebi
lityt
The
max
imum
tota
lMo-
bilit
y fo
r su
rger
y, w
ith r
espe
ct to
all
oper
atio
nsdu
e to
the
sam
e or
mla
ted
caus
e w
hich
are
per
form
eddu
ring
a co
ntin
uous
per
iod
of d
isab
ility
*ha
ilbe
$27
7 un
der
Pla
n A
and
$40
4 un
der
Pla
n B
, sw
ept a
she
rein
afte
rpr
ovid
ed.
3. A
Con
tinuo
usPe
riod
al D
isab
ility
:(*
orat
ions
for
the
sam
e or
rel
ated
cau
se w
hich
am
net
sepa
rate
d by
10
days
she
ll be
dee
med
to h
ew b
een
pedo
nned
dur
ing
"aco
ntin
uous
per
iod
of d
leab
liity
ft
4. M
ultip
le S
urgi
cal P
rem
atur
e. T
hrou
gh th
eS
ame
Mei
-ai
m W
hen
two
or m
ore
sera
il* p
roce
dure
s ar
e pe
r:fo
rmed
(us
ually
) th
roug
h th
e sa
me
inci
sioo
, pay
meM
will
be m
ade
only
for
the
proc
edur
e ca
lling
for
the
high
est
allo
wan
ce.
Mai
liple
film
iest
Pes
sim
ism
rim
s. S
epar
ate
laci
sien
ss W
hen
two
or m
ore
surg
ical
pro
cedu
res
are
perf
orm
ed th
roug
h se
para
le in
cisi
ons
and
in m
eet,
oper
ativ
e fie
lds,
pay
men
t will
be
mad
e pe
r sc
hedi
de,e
rth
e pr
oced
ure
carr
ying
the
high
est a
llow
ence
and
one
-ha
lf of
the
sche
dule
d al
low
ance
for
the
min
orpr
oced
ure(
s).
IL B
ilate
ral P
roce
dure
s, in
sep
arat
e op
erat
ive
field
s, w
illbe
allo
wed
an
addi
tiona
l 50%
unl
ess
°Dim
wit*
spe
cille
din
the
sche
dule
.
7. W
hen
twe
surg
eons
, dur
ing
any
oper
ativ
e in
tima-
tion,
per
form
sep
arat
e O
PO
ratiO
nt, a
cIP
!.n m
aybe
subm
itted
bY
oet
h N
NW
" re
port
ing
the
proc
odur
epe
rfor
med
end
the
circ
umst
ance
s in
volv
ed. I
ndiv
idus
ico
nsid
erat
ion
will
be
give
n to
suc
h cl
aim
&
Die
gneM
ie P
f800
1111
114
(III.
P.)
, whe
n pe
rfor
med
as
in-
depe
nden
t pro
cedu
res
(LP
.) a
nd a
sier
iehe
d C
I I. t
heS
ched
ule
of A
llow
ance
s, a
re n
ot li
mite
d to
the
surg
ical
max
imum
s of
$27
7 un
der
Pio
n A
and
$40
4 w
ider
Pie
s R
.
Inde
pead
eat P
rem
ium
s (L
P*
Pay
men
tbe
mul
efo
r pr
oced
ures
so
desi
gnat
ed o
nly
whe
n cl
one
alon
e sr
inde
pend
ently
of a
noth
er p
roce
dure
.10
. led
ivid
ual C
oasi
dera
tien
(LC
.) w
iN b
e gi
ven
to p
ro-
cedu
res
in th
e sc
hedu
le w
here
asp
ecifi
c al
low
ance
isno
t ind
icat
ed a
nd th
e in
itial
s"L
C."
app
ear.
Con
side
ra-
tion
also
will
be
give
n fo
r a
paym
ent k
r M
OO
NS
of &
spec
ific
allo
wan
ce w
here
unu
sual
cond
ition
s re
wire
addi
tion"
, sur
gica
l pro
cedu
re&
The
Cor
pora
tion
rese
rves
the
right
, in
its s
ole
disc
retio
n,lo
det
erm
ine
the
awai
tof
allo
wan
ces,
if a
ny, t
o be
paid
. The
gen
eral
ity o
f thi
s
Pro
visi
onis
not
lim
ited
by a
nyof
the
fore
goin
gP
rovi
sion
s.
(Abr
idge
d S
ched
ule)
AB
DO
ME
NP
LAN
AP
LAN
App
ende
ctom
y (I
.P.)
.$1
03$1
50R
emov
al o
f gal
l-bla
dder
154
225
Par
tial r
emov
al o
f sto
mac
h20
6B
OO
Res
ectio
n of
sm
all i
ntes
tines
, with
anas
tom
osis
166
342
1111
1110
Val
of p
art o
f col
on22
632
9C
losu
re o
f per
fora
ted
ulce
r in
test
ine
134
GY
NE
CO
LOG
YD
ilata
tion
and
cure
ttage
$ 34
$ 50
Hys
tere
ctom
y, s
ubto
tal
134
196
Hys
tere
ctom
y, to
tal
172
250
Rep
air
of c
ysto
cele
(I.P
.)12
1R
emov
al o
f ova
rian
cyst
(LP
.)10
3
HE
RN
iAIn
guin
al o
r fe
mor
al, u
nila
tera
l$1
03$1
50In
guin
al o
r fe
mor
al, b
ilate
ral
134
196
Um
bilic
al (
I.P.)
100
146
Dia
phra
gmat
ic20
029
2
PROCTOLOGY
Hem
orrh
oide
ctom
y, in
tern
al$
72$1
04D
rain
age
of is
chio
rect
al a
bsce
ss (
I.P.)
2638
BREAST
Mas
tect
omy,
sim
ple
$ 83
$121
Mas
tect
omy,
rad
ical
186
271
Exc
isio
n of
ben
ign
brea
st tu
mor
, uni
-la
tera
l43
63
EAR, NOSE AND THROAT
Ton
sille
ctom
y an
d ad
enoi
dect
omy
Und
er a
ge 1
2$
40$
58A
ge 1
2 or
ove
r46
67R
emov
al o
f nas
al p
olyp
s, u
nila
tera
l17
25M
asto
idec
tom
y, r
adic
al18
627
1A
ntru
m o
pera
tion,
rad
ical
109
158
Bro
ncho
scop
y (I
.P.)
4058
THYROID
Thy
roid
ecto
my,
sub
tota
l$1
52$2
21E
xcis
ion
of th
yrog
loss
al d
uct,
cyst
or
sinu
s10
615
4
UROLOGY
Rem
oval
of k
idne
y$1
80$2
63R
emov
al o
f sto
ne fr
om k
idne
y17
425
4P
rost
atec
omy,
per
inea
!, su
btot
al18
326
7E
xcis
ion
of h
ydro
cele
, uni
late
ral (
I.P.)
6088
Rem
oval
of s
tone
from
ure
ter
by c
ys-
tosc
opy
6088
Rem
oval
of s
tone
from
ure
ter
by o
per-
ativ
e in
cisi
on15
422
5
NEURO-SURGERY
Dra
inag
e of
bra
in a
bsce
ss$2
17$3
17R
emov
al o
f bra
in tu
mor
277
404
Dec
ompr
essi
on, s
ubte
mpo
ral
114
167
Sym
path
ecto
my,
thor
aco
cerv
ical
, uni
-la
tera
l13
219
2F
ront
al lo
boto
my,
bila
tera
l17
225
0A
vuls
ion
of s
upra
orbi
tal n
erve
2942
OPHTHALMOLOGY
Cat
arac
t ope
ratio
n$1
74$2
54N
eedl
ing
of le
ns57
83R
emov
al o
f iris
103
150
Enu
clea
tion
of e
yeba
ll, s
impl
e10
615
4E
nucl
eatio
n of
eye
ball,
with
non
-mov
-ab
le im
plan
t14
320
9
LUNGS AND PLEURA
Rem
oval
of l
ung,
tota
l or
part
ial
$257
$375
Dra
inag
e of
em
pyem
a, o
pen
103
150
HEART AND BLOOD VESSELS
Sut
ure
of h
eart
wou
nd o
r in
jury
$220
$321
Ope
ratio
n on
the
hear
t val
ves
266
388
Var
icos
e ve
ins:
Hig
h lig
atio
n an
d in
ject
ion,
uni
late
ral
5175
Hig
h lig
atio
n an
d in
ject
ion,
bila
tera
l77
113
MIS
CE
LLA
NE
OU
SP
iloni
dal s
inus
or
cyst
, exc
isio
n$
77$1
13D
rain
age
of in
fect
ed b
ursa
1117
OR
TH
OP
ED
IC S
UR
GE
RY
FR
AC
TU
RE
S:
1. A
ll fr
actu
re a
llow
ance
s in
clud
e th
e in
itial
and
sub
se-
quen
t app
licat
ion
and
rem
oval
of c
asts
or
splin
ts.
2. A
sin
gle
paym
ent w
ill b
e m
ade
for
the
trea
tmen
t of
any
frac
ture
. If a
n op
en r
educ
tion
is p
erfo
rmed
with
inth
ree
wee
ks fo
llow
ing
a cl
osed
red
uctio
n, o
nly
the
pay-
men
t for
the
open
red
uctio
n w
ill b
e al
low
ed.
3. P
aym
ent w
ill b
e m
ade
only
on
the
basi
s of
a s
ingl
efr
actu
re o
f a b
one,
reg
ardl
ess
of w
heth
er m
ultip
le fr
ac-
ture
s of
the
sam
e bo
ne a
re p
rese
nt.
4. P
aym
ent f
or p
last
er c
asts
(in
depe
nden
t pro
cedu
re)
islim
ited
to o
ne, u
nles
s ot
herw
ise
stat
ed in
the
sche
dule
.A
llow
ance
incl
udes
the
appl
icat
ion
and
rem
oval
of c
ast.
(Abr
idge
d S
ched
ule)
PLA
N A
PLA
N IS
Cla
vicl
e, w
ith r
educ
tion
$ 34
$ 50
Cla
vicl
e, o
pen
redu
ctio
n86
125
Hum
erus
, sha
ft w
ith r
educ
tion
7210
4H
umer
us, o
pen
redu
ctio
n12
61
Wris
t (C
ones
) w
ith r
educ
tion
51jig
Fem
uren
eck,
with
red
uctio
n10
315
0P
atel
la, o
pen
redu
ctio
n10
315
0A
nkle
, Pot
ts, w
ith r
educ
tion
"
7410
8A
nkle
, Pot
ts, o
pen
redu
ctio
n
el V
AC
AT
ION
S:
132
192
Hip
, clo
sed
redu
ctio
n72
104
Hip
, ope
n re
duct
ion
160
234
Sho
ulde
r, c
lose
d re
duct
ion
3450
Shq
ulde
r, o
pen
redu
ctio
n12
918
8
OP
ER
AT
ION
S:
Exc
isio
n of
sem
iluna
r ca
rtila
ge o
f kne
e11
717
1P
last
ic r
econ
stru
ctio
n of
join
t, w
ith o
rw
ithou
t gra
ft-hi
p .
243
354
Elb
ow17
22_
50
AM
PU
TA
TIO
NS
:S
houl
der
172
250
Arm
8612
5F
orea
rm86
125
Fin
ger
3450
B. S
CH
ED
ULE
OF
ALL
OW
AN
CE
S F
OR
SU
RG
ICA
LA
SS
IST
AN
TS
:
Whe
n a
licen
sed
phys
icia
n as
sist
s a
surg
eon
durin
g an
oper
atio
n fo
r w
hich
the
"Sch
edul
e of
Allo
wan
ces
for
Sur
gery
" pr
ovid
es a
fee
of $
50 o
r m
ore
unde
rP
lan
A o
r$7
5 or
mor
e un
der
Pla
n E
l, th
en:
1. If
the
serv
ices
of a
n as
sist
ing
surg
eon
are
nece
ssar
yan
d,
2. If
the
assi
stin
g su
rgeo
n is
a p
hysi
cian
eng
aged
inpr
ivat
e pr
actic
e_an
d is
not
an
empl
oyee
of th
e H
ospi
tal,
this
Con
trac
t sha
ll pr
ovid
e an
allo
wan
ce fo
r su
chas
sist
-in
g su
rgeo
n eq
ual t
o 15
% o
f the
sur
gica
lfee
allo
wan
ce.
Min
imum
pay
men
t und
er "
Ian
A to
be
$10,
and
unde
rP
lan
fi $1
5.
C. S
CH
ED
ULE
OF
ALL
OW
AN
CE
S F
OR
AN
ES
TH
ES
IA:
1. B
enef
its fo
r an
esth
esia
ser
vice
will
be
prov
ided
whe
nad
min
iste
red
by a
lice
nsed
phy
sici
an im
aged
in p
rivat
epr
actic
e ot
her
than
the
oper
atin
g su
rgeo
n or
his
assi
stan
t.
2. A
nest
hesi
a se
rvic
es in
clud
e al
l oth
er s
ervi
ces
con-
curr
ently
ren
dere
d by
the
anes
thet
ist d
urin
g th
e pe
riod
of a
nest
hesi
a.
3. T
here
is n
o an
esth
esia
allo
wan
ce in
con
nect
ion
with
obst
etric
al v
agin
al d
eliv
ery.
4. A
llow
ance
s fo
r an
esth
esia
ser
vice
sha
ll be
Wis
ed o
n20
% o
f the
sur
gica
l alio
wan
ce w
ith a
$13
min
imum
pey
-m
ent u
nder
Pla
n A
and
a $
20 m
inim
um p
aym
ent u
nder
Pla
n B
.
D. S
CH
ED
ULE
OF
ALL
OW
AN
CE
S F
OR
DIA
GN
OS
TIC
PR
OC
ED
UR
ES
:
1. D
iagn
ostic
Pro
cedu
res
(D.P
.) w
hen
perf
orm
ed m
inde
-pe
nden
t pro
cedu
res
(LP
.) a
nd w
hen
eim
igna
ted
in th
e"S
ched
ule
of A
llmva
nces
for
Sur
aery
" as
dia
gnoe
t,c,
are
paya
ble
in a
dditi
on to
the
surg
ical
max
imum
s of
;277
und
er P
lan
A a
nd $
404
unde
r P
lan
O.
2. E
xcep
ting
Par
agra
ph 2
, Sub
sect
ion
A o
f PA
RT
VIII
,al
l oth
er p
rovi
sion
s of
PA
RT
VIII
app
ly to
the
Sch
edul
e of
Allo
wan
ces
for
Dia
gnos
tic P
roce
dure
s.
(Abr
idge
d S
ched
ule)
PLA
N A
PLA
N IB
Bio
psy
of b
reas
t$
29$
42B
ronc
hosc
opy,
dia
gnos
tic40
58R
ight
hea
rt c
athe
teriz
atio
n43
63B
iops
y af
mou
th9
13
Eso
phag
osco
py, d
iagn
ostic
4058
Gas
tros
copy
, dia
gnos
tic40
58C
ysto
scop
y, d
iagn
ostic
, ini
tial
1725
Enc
epha
logr
aphy
Ven
tric
ulog
raph
y37 60
54 811
E. S
CH
ED
ULE
OF
ALL
OW
AN
CE
S F
OR
OR
AL
SU
RG
ER
Yk
1. A
ll pr
ovis
ions
for
surg
ery
as c
onta
ined
in P
AR
TV
III,
Sub
sect
ion
A a
pply
to th
e S
ched
ule
of A
llow
ance
s fo
rO
ral S
urge
ry.
2. T
he P
lan
will
not
mak
e pa
ymen
t for
gen
eral
den
tal
serv
ices
suc
h as
rou
tine
extr
actio
ns, (
incl
udin
g fu
llm
outh
ext
ract
ions
) pr
osth
esis
, ort
hodo
ntia
, ope
rativ
ere
stor
atio
ns, f
illin
gs, m
edic
al o
r su
rgic
al tr
eelm
ent o
fde
ntal
car
ies
or g
ingi
vitis
, or
any
dent
istr
y ot
her.
than
prov
ided
in th
e S
ched
ule
of A
llow
ance
s fo
r O
ral S
urge
ry.
(Abr
idge
d S
ched
ule)
PLA
N A
PLA
N S
Dra
inag
e of
alv
eola
r ab
sces
s$
9$
13S
urgi
cal r
emov
al o
f par
tially
impa
cted
man
dibu
lar
toot
h34
SO
Sur
gica
l rem
oval
of C
ompl
etel
y im
-pa
cted
man
dibu
lar
toot
h40
58D
enta
l Roo
t Res
ectio
n20
29S
urgi
cal E
xcis
ion
of im
pact
ed m
axil-
lary
toot
h23
33E
xcis
ion
of M
andi
bula
r to
ri40
58
F S
CH
ED
ULE
OF
ALL
OW
AN
CE
S F
OR
IN-H
OS
PIT
AL
ME
DIC
AL
CA
RE
:
Thi
s in
dem
nity
, in
the
form
of a
cas
h al
iow
ance
, win
be
mad
e fo
r m
edic
al s
ervi
ces
rend
ered
by
a ph
ysic
ian
to a
subs
crib
er, o
nly
whi
le a
bed
pat
ient
in a
nos
pita
i Tor
trea
tmen
t of a
n ac
ute
illne
ss o
r in
jury
sub
ject
to th
efo
llow
ing!
:1.
No
surg
ical
ser
vice
s ar
e pe
rfor
med
dur
ing
the
sam
eco
ntin
uous
per
iod
of d
isab
ility
, exc
ept a
s pr
ovid
ed u
nder
"Con
curr
ent C
are"
.
2. A
ny a
dmis
sion
to th
e sa
me
or a
ny o
ther
hos
pita
l for
the
sam
e or
rel
ated
cau
se, o
ccur
ring
with
in 9
0 da
ys o
fth
e da
te o
f dis
char
ge o
f a p
revi
ous
adm
issi
on fo
r su
chca
use,
sha
ll be
con
side
red
to b
e th
e sa
me
adm
issi
on.
3. In
com
putin
g th
e nu
mbe
r of
day
s el
igib
le fo
r pa
y-m
ent,
the
day
of a
dmis
sion
sha
ll be
cou
nted
but
not
the
day
of d
isch
arge
.A
slow
ance
s In
A G
ener
al H
ospi
tal:
A s
ubsc
riber
who
is a
bed
pat
ient
in a
hos
pita
l cla
ssifi
edas
a G
ener
al H
ospi
tal b
y th
e A
mer
ican
Hos
pita
l Ass
ocia
-tio
n, a
ndlo
r ac
cept
able
as
such
to th
e C
orpo
ratio
n sh
all
be e
ntitl
ed to
a p
aym
ent a
s fo
llms:
Pla
n A
- $
4 pe
r da
y fo
r 70
day
s up
to a
max
imum
of
$280
for
any
one
hosp
ital a
dmis
sion
.P
lan
S -
$5
per
day
for
the
first
14
days
and
$4
per
day
for
the
next
84
days
, for
a m
axim
um p
aym
ent o
f $40
6fo
r an
y on
e ho
spita
l adm
issi
on.
Allo
wan
ces
In A
ny O
ther
Hos
pita
l:
A s
ubsc
riber
who
is a
bed
pat
ient
in a
ny O
ther
Hos
pita
lsh
all b
e en
title
d to
a p
aym
ent a
s fo
llow
s:
Pla
n A
- $
4 pe
r da
y fo
r a
max
imum
of 4
5day
s in
the
aggr
egat
e in
eac
h ca
lend
ar y
ear.
Pla
n Il
- $5
per
day
for
first
14
days
and
$4
per
day
from
the
15th
day
thro
ugh
the
45th
day
for
a m
axim
umof
45
days
in th
e ag
greg
ate
in e
ach
cale
ndar
yea
r.
Allo
wan
ces
for
In-H
ospi
tal M
edic
al C
are
in a
Gen
eral
or O
ther
Hos
pita
l will
be
as s
tate
d ab
ove
or s
uch
othe
ram
ount
as
show
n on
the
mem
bers
hip
card
.
All
char
ges
for
phys
icia
ns' m
edic
al s
ervi
ces
whi
ch e
x-ce
ed th
e ca
sh a
llow
ance
sha
ll be
the
oblig
atio
n of
the
subs
crib
er a
nd n
ot th
e C
orpo
ratio
n.In
-Hos
pita
l Con
curr
ent C
are:
Ben
efits
for
In-H
ospi
tal
Med
ical
Car
e sh
all n
ot b
e pr
ovid
ed in
con
junc
tion
with
any
hosp
italiz
atio
n in
volv
ing
surg
ical
or
obst
etric
al c
are
exce
pt a
s fo
llow
s:1.
Whe
rein
the
sam
e co
nditi
on, d
isea
se o
r ai
lmen
t (ot
her
than
mat
erni
ty)
is tr
eate
d m
edic
ally
for
a pe
riod
of ti
me
prio
r to
sur
gica
l tre
atm
ent b
y ot
her
than
the
surg
eon,
allo
wan
ces
may
be
mad
e up
to b
ut n
ot in
clud
ing
the
day
of s
urge
ry,
2. If
(be
caus
e of
the
nece
ssity
of s
uppl
emen
tary
ski
lls)
two
licen
sed
phys
icia
ns c
oncu
rren
tly tr
eat a
dis
tinct
and
seoa
rate
con
ditio
n, d
isea
se, o
r ai
lmen
t, on
e ph
ysic
ian
rend
erin
g m
eolO
ill c
are
ma
tWi o
tner
pny
sici
an s
urgi
cal
care
, allo
wan
cei m
ay b
e m
ade
for
the
med
ical
car
eup
on th
e ph
ysic
ian'
s w
ritte
n re
port
exp
lain
ing
such
serv
ices
.
The
Cor
pora
tion
will
not
pay
for
In-H
ospi
tal M
edic
alC
are
whi
ch c
ould
be
cons
ider
ed r
outin
e pr
e or
pos
t-op
erat
ive
care
; or
for
such
ser
vice
s as
det
erm
inin
g po
st-
oper
ativ
e flu
id o
r el
ectr
olyt
e ba
lanc
e, o
bser
vatio
n or
reas
sura
nce
of th
e pa
tient
, or
stan
d-by
ser
vice
s su
ch a
ssu
perv
isio
n of
mai
nten
ance
ther
apy
for
a ch
roni
c di
seas
ew
hich
is n
ot in
fact
agg
rava
ted
by th
e pe
rfor
man
ce o
fsu
rge
ry.
G. S
CH
ED
ULE
OF
IND
EM
NIT
Y A
LLO
WA
NC
ES
FO
R X
-RA
Y:
1. P
aym
ent w
ill b
e m
ade
unde
r P
lan
A a
nd P
lan
Bac
cord
ing
to th
e S
ched
ule
of A
llow
ance
s fo
r D
iagn
ostic
X-r
ay, o
r in
suc
h ot
her
amou
nt a
s m
ay b
e sh
own
on th
esu
bscr
iber
's m
embe
rshi
p ca
rd, a
s an
allo
wan
ce to
war
d_t
he to
tal c
harg
es fo
r X
-ray
s.2.
All
char
ges
for
X-r
ays
whi
ch e
xcee
d th
e al
low
ance
ssh
all b
e th
e ob
ligat
ion
of th
e su
bscr
iber
and
not
the
Cor
pora
tion.
3. N
o al
low
ance
s w
ill b
e m
ade
for
X-r
ay o
r ra
dium
ther
apy,
X-r
ay in
con
nect
ion
with
rou
tine
proc
edur
es o
nad
mis
sion
to a
hos
pita
l, X
-ray
s as
par
t of a
rou
tine
phys
ical
exa
min
atio
n, fl
uoro
scop
ic s
ervi
ces,
scr
eeni
ngm
inia
ture
film
s, o
r de
ntal
X-r
ays
(exc
ept i
n ca
se o
ftr
aum
atic
inju
ry).
(Abr
idge
d S
ched
ule)
PLA
N A
PLA
N B
Sku
ll$7
.50
$7.5
0M
andi
ble
7.50
7.50
Che
st, P
A &
late
ral
6.00
6.00
Pel
vis,
bot
h hi
ps5.
005.
00S
pine
, com
plet
e17
.50
17.5
0S
pine
, tho
raci
c6.
006.
00C
lavi
cle
5.00
5.00
Wris
t2.
502.
50T
oe2.
502.
50B
ariu
m e
nem
a, w
/con
tras
t12
.50
12.5
0G
.I. S
erie
s, c
ompl
ete
27.5
027
.50
Cys
togr
aphy
10.0
010
.00
H. S
CH
ED
ULE
OF
IND
EM
NIT
Y A
LLO
WA
NC
ES
FO
R M
AT
ER
NIT
Y:
1. A
cas
h al
low
ance
of $
60 u
nder
Pla
n A
, or
$75
unde
rP
lan
B, o
r su
ch a
mou
nt a
s m
ay b
e sh
oow
n on
the
sub-
scrib
er's
mem
bers
hip
card
, will
be
prov
ided
tow
ard
the
serv
ices
of a
ll ph
ysic
ians
, inc
ludi
ng a
phy
sici
an a
nes-
thet
ist,
in c
onne
ctio
n w
ith e
ach
vagi
nal o
bste
tric
alde
liver
y.
2. A
ll ch
arge
s fo
r se
rvic
es r
ende
red
by a
phy
sici
an fo
rpe
ri-na
tal c
are,
and
for
deliv
ery
that
exc
eeds
the
max
i-m
um to
tal h
erei
n sp
ecifi
ed s
hall
be th
e ob
ligat
ion
of th
esu
bscr
iber
and
not
the
Cor
pora
tion.
3. M
ater
nity
cas
es r
equi
ring
addi
tiona
l sur
gica
l pro
ce-
dure
s, s
uch
as C
aesa
rean
Sec
tion,
sha
ll be
ent
itled
toth
e al
low
ance
in th
e "S
ched
ule
of A
llow
ance
s fo
tS
urge
ry"
I. sC
HE
OU
LE O
F IN
DE
MN
ITY
ALL
OW
AN
CE
S.
FO
R E
LEC
TR
OC
AR
DIO
GR
AM
S:
1. A
cas
h al
low
ance
of $
10 w
ill b
e m
ade
unde
r P
lan
Aor
Pla
n B
for
each
ele
ctro
card
iogr
am w
hen
rend
ered
toa
subs
crib
er w
hile
a b
ed p
atie
nt in
a h
ospi
tal a
fter
the
first
one
in e
ach
hosp
ital a
dmis
sion
, the
tota
l pay
men
tfo
r ea
ch a
dmis
sion
not
to e
xcee
d $5
0 or
suc
h ot
her
amou
nt a
s m
ay b
e sh
own
on th
e su
bscr
iber
's m
embe
r-sh
ip c
ard.
2. a
ny a
dmis
sion
to th
e sa
me
or a
ny o
ther
hos
pita
l for
the
sam
e or
rel
ated
cau
se o
ccur
ring
with
in 9
0 da
ys o
fth
e da
te o
f dis
char
ge o
f a p
revi
ous
adm
issi
on fo
r su
chca
use
shal
l be
cons
ider
ed to
be
the
sam
e ad
mis
sion
.
3- A
ll ch
arge
s w
hich
exc
eed
the
allo
wan
ce s
hall
be th
eoh
ligat
iOn
of th
e su
bscr
iber
and
not
the
Cor
pora
tion.
TH
E M
AT
ER
IAL
BE
LOW
IS F
OR
EX
PLA
NA
TIO
NO
NLY
AN
D IS
NO
T P
AR
T O
F T
HIS
CO
NT
RA
CT
.
Kee
p yo
ur P
hysi
cian
s S
ervi
ce C
ontr
act i
n a
safe
plac
e, a
long
with
you
r ot
her
valu
able
pap
ers.
If yo
u sh
ould
hav
e a
ques
tion
abou
t you
r m
em-
bers
hip,
or
your
ben
efits
, you
mig
ht w
ant t
o re
fer
to th
is c
ontr
act O
r, c
all o
r w
rite
the
Blu
e C
ross
-P
hysi
cian
s S
ervi
ce o
ffice
.O
ur m
ost i
mpo
rtan
t job
is to
pro
vide
you
with
the
very
bes
t ser
vice
pos
sibl
e.
To
Hel
p Y
ou D
eter
min
e Y
our
Ben
efits
To
dete
rmin
e yo
ur P
hysi
cian
s S
ervi
ce b
enef
its,
here
's a
ll yo
u ne
ed d
o.
1.R
efer
to y
our
Mem
bers
hip
Car
t Thi
s sh
ows
whe
ther
you
hav
e P
lan
A o
r P
lan
B, i
ndiv
idua
lor
fam
ily p
lan.
2. T
hen,
rea
d yo
ur c
ontr
act.
Par
ts I
thro
ugh
VII
desc
ribe
the
type
s of
ben
efits
pro
vide
d, th
eco
nditi
ons
of y
our
mem
bers
hip,
and
wha
t is
not c
over
ed.
Par
t VIII
con
tain
s a
cond
ense
d lis
ting
of th
eP
hysi
cian
s S
ervi
ce S
ched
ule
of A
llow
ance
s. A
com
plet
e lis
ting
of th
e su
rgic
al p
roce
dure
s,an
d ot
her
bene
fift,
is a
vaila
ble
at p
hysi
cian
s'of
fices
, at R
hode
Isla
nd P
hysi
cian
s S
ervi
ce,
and
at th
e S
tate
Dep
artm
ent o
f Bus
ines
sR
egul
atio
n.
How
To
Get
You
r B
enef
itsW
hen
you
rece
ive
serv
ices
that
are
cov
ered
by
your
pla
n, s
impl
y sh
ow y
our
mem
bers
hip
card
toth
e do
ctor
. He
will
them
1. A
sk y
ou to
com
plet
e a
port
ion
of th
e cl
aim
form
that
he
will
sen
d to
Phy
sici
ans
Ser
vice
for
paym
ent.
In m
ost c
ases
the
doct
or w
ill b
epa
id d
irect
ly, a
nd a
cop
y of
the
paid
cla
im w
illbe
mai
led
to y
ou.
OR
2. R
eque
st P
aym
ent D
irect
ly F
rom
You
- if
heis
a n
on-p
artic
ipat
ing
doct
or. I
n th
is c
ase,
mer
ely
send
you
r ite
miz
ed b
ill (
that
exp
lain
sth
e se
rvic
e re
nder
ed),
or
the
doct
or's
cla
imfo
rm to
the
Phy
sici
ans
Ser
vice
Cla
ims
Dep
art-
men
t The
bilt
will
be
proc
esse
d, a
nd y
ou w
illbe
pai
d di
rect
ly.
PLE
AS
E G
IVE
YO
UR
ME
MB
ER
SH
IP N
UM
-B
ER
WH
EN
EV
ER
YO
U C
ON
TA
CT
PH
YS
ICIA
NS
SE
RV
ICE
.
Mod
e is
land
Med
ical
Soc
iety
Phy
sici
an S
ervi
ce31
Can
al S
tree
t, P
rovi
denc
e, Ik
eda
Isla
nd 0
2001
Tel
epho
ne 0
31-7
3110
YO
UR
BLU
E C
RO
SS
PH
YS
ICIA
NS
SE
RV
ICE
SU
PP
LEM
EN
TA
L
CO
NT
RA
CT
FO
R
MA
JOR
ME
DIC
AL
BE
NE
FIT
S
Issu
ed J
oint
ly B
y
HO
SP
ITA
L S
ER
VIC
E C
OR
PO
RA
TIO
N
OF
RH
OD
E IS
LAN
D
RH
OD
E IS
LAN
D M
ED
ICA
L S
OC
IET
Y
PH
YS
ICIA
NS
SE
RV
ICE
Ser
ies
1 (R
ev. 1
1/1/
64)
Sec
tion
IDef
initi
ons
TE
RM
S A
ND
Whe
n us
ed h
erei
n,
(a)
"Bas
ic C
ontr
acts
" sh
all m
ean
tne
Cor
pora
tions
'C
ontr
acts
and
any
rid
ers
and
endo
rsem
ents
ther
eto,
excl
udin
g th
is r
ider
, iss
ued
by th
e C
orpo
ratio
ns to
the
appl
ican
t.
(b)
The
term
s "A
pplic
ant,"
"S
ubsc
riber
," "
Phy
si-
cian
," a
nd "
Hos
pita
l," s
hall
have
the
sam
e m
eani
ng a
sin
the
Bas
ic C
ontr
acts
.
(c)
"Ret
ired
Sub
scrib
er"
shal
lin
clud
e on
ly a
nap
plic
ant a
nd h
is o
r he
r sp
ouse
, pro
vide
d th
at th
eap
plic
ant i
s a
retir
ed e
mpl
oyee
who
is r
etai
ned
in th
egr
oup
cove
rage
of a
n em
ploy
er b
oth
for
the
Bas
ic C
on-
trac
ts a
nd th
is s
uppl
emen
tal c
ontr
act f
or M
ajor
Med
ical
bene
fits.
A c
hild
of s
uch
a re
tired
sub
scrib
er s
hall
bede
emed
to b
e a
"sub
scrib
er"
for
purp
oses
of t
his
rider
if su
ch c
hild
is a
"su
bscr
iber
" un
der
the
Bas
ic C
ontr
acts
.
(d)
"Em
ploy
er"
mea
ns a
ny in
divi
dual
, firm
, ass
ocia
-tio
n or
cor
pora
tion
whi
ch e
mpl
oyed
the
appl
ican
t (ot
her
than
a r
etire
d su
bscr
iber
app
lican
t) o
n a
full-
time
basi
s(n
ot le
ss th
an 2
0 ho
urs
per
wee
k) a
t the
tim
e th
is r
ider
was
issu
ed a
nd h
as, a
gree
d w
ith th
eC
orpo
ratio
ns, a
sag
ent f
or th
e ap
plic
ant,
incl
udin
g re
tired
sub
scrib
ers,
to p
ay o
r co
llect
and
rem
it to
the
Cor
pora
tions
the
sub-
scrip
tion
char
ges
paya
ble
here
unde
r.(e
) "C
over
ed M
edic
al E
xpen
ses"
mea
ns th
e re
ason
-ab
le a
nd c
usto
mar
y ch
arge
s fo
r ne
cess
ary
serv
ices
and
supp
lies
of th
e ty
pes
liste
d be
low
in th
is p
arag
raph
I(e
), fo
r an
illn
ess,
inju
ry, o
r bo
dily
mal
func
tion,
whe
nre
nder
ed, p
resc
ribed
or
orde
red
for
a su
bscr
iber
or
are
tired
sub
scrib
er b
y a
phys
icia
n, to
the
exte
nt th
at s
uch
char
ges
are
with
in th
e lim
its h
erei
nafte
r se
t for
th a
ndar
e no
t cov
ered
by
Bas
ic C
ontr
acts
or
spec
ifica
lly e
x-cl
uded
und
er S
ectio
n V
bel
ow; s
uch
serv
ices
and
sup
-pl
ies
rend
ered
, pre
scrib
ed o
r or
dere
d fo
r a
subs
crib
eror
a r
etire
d su
bscr
iber
in a
n em
erge
ncy
whe
n a
phys
i-ci
an is
not
ava
ilabl
e w
ill a
lso
be tr
eate
d as
cov
ered
med
ical
exp
ense
s if
they
are
suc
h as
mig
ht r
easo
nabl
yha
ve b
een
rend
ered
, pre
scrib
ed o
r or
dere
d by
a p
hysi
-ci
anif
avai
labl
e. T
he C
orpo
ratio
ns w
ill d
eter
min
ew
heth
er a
cha
rge
is r
easo
nabl
e an
d cu
stom
ary
by c
om-
parin
g it
with
cha
rges
mad
e fo
r si
mila
r se
rvic
es o
r su
p-pl
ies
prov
ided
und
er s
imila
r co
nditi
ons
to p
erso
ns u
nder
like
circ
umst
ance
s an
d th
e de
term
inat
ion
of th
e C
orpo
-ra
tions
sha
ll.be
fina
l. A
s to
sur
gica
l or
anes
thes
ia s
erv-
,ic
es, t
he te
rm."
reas
onab
le a
rid c
usto
mar
y ch
arge
s" s
hall,
if su
ch s
ubsc
riber
or
retir
ed s
ubsc
riber
is c
over
ed b
yan
d el
igib
le fo
r se
rvic
e be
nefit
s of
a P
lan
A o
i Pla
n B
Phy
sici
ans
Ser
vice
con
trac
t, m
ean
an a
mou
nt n
ot in
CO
ND
ITIO
NS
exce
ss o
f the
am
ount
pro
vide
d in
the
Mas
ter
Sch
edul
eof
Inde
mni
ties
of th
e P
lan
appl
icab
le to
suc
h su
bscr
iber
or r
etire
d su
bscr
iber
whe
ther
suc
h se
rvic
es a
re r
ende
red
by a
par
ticip
atin
g or
non
-par
ticip
atin
g ph
ysic
ian.
The
follo
win
g se
rvic
es a
nd s
uppl
ies,
if w
ithin
the
term
s of
the
first
sen
tenc
e of
this
par
agra
ph I
(e)
are
cove
red
med
ical
exp
ense
s, w
heth
er p
rovi
ded
in o
r ou
t of a
hosp
ital:
:1)
Phy
sici
ans'
ser
vice
s, in
clud
ing
but n
ot li
mite
dto
sur
gery
, con
sulta
tions
and
hom
e, o
ffice
and
hosp
ital v
isits
.
(2)
Rou
tine
and
spec
ial h
ospi
tal s
ervi
ces
in fu
ll if
in w
ard
or s
emi-p
rivat
e ac
com
mod
atio
ns, a
nd if
in a
priv
ate
room
, the
n in
full
exce
pt fo
r so
muc
hof
the
hosp
ital's
cha
rge
for
priv
ate
room
and
boar
d as
is in
exc
ess
of ;2
8 pe
r da
y (o
r su
chot
her
amou
nt a
s m
ay b
e sh
own
on th
e m
embe
r-sh
ip c
ard)
; als
o in
clud
ed a
re a
ll sp
ecia
l cha
rges
for
serv
ices
whi
le a
pat
ient
in a
n In
tens
ive
Car
eun
it of
a h
ospi
tal.
(3)
Ane
sthe
tics
and
thei
r ad
min
istr
atio
n.
(4)
Oxy
gen
and
the
rent
al o
r pu
rcha
se, w
hich
ever
cost
s le
ss, o
f equ
ipm
ent f
or it
s ad
min
istr
atio
n.
(5)
Cro
ss m
atch
ing,
gro
upin
g an
d ty
ping
, pro
cess
-in
g an
d ad
min
istr
atio
n fe
es a
ssoc
iate
d w
ithbl
ood
tran
sfus
ions
; blo
od p
lasm
a an
d bl
ood
prod
ucts
, sub
ject
te th
e ex
clus
ion
prov
ided
inS
ectio
n V
(16
).
(6)
Rad
iatio
n th
erap
y.
(7)
Dia
gnos
tic e
xam
inat
ions
, inc
ludi
ng x
-ray
s, la
bo-
rato
ry,
basa
lm
etab
olis
m, e
lect
roca
rdio
gram
,el
ectr
oenc
epha
logr
am a
nd r
adio
isot
ope.
(8)
Pro
fess
iona
l am
bula
nce
serv
ice
loca
lly to
or
from
a h
ospi
tal f
or in
-pat
ient
s, o
r fo
r ou
t-pa
tient
s re
ceiv
ing
acci
dent
car
e.
(9)
Phy
sica
l the
rapy
ren
dere
d by
a q
ualif
ied
pro-
fess
iona
l phy
sica
l the
rapi
st.
(10)
Ort
hope
dic
brac
es (
exce
pt c
orre
ctiv
e sh
oes)
,cr
utch
es, a
nd p
rost
hetic
app
lianc
es s
uch
asar
tific
ial l
imbs
end
ers,
incl
udirl
gthe
ir re
plac
tm
ent,
repa
ir, o
r ad
just
men
t, su
bjec
t tu
excl
ufsi
ons
liste
d in
Sec
tion
V h
ereo
f.
(11)
Ren
tal o
r pu
rcha
se, w
hich
ever
cos
ts le
ss, o
fw
heel
chai
r an
d ot
her
dura
ble
equi
pmen
t use
dfo
r m
edic
al tr
eatm
ent e
xclu
sive
ly.
(12)
Dru
gs a
nd m
edic
ines
whi
ch b
y la
w r
equi
re a
writ
ten
pres
crip
tion.
(13)
Ser
vice
s of
priv
ate
duty
nur
ses
as fo
llow
s: In
aho
spita
lser
vice
s of
a r
egis
tere
d nu
rse
or a
licen
sed
prac
tical
nur
se. O
utsi
de a
hos
pita
lse
rvic
es o
f a r
egis
tere
d nu
rse,
or
of a
lice
nsed
prac
tical
nur
se u
pon
writ
ten
cert
ifica
tion
by th
eat
tend
ing
phys
icia
n th
at th
e se
rvic
es o
f a r
egis
-te
red
nurs
e w
ere
nece
ssar
y bu
t uno
btai
nabl
e.
(14)
Den
tal s
ervi
ces
liste
d un
der
Mas
ter
Sch
edul
e of
Inde
mni
ties
of th
e P
hysi
cian
s S
ervi
ce C
ontr
act
and
othe
r de
ntal
ser
vice
s, s
uppl
ies,
and
app
li-an
ces
requ
ired
as a
res
ult o
f acc
iden
tal i
njur
yto
nat
ural
teet
h an
d/or
faci
al fr
actu
res
occu
r-rin
g w
hile
the
subs
crib
er o
r re
tired
sub
scrib
eris
cov
ered
und
er th
is r
ider
.
Cov
ered
Med
ical
Exp
ense
s sh
all b
e de
emed
to b
ein
curr
ed a
s of
the
date
the
serv
ice
is r
ende
red
or th
esu
pplie
s fu
rnis
hed.
(f)
"Ben
efit
Per
iod"
with
res
pect
to a
sub
scrib
er o
rre
tired
sub
scrib
er m
eans
a p
erio
d of
twel
ve (
12)
con-
secu
tive
mon
ths,
the
first
suc
h pe
riod
com
men
cing
On
the
first
day
occ
urrin
g af
ter
the
effe
ctiv
e da
te o
f thi
irid
er o
n w
hich
a c
harg
e is
incu
rred
for
serv
ices
or
sup-
plie
s of
the
type
list
ed a
s C
over
ed M
edic
al E
xpen
ses
unde
r th
e im
med
iate
ly p
rece
ding
sub
sect
ion
(e)
of th
isS
ectio
n I,
even
thou
gh s
uch
char
ge is
cov
ered
in w
hole
or in
par
t by
the
Bas
ic C
ontr
acts
. The
sec
ond
and
sub-
sequ
ent b
enef
it pe
riods
sha
ll co
mm
ence
on
the
first
day
on w
hich
suc
h a
char
ge is
incu
rred
afte
r th
e te
rmin
atio
nof
the
prec
edin
g be
nefit
per
iod.
The
dat
e on
whi
ch s
erv-
ices
or
supp
lies
wer
e fu
rnis
hed
shal
l gov
ern
rath
er th
anth
e da
te o
f bill
ing
ther
efor
.
Sec
tion
II B
enef
its P
rovi
ded
(a)
If a
subs
crib
er o
r re
tired
sub
scrib
er, w
hile
cov
-er
ed h
ereu
nder
sha
ll in
cur,
dur
ing
any
Ben
efit
Per
iod,
Cov
ered
Med
ical
Exp
ense
s in
exc
ess
of
(1)
the
bene
fits,
if a
ny, c
over
ed u
nder
the
Bas
icC
ontr
acts
, plu
s(2
) th
e D
educ
tible
Am
ount
, if a
ny, a
pplic
able
to th
eB
asic
Con
trac
ts, p
lus
(3)
the
Ded
uctib
le A
mou
nt a
pplic
able
to th
is r
ider
(see
Sec
ticn
III h
ereo
f),
such
sub
scrib
er o
r re
tired
sub
scrib
er s
hall
been
title
d to
cre
dits
from
the
Cor
pora
tions
equ
alto
eig
hty
per
cent
(80
%)
of th
e em
ount
of s
uch
exce
ss e
xpen
ses,
or
such
oth
er p
erce
ntag
e as
may
be
show
n on
the
mem
bers
hip
card
, exc
ept
that
for
Cov
ered
Med
ical
Exp
ense
s in
curr
ed in
conn
ectio
n w
ith th
e ne
cess
ary
care
and
trea
t-m
ent o
f men
tal d
isor
ders
pro
vide
d in
the
out-
patie
nt d
epar
tmen
t of a
hos
pita
l or
outs
ide
a
hosp
ital,
such
sub
scrib
er o
r re
tired
sub
scrib
ersh
all b
e en
title
d to
cre
dits
from
the
Cor
pora
-tio
ns e
qual
to fi
fty p
er c
ent (
50%
) of
suc
hex
cess
exp
ense
s in
eith
er c
ase
subj
ect t
o al
lot
her
term
s an
d co
nditi
ons
of th
is r
ider
.
(b)
For
eac
h su
bscr
iber
, oth
er th
an a
ret
ired
sub-
scrib
er (
see
Sec
tion
11 (
c) b
elow
), th
e m
axim
um c
redi
tsfo
r be
nefit
s fr
om th
e C
orpo
ratio
ns u
nder
this
rid
er d
ur-
ing
any
Ben
efit
Per
iod
shal
l be
Ten
Tho
usan
d D
olla
rs($
10,0
00.0
0), o
r su
ch o
ther
am
ount
as
may
be
show
non
the
mem
bers
hip
card
, and
the
max
imum
cre
dits
for
bene
fits
from
the
Cor
pora
tions
dur
ing
the
entir
e tim
esu
ch s
ubsc
riber
is c
over
ed u
nder
this
rid
er s
hall
beT
wen
ty T
hous
and
Dol
lars
($2
0,00
0.00
) or
suc
h ot
her
amou
nt a
s m
ay b
e sh
own
on th
e m
embe
rshi
p ca
rd,
subj
ect,
how
ever
, to
Sec
tion
11 (
e) b
elow
.
(c)
For
eac
h re
tired
sub
scrib
er, t
he m
axim
um c
redi
tsfo
r be
nefit
s fr
om th
e C
orpo
ratio
ns u
nder
this
rid
er d
ur-
ing
any
Ben
efit
ftrio
d sh
all b
e T
wo
Tho
usan
d F
ive
Hun
dred
Dol
lars
($2
,500
.00)
or
such
oth
er a
mou
nt a
sm
ay b
e sh
own
on th
e m
embe
rshi
p ca
rd, a
nd th
e m
axi-
mum
cre
dits
for
bene
fits
from
the
Cor
pora
tions
dur
ing
the
entir
e tim
e su
ch r
etire
d su
bscr
iber
is c
over
ed u
nder
this
rid
er a
s a
retir
ed s
ubsc
riber
sha
ll be
Fiv
e T
hous
and
Dol
lars
($5
,000
.00)
or
such
oth
er a
mou
nt a
s m
ay b
esh
own
on th
e m
embe
rshi
p ca
rd.
(d)
A s
ubsc
riber
who
, dur
ing
a be
nefit
per
iod,
has
incu
rred
exp
ense
s in
exc
ess
of th
e ap
plic
able
Ded
uct-
ible
Am
ount
bef
ore
beco
min
g a
retir
ed S
ubsc
riber
sha
ll,fo
r th
e ba
lanc
e of
that
Ben
efit
Per
iod,
be
elig
ible
to.
rece
ive
the
max
imum
cre
dits
of a
"S
ubsc
riber
," a
nd in
subs
eque
nt B
enef
it P
erio
ds w
ill b
e el
igib
le to
rec
eive
cred
its a
s a
"Ret
ired
Sub
scrib
er"
but i
n no
eve
nt w
illbe
elig
ible
to r
ecei
ve to
tal b
enef
it pa
ymen
ts in
exc
ess
of th
e "s
ubsc
riber
" m
axim
um c
redi
t A s
ubsc
riber
tota
llydi
sabl
ed b
efor
e be
com
ing
a re
tired
sub
scrib
er s
hall
beel
igib
le to
rec
eive
the
cred
its o
f a "
tota
lly d
isab
led
sub-
scrib
er"
as s
tate
d in
Sec
tion
VI (
e) (
2) o
f thi
s rid
er.
(e)
If at
any
tim
e, a
sub
scrib
er, o
ther
than
a r
e-tir
ed s
ubsc
riber
, sha
ll ha
ve b
ecom
e en
title
d to
cre
dits
for
bene
fits
tota
ling
at le
ast T
wo
Tho
usan
d D
olla
rs($
2,00
0.00
) un
der
this
rid
er, t
he m
axim
um li
abili
ty o
fth
e C
orpo
ratio
ns, w
ith r
espe
ct to
suc
h su
bscr
iber
dur
-in
g su
ch s
ubse
quen
t tim
e as
suc
h su
bscr
iber
may
be
cove
red
unde
r th
is r
ider
, may
be
rest
ored
to th
e ad
di-
tiona
l am
ount
of T
wen
ty T
hous
and
Dol
lars
($2
0,00
0.00
),or
suc
h ot
her
amou
nt a
s m
ay b
e sh
own
on th
e m
embe
r-sh
ip c
ard,
upo
n re
ceip
t by
the
Cor
pora
tions
of e
vide
nce
of s
uch
subs
crih
er's
insu
rabi
lity
reas
onab
ly s
atis
fact
ory
to a
nd a
ppro
ved
by th
e C
orpo
ratio
ns. A
ny s
uch
evid
ence
of in
sura
bilit
y m
ust b
e fu
rnis
hed
with
out e
xpen
se to
the
Cor
pora
tions
. The
Cor
pora
tions
res
erve
the
right
to
exam
ine
such
sub
scrib
er b
y th
eir
own
phys
icia
n at
thei
row
n ex
pens
e.
(f)
It is
inte
nded
that
eac
h su
bscr
iber
or
retir
edsu
bscr
iber
sha
ll be
ent
itled
to b
enef
its fr
om th
e C
orpo
-ra
tions
und
er o
nly
one
maj
or m
edic
al b
enef
it ex
pens
erid
er d
urin
g hi
s or
her
life
time,
sub
ject
to a
djus
tmen
tas
pro
vide
d in
Sec
tion
VII
(f)
here
of in
the
case
ofte
rmin
atio
n of
cov
erag
e un
der
one
empl
oyer
and
re-
sum
ptio
n of
cov
erag
e un
der
anot
her.
A s
ubsc
riber
or
retir
ed s
ubsc
riber
who
wou
ld b
e en
title
d to
ben
efits
unde
r m
ore
than
one
maj
or m
edic
al b
enef
it ex
pens
erid
er o
f the
Cor
pora
tions
but
for
this
Sec
tion
11(f
)m
ay e
lect
aga
inst
whi
ch o
ne o
f the
rid
ers
hew
ishe
sth
e be
nefit
s to
be
char
ged,
and
if h
is c
over
age
unde
ron
e of
the
rider
s is
term
inat
ed, h
e m
ayco
ntin
ue to
char
ge b
enef
its a
gain
st th
e ot
her,
but
the
aggr
egat
e of
bene
fits
shal
l not
exc
eed
the
tota
l of m
axim
um b
enef
itsfo
r ea
ch B
enef
it P
erio
d an
d ot
her
max
imum
ben
efits
set
fort
h in
any
one
suc
h rid
er. I
f the
sub
scrib
er o
r re
tired
subs
crib
er is
ent
itled
to b
enef
its u
nder
this
rid
er a
ndun
der
any
othe
r pl
an o
r co
ntra
ct o
f ins
uran
ce o
r pr
e-pa
ymen
t of m
edic
al e
xpen
ses
othe
r th
an th
e ba
sic
con-
trac
ts, t
he C
orpo
ratio
ns s
hall
be li
able
on
a pr
o ra
taba
sis
only
, to
prov
ide
cred
its o
nly
for
such
pro
port
ion
of th
e ch
arge
s fo
r su
ch b
enef
its a
s th
e to
tal o
f cre
dits
unde
r th
is r
ider
bea
rs to
the
tota
l of c
redi
ts-a
nd p
ay-
men
ts fo
r su
ch b
enef
its s
peci
fied
unde
r th
is r
ider
and
all o
ther
cov
erag
es.
Sec
tion
IIID
educ
tible
Am
ount
The
ded
uctib
le a
mou
nt a
pplic
able
to th
is r
ider
sha
llbe
One
Hun
dred
Dol
lars
($1
00.0
0), o
r su
ch o
ther
am
ount
as m
ay b
e sh
own
on th
e m
embe
rshi
pca
rd, o
f cov
ered
Med
ical
Exp
ense
s fo
r ea
ch s
ubsc
riber
or
retir
ed s
ub-
scrib
er w
hich
am
ount
sha
ll be
app
lied
once
in e
ach
bene
fit p
erio
d. If
a c
omm
on a
ccid
ent o
ccur
s to
two
orm
ore
subs
crib
ers
or r
etire
dsu
bscr
iber
s co
vere
d by
the
sam
e fa
mily
con
trac
t, a
sing
lede
duct
ible
am
ount
sha
llbe
app
licab
le to
the
Cov
ered
Med
ical
Exp
ense
s of
such
subs
crib
ers
attr
ibut
able
to s
uch
acci
dent
Sec
tion
IV W
aitin
g P
erio
d
As
to a
ny c
ondi
tion,
dis
ease
, or
inju
ry w
hich
exi
sted
on o
r be
fore
the
effe
ctiv
e da
te o
f thi
s rid
er, c
over
edm
edic
al e
xpen
ses
shal
l inc
lude
onl
y -s
o m
uch
of th
eex
pens
e fo
r su
ch c
ondi
tion,
dis
ease
, or
inju
ry a
s is
incu
rred
on
acco
unt o
f ser
vice
s or
sup
plie
s re
nder
edor
furn
ishe
d to
the
subs
crib
er o
r re
tired
sub
scrib
er o
nor
afte
r th
e 91
st d
ay s
ucce
edin
g su
ch e
ffect
ive
date
,pr
ovid
ed th
at n
o cr
edits
for
such
exp
ense
s w
ill b
e gi
ven
in th
e ca
se o
f a s
ubsc
riber
or
retir
ed s
ubsc
riber
who
, on
.the
effe
ctiv
e da
te o
f thi
s rid
er, i
s co
nfin
ed in
a h
ospi
tal,
nurs
ing
hom
e, a
t hom
e, o
r el
sew
here
on
acco
unt o
f suc
ha
cond
ition
, dis
ease
, or
inju
ry, u
ntil
a th
irty-
one-
day
perio
d af
ter
such
effe
ctiv
e da
te h
as e
laps
ed in
whi
chth
ere
has
been
no
such
con
finem
ent.
Sec
tion
V E
xclu
sion
s
ofN
o be
nefit
s sh
all b
e pr
ovid
ed h
ereu
nder
on
acco
unt
1.S
ervi
ces
or s
uppl
ies
for
any
occu
patio
nal c
on-
ditio
n, a
ilmen
t or
inju
ry a
risin
g ou
t of a
nd in
the
cour
se o
f gai
nful
em
ploy
men
t, co
nnec
ted
ther
ewith
and
ref
erab
le th
eret
o.
2. S
ervi
ces
or s
uppl
ies
requ
ired
for
obst
etric
alde
liver
y, n
orm
al p
rena
tal a
nd p
ostn
atal
car
e,or
any
con
ditio
n re
late
d to
pre
gnan
cy, (
exce
ptas
to e
xpen
ses
incu
rred
for
Cae
sare
an D
eliv
ery
and
the
follo
win
g C
ompl
icat
ions
of P
regn
ancy
durin
g a
perio
d of
hos
pita
l con
finem
ent o
f asu
bscr
iber
or
retir
ed s
ubsc
riber
who
has
sat
is-
fied
the
wai
ting
perio
d, if
any
, of t
he B
asic
Con
trac
ts, a
nd o
f thi
s rid
er.
Any
pre
gnan
cy te
rmin
atin
g be
fore
exp
ira-
tion
of 2
6 w
eeks
, ect
opic
pre
gnan
cy, m
is-
carr
iage
, or
abor
tion.
Pla
cent
a pr
evia
or
plac
enta
abr
uptio
.
Agg
rava
tion
of a
hea
rt c
ondi
tion
or d
iabe
tes.
Nep
hriti
s or
pye
litis
of p
regn
ancy
.
Hyp
erem
esis
gra
vida
rum
.
Tox
emia
.
Pre
mat
ure
rupt
ure
of m
embr
anes
.)
3. P
hysi
cian
s' v
isits
for
the
rout
ine
care
or
exam
i-na
tion
of a
new
born
chi
ld, p
rior
to h
is o
r he
rbe
com
ing
a su
bscr
iber
und
er th
e B
asic
Con
-tr
acts
.4.
Den
tal s
ervi
ces
othe
r th
an th
ose
spec
ified
inS
ectio
n I (
e) (
14)
abov
e.
5. S
ervi
ces
or s
uppl
ies
requ
ired
for
cosm
etic
pur
-po
ses
unle
ss r
elat
ed to
an
acci
dent
al in
jury
occu
rrin
g w
hile
the
subs
crib
er o
r re
tired
sub
-sc
riber
is c
over
ed u
nder
this
rid
er.
6. E
yegl
asse
s, c
onta
ct le
nses
, hea
ring
aids
, and
exam
inat
ions
and
fitti
ngs
ther
efor
.
7. S
ervi
ces
or s
uppl
ies
rend
ered
or
furn
ishe
d in
ahn
spita
l ope
rate
d by
any
age
ncy
of th
e U
nite
d
Sta
tes
gove
rnm
ent,
or fo
r w
hich
the
subs
crib
eror
ret
ired
subs
crib
er w
ould
be
entit
led
to fu
llor
par
tial b
enef
its u
nder
any
mun
icip
al, s
tate
or fe
dera
l law
, ord
inan
ce o
r re
gula
tion
if th
isrid
er w
ere
not i
n ef
fect
.
8. S
ervi
ces
or s
uppl
ies
for
or c
onne
cted
with
rout
ine
orpe
riodi
cph
ysic
alex
amin
atio
ns,
scre
enin
g ex
amin
atio
ns, i
mm
uniz
atio
n sh
ots,
rem
oval
of c
orns
or
callu
ses,
or
trim
min
g of
toen
ails
.
9. S
ervi
ces
and
supp
lies
for
pers
onal
com
fort
,su
ch a
s ra
dio,
tele
visi
on, t
elep
hone
, new
s-pa
pers
, bea
uty
and
barb
er s
ervi
ces
or s
uppl
ies,
air
cond
ition
ers,
deh
umid
ifier
s, e
tc.,
whe
ther
or
not o
rder
ed b
y a
phys
icia
n.
10. S
ervi
ces
and
supp
lies
requ
ired
as a
res
ult o
fw
ar, d
ecla
red
or u
ndec
lare
d, o
r m
ilita
ry a
ctio
n,oc
curr
ing
afte
r th
e ef
fect
ive
date
of t
his
rider
.
11. T
rave
l, w
heth
er o
r no
t pre
scrib
ed b
y a
phys
icia
n.
12. C
usto
dial
car
e, r
est c
ures
, or
care
in c
onva
les-
cent
or
nurs
ing
hom
es o
r ho
mes
for
the
aged
.
13. S
ervi
ces
and
supp
lies
for
whi
ch th
e su
bscr
iber
or r
etire
d su
bscr
iber
has
no
lega
l obl
igat
ion
topa
y or
for
whi
ch n
o ch
arge
wou
ld b
e m
ade
ifth
is r
ider
wer
e no
t in
effe
ct.
14. S
ervi
ces
of a
priv
ate
duty
nur
se w
ho is
am
embe
r of
the
hous
ehol
d of
the
subs
crib
er o
rre
tired
sub
scrib
er o
r hi
s or
her
spo
use,
par
ent,
child
, bro
ther
or
sist
er b
y bl
ood,
mar
riage
or
adop
tion.
15. S
ervi
ces
and
supp
lies
not m
edic
ally
nec
essa
ryfo
r th
e di
agno
sis
or tr
eatm
ent o
f an
illne
ss,
inju
ry o
r bo
dily
mal
func
tion.
16. W
hole
blo
od, r
ed b
lood
cel
ls, a
nd/o
r re
spon
si-
bilit
y or
pen
alty
fees
of b
lood
ban
ks.
17. S
ervi
ces
or s
uppl
ies
not l
iste
d as
"C
over
edM
edic
al E
xpen
ses"
in S
ectio
nI
(e).
Sec
tion
Vi T
erm
inat
ion
and
Am
endm
ent
Cov
erag
e un
der
this
rid
er s
hall
term
inat
e
(a)
As
to a
ny s
ubsc
riber
or
retir
ed s
ubsc
riber
on
the
date
he
or s
he c
ease
s to
be
such
.
Ben
efits
, Exc
lusi
ons
and
Gen
eral
Con
ditio
ns
(b)
At t
he e
xpira
tion
of th
e 30
th d
ay, i
f a d
efau
lttc
;
shal
l exi
st fo
r th
irty
(30)
day
s in
the
paym
ent o
f the
subs
crip
tion
char
ges
for
this
rid
er.
(c)
On
the
date
to w
hich
sub
scrip
tion
char
ges
have
been
pai
d if
the
appl
ican
t, ot
her
than
a r
etire
d ap
pli-
cant
, cea
ses
to b
e in
the
full
time
empl
oym
ent (
not l
ess
than
20
hour
s pe
r w
eek)
of t
he E
mpl
oyer
who
has
pai
dor
col
lect
ed s
ubsc
riptio
n ch
arge
s pa
yabl
e he
reun
der.
(d)
On
the
date
whe
n to
tal c
redi
ts d
ue fr
om th
eC
orpo
ratio
ns to
the
subs
crib
er o
r re
tired
sub
scrib
er s
hall
equa
l the
max
imum
liab
ility
dur
ing
the
entir
e tim
e of
cove
rage
und
er S
ectio
n II
(b)
or (
c) a
bove
, unl
ess
the
max
imum
is r
esto
red
unde
r S
ectio
n II
(e)
abov
e, b
ut if
the
subs
crib
er o
r re
tired
sub
scrib
er e
xhau
stin
g su
chto
tal
cred
it3is
the
appl
ican
t, co
vera
ge fo
r ot
her
subs
crib
ers
or r
etire
d su
bscr
iber
s lis
ted
on h
is a
ppli-
catio
n, if
any
, may
be
cont
inue
d, s
ubje
ct to
pay
men
tby
the
empl
oyer
of s
ubsc
riptio
n ch
arge
s pr
escr
ibed
by
the
Cor
pora
tions
.
(e)
The
Cor
pora
tions
res
erve
the
right
to te
rmin
ate
this
cov
erag
e, o
r to
am
end
the
sam
e, a
s pr
ovid
ed in
the
Bas
ic C
ontr
acts
.
The
Cor
pora
tions
sha
ll be
rel
ieve
d of
all
liabi
lity
for
any
expe
nses
incu
rred
afte
r th
e da
te o
f ter
min
atio
n,ex
cept
: (1)
if a
sub
scrib
er o
r re
tired
sub
scrib
er is
, on
such
dat
e, c
onfin
ed a
s a
bed
patie
nt in
a h
ospi
tal,
such
subs
crib
er o
r re
tired
sub
scrib
er s
hall
be e
ntitl
ed to
bene
fits
here
unde
r fo
r C
over
ed M
edic
al E
xpen
ses
in-
curr
ed (
as a
res
ult o
f the
acc
iden
t, ill
ness
, or
inju
ryre
quiri
ng s
uch
hosp
italiz
atio
n) w
hile
in s
uch
hosp
ital
and
for
a pe
riod
not t
o ex
ceed
thirt
y (3
0) d
aYs
from
the
date
of d
isch
arge
from
the
hosp
ital;
(2)
if a
subs
crib
eror
ret
ired
subs
crib
er is
tota
lly d
isab
led
onsu
ch d
ate,
such
sub
scrib
er o
r re
tired
sub
scrib
er s
hall
be e
ligib
leto
rec
eive
cre
dits
for
Cov
ered
Med
ical
Exp
ense
s in
-cu
rred
dur
ing
the
Ben
efit
Per
iod
in w
hich
suc
h te
rmi-
natio
n da
te o
ccur
s an
d du
ring
the
imm
edia
teiy
suc
-ce
edin
g B
enef
it P
erio
d, b
ut o
nly
if th
e C
over
ed M
edic
alE
xpen
ses
are
incu
rred
with
res
pect
to th
e ac
cide
nt,
illne
ss, o
r in
jury
on
acco
unt o
f whi
ch th
e su
bscr
iber
or r
etire
d su
bscr
iber
is to
tally
dis
able
d at
such
ter-
min
atio
n da
te, a
nd o
nly
if su
ch to
tal d
isab
ility
is c
on-
tinuo
us to
the
date
or
date
s on
whi
ch s
uch
expe
nses
are
incu
rred
.
Sec
tion
VII
Gen
eral
Pro
visi
ons
(a)
The
Cor
pora
tions
may
pay
any
cha
rges
giv
ing
rise
to c
redi
ts d
ue u
nder
this
rid
er d
irect
ly to
the
hos-
pita
l, do
ctor
, nur
se o
r ot
her
rend
erer
of s
ervi
ce o
rfu
rnis
her
of s
uppl
ies
here
unde
r or
may
mak
e su
ch p
ay-
men
t to
the
appl
ican
t for
him
self
and
his
depe
nden
tsu
bscr
iber
s, o
r to
the
subs
crib
er o
r re
tired
sub
scrib
er.
(b)
Thi
s rid
er is
mad
e up
on th
e ex
pres
s co
nditi
onth
at a
ny h
ospi
tal,
phY
sici
an, p
harm
acis
t, or
oth
er s
up-
plie
r of
ser
vice
s an
d su
pplie
s is
aut
horiz
ed to
dis
clos
eto
the
Cor
pora
tions
any
info
rmat
ion
rega
rdin
g or
ac-
quire
d in
con
nect
ion
with
the
atte
ndan
ce, c
are,
ort
reat
-m
ent o
f any
sub
scrib
er o
r re
tired
sub
scrib
er h
ereu
nder
and
that
all
prov
isio
ns o
f law
or
prof
essi
onal
eth
ics
forb
iddi
ng s
uch
disc
losu
res
are
wai
ved
by o
r in
beh
alf
of e
ach
such
sub
scrib
er o
r re
tired
sub
scrib
er h
ereu
nder
.
(c)
The
ben
efits
of t
his
rider
are
non
assi
gnab
le.
(d)
All
clai
ms
here
unde
r m
ust b
e fil
ed in
writ
ing
with
the
Cor
pora
tions
with
in s
i Ay
(60)
day
s af
ter
the
serv
ices
hav
e be
en r
ende
red
or th
e su
pplie
s fu
rnis
hed.
No
actio
n or
sui
t at l
aw o
r in
equ
ity s
halt
be c
omm
ence
dun
til th
irty
(30)
day
s af
ter
writ
ten
notic
e of
cla
im h
asbe
en g
iven
by
the
subs
crib
er o
r re
tired
sub
scrib
er to
the
Cor
pora
tions
, nor
sha
ll an
y ac
tion
or s
uit b
e br
ough
tat
all
late
r th
an o
ne (
1) y
ear
afte
r th
e se
rvic
es o
r su
p-pl
ies
on w
hich
suc
h cl
aim
is b
ased
sha
ll ha
ve b
een
rend
ered
or
furn
ishe
d.
(e)
Thi
s rid
er is
inva
lid fo
ran
y pu
rpos
e w
hats
oeve
run
less
issu
ed b
y th
e C
orpo
ratio
ns a
s an
end
orse
men
tto
Bas
ic C
ontr
acts
whi
ch a
re a
nd r
emai
n in
full
forc
ean
d ef
fect
.
.(f)
The
Pro
visi
ons
here
of r
elat
ing
to m
axim
um b
ene-
fits,
ded
uctib
le a
mou
nt, w
aitin
g pe
riod
and
othe
r pe
rti-
nent
pro
visi
ons
shal
t be
adju
sted
by
the
Cor
pora
tions
inth
eir
disc
retio
n in
the
case
of a
sub
scrib
er w
hose
cov-
erag
e un
der
one
empl
oyer
may
be
term
inat
ed a
ndre
sum
ed u
nder
ano
ther
em
ploy
er, b
ut in
no
ease
sha
llsu
ch s
ubsc
riber
be
entit
led
to g
reat
er b
enef
its th
an h
ew
ould
hav
e re
ceiv
ed h
ereu
nder
if th
ere
had
been
note
rmin
atio
n.
(g)
All
of th
e te
rms,
con
ditio
ns a
nd d
efin
ition
sof
said
Bas
ic C
ontr
acts
not
inco
nsis
tent
with
the
term
san
d co
nditi
ons
of th
is r
ider
sha
ll ap
ply
to a
nd b
e an
dbe
com
e a
part
of t
his
rider
as
fully
and
as c
ompl
etel
yas
thou
gh s
peci
fical
ly s
et fo
rth
here
in; t
he p
rovi
sion
s of
the
Bas
ic C
ontr
acts
rel
atin
g to
sub
roga
tion
are
expr
essl
yin
corp
orat
ed h
erei
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HO
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PO
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0244
1414
Pre
side
nt
TH
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DIC
AL
SO
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PH
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RV
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with
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hysi
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s S
ervi
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acts
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if yo
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ques
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abou
t you
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enef
its, y
ou m
ight
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con
trac
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r, c
all o
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Blu
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ross
-Phy
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to p
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ry b
est s
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ossi
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AS
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CR
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SIC
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S S
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VIC
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BLU
E C
RO
SS
PH
YS
ICIA
NS
SE
RV
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31 C
anal
Str
eet
Pro
vide
nce,
Rho
de Is
land
029
01
TE
1-7
300
30
(MM-610)
II any prior Certificate describing the same kind of group insurancehas boon issued to the Employee named herein such Certificate is void.
THE EQUITABLE LIFE ASSURANCE SOCIETYOF THE UNITED STATES
HEREBY CERTIFIES THAT,
Subject to the terms and conditions of Group policy No. 12703M
the Employee named on the back page of this
certificate, an Employee of
SCHOOL DISTRICT #11Colorado Springs, Colorado
(Hereinafter Called the Policyholder)
and his Dependents
(if he has elected to insure them)
are insured for Major Medical Expense Benefits as therein limited.
This Individual certificate is furnished in accordance with and subject to the terms of
the said policy, which policy, and the application therefor, constitute the entire contract
between the parties. This certificate is merely evidence of insurance provided under said
policy, which insurance is effective only if the person concerned is eligible for insurance
and becomes and remains insured in accordance with the provisions, terms and conditions
of the said policy.
NOTE: The insurance described herein for Dependents is void and of no effectunless the insured Employee has eligible Dependents and such Dependents becomeinsured in accordance with the terms set forth on the back page of this certificate.
(For additional provisions see subsequent pages hereof)
THE EQUITABLE LIFE ASSURANCE SOCIETY OF THE UNITED STATES
Health Care PlanGroup Major Medical Expense CertificateNon-Occupational
Printed in U. S. A.
PF 13745 Amended by PF 12473-13974-14364-15354-15590(6309) C Colorado No. 2
31
DEFINITIONSDEPENDENT. The term Dependedt shall mean any of the following not eligible for insurance as an Employee of the Policy-holder:(a) An insured Employee's wife or husband not legally Separated from the Employee.(b) An insured Employee's unmarried child who has not attained the age of nineteen years.(c) An insured Employee's unmarried child who is a full-time student, and has attained the age of nineteen years but has not
attained the age of twenty-three years.
PERIOD OF HOSPITAL CONFINEMENT. A period of hospital confinement shall mean confinement in a legally constituted andoperated hospital, (1) for any period when confinement is on account of accidental bodily injury and commences within 24 hoursfollowing such injury or for a surgical operation, or (2) for not less than 18 hours when confinement is for any other cause.Any confinement which is not separated from any other confinement by (a) return to active employment in the case of an Em-ployee, or (b) an interval of three months or more in the case of a Dependent, shall be considered as the same period of con-finement as such other confinement if both are due to the same or related cause.
MAJOR MEDICAL EXPENSE BENEFITSThe Group policy Provides that the benefits hereinafter set forth are payable for "covered charges" (defined below) incurred onaccount of a non-occupational accidental bodily injury or a non-occupational sickness, and are subject to the other provisions andlimitations therein contained.A. BENEFITS.
1. AMOUNT OF BENEFITS. When an Employee or Dependent has incurred covered charges while insured under the policyand such covered charges during a calendar year exceed the deductible amount (defined below) the Society shall pay anamount of benefits equal to 1. with respect to such excess covered charges made by a hospital for expenses incurredduring a period of hospital confinement (a) with respect to the first $500 of such covered charges: (i) 100% of anysuch covered charges, excluding charges for private room and board, (ii) 80% of such covered charges for private roomand board, (b) with respect to all other such covered charges during such confinement: 80%, and 2. with respect tosuch excess covered charges, induding charges for pre-operative and post-operative care, made by a physician legallylicensed to practice medicine and surgery for the performance of a surgical procedure, an amount determined in accord-ance with the provision entitled "Schedule of Operations," 3. with respect to all other such excess covered charges in-curred during such calendar year: 80%, subject to a Maximum Amount of Benefits with respect to each insured personunder the policy of $10,000.
2. REINSTATEMENT OF MAXIMUM AMOUNT OF BENEFITS. At any time after the payment of total benefits of $1,000cr. more with respect to an insured person, such person may'reestablish his Maximum .Amount of Benefits by furnishineg,without expense to the Society, evidence of his insurability satisfactory to the Society or, in the case of an Employee, bycompleting a continuous period of six months of active employment with the Policyholder. Effective as of the date of theSociety's acceptance of such evidence or the date of the expiration of such six-month period, the amount of benefitspreviously paid with respect to such person shall not be considered in applying the Maximum Amount of Benefits. If theMaximum Amount of Benefits has been paid, the person shall become insured again as of the date of the Society'sacceptance of such evidence or the date of the expiration of such six-month period.
B. COVERED CHARGES. "Covered charges" shall consist of the following charges for services, supplies, and treatment:1. Charges made by a legally constituted and operated hospital for room and board and other services.2. Charges made for diagnosis, treatment and surgery by a physician leelly licensed to practice medicine and surgery.3. Charges made by a Registered Nurse for private duty nursing service.4. Charges for the following: local ambulance service, equipment, medication, appliances, x-ray services, laboratory tests,
the use of radium and radioactive isotopes, oxygen, iron lung, physiotherapy, and similar services, supplies, and treatment.The charges referred to shall in no event include any amount of such charges in excess of the regular and customary chargesfor the services, supplies and treatment furnished.
C. DEDUCTIBLE AMOUNT. The deductible amount for any calendar year shall be an amount equal to the sum of1. the total amount of benefits provided (including the value of benefits provided on a service basis) with respect to cov-
ered charges incurred during such calendar year under any other group plan or plans toward the cost of which anyemployer makes contributions or payroll deductions or any labor union makes contributions, and
2. (except with respect to covered charges made by a legally constituted and operated hospital for expenses incurred duringa period of confinement therein or fees of a physiciln legally licensed to practice medicine and surgery for the perfor-mance of a surgical procedure) a cash deductible of $50.
The deductible amount shall be applied separately to the amount of covered charges incurred during each calendar year byeach person while insured under the policy, subject to the following exceptions:(i) The cash decluctible shall be reduced by any amourit of covered charges incurred for the insured person involved during
the last three months of the preceding calendar year which were applied toward the cash deductible for such precedingcalendar year.
(ii) If two or more persons, while insured under the policy as members of the same family, incur covered charges on accountof the same acci.dent occurring while insured thereunder, a single cash deductible shall apply to the combined coveredcharges incurred by all such insured persons on account of the common accident during the calendar year in which suchaccident occurs and again during the following calendar year. Furthermore, any benefit paid that would not have beenpayable were it not for this provision, shall not be charged against the Maiimum Amount of Benefits of the personinvolved.If during any calendar year one of the insured persons incurs covered charges not related to the common accident suchperson may apply toward the cash deductible applicable to such charges any covered charges which he incurred duringsuch calendar year and which were applied toward the common-accident cash deductible.
If greater benefits should be payable without application of exception (ii), the greater amount shall be paid.
Il
32
LIMITATIONS APPLICABLE TO MAJOR MEDICAL EXPENSE BENEFITSIL "Covered Charges" shall in no eventbe deemed to include expenses incurred for services, supplies, or treatment
1. unless such services, supplies, or treatment (including the entire period of hospital confinement) were prescribed as necessarybY a physician legally licensed to practice medicine and surgery.
2. in any Federal hospital.
3. if they were incurred on account ofa. dental work or treatment or dental x-rays, except as required because of accidental injury of sound, natural teeth
occurring while insured under the Group policy,
b, eye refractiOns, eyeglasses, or the fitting thereof,c. hearing aids or the fitting thereof*cl. transportation, except for local ambuynce service,e. war, Aleclared or undeclared, including armed aggression,f. bodily injury arising out nf and in the course of employment by any employer or disease with respect to which benefits
are payable under any Workmen'i Compensation or Occupational Disease A.ct or Law, :g. health examinations not required in tonnertion with treatment of sickness or. injury.
B. No payment shall be made under the provisions of the Group policy entitled "Major Medical Expense Benefits" and "ExtendedBenefits" fot any expenses incurred on account of pregnancy or resulting childbirth, abortion, or miscarriage, except that in thecase of any complication arising out of such pregnancy, benefits shall be payable in acCordance with said provisions, but with thefollowing modifications:1. Benefits shall )hi payable may for covered charges for which benefits are not payable under the provisions entitled "Mater-
nity. 1,3enefite, and "Extended. Maternity Benefits" and which are in excess of those which would have been incurred in the.absence of cothplications, as determined by the Society.
2. U. in addition to * coMplication arising out of pregnancy there is a complication with respect to the newborn child, thecovered charges therefor with respect to the child shall be combined with those of the mother for the purpose of the appli-cation of the Deductible 'Amount provision, and the deductible amount ;,shall be calculated as though the combined chargeswere for one person; hoWever, fOr the pumose of the Maximum Amount of Benefits set forth in the Benefits provision,the benefits pabi shall be considered those oithe one for whom the respective charges were made.
3. If a person is pregnant on terminatkin of.. her Major Medical Expense Insurance and termination of insurance is for causeother than the termination of iaid Group politY or its aniendment to terminate the Major Medical Expense Insurance ofthe class of which she is a member, the benefits set* fotth under this paragraph shall be applicable with respect fo coveredcharges incurred within a period ending cid December'', 31 ,of the calendar year following the calendar year in which suchtermination of insurance occurs.
4. If on termination of her Major Medical Expense Insurance a person is totally disabled because of pregnancy or a conditionresulting therefrom so as to be continuously prevented from engaging in any occupation and performing all regular andcustomary duties and such termination of insurance is because of the ternitnation of said Group policy or its amendmentto terminate the Major Medical Expense Insurance cif 'the class of which she is a member, the benefits set forth underthis para,graph shall Ix applicable with respect to covered charge4 incurred during the continuance of such total disabilitybut not beyond the date,nine months following such' termination of insurance,
C. "Covered charges* shall bi no event he deemed to include expenses incurred for services, supplies or treatment if they wereincurred on account of injury or sickness which existed within three months prior to the effective date of a person's inswanceor any condition related to said iniury or sickness, except that this limitation shall not apply to any such expenses incurredafter the date such person was continuously insured under said Group policy for a twelve month period,
D, Payment for psychiatric treatment shall be subject to the provisions and limitations of the policy and the following additionallimitations:
L "Covered Charges" incurred while not confined to a hospital shall not include any amount of professional fees in excessof $10, 00 per visit and shall not in any event inclide the fees of any practitioner other than a physician legally licensedto practice medicine and surgery.
2, Benefits for "Covered Charges" incurred during a calendar year shall not exceed $500.
EXTENDED BENEFITSIf a person's Major Medical Expense Insurance under the Group policy terminates for cause other than payment of the MaximumAmount of Benefits, and, if at the date of such termination the faerson is totally disabled by bodily injury or disease so as to becontinuously prevented from engaging in any occupation and performing all regular and customary duties, then benefits shall beprovided under said Group policy, as if insurance had not terminated, for covered diarges incurred solely on account of such injuryor disease during the uninterrupted continuance of such disability and ivithin the following period: (a) in any case in which suchtermination of insurance is for cause other than the termination of said Group policy or its amendment to terminate the' MajorMedical Expense Insurance of the class of which' such person is a' member, within a period ending on the December 31 of thecalendar year following die calendar year in which such termination of insurance occurs, (b) in any case in which such terminationof insurance is because of the termination of said Group policy or its amendment to terminate the Major Medical Expense Insur-ance of the class of which such perion is a member, within nine months following such termination of insurance.
33
MATERNITY BENEFITSIf a female Employee or a male Emrloyee's wife, while insured under the policy, incurs covered charges on account ofpregnancy or resulting childbirth, abortion, or miscarriage, benefits will be payable under this provision, subject to theother provisions and limitations of the policy, in an amount equal to the excess of such charges over the total amount ofbenefits provided (including the value of benefits provided on a service buis) with respect to such charges under anyother group plan or plans toward the cost of whkh any employer makes contributions or payroll deductions or anylabor union makes contributions, subject to a maximum payment for any one pregnancy under this provision of $200.
LIMITATIONS APPLICABLE TO MATERNITY BENEFITS"Covered charges" shall in no event be deemed to indude expenses incurred for services, supplies, or treatment
1. unless such services, supplies, ur treatment (induding the entire period of hospital confinement) were prescribedas necessary by a physician legally licensed to practice medicine and surgery.
2. in any Federal hospital.
3. if they were incurred on account of transportation except local ambulance service.
4. if they were incurred within nine months of the effective date of the female Employee's or the wife's insuranceunder the polky.
EXTENDED MATERNITY BENEFITSIf at the date of termination of a female Employee's or wife's insurance under the Group policy, such person is preg-nant, benefits shall be payable under the provision entitled "Maternity Benefits" as if insurance had not terminated forany covered charges incurred on account of such pregnancy or resulting childbirth, abortion or miscarriage, during thefirst nine months following termination of insurance.
INDIVIDUAL TERMINATIONSA. 'The insurance of any Employee under said Group policy shall cease automatically upon the occurrence of any one
of the following events:(1) the termination of the policy,
(2) the cessation of premium payments on account of such Employee's insurance thereunder,
(3) the termination of his employment in the dasses of Employees insured thereunder,
(4) the payment of the Maximum Amount of Benefits with respect to such Employee.Note: In case the Employee ceases active work due to sickness, injury, leave of absence cr temporary lay-off the termsof the Group policy may provide for continuance of insurance for a limited period. The Employee should consult thePolicyholder who is in a position to inform the Employee as to the terms of the policy in this respect.B. The insurance under the Group policy of any Employee's Dependent shall cease automatically upon the occurrence
of any one of the following events:(1) the termination of the Employee's insurance under said Group policy, providei that when such termination
results from
(a) the payment of the Maximum Amount of Benefits with respect to the Employee, the insurance of hisDependents may be continued but not beyond the termination 'of his insurance in the classes of Em-ployees insured thereunder except as provided in (b) below in the event of the Employee's death, or
(b) the death of the Employee, the insurance may be continued but not beyond one year immediately follow-ing such death.
(2) the cessation of premium payments on account of the insurance of such Employee's Dependent,
(3) when he ceases to be a Dependent as defined, except as provided in B (1) above,
(4) the payment of the Maximum Amount of Benefits with respect to such Dependent.PRIVILEGE ON TERMINATION OF INSURANCE
I. Upon termination of insurance due to termination of employment in the class or classes of Employees insuredunder the Group policy, the Employee may obtain from the Society, without furnishing evidence of insurability, anindividual policy of insurance covering himself and his spouse and children insured under the Group policy, by makingwritten application and the first premium payment therefor to the Society within thirty-one days after such terminationof insurance. The form of the individual insurance policy, the coverage thereunder, and all other terms and conditionsthereof shall be as provided by the rules of the Society for such individual policy at the time of such application. Theindividual policy, if issued, shall become effective upon the day folkwing the date of termination of insurance underthe Group policy.II. If termination of employment in the class or classes of Employees insured under the Group policy is caused by theEmployee's death, or if such termination is due to other cause and the Employee dies within thirty-one days thereafter,with respect to the insurance of his surviving spouse and children under the Group policy, his surviving spouse shallhave the privilege of obtaining an individual policy of insurance on the same basis and subject to the conditions indi-cated in Section I hereof.III. Where the insurance of a dependent child under the Group policy is terminated by reason of the age or marriageof the child, such child shall have the privilege of obtaining an inclividual policy of insurance on the basis and subjectto the conditions indicated in Section 1 hereof.
34
The amount ot benefits for surgery referred1, 80% of such excess covered charges, an2. the Basie Amount of Pa men i. set forth
charges made by such
SCHEDULE OF OPERATIONSto in the provision entitled "Amount of Benefits" shall be the greater of
below, with respect to such operation, but in no event shall such amount exceed the actual
Basic Amountof Payment
ABDOMENAppendectomy, freeing of ad-
hesions or exploration of, orcutting into, the abdominalcavity $150.00
Removal of gall bladder 225.00Gastro-enterostomy 225.00Resection of stomach, bowel or
rectum 300.00ABSCESSES (see Tumors)AMPUTATIONS
Thigh, leg 187.50Upper arm, forearm, entire hand
or foot 150.00Fingers or toes, each 22.50
BLOOD TRANSFUSION, each 37.50BREAST.
Removal of benie tumor or cystg hospital confinement .75110
amputation 150.00Raul amputation 225.00
CHEST.Complete thoracoplasty, transtho-
ram approach to stomach, dia.giu, esophagus; sYmPa.
or laryngectomy .Removal of lung or portion of
II -III/ II 300.00
"°Brioinnto.scopt opy 60.°°00Induction o pneumo-
thorax, initial 37.50refills each (not more than 12) 15.00
CYSTS. (see Tumors)
DISLOCATION. Reduction ofHip, Vertebra, ankle joint, elbowor knee joint (patella excepted) 52.50
Shoulder 37.50Lower 'ew, collar bone, wrist or
For
Basic Amountof Payment
Submucous resection of nasalseptum $ 75.00
Tractomy 75.00EYE
Operation for detached retina 300.00Cataract, removal of 225.00Cutting into eyeball (through the
cornet or sclera) or cuttingoperation on eye muscles 150.00
Pterygium (excision) 30.00Removal of eyeball 112.30
FRACTURE. Treatment ofThigh, vertebra or vertebrae,
pelvis, (coccyx excepted) 112.50Leg, kneecap, upper arm, ankle
(Potts) 75.00Lower jaw, collar bone, shoulder
blade, forearm, wrist (Colles),skull 37.50
Hand, foot 22.50Fingers or toes, each 15.00Nose 13.00Rib or ribs, three or more 37.50
fewer than three 15.00
If compound fracture, basic amount of pay-ment is one and one-half times amountindicated. If open operation, basic amountof payment is 2 times amount indicated.(Bone grafting or bone splicing consideredas om operation; skeletal traction pin isnot so-considered.)GENITO-URINARY TRACT -
Removal of, or cutting into,kidney 300.00
Fixation of kidney 225.00Removal of tumors or stones in
ureter or bladderby cutting operation 150.00
22.50 by endoscopic means 52.50
'ons requiring an open opera-tion, the' basic amount of payment is 2times amount indicated.
EXCISION OR FIXATIONBY CUTIING
Hip joint 225.00Shoulder, knee joint, semilunar
cartilage, elbow, wrist or anklejoint
Removal of diseased portion ofbone, including curettage
EAR, NOSE OR THROAT.Fenestration, one or both sidesMastoidectomy, one or both sides,
130.00
75.00
300.00
130.00225.00
Tonsillectomy, adenoidectomy, orboth .... . 45.00
Sinus operation by cutting (punc-ture of antrum excepted)
The Basic Amount of Payment forwith the Basic Amounts of Payment
Cystoscopy , 37.50Removal of prostate by open
operation 225.00Removal of prostate by endo-
scopic means 150.00Grcumcision 22.50Varicocele, hydrocele, orchectomy
or epididymectomy,single 75.00bilateral 112.50
Hysterectomy 225.00Salpingectomy or oophorectomy,
or both 150.00Cervix amputation 75.00Dilation and curettage (non-
puerperal), cervix cauteriza-tion or conization, polypec-tom, or any combination ofthese .
Vaginal plastic, operation for75.00 cystocele or rectocele . 112.50
Basic Amountof Payment
GOITRERemoval of thiroid, subtotal $225.00Removal of a enoma or benign
tumor of thyroid 150.00HERNIA
Single hernia 150.00More than one hernia 187.50
JOINTIncision into, tapping excepted 37.50
LIGAMENTS AND TENDONSCutting or transplant, single 75.00
multiple 112.50Suturing of tendon, single 52.50
multiple 75.00PARACENTESIS
Tapping 22.50PILONIDAL CYST OR SINUS
Removal of 75.00RECTUM
Hemorrhoidectomy, external 37.50internal or internal and ex-
ternal 75.00Cutting operation for fissure 37.50Cutting operation for thrombosed
hemorrhoids 22.30Cutting operation for fistula:in-
ano,single 75.00multiple 112.50
SKULLCutting into cranial cavity
(trephine excepted) 300.00trephine 37.50
SPINE OR SPINAL CORDOperation for spinal cord tumor 300.00Operation with removal of por-
tion of vertebra or vertebrae(except coccyx, transverse orspinous process) 225.00
Removal of part or all of coccyx,or of transverse or spinousprocess 75.00
TUMORSBenign or superficial tumors and
cysts or abscesses requiringhospital confinementnot requiring hospital confine-ment 15.00
Malignant tumors of face, lip orskin 75.00
VARICOSE VEINSInjection treatment, complete
procedure,one or both legs 60.00
Cutting operation, complete37.50 procedure,
one leg . 75.00both legs 112.50
any cutting operation not specified above shall be determined by the Society, on a basis consistentappearing in the above schedule.
35
GENERAL PROVISIONS OF THE GROUP MAJOR MEDICAL EXPENSE POLICYAPPLICABLE TO THIS CERTIFICATE
PROOF OF CLAIM. Written proof of claim covering the occurrence, character, and extent of the loss for which claim is
made must be furnished to the Society at its Home Office in the City of New York within ninety days after the date of the
loss with respect to which claim is made. Failure to furnish such proof within the time required by the policy shall not
invalidate or reduce any claim if it shah be shown not to have been reasonably possible to furnish such proof within the
required time and that proof was given as soon as was reasonably possible.
The Society may require as part of the proof of claim, itemized bills of the hospital, physician, or other source of the
services, supplies, and treatment, and a statement of the benefits provided therefor under any other group plan or plans
toward the cost of which any employer makes contributions or payroll deductions or any labor union makes contributions.
PAYMENT OF CLAIMS. All benefits payable under the policy will be paid to the Employee immediately upon receipt of
due written proof.
EXAMINATIONS. 'Me Society at its own expense shall have the right and opportunity to examine any person when and so
often as it may reasonably require during the pendency of claim under the policy.
LEGAL PROCEEDINGS. No action at law or in equity shall be brought to recover under the policy prior to the expiration
of sixty days after proof of claim has been furnished in accordance with the requirements of the policy, nor shall any such
aetion be brought at all unless commenced within thfee years from the expiration of the time within which proof of claim
is required by the provisions thereof.
TERMINATION AND CHANGE OF POLICY. On any premium due date the Policyholder may terminate the policy or,subject to the Society approval, may modify, amend or change the provisions, terms and conditions of the policy. No con-
sent of any Employee or any other person referred to in the policy shall be required to effect termination of the policy or
any modification, amendment, or change thereof.
36
Group 203-01
KAISER FOUNDATION HEALTH IDLAN, INA Nonprofit Corporation
Northern California Region
GROUP MEDICAL AND HOSPITAL SERVICE AGREEMENT RECEIVED
FACE SHEET MAY 4 1065
HEALTH PLANThis Service Agreement, consisting of the attached Group Medical and HospitalWerIXPERSP
and Benefit Schedules as supplement9d by this Face Sheet, has been entered into between Kaiser Founda-tion Health Plan, Inc., a California non-profit corporation, and the group defined in Section 1-B below inorder to provide eligible Subscribers and eligible Family Dependents electing to enroll hereunder withmedical, surgical, hospital and related health care benefits as specified in the attached Benefit Schedules.
The following provisions supplement corresponding provisions of the attached Group Medical andHospital Service Agreement.
Section 1. Definitions.B. Sacramento County Supt. of Schools"Group" shall
Section 2. Eligibility and Enrollment.A. (1). Subscribers must meet the following additional requirements: aunt
esployee who is eligible for Group contribution towardEmployees who are ellxible for retirement after May 1,Group membership in retirement.
be an activeHealth Plan dues.1965 continue
A. (2). Family Depencients must meet the following additional requirements: Barellant-el-es36.Snb-4aribee&aseumalgamAka41.4.4f40.4"ithisat 4.4.4diesi jimmy. Unmarried dependent children-whilis-VsitistereitrOa-ti-full=t-iimi-liiiiiiiiit a recognized educationalinstitution may continue as Family Dependents until reaching age 24.
Section 3. Relations Among Parties Affected by Agreement.No supplemental provisions.
Section 4. Rates and Payment.A. The initial enrollment charge shall be none
B. The periodic payment schedule is as follows:Subscriber only
Subscriber and one dependent
Subscriber and two or more dependents $-0----19
FsemON12
8.35.
Composite rate per Subscriber $
Additional periodic payment:Subscriber age - or over
Dependent age or over
OD
37
Section S. Services and Benefits.
A. Within the Northern California Service Area the Benefit Schedule or Schedules applicable underthis Agreement are as follows:
For Subscribers, Benefit Schedule ONE B
For Dependents, Benefit Schedule ONE_B.
Section 6. Exclusions and Limitations.B. (7). Benefits for pre-existing conditions are those specified in the following schedules:
For Subscribers, Benefit Schedule ONE BC
For Dependents, Benefit Schedule ONE_EP*Section N of Schedule One-II does not apply. In the case of any pre -
are entitled to the same benefits underthe same provisions as specified for conditions arising after the_affective date of membership.
Section 7. Conversion and Transfer.No supplemental provisions.
Sectioti 8. Term and Termination.No supplemental provisions.
Section 9. Amendment.This Agreement, including the attached schedules and addenda, may be amended by Health Plan at
any time with respect to any matter other than rates, by mutual agreement between Health Plan and Group.Health Plan may amend this Agreement with respect to any matter, including rates, effective as of any an-niversary date by written notice to Group at least sixty (60) days prior to the anniversary date. All suchamendments shall be deemed accepted by Group unless Group gives Health Plan written notice of non-acceptance at least thirty (30) days prior to the anniversary date, in which event this Agreement shall termi-nate in accordance with Section 8-D effective on the anniversary date.
Section 10. Miscellaneous Provisions.E. The address of Group iq 6011 Jolson Boulevard
sacramento, California
I
Executed at Oakland, CaliforniaApe il 26
,May 1
Accepted
By
By
1.19.634.and
420 1 7
19.11_, to take effect as of
continuing through November 30, 1965,from year to year thereafter.
IISER FOUNDATION HEALTH PLAN, INC.,A California nonprofit corporation
uthorized RepresentativeNorthern California Region
38
KALSER FOLJAIL7ATICIN HEALTH 1-,LAN, INC".A NONPROFIT CORPORATION
NORTHERN CALIFORNIA REGION
GROUP MEDICAL AND HOSPITAL SERVICE AGREEMENT
INTRODUCTION
Health Plan, in consideration of the periodic payments to be paid to Health Plan by Group and in consideration of the supplemental charges to bepaid by or on behalf of Members, agrees to arrange Medical and Hospital Services and other benefits during the term of this Service Agreement, subject,however, to all terms and conditions of this Service Agreement and the attached Benefit Schedules.
Interpretation of Agreement. In order to provide the advantages of integrated medical and hospital facilities and of group medical r tice, HealthPlan operates on a direct-service rather than indemnity basis. The interpretation of this Agreement shall be guided by the direct-service nature of theHealth Plan program.
1. DEFINITIONS
As used in this Medical and Hospital Service Agreement and ell schedulesnecessary by the context):
A. "Health Plan" shall mean Kaiser Foundation Health Plan, Inc., anonprofit corporation organized for the primary purpose of arranging forMedical and Hospital Servicesi "Northern California Region" shall meanthat division of Health Plan which operates in the San Francisco Bay Area.
g, "Group" is defined in Section 1-B of the Face Sheet.C. "Subscriber" shall mean a person Who meets all applicable eligibility
requirements of Section 2 and enrolls hereunder, and for whom the pre-payment required by Section 4 has been actually received by Health Plan.
D. "Family Dependent" shall mean any member of a Subscriber'sfamily residing in the Subscriber's household who meets all applicableeligibility requirements of Section 2 and is enrolled hereunder and forwhom the prepayment required by Section 4 has been actually received byHealth Plan.
E. "Member" shall mean any Subscriber or Family Dependent.F. "Medical Group" shall mean The Permanente Medical Group, a
partnership of physicians.
G. "Physician" shall mean any, doctor of medicine associated with orengaged by Medical Group_; "Attending Physician" shall mean the Physi-cian primarily responsible for the care of a Member with respect to anyparticular injury or illness.
H. "Hospital" shall mean any hOspital in Health Plan's Northern Cali-fornia Region with which Health Plan maintains contractual arrangementsfor Hospital Services. A current list of such Hospitals may be obtainedfrom any Health Plan office.
"Medical Office" shall mean any outpatient treatment facility inHealth Plan's Northern California Region which is staffed by MedicalGroup. A current list of such Medical ODIffices may be obtained from anyHealth Plan office.
K. "Medical Services" shall (except as expressly limited or excluded bythis Agreement) mean those professional services of physicians and sur-
or addenda hereto (except as otherwise expressly provided or made
geons, and para-medical personnel, including medical, surgical, diagnostic,therapeutic and preventive services, (i) which are generally and customarilyprovided in the San Francisco Bay Area, and (n) which are performed,prescribed, or directed by Physicians.
L. "Hospital Services" shall (except as expressly limited or excludedby this Agreement) mean those services for registered bed patients whichare (i) generally and customarily provided by acute general hospitals inthe San Francisco Bay Area, and (ii) which are prescribed, directed orauthorized by a Physician.
M. "Prevailing Rates" shall mean the rates generally prevailing in theSan Francisco Bay Area for hospital, medical and related services.
N. "Health Plan Rates" shall mean the rates set forth in the Scheduleof Supplemental Charges maintained at Hospitals and Medical Offices.Such rates are maintained at approximately 5(196 of Prevailing Rates forsimilar services. Said Schedule of Supplemental Charges may be revisedwithout notice from time to time.
0. "Service Area" shall mean that geographical area within the nineSan Francisco Bay Area counties (Alameda, Contra Costa, Marin, Napa,San Francisco, San Mateo, Santa Clara, Solano and Sonoma) lying withina radius of thirty miles of any Hospital or Medical Office.
p. "House Call Service Area" shall mean that geographical area sur-rounding each Hospital and Medical Office within which house calls arerendered under this Agreement. Such areas may be revised without noticefrom time to time. A current definition of each House Call Service Areamay be obtained at the Hospital or Medical Office upon which such HouseCall Service Area is based.
Q. "Pre-existing Condition" shall mean any injury, illness or conditionexisting, contracted or sustained prior to the commencement of a person'scurrent term of uninterrupted Health Plan membership, and includes anyrecurrence or complication of any such injury, illness or condition. Con-genital conditions are considered Pre-existing Conditions.
2. ELIGIBILITY AND ENROLLMENT
A. ELIGIBILITY OF INDIVIDUALS. Individuals will be accepted for en-rollment hereunder only upon meeting all applicable requirements set forthbelow.
(1) subscribers. To be eligible to enroll as a Subscriber a person mustbe either (a) an actual and bona fide member of Group or (b) entitledunder the trust agreement, employment contract or other establishedstandard of Group, on his own behalf and not by virtue of dependencystatus, to participate in medical and hospital care benefits arranged byGroup.
Subscribers must meet the additional requirements specified in Section2-A (1) of the Face Sheet.
(2) Family Dependents. To be eligible to enroll as a Family Dependenta person must be either (a) the spouse of the Subscriber or (b) a de-pendent unmarried child under the age of 19 of either the Subscriber orhis spouse. Foster children entirely supported by the Subscriber and hisspouse and legally adopted children of either, as well as natural children,are included. Newborn children will be treated as Family Dependentsfrom birth if promptly enrolled by a parent.
Family Dependents must meet the additional requirements specified
in Section 2-A (2) of the T ve Sheet.(3) Membership Previously Terminated. No person is eligible to enroll
hereunder who has had Health Plan coverage terminated for cause underSection 8-B of this or any other Health Plan Medical and HospitalService Agreement.
(4) Change of Group Eligibility Rules. The composition of Group andrequirements determining eligibility for membership in Group and forparticipation in medical and hospital care benefits arranged by Groupare considerations material to the execution of this Agreement by HealthPlan; during the tertn of this Agreement no change in Group's eligibilityor participation requirements aiall be permitted to affect eligibility ,orenrollment under this Agreement in any manner deemed adverse byHealth Plan unless such change is effected by mutual agreement withHealth Plan.
B. ENROLLMENT. While enrollment is open for Group, Subscribers andFamily Dependents who meet the requirements of Section 2-A may enrollhereunder by submitting complete applications on forms provided byHealth Plan.
3. RELATIONS AMONG PARTIES AFFECTED BY AGREEMENT
The relationship between Health Plan ,and Medical Group and betweenHealth Plan and Hospitals is an independent contract relationship; Physi-cians and Hospitals are not agents or employees of Health Plan, nor isHealth Plan, nor any employee of Health Plan, an employee or agent ofHospitals or Medical Group.
Physicians maintain the physician-patient relationship with Membersand are solely responsible to Members for all Medical Services, Hospitalsmaintain the hospital-patient relationship with Members and are solelyresponsible to Members for all Hospital Services.
Information from medical records of Members and information
39
received by Physicians or Hospitals incident to the physician-patient orhospital-patient relationship is kept confidential, and, except for use inci-dent to bona fide medical research and education or reasonably necessaryin connection with the administration of this Agreement, is not disclosedwithout the consent of the Member.
Neither Group nor any Member is the agent or representative ofHealth Plan, and neither shall be liable for any acts or omissions of HealthPlan,its agents or employees, or of Medical Group! any Physician, orHospital, or any other person or organization with which Health Plan hasmade or hereafter shall make arrangements for the performance of servicesunder this Agreement.
4. RATES AND PAYMENTPayment for Health Plan coverage shall be made as follows:
A. INITIAL ENROLLMENT. Along with each initial application for enroll-ment the prospective Subscriber or Group shall remit to Health Plan theamount specified in Section 4-A of the Face Sheet to cover enrollment ofthe Subscriber and his Family Dependents.
B. PERIODIC PAYMENT SCHEDULE. Group shall remit to Health Planon behalf of each Subscriber and his Family Dependents the amountsspecified in Section 4-B of the Face Sheet for each month on or before thelast day of the preceding month. Only Members for whom the stipulatedpayment is actually received by Health Plan shall be entitled to Medicaland Hospital Services hereunder and then only for the period for whichsuch payment is received.
If any payment required above is not timely paid by or on behalf ofany Member, all rights of such Member hereunder shall terminate and maybe reinstated only by renewed application and re-enrollment in accordancewith .:11 requirements of this Agreement.
C. SUPPLEMENTAL CHARGES. In addition, Members shall pay or ar-range for payment of applicable supplemental charges as provided in theaccompanying Schedules of Medical and Hospital Services, and in caseof failure to do so, the Members' rights may be terminated on fifteen (15)days' notice and may be reinstated only by renewed application andre-enrollment in accordance with all requirements of this Agreement.
5. SERVICES AND BENEFITSSubject to all terms and provisions of this Agreement, Members shall be entitled to receive services and other benefits as follows:
A. WITHIN NORTHERN CALIFORNIA SERVICE AREA. Within the definedService Area in Northern California, Subscribers and Dependents areentitled to receive the services and other benefits specified in the benefitschedules described in Section 5-A of the Face Sheet, all as provided, pre-scribed, or directed by Physicians. Within this Area, Medical and HospitalServices are available only from Medical Group and Hospitals, and neitherHealth Plan, Hospitals nor Medical Group shall have any liability orobligation whatsoever on account of any service or benefit sought orreceived by any Member from any other doctor or hospital, or other
person, institution or organization, unless prior special arrangements aremade by a Physician and confirmed by written referral from MedicalGroup.
B. OUTSIDE NORTHERN CALIFORNIA SERVICE AREA. Members regularlyresiding in the Northern California Service Area while temporarily awayfrom home and outside said Service Area may receive the additional bene-fits specified in Schedule TWO as therein defined and limited.
6. EXCLUSIONS AND LIMITATIONS
Health Plan operates on a direct-service basis to make available Medical and Hospital Services and related benefits in the manner which appears mostadvantageous to most Members. The general objective Health Plan coverage is to provide necessary hospital and medical care:
Within the scope of the general public's willingnesE and ability to prepay;Without duplicating care financed by other sources; andWithout devoting excessive resources to costly specialized facilities.Moreover, Medical and Hospital Services available under this Agreement may be limited by the nature and capacity of Hospital and Medical Group
facilities and personnel,Accordingly, the following exclusions and limitations are established:
A. EXCLUSIONS. All services for conditions within any of the follow-ing classifications are excluded from the coverage of this Agreement:
(1) Psychiatric Conditions. Psychiatric care, including any treatmentfor insanity, mental illness or disorders; alcoholism, drug addiction.
(2) Self-Inflicted or Self-Induced Injuries. Conditions, and any compli-cations thereof, resulting from attempts at suicide or other intentionallyself-inflicted or self-induced injuries or illnesses.
(3) Employer or Governmental Responsibility. Illnesses, injuries or con-ditions covered by services or indemnification or reimbursement avail-able either:a. Pursuant to any federal, state, county or municipal workmen's com-
pensation or employer's liability law dr other legislation of similarpurpose or import; or
b. From any federal, state, county, municipal or other governmentalagency, Including, in the case of service-connected disabilities, theVeteran's Administration.
In case of reasonable doubt as to whether a Member should receivebenefits under this Agreement or from any such source, if the Memberseeks diligently to establish his rights to benefits from such other source,services will be furnished under this Agreement; provided, however,that the value of such services, at Prevailing Rates, shall be recov-erable by Health Plan or its nominee from such other source, or \fromthe Member, if and to the extent it is determined that monetary benefitsshould have been provided by such other source.
(4) Custodial, Domiciliary, or Convalescent Cars. Custodial care, domi-ciliary care, or convalescent care for which! in the judgment ofA theAttending Physician, the facilities and services of an acute gentralhospital and not medically required.
(5) Cosmetic Surgery and Dentistry. Conditions for which plastic sur-gery is indicated primarily for cosmetic purposes. Dental care anddental X-rays.
(6) Tuberculosis and Poliomyelitis. Tuberculosis after diagnosis andacute or contagious poliomyelitis after diagnosis and their complications.
B. LIMITATIONS. The rights of Members and obligations of HealthPlan, Hospitals and Medical Group hereunder are subject to the followinglimit ations:
(I) Major Disaster or Epidemic. In the event of any major disaster orepidemic,. Physicians and Hospital shall render Medical and HospitalServices Insofar as practical, according to their best judgment, withinthe limitations of such facilities and personnel as are then available,but neither Health Plan, Hospitals nor Medical Group shall have anyliability or obligation for delay or failure to provide Medical andHospital Services due to lack of available facilities or personnel if suchlack is the result of such disaster or epidemic.
(2) Circumstances Beyond Health Plan's Control. In the event that, dueto circumstances not reasonably within the control of Health Plan, suchas complete or partial destruction of facilities, war, riot, civil insurrec-tion, labor disputes, disability of a significant part of Hospital or MedicalGroup personnel, or similar causes, the rendition of Medical or HospitalServices hereunder is delayed or rendered impractical, neither HealthPlan, Hospitals, Medical Group nor any Physician shall have any liabil-ity or obligation on account of such delay or such failure to provideservices.
(3) Corrective Appliances and Artificial Aids. Artificial aids, such ascrutches or canes, and corrective appliances, such as braces, prostheticdevices, hearing aids, corrective lenses and eyeglasses, are not providedunder this Agreement, but Health Plan will attempt to make arrange-
40
ments whereby such aids and appliances may be obtained at reasonablerates; services necessary to determine the need therefor will be provided,
(4) Iniurios Caused Sy Third Portia,. In case of injuries caused by anyact or omission of a third party, and complications incident thereto,services and other benefits requested hereunder will be furnished but willbe charged at Prevailing Rates. However, the Member shall not berequired .to pay any amount in excess of the total amount collected on
iaccount of the njury.(5) Contagious Disaasos, Services are provided for contagious diseases
other than tuberculosis and acute or contagious poliomyelitis, only inaccordance with Section K of the benefit schedules described in Section5-A.
(6) Rohabilitation. Neuromuscular rehabilitation and postpolio rehabil-itation are excluded except as specifically provided in Section E-2 andSection L of the benefit schedules described in Section 5-A.
j7) Pre-wasting Conditions. Services are provided for Pre-existing Con-ditions only in accordance with Section H of the benefit schedulesdescribed in Section 6-B (7) of the Face Sheet.
7. CONVERSION AND TRANSFER
A. CONVERSION TO INDIVIDUAL ENROLLMENT. If any person who hasbeen a bona fide Member under this Agreement for at least ninety (90)days shall cease to be qualified to continue as a Member for any reasonother than:
11) Nonpayment of applicable charges or(2) Termination of Membership rights pursuant to Section 8;Then said person may, within thirty (30) days after termination of
rights under this Agreement, convert his membership to such classificationof Health Plan individual coverage as may be in effect at the time of hisapplication for conversion.
B. TRANSFER OF RESIDENCE. Members who transfer their residencefrom the Northern California Region to any geographical area not servedby Health Plan may, if they so desire, continue their Health Plan coverageby paying applicable charges. However, the only benefits provided outsideof Health Plan service areas are those specified in Schedule TWO, Section
B. For service benefits under Schedule ONE or Schedule TWO, Section A,the Member must return to the defined Service Area in Northern Cali-fornia or to another Health Plan service area identified in Schedule TWO,Section A.
Members who transfer their residence to another Health Plan Regionmust promptly apply to a Health Plan office in such Region for transferof their membership. Acceptance of transfer applications is discretionarywith Health Plan management in the Region to which transfer is sought;ordinarily, a person who has been a bona fide member in one Region forat least one year will be accepted for transfer.
No right to service benefits under Schedule TWO, Section A. shallexist in another Health Plan service area after a Member has lived in thevicinity of such service area more than 90 days, unless the Member, byprior application to Health Plan, demonstrates special circumstancesunder which a longer period is "temporary" and the Member's continuingstatus of temporary residence is confirmed in writing by Health Plan.
8. TERM AND TERMINATIONThis agreement shall continue in effect for one year from the effective date hereof and from year to year thereafter, subject to:
A. TERMINATION ON NOTICE. Termination by either party by givingwritten notice to the other party at least thirty (30) days prior to the anni-versary date.
B. INDIVIDUAL TERMINATION FOR CAUSE. In the event that Hospitalsor Medical Group shall, after reasonable efforts to establish and maintainsatisfactory hospital-patient or physician-patient relationships with anyMember, be unable to do so, then the rights of such Member and otherMembers of his family under this Agreement may be terminated on notless than fifteen (15) days' written notice to Subscriber. At the effectivedate of such termination, prepayments received on account of such termi-nated Member or Members applicable to periods after the effective dateof termination shall be refunded, all(' Health Plan shall have no furtherliability or responsibility under this Agreement.
C. leRMINATION BY HEALTH PLAN HOSPITAL AND OBSTETRICALBENEFITS. In the event that Health Plan terminates this Agreement pur-suant to Section 8-A, any Member who is a registered bed patient in aHospital at the effective date of termination shall receive these benefits:all benefits otherwise available hereunder to hospitalized patients, for thecondition under treatment, during the remainder of that particular episodeof hospitalization, until either (1) the expiration of such benefits, or (2) de-terminatir-n by the Attending Physician that hospitalization is no longer
medically indicated, whichever shall first occur. In maternity cases undercare at the effective date of termination Health Plan may either, atits election (a) continue obstetrical care only, through confinement anddischarge, subject to payment of applicable supplemental charges, or(b) convert the Member from group to individual membership. Except asexpressly provided in this Subsection, all rights to benefits shall cease asof the effective date of termination.
D. TERMINATION BY GROUP. In the event that Group terminates thisAgreement pursuant to Section 8-A, then all rights to benefits shall ceaseas of the effective date of termination. Health Plan will cooperate withGroup in attempting to work out equitable arrangements for continuingcare of Members who are hospitalized at the termination date.
E. DISCONTINUANCE OF HEALTH PLAN OPERATIONS. If, due to cir-cumstances beyond Health Plan's control, it shall become impractical, inthe judgment of Health Plan's Board of Directors, to continue the opera-tion of Health Plan within the Service Area, then Health Plan may termi-nate this Agreement at any time on thirty (30) days' written notice toGroup, and neither Health Plan, Hospitals nor Medical Group shall haveany further liability or responsibility by reason of or pursuant to thisAgreement after the effective date of such termination.
9. AMENDMENT
This Agreement, including the attached' schedules and addenda, may be amended by Health Plan pursuant to Section 9 of the Face Sheet.
10. MISCELLANEOUS PROVISIONS
A. ACCEPTANCE OF AGREEMENT. Group may accept this Agreementeither by execution of the acceptance provided on the Face Sheet or bymaking payments to Health Plan pursuant to Section 4-B hereof, andsuch acceptance shall render all terms and provisions hereof binding onHealth Plan and Group.
B. AGREEMENT BINDING ON MEMBERS. By this Agreement, Groupmakes Health Plan coverage available to persons who are eligible underSection 2; however, this Agreement shall be subject to amendment, modi-fication or termination in accordance with any provision hereof or bymutual agreement between Health Plan and Group without the consent orconcurrence of the Members. By electing medical and hospital coveragepursuant to this Agreement, or accepting benefits hereunder, all Memberslegally capable of contracting, and the legal representatives of all Membersincapable of contracting, agree to all terms, conditions and provisionshereof.
C. APPLICATIONS, STATEMENTS, ETC. Members or applicants for mem-bership shall complete and submit to Health Plan such applications,medical review questionnaires, or other forms or statements as HealthPlan may reasonably request; Members warrant that all information con-tained in such applications, questionnaires, forms or statements submittedto Health Plan incident to enrollment under this Agreement or the admini-stration hereof shall be true, correct and complete, and all rights tobenefits hereunder are subject to the condition that all such informationshall be true, correct and complete.
D. IDENTIFICATION CARDS. Cards issued by Health Plan to Memberspursuant to this Agreement are for identification only. Possession of aHealth Plan identification card confers no right to services or other bene-fits under this Agreement. To be entitled to such services or benefits theholder of the card must, in fact, be a Member on whose behalf all appli-cable charges under this Agreement have actually been paid. Any personreceiving services or other benefits to which he is not then entitled pursuantto the provisions of this Agreement shall be chargeable therefor at Pre-vailing Rates. If any Member permits the use of his Health Plan identi-fication card by any other person, such card may be retained by HealthPlan, and all rights of such Member pursuant to this Agreement shallbe immediately terminable at the will of Flealth Plan.
E. NOTICES. Any notice under this Agreement may be given by UnitedStates Mail, postage prepaid, addressed as follows:
If to Health Plan: Kaiser Foundation Health Plan, Inc.P.O. Box 116Oakland, California 94604
To the latest address provided for the Member onenrollment or change of address forms actuallydelivered to Health Plan.
To the address indicated in Section 10-E of theFace Sheet.
If to a Member:
If to Group:
41
SCHEDULE TWO-BENEFITS FOR SUBSCRIBERS AND FAMILY DEPENDENTS
OUTSIDE THE NORTHERN CALIFORNIA SERVICE AREA
This Schedule TWO supplements Schedule ONE and specifies the benefits available to Health Plan Members outside the Northern CaliforniaService Area.These benefits are added to assist a Member who sustains accidental injury or becomes ill while temporarily away from his regular residence and
from the Health Plan Service Area in Northern California. Accordingly, such benefits are limited to emergencies or other circumstances in which care isrequired immediately and unexpectedly; elective care or care required as a result of circumstances which could reasonably have been foreseen prior todeparture from the Northern California Region is not covered.
A. SERVICE BENEFITS IN OTHER HEALTH PLAN SERVICE AREAS
Health Plan, either directly or through an affiliated corporation, con-ducts direct-service hospital and medical care programs in the GreaterLos Angeles Area in California, on the Island of Oahu, Hawaii, and inPortland, Oregon and vicinity. Members regularly residing in the NorthernCalifornia Region, while temporarily in another Health Plan service area,may receive hospital and medical services for emergency or other non-elective medical care requirements. To obtain such services Members mustapply to a hospital or medical office, within such service area, which iscovered by a contractual arrangement maintained by Health Plan for
hospital or medical services and must pay applicable supplemental charges.Services and supplemental charges shall be those prevailing in such
service area for the Health Plan coverage generally provided within theservice area which is most nearly comparable to the Member's coverage inthe Northern California Region.
A description of such other service areas and a list of contractinghospital and medical office faclities located therein may be obtained atany Health Plan office in the Northern California Region upon request.
B. ADDITIONAL BENEFITS OUTSIDE THE NORTHERN CALIFORNIA SERVICE AREASubject to all the terms and conditions of the foregoing Service Agree-
ment as modified and supplemented by this Schedule 'TWO, a Member isentitled to monetary benefits as provided in, and subject to the limitationsof, this Section B.
1. Accidental Injury Outside Northern California Service Area. If a Mem-ber, while outside the Northern California Service Area, is accidentallyinjured and receives emergency treatment, Health Plan shall, subject tothe limitations hereafter set forth, pay such Member up to an aggregatemaximum of $500.00 on account of expenses actually incurred by suchMember for;
emergency medical services;emergency hospital services;
c. emergency ambulance service.
2. Emergency Illness Outside Northern California Service Area. If a Mem-ber becomes ill and requires emergency hospitalization while temporarilymore than thirty miles from his regular place of residence and outside theNorthern California Service Area, Health Plan shall, subject to the limi-tations hereafter set forth, pay such Member up to an aggregate maximumof $500.00 on account of expenses actually incurred by such Member for:
a. hospital services received as a registered bed patient in a generalhospital;
b. medical services received as a registered bed patient in a generalhospital;
c, emergency ambulance service.
a.b.
Obstetrical Cases. Payment as outlined above will be made on accountof emergency hospitalization required as a result of complications of preg-nancy but not for normal delivery. Any unpaid portion of the supplementalcharge specified in Schedule ONE, Section J, will be offset against amountsotherwise payable hereunder.
3. Continuing or Follow-up Treatment. Monetary payment on account ofaccidental injury or emergency illness is limited to emergency care requiredbefore the Member can, without medically harmful or injurious conse-quences, return to the Northern California Service Area or a Hospital orMedical Office in the nearest Service Area. Benefits for continuing orfollow-up treatment are provided only at an appropriate Hospital or Med-ical Office in the nearest Service Area. If the Member obtains prior ap-proval from Health Plan or a Physician in Vic nearest Service Area, aportion of the $500.00 allowance may be applied toward the cost of neces-sary ambulance service or other special transportation arrangements med-ically required to transport the Member to such Service Area for contin-uing or follow-up treatment.
4. Notification and Claims. Any Member having an emergency illnesswithin the scope of Section B-2 shall notify a Northern California HealthPlan office within forty-eight (48) hours after care is commenced.
No claim pursuant to this Section B shall be allowed unless a completeapplication for payment, on forms to be provided by Health Plan, is filedwith a Health Plan office in the Northern California Region within sixty(60) days after the date of the first service for which payment is requested.
42
KA/5ER FOUNDATION HEALTH PLAN, INC.NORTHERN CALIFORNIA REGION
SCHEDULE ONE-B MEDICAL AND HOSPITAL SERVICES
GROUP MEMBERSHIP, B COVERAGE
Subject to all terms, conditions and definitions in the foregoing Service Agreement, Members holding "B" coverage are entitled toreceive the Medical and Hospital Services and other benefits set forth in this Schedule, upon payment of specified supplemental charges.These services and benefits are available only in the Northern California Service Area and only if and to the extent that they are (1) pro-vided, prescribed or directed by a Physician, and (2) requested and, except for house calls pursuant to Section C, contagious disease bene-fits pursuant to Section K, and special benefits under Section M, received at a Hospital or Medical Office, all as defined in Section 1 ofthe Service Agreement.
For services and other benefits available outside the Northern Califoinia Service Area, see Schedule TWO.
A. MEDICAL CARE IN HOSPITAL AND OFFICE1. CARE WHILE HOSPITALIZED. All services of Physicians and
para-medical personnel as requested or directed by the AttendingPhysician, including operations, other surgical procedures, anesthe-sia, consultation with and treatment by specialists, laboratory andX-ray services as specified in Section D, and physical therapy asspecified in Section E-1, are provided without charge while theMember is admitted to a Hospital as a registered bed patient.
2. CARE IN MEDICAL OFFICES OR EMERGENCY DEPARTMENTS.
a. Diagnosis and Treatment. All services of Physicians and para-medical personnel, as requested or directed by the Attending Physi-cian, including surgical procedures, eye examinations for glasses,and consultation with and treatment by specialists, are provided atMedical Offices and Hospital emergency departments upon paymentof a $1.00 registration charge per visit.
b. Preventive Services. In addition to diagnosis and treatment,Physicians' services for health maintenance, including physicalcheck-ups and other preventive medical services, are provided uponpayment of a $1.00 registration charge per visit. X-ray and labora-tory examinations in conjunction with physical check-ups are pro-vided pursuant to Section D.
Physical examinations required for obtaining or continuingemployment or governmental licensing are not provided underHealth Plan coverage.
B. HOSPITAL CARE.For each injury or illness requiring hospitalization, including
its recurrences and complications, 111 days of prescribed hospitalcare will be provided during each calendar year without charge.Hospital care includes room and board and general nursing carewhile the patient is admitted to the Hospital as a registered bedpatient, and the following additional facilities, services and suppliesas prescribed: use of operating room, private room, intensive careroom and related hospital services; special diet, special-duty nursing,and medications and supplies as specified in Section F. Prescribedblood transfusions are provided without charge if blood is replacedat a Medical Group Blood Bank. If blood is replaced at any otherblood bank, the Member is responsible for the applicable processingcharge. Prevailing Rates will be charged if blood is not replaced.(A blood transfusion program is available to satisfy blood replace-ment obligations for Members desiring to make periodic bloodcontributions.)
C. HOUSE CALLS FOR EMERGENCIES OR ACUTECONDITIONS.
All necessary house calls by Physicians for emergencies oracute conditions, and by visiting nurses when prescribed by a Phy-sician, are provided within House Call Service Areas. For Physi-cians' house calls, payment in accordance with the followingschedule is required:
Calls requested or made between9 A.M. and 5 P.M.
Calls requested and made between5 P.M. and 9 A.M.
$3.50 per call
$5.00 per call
An additional charge of $2.00 will be made for each additionalMember who requires attention at the same household.
No charge is made for prescribed calls by visiting nurses.If, in the Physician's judgment, more than two house calls are
required during a particular episode of treatment on account of anemergency or acute condition, no further payment for house callsis required after the second house call.
D. X-RAY AND LABORATORY.All prescribed X-ray and laboratory tests and services, includ-
ing diagnostic X-rays, X-ray therapy, fluxoscopy, electrocardio-grams, metabolism, blood and urine and other laboratory tests,and diagnostic clinical isotope services, are provided without charge.
E. PHYSICAL THERAPY AND NEUROMUSCULARREHABILITATION.
1. PHYSICAL THERAPY. Prescribed physical therapy will be pro-vided upon payment of a $1.00 registration charge per visit. Physi-cal therapy prescribed hereunder is limited to conditions which, inthe judgment of the Attending Physician, are subject to significantimprovement through relatively short-term therapy.
2. NEUROMUSCULAR REHABILITATION. More extensive specializedphysical medicine and rehabilitation services, including physicaltherapy, provided at the Kaiser Foundation Rehabilitation Centerin Vallejo, are available to Members at Health Plan Rates if theAttending Physician and the Kaiser Foundation RehabilitationCenter medical staff, after consultation, are of the opinion that theMember is apt to derive substantial benefits from a course oftreatment of limited duration at the Rehabilitation Center. Hospital-ization at the Kaiser Foundation Rehabilitation Center primarilyfor purposes of Neuromuscular Rehabilitation will be provided atHealth Plan Rates.
F. PRESCRIBED MEDICATIONS.A reasonable charge is made for medications, for injectables,
for radioactive materials used for therapeutic purposes, for allergytest and treatment materials, and for supplies furnished to out-patients at Medical Offices, at Hospital emergency departments,or on house calls. A moderate charge may be made for adminis-tration of medications supplied by the patient.
During the 111-day period of prepaid hospitalization specifiedin Section B of this Schedule, all prescribed medications, injectables,radioactive materials used for therapeutic purposes, allergy mater-ials and supplies are provided without charge.
Prescribed dressings and casts are provided without charge toMembers at Hospitals, Medical Offices or on House Calls.
G. EMERGENCY AMBULANCE SERVICE.Necessary ambulance service will be provided without charge
within the Service Area if such service is ordered or approved bya Physician.
H. PRE-EX'::ING CONDITIONS.In the case of any Pre-existing Condition, Members are en-
titled to the same benefits upon the same conditions as are other-wise specified in this Schedule, subject, however, to the followingprovisions:
1. NO ADDIT IONAL PAYMENT. Services of Physicians and para-medical personnel as specified in Sections A and C are furnishedon payment of supplemental charges as provided in said Sections.
2. HEALTH PLAN RATES. All other benefits listed in Sections Bthrough E except prescribed special-duty nursing and blood trans-fusions are previded upon payment of Health Plan Rates. Pre-scribed items as specified in Section F are provided at reasonablerates to both outpatients and hospitalized patients.
3. PREVAILING RATES. Special-duty nursing is provided at Pre-vailing Rates.
4. ROOD TRANSFUSIONS. Prescribed blood transfusions areprovided on the same basis and subject to the same charges asspecified in Section B.
J. OBSTETRICAL CARE.
Full obstetrical care, after pregnancy is confirmed, includingall applicable benefits set forth above, is provided upon payment of$60.00 if confinement is due after ten months' continuous member-ship, or upon payment of $140.00 if confinement is due before tenmonths' continuous membership. The supplemental charges speci-fied in Section A of this Schedule will not be made for obstetricalcare.
Obstetrical care includes the following services for the motherbefore and during confinement and during the post partum period:Hospital care, including use of delivery room; all services ofPhysicians including operations and special procedures such asCaesarean sections if necessary; anesthesia; medications, includinginjectables; X-ray and laboratory services as required for conditionsrelating to pregnancy.
Outpatient medications, including injectables, are subject to areasonable charge.
Care for the newborn child is provided during the mother'sconfinement.
INTERRUPTED PREGNANCY. If care is required for interruptedpregnancy, Prevailing Rates shall be charged for all services rend-ered, but payment required hereunder shall not exceed two-thirdsof the payment above specified for full obstetrical care.
INFERTILITY STUDIES. If requested by a Member, an infertilitystudy series will be conducted under the direction of a Physicianupon payment of a reasonable charge for the tests.
ula
43
K. CONTAGIOUS DISEASES.Diagnostic services and house calls are provided for contagious
diseases; however, house calls are not provided for tuberculosis oracute or contagious poliomyelitis after diagnosis. Hospitalizationwill be provided if a Member is hospitalized at the direction of aPhysician for treatment of a contagious disease in a Hospital.
In the case of contagious diseases, other than tuberculosis oracute or contagious poliomyelitis, for which isolation facilities ortechniques are either required by Public Health authorities ormedically recommended, and which, in the judgment of the Attend-ing Physician, require hospital care, a Member, who is admitted atthe direction of his Attending Physician to a hospital which doesnot contract with Health Plan, for treatment of such a contagiousdisease, will be reimbursed up to an aggregate maximum of $300.00on account of expenses actually incurred by such Member forhospital and medical services. A current list of such contagiousdiseases may be obtained from any Health Plan office upon request.
A portion of the $300.00 allowance may be applied towardthe cost of necessary ambulance service to a hospital which doesnot contract with Health Plan if such service is ordered by aPhysician.
All benefits for treatment of contagious diseases are subject toall the terms and conditions contained in this Ben,fit Schedule,including supplemental charges.
L. POST-POLIO REHABILITATIVE CARE.If ordeied by the Attending Physician, post-polio rehabilita-
tion, following the contagious and acute stage, provided at theKaiser Foundation Rehabilitation Center in Vallejo, including hos-pitaiization, if necessary, and incidental Hospital and MedicalServices as medically indicated, is furnished to Members withoutcharge under these circumstances:
1. This benefit is limited to persons who (a) contracted polio-myelitis after March 31, 1954, (b) were Members prior to contract-ing poliomyelitis, and (c) have maintained continuous membership.
2. Rehabilitative care under this benefit is limited to the lesserof (a) a maximum period of one year or (b) a maximum value .of$2,500 computed at Prevailing Rates for all services rendered.
M. PAYMENT IN LIEU OF SERVICE BENEFITS.If, in the professional judgment of Medical Group, a Member
requires Medical or Hospital Services included in the coverage ofthis Service Agreement which require skills not available withinMedical Group or facilities not available in Hospitals and MedicalOffices, and Medical Group determines that it would be in the bestinterests of the Member to obtain care from another source in thecommunity, then, upon written referral by Medical Group, pay-ment, in lieu of service benefits hereunder, will be made for pre-scribed services within the coverage of this Agreement subject tothe following limits: Medical Services will be reimbursed under theCalifornia Medical Association's Relative Value Study, Third Edi-tion, using a unit value of $4.00. Charges for Hospital Serviceswill be reimbursed in accordance with the benefits to which theMember would be entitled at a contracting Hospital.
44
KALSER FOUNDATION HEALTH PLAN, INC.A Nonprofit Corporation
Northern California Region
AMENDMENT I TO
GROUP MEDICAL AND HOSPITAL SERVICE AGREEMENT
Subsection 0 of Section 1. DEFINITIONS, is amended as follows.
1. DEANITIONS
0. "Service Area" shall mean that geographical area within the sixteen Northern Californiacounties (Alameda, Amador, Contra Costa, El Dorado, Marin, Napa, Placer, Sacramento, San Fran-cisco, San Mateo, Santa Clara, Solano, Sonoma, Sutter, Yolo and Yuba) lying within a radius ofthirty miles of any Hospital or Medical Office.
May 1, 1965
AMENDMENT II TO
Effective July 1, 1965, in the case of any Pre-Existing Condition, Members
are entitled to the same benefits upon the. same conditions as are otherwise speci-
fied in the applicable Benefit Schedule. Therefore, the Group Medical and Hospital
Service Agreement and the applicable Benefit Schedule or Schedules are amended
as follows:
A. Group Medical and Hospital Service Agreement
1. Section 1-Q Pre-Existing Condition, is deleted.
2. Section 6-B, the limitation on Pre-Existing Conditions is deleted.
B. Applicable Benefit Schedule or Schedules
Section H. PRE-EXISTING CONDITIONS, is deleted.
V. D
IGE
STS
OF
GR
OU
P IN
SUR
AN
C2
PLA
NS
FOR
PUB
LIG
SCH
OO
L P
FRSO
NN
EL
, 196
4-65
, MA
XIM
UM
AL
LO
WA
NC
ES
AN
D B
EN
EFI
TS
Dollar anemias shown in () are cbarges to the imdividual foc the specified beasfit.
Dollar amounts shown in [
] are deductibles which must be satisfied by
tha individual before
coin
sura
acecaa be applied or benefits received.
School system and
underwriter of
hodltl, plan
1
Egpita teat 91aL
Sorsiro
Daily room
Allow-
Benefits
and board
ances
Mod
ica
Allo
wan
ces
Ben
efits
.Jrn
Al w
eave
sM
ater
nity
Com
ing
for nom' 4olivy
after
23
45
67
Altownsoes
Sematite
1.0
retir
emen
t
risoostaz
Coot
per
Contributor
memtk
Stratum 1--enrollment
CALIFORNIA
California phy-
sicians service
Blue Cross witk
major
med
ical
!"
100.000 and over
3 or more bed
ward for 180
days per ill-
ness
3 or more bed
ward for 180
days per ill-
ness
Occidental Life
Major medics'.
Raiser Younda-
Full coverage
tion
for 125 days
per year, 1/2
rate for 240
days
Ross3.1.00s and
Independent Life
$22.00/day,
4500.00 maximum
hospital care,
thereafter 807
coinsurance to
410,000
4200.00 Appendectomy
$5.00
100.00
Tonsillectomy
300.00 Single opera-
tion
150.00 Appendectomy
50.00 Tonsillectomy
Major medical
5.00
10.0
0
3.00
3.00
4.50
225.00
Per day for 180 days
in hospitel
Office visit
Home call, home and
office visit for
employee only;
start 3rd day of
illness; 100 vis-
its/year
Hospital visit
Office visit
Home call
Per year for all
visits
Major medical
Pull coverage
Pull cover-
In hospital and of-
age
fice visits
(5.00)
Home call, no limit
Full cuverage
Full cover-
age
(2.00)
(5.00)
Hospital visits
Office visit
Home call
[4100.00I
80%
420,000.00
Deductible/yr.
#50.00
Coinsurance
Per lifetime
[4100.00]
Deductible/yr.
SO%
Coinsurance
420,000.00 Per lifetime
[4200.00]
Deductible/yr.
807.
Coinsurance for
hospital
100L
Of scheduled
medical and
surgical
420,000.00
Per lifetime
None
None
Nw.pital care Excludes ma-
jor medical
50.00
Noepital care Reduced bene-
fits
Major medicel Same coverage
Full coverage Same coverage
after 10
months' mem-
bership
Before 10
months' mom-
bersbip
125.00
Hospital care Same coverage
(50.00)
Normal deliv-
ery and phy-
sician visits
Individual
$ 4.
71em
ploy
ee 0
)7.
38em
ploy
ee (
V)
5.00
system
Family
21.33
employee
5.00
system
Individeal
5.32
employee
(10
7.45
employee (V)
5.00
system
family
21.41
employee
5.00
system
Individual
0.70
employs*
5.00
system
Family
10.89
employe:
5.00
system
Iudividual
4.05
employee
5.00
system
Family
20.45
employee
5.00
system
Individual
6.04
employee
5.00
system
Family
20.97
employee
5.00
system
DIs
pa
Pacific Mutual
Major medical
Major medical
Major medical
[475.00]
Deductible/yr.
Major medical Same coverage
Individual
Life Insurance
Co.
80%
Coinsurance for
hospital
None
employee
7.58
system
1007.
Of scheduled
medical and
surgical
Family
18.17
employee
7.58
system
420,000.00
Per lifetime
DISTRICT OF COLUMBIA
Washinaton
Blue Cross-
semi-private for
120.00 Appendectcmy
18.00
1st day in hospi-
[4100.001
Deductible/ill-
Basic cow-
Hospital care Sane coverage
Iudividual
6.32
employee
Blue Shield!!!
365 days per
55.00 Tonsillectomy
tal
ness
*rage
illness
12.00
2nd day
80%
Coinsurance
85.00
Normal deliv-
2.82
system
6.00
Thereafter to 365
days
430,000.00
Per lifetime
Basic cov-
erage
ery
Physicians AS..
iti
zzmily
17.07
employee
6.76
system
12
Group Health
Association!'
Aetna Life
Insurance
FLORIDA
Dade Co. (Miami)
Blue Cross-
Blue Shield
Full coverage
Major medical
$15.00/day for
120 days per
illness
Duval Co. (Jacksonville)
Protective Life
Insurance Co.
GEORGIA
Atlanta
Blue Cross-
Blue Shield
LOUISIANA
Orleans Parish
(P.O. Ne: Orleans)
Blue Cross and
Standard Life
MARYLAND
$11.00/day for
70 days per
year extended
coverage
$7.00/day for
70 additional
days
$15.00 for pri-
vete, semi-
private full
coverage for
30 days per
illness
$14.00/day for
125 days after
[$25.00] de-
ductible, ex-
tended cover-
age $10,000
Baltimore
Educators Mutual
$12.00/day for
Insurance Co.
70 days per
illness
Montgomery Co.
Blue Cross-
Blue Shield
Full coverage for
31 days pee
illness; there-
after $0.00/
day to 180 addi-
tional days
34
56
79
10
11
12
13
Full coverage
Full cover-
age
$ (5.00)
Hospital and office
visits
First home call in
each 411ness
$(50.00)
Full cov-
erage
Hospital care
Normal deliv-
eryandphysi-
cians visits
Same coverage
Individual
$11.18
employee
2.82
system
Family
28.75
employee
6.76
system
Major medical
Major medical
[$50.00]
Deductible/yr.
Major medical
Same coverage
Individual
100%
First $1,000 for
hospital care
6.15
employee
2.82
system
80%
Coinsurance
Family
$40,000.00
Per lifetime
16.75
employee
6.76
system
$333.00
Single operation
12.00
1st day in hos-
[$100.00]
Deductible/yr.
100.00
Hospital care
Excludes ma-
Individual
117.00 Appendectomy
pital
80%
Coinsurance
83.00
Normal deliv-
jor medical
8.10
employee
50.00
Tonsillectomy
5.00
Thereafter to 120
days
$10,000.00
Per lifetime
ery
1.67
system
Family
21.85
employee
1.67
system
200.00
single operation
100.00 Appendectomy
None
None
100.00
Normal deliv-
ery
N.I-
Individualb/ -
4.95
employee
30.00 Tonsillectomy
None
system
Familyt!
10.95
employee
Nom
system
250.00
Single operation
Major medical
[$100.00]
Deductible/yr.
10
..ys
Hospital care
N.I.
Individual
125.00
Appendectomy
807.
Coinsurance
75.00
Normal deliv-
12.24 to 4.70 emp.
42.50 Tonsillectomy
$10,000.00
Per lifetime
ery
None to 1.00 sys.
Family
33.10 to 13.72 amp.
Mom to 1.00 sys.
200.00
Single operation
Per day for 50
$5,000.00
Over 3 years
10 days
Hospital care
Same coverage
Individual
100.00 Appendectomy
days in hospi-
for spec-
50.00
Normal deliv-
6.47
employee
35.00 Tonsillectomy
tal
ified dis-
eases
ery
None
system
Family
17.60
employee
None
system
300.00
single operation
75.00
All physician's
visits
100.00
Imp stmt
N.I.
IndividualW
7.63
employee
None
system
17.89
employee
None
system
300.00
Single operation
15.00
1st visit in hos-
[$150.00]
Deductible/90
150.00
Hospital care
Same coverage
Individual
120.00 Appendectomy
pital
dayn
105.00
Normal deliv-
3.077.
employee
60.00 Tonsillectomy
10.00
2nd and 3rd
807.
Coinsurance
ery
3.07
system
5.00
Thereafter to
$10,000.00
Per illness
Family
177 visits
8.70
employee
8.70
system
DIGESTS OF GROUP HEALTH INSURANCE PLANS FOR PUBLIC-SCHOOLPERSONNEL, 1964-65, MAXIMUM ALLOWANCES AND BENEFITS (Continued)
Dollar amounts shown in () are charges to the individual for the
specified benefit.
Dollar amounts shown in [
] are deductibles which must be satisfied by
the individual before coinsurance can be applied or benefitsreceived.
School system and
underwriter of
health
lan
Hos italization:
Daily room
and board
Surgical
Allow-
Benefits
ances
12
34
Stratum 1.--enrollment 100,000 and over (Cont.)
MARYLAND (Cont.)
Prince Georges Co.
(Upper Marlboro)
Blue Cross-
Blue Shield
Semi-private for
180 days per
illness
$300.00
Single operation
120.00 Appendectomy
55.00 Tonsillectomy
MICHIGAN
Detroit
$22.00/day for
365 per ill-
ness
Scheduled fees
Provident Lae
and Accident
Ins.
MISSOURI
St. Louis
Blue Cross-
$12.00 forprivate,
300.00
Single operation
Blue Shielee
semi-private,
150.00
Appendectomy
full coverage
for 70 days per
illness; extend-
ed coverage at
50.00
Tonsillectomy
$6.00 for 180
days
Continental
$20.00/day for
300.00
Single operation
Casualtya/
120 days per
200.00
Appendectomy
illness
50.00
Tonsillectomy
NEW YORK
New York City
Health Insurance
Semi-private for
Full coverage
Plane
21 days per ill-
ness, extended
coverage for
180 days @ 507
discount
OHIO
Cleveland
Blue Cross-
2 or 3 bed ward
50.00
Single operation
Blue Shield
for 730 days
165.00
Appendectomy
per illness
75.00
Tonsillectomy
Medical
Major medical
Maternity provisions
for normal delivery
Coverage
after
retirement
NN
IIN
IN
Fiaancine
Allowances
Benefits
Allowances
Benefits
Cost per Contributot
mocth
Allowances
Benefits
56
78
910
11
12
13
$ 15.00
1st day, start 3rd
day in hospital
None
$ 100.00
85.00
Hospital care
Normal delive:y
N.I.
Individual
All
employee
10.00
2nd day
Noce
system
5.00
Thereafter to 177
days
Family
All
employee
None
system
15.00
1st day in hospital
($50.00]
Deductible/yr.
Basic cov-
Hospital, nor-
Individual
6.00
2nd - 19th
807.
Coinsurance
erage
mal delivery
$ 1.23
employeeSt
4.80
Thereafter to 365
days
$10,000.00
Per lifetime
and physi-
cians visits
9.21
system
Family
11.46
employee
16.48
systeMEr
5.00
2nd - 8th day in
hospital
[$100.00]
Deductible/3
months
Basic cov-
erage
Hospital care
N.I.
Individual
7.35
employee
3.00
Thereafter to 70
75%
Coiasurance
90.00
Normal delivery
None
system
days
$5,000.00
Per illness
Family
1.00
Additional for 2nd
visit
20.00
employee
Noce
system
5.00
Per day for 120 days
[$500.00]
Deductible/ill-
10 days
Hospital care
Same coverage
IndividualE/
in hospital
ness
100.00
Normal delivery
5.04
employee
($750.00]..
Deductible age
50 and over
None
syscem
yemily7S!
807.
Coinsurance
14.16
employee
$10,000.00
Per two years
Noce
system
Full coverage
None
80.00
Hospital care
Same coverage
Individual
$750.00 maximum out-
side medical group
care
Full cov-
erage
Normal delivery
and physi-
cians visits
4.70
employee
4.67
system
Family
12.45
employee
12.41
system
15.00
let day in hospital
5.00
Next 29 days
4.00
Next 90 days
4.00
Per visit next 610
days after [$50.00],
deductible for post -
hospital care
5.00
Office visit
7.50
Home call
None
Basic cov-
Hospital care
V.I.
erage
60.00
Normal delivery
Individual
11.75
employee
None
system
pally
23.50
employee
None
system
12
Columbus
Blue Shield
Semi-private
for 120 days
per illness
PENNSYLVANIA
Philadelphia
Blue Cross-
Semi.private for
major medicAl
120 days per
illness
TENNESSEE
Memphis
Metropolitan Life Major medical
Insurance Co.
TEXAS
Dallas
Blue Cross-Blue
Shield, major
medical
Houston
Blue Cross-
Blue Shield
$12.00/day for
70 days per
illness
$12.00/day for
120 days per
illness after
($25.00] de-
ductible
WISCONSIN
Milwaukee
Blue Cross-
Semi-private
Blue Shield,
for 70 days
major medical
per illness
Stratum 2--enrollment 50.000-99,999
ALABAMA
Jefferson Co.
(excl. Birmingham)
Blue Cross-
Blue*Shield
Semi-private for
70 days per
illness after
1$25.00] de-
ductible
35
67
89
1011
12
13
$300.00
Single operation
$ m
oolst day in hosp.
None
$80.00
Hospital care
N.I.
Individual
125.00 Appendectomy
5.00
Next 3 days
50.00
Normal delivery
$ 4.77
employee
60.00 Tonsillectomy
4.00
Thereafter to 12C days
None
system
Family
13.40
employee
None
system
300.00
Single operation
15.00
1st day in hospital
[$100.00]
Deductible/yr.
6 days
Hospital care
Reduced bene-
Individual
10.00
2nd
80%
Coinsurance
fits
4.09
employee
4.00
Next 8 days
$25,000.00
Per lifetime
part
system
3.00
Thereafter to 70 days
Family,
4.00
Office visit
15.06
employee
5.00
Home call, office and
home visits for em-
ployee only, start
part
system
4rh day to 21 days
per year
Major medical
Major medical
[$50.00]
Deductible/yr.
150.00
Normal delivery
Reduced bene-
Individual
100%
Next $300.00
hospital care
fits
2.25
employee
part
system
80%
Coinsurance
Family
$10,000.00
Per lifetime
10.28
employee
part
system
390.00
Single operation
5.00
Per day for 30 days
1$100.00]
Deductible/yr.
10days
After [$25.00]
Same coverage
Individual
150.00 Appendectomy
in hospital
80%
Coinsurance
deductible
2.65
employeeb/-
40.00 Tonsillectomy
$5,000.00
Per year
hospital care
4.17
system
$10,000.00
Per lifetime
75.00
Normal delivery
irelLY.
11.00
employee=i
4.17
system
300.00
Single operation
150.00
Appendectomy
4-6.00
Per day in hospi-
tal
($100.00]
Deductible/90
days
Basic cov-
erage
Hospital care
Same coverage
Individual
3.63
employeeh!
300.00
Maximum
80%
Coinsurance
75.00
Normal delivery
4.17
system
$10,000.00
Per year
6.00
1st 5 physi-
cian's visits
Family
13.95
employeehl
5.00
Next 5 visits
4.17
system
1,000.00
single operation
4.00
Per day for 70 days
[$100.00]
Deductible/yr.
Basic cov-
Hospital care
N.I.
Individual
150.00
Appendectomy
in hospital
807
Coinsurance
erage
None
employee
75.00 Tonsillectomy
$10,000.00
Per lifetime
85.00
Normal delivery
9.94
system
Family
16.61
employee
9.94
system
200.00
Single operation
100.00
Appendectomy
3.00
Per day for 70 days
in hospital
None
10 days
50.00
Hospital care
Normal delivery
Same coverage
Individual
3.91
emp1oyee00
25.00
Tonsillectomy
5.01
employee.°
None
system
Family
11.61
employee
None
system
.c-
m)
DIGESTS OF GROUP HEALTH INSURANCE PLANS FOR PUBLIC-SCHOOL PERSONNEL,
1964-65, MAXIMUMALLOWANCES AND BENEFITS (Continued)
Dollar amounts shown in () are charges to the individual for the
specified benefit.
Dollar amounts shown in [
] are deductibles which must be satisfied by
the individual before coinsurance can be applied or benefits received.
School system and
underwriter of
health plan
Hospitalization:
Surgical
Medical
Major medical
Maternity provisions
for normal delivery
Coverage
after
retirement
Financing
Daily room
and board
Allow-
ances
Benefits
Allowances
Benefits
Allowances
Benefits
Cost per Contributor
month
Allowances
Benefits
12
34
56
78
910
11
12
13
Stratum 2--enrollment 50,000-99.999 (Cont.)
ALABAMA
Mobile County
Protective Life
$12.00/day for
$225.00
Single operation
$4.00
Per day for 70 days
01,000.00] Deductible of
$100.00
Hospital care
Same coverage
Individuallf
Insurance Co.
70 days per
100.00
Appendectomy
in hospital
covered ex-
and normal
$ 9.10
employee
illness after
025.00] de-
deductible
25.00
Tonsillectomy
pense per
year
807;
Coinsurance
delivery
None
system
FastIA
/16.32
employee
$5,000.00
Per lifetime
None
system
CALIFORNIA
Fresno
Blue Shield
3 or more bed
1,500.00
Single operation
5.00
Per day for 180
0100.001
Deductible/yr.
50.00
Hospital care
Same coverage
Individual
ward for 180
275.00
Appendectomy
days in hospital
807;
Coinsurance
30.00
Normal delivery
2.84
employee
days per ill-
ness
130.00
Tonsillectomy
Varies
Office and home vis-
its based on fee
schedule for em-
ployee only, starts
$10,000.00
Per lifetime
6.00
system
Family
12.97
employee
6.00
system
3rd day of illness,
50 visits per year
Long Beach
Family Health
Program
Ward for 125
days per ill-
ness
Full coverage
Full cover-
age (1.00)
(5.00)
In hospital
Office visits
Home calls no limit
None
Full cover-
age
For hospital,
delivery, and
physicians
visits
Same coverage
Individual
1.00
employee
6.18
system
Family
15.67
employee
6.18
system
Prudential
Major medical
Major medical
Major medical
050.001
Deductible/yr.
75.00
Lump sum
Same coverage
Individual
Insurance
1007;
Scheduled fees
for surgical
and medical
None
employee
6.18
system
Family
807;
Hospital care
16.80
employee
$10,000.00
Per lifetime
6.18
system
Kaiser Founda-
Full coverage
Full coverage
Full cover-
Hospital and office
None
(100.00)
Full coverage
Same coverage
Individual
tion
for 125 days
per year, 1/2
rate for 240
days
age (5.00)
visits
Home call
(175.00)
after 10
mos. member-
ship
Before 10 mos.
membership
2.12
employee
6.18
system
Family
19.54
employee
6.18
system
Oakland
Kaiser Founda-
tion
Full coverage
for 111 days
for illness in
Full coverage
Full cover-
age (1.00)
Hospital visits
Office visit
None
(60.00)
Full coverage
after 10 mos.
membership
Same coverage
Individual
0.20
employee
8.00
system
one year
(3.50)
1st 2 routine home
calls, no charge
thereafter
(140.00)
Before 10 mos.
membership
Family
14.95
employee
8.00
system
Blue Cross and
major medical
3 bed ward fot 180 600.00
days per ill-
ness
Single operation
4.00
4.00
Per day for 180
days in hospital
Office visit
0100.001
Deductible/yr.
807;
Coinsurance
$10,000.00
Per lifetime
50.00
Hospital care
Same coverage
Individual
2.03
employee
8.00
system
6.00
Home call
Family
300.00
Maximum for office
and home visits
19.11
employee
8.00
system
San Francisco
Bay Medical
Group
Full coverage
Full coverage
Full cover-
age
Hospital days
None
Full cover-
age or
Within serv-
ice area
N.I.
Individual
4.70
employee
(1.00)
(5.00)
Office visit
Home call
100.00
Lump sum upon
election of
member
33%
system
Family
17.76
employee
Part
system
Basic and major
edical
Fee schedule
Fee schedule
Yee schedule
5 visits/month for
office or home
visits
0200.001
757,
$12,500.00
$20,000.00
Deductible/yr.
Coinsurance
Per year
Per lifetime
$120.00
Lump sum
Same coverage
Individual
67%
employee
33%
system
Family
N.I.
Kaiser Founda-
Full coverage for
Full coverage
Full cover-
In hospital and
Non
eFull cover-
Subscriber
Same coverage
Individual
tion
111 days per
age
office
age
$ 5.02
employee
illness per
year
$ (1.00)
Office visit for
dependents
(60.00)
Dependent
33%
system
Family
(3.50)
1st 2 routine home
calls, no charge
thereafter
19.02
employee
Part
system
FLORIDA
Broward Co.
(Ft. Lauderdale)
Blue Cross-
$14.00/day for
$333.00
Single operation
12.00
1st day in hospital
0100.001
Deductible/yr.
80.00
Hospital care
N.I.
Individual
Blue Shield,
major medical
70 days per
illness
5.00
Thereafter to 31
days per year
80%
$10,000.00
Coinsurance
Per lifetime
83.00
Normal delivery
and physicians
visits
6.05
employee
None
system
Family
16.89
employee
None
system
Orlando Co. (Orlando)
Blue Cross-
Semi-private
333.00
Single operation
12.00
1st day in hospital
None
$100.00
Hospital care
Sane coverage
Individual
Blue Shield
for 120 days
117.00
Appendectomy
5.00
Thereafter to 120
83.00
Normal delivery
All
employee
per illness
50.00
Tonsillectomy
days
None
system
Family
All
employee
None
system
Protective
$12.00/day for
250.00
Single operatioo
None
None
100.00
Normal delivery
Same coverage
Individual
Life
120 days
per illness
4.95
employeell
None
system
Family
10.95
employeeki
None
system
Palm Beach Co.
(Vest Palm Beach)
IlumCross-
$18.00/day for
333.00
Single operation
12.00
1st day in hospital
0100.001
Deductible/yr.
80.00
Hospital care
Major medical
Individual
Slue Shield,
maj
or m
edic
al31 days per
illness
117.00
50.00
Appendectomy
Tonsillectomy
5.00
Thereafter for
31 days
80%
$10,000.00
Coinsurance
Per lifetime
83.00
Normal delivery
reduced ben-
efits
4.29
employee
None
system
Aramily
14.53
employee
None
system
Pin.11au Co.
"(Clearwater)
Blue Cross-
$12.00/dsy for
333.00
Single operation
12.00
1st day in hospital
0100.001
Deductible/yr.
80.00
Hospital care
N.I.
Individual
Blue Shield,
70 days per
117.00
Appendectomy
5.00
Thereafter to 70
80%
Coinsurance
83.00
)Iormal delivery
5.84
employee
*Oar
med
ical
illness
50.00
Tonsillectomy
days
$5,000.00
Per year
None
system
375.00
Maximum
$10,000.00
Per lifetime
Family
15.64
employee
None
system
GE
OR
GIA
.
Deicalb Co.
(Dec
atur
)
Pravident Life
$15.00/day for
300.00
Single operation
Major medical
($50.001
Deductible/yr.
150.00
Lump sum
Excludes ma-
Individual
and Ateldent In-
31 days per
150.00
Appendectomy
80%
Coinsurance
jor medical
1.45
employee
suramce Co.
illness
45.00
Tonsillectomy
$10,000.00
Per lifetime
Basic cow. system
..=11
116
Family
8.41
employee
Emp. basic cov. sys-
tem
DIGESTS OF GROUP HEALTH INSURANCE PLANS FOR PUBLIC-SCHOOL PERSONNEL, 1964-65, MAXIMUM ALLOWANCES AND
BENEFITS (Continued)
Dollar amounts shown in () are charges to the individual for the specified benefit.
Dollar amounts shown in [
" are deductibles which must be satisfied by
the individual before coinsurance can be applied or benefits received.
School system and
Hospitalization:
Surgical
underwriter of
Daily room
Al:ow-
health plan
and board
ances
23
Benefits
4
Medical
Major medical
Allowances
Benefits
Allowances
Benefits
56
78
Stratum 2--enrollment 50,000-99,999 (Cont.)
KENTUCKY
Jefferson Co.
(excl. Louisville)
Blue Cross-
Blue Shield
Louisville
$15.00/day for
70 days per
illness
Blue Cross-
$15.00/day for
Blue Shield
70 days per
preferred2/
illness
LOUISIANA
Caddo Parish
(Shreveport)
Washington Na-
$14.00/day for
tiongl Insurance
120 days per
Co.2!
illness
East Baton Rouge
Parish (Baton Rouge)
Pan American
Lifeli
MASSACHUSETTS
Boston
$16.00/day for
31 days per
illness
Blue Cross and
Semi-private for
Blue Shield
120 days per
illness after
($25.00] de-
ductible
MINNESOTA
Minneapolis
Northwestern Na-
$26.00/day for
tional Life In-
120 days per
surance Co.
illness
$225.00
100.00
30.00
Single operation
Appendectomy
Tonsillectomy
$5.00
Per day, starts 4th
day in hospital
to 27 days per
year
None
300.00
Single operation
5.00
Per day for 30 days
None
150.00
Appendectomy
in hospital
40.00
Tonsillectomy
300.00
Single operation
4.00
Per day for 120 days
in hospital
$10,000.00
Over 3 years
for specified
480.00
Maximum
diseases
300.00
Single operation
5.00
Per day for 31 days
[$100.00]
Deductible/yr.
150.00
Appendectomy
in hospital
80%
Coinsurance
45.00
Tonsillectomy
155.00
Maximum
$10,000.00
Per illness
125.00
Appendectomy
10.00
First day in hos-
$5,000.00
For specified
35.00
Tonsillectomy
pital
diseases
5.00
Thereafter to 120
days
300.00
Single operation
4.00
Per day for 120 days
[$100.00]
Deductible/yr.
150.00
Appendectomy
in hi,spital
807
Coinsurance
45.00
Tonsillectomy
480.00
Maximum
$15,000.00
Per lifetime
Maternity provisions
for normal delivery
Coverage
after
retirement
Financing
Cost per
Contributor
month
Allowances
Benefits
910
11
12
13
10 days
Hospital care
Same coverage
Individual
$50.00
Normal delivery
$ 4.65
employee
None
system
Family
11.45
employee
None
system
10 days
Hospital care
Same coverage
Individual
90.00
Normal delivery
All
employee
None
system
Family
All
employee
None
system
14.00
Hospital care
same coverage
Individualki
75.00
Normal delivery
4.70
employee
5.24
syscem
Family:12!
18.53
employee
5.24
system
160.00
Hospital care
Same coverage
Individual
75.00
Normal delivery
3.05
employee
3.06
system
Family
18.74
employee0$
16.50
emp1oyee00
3.06
system
Basic cov-
Hospital care
Same coverage
Individua1k!
.61
employee
elge
3
.00
Physician's
3.60
system
visits
Family!!!
10.34
employee
10.47
system
225.00
Hospital care
None
75.00
Normal delivery
Individual
2.18
employee
6.91
syst
enili
Family
10.70
employee
13.63
syst
emki
23
46
79
1011
12
13MISSOURI
Kansas City
$20.00/day for
120 days per
illness
$300.00
Single operatioa
200.00
Appendectomy
50.00 Tonsillectomy
$5.00
600.0G
Per day for 120 days
in hospital
Maximum
1$500.00]
[$750.001
80%
$10,000.00
Deductible/2
Basic cov-
yrs. (50 and
erage
under)
lee sched-
Deductible/2
ule
yrs. (over
50)
Coinsurance
Per 2 yrs.
Hospital care
Normal delivery
N.I.
Individual
Continental
Casualty Co,-a/
$ 9.26
employee
None
system
Family,
14.77
employee
None
system
NEBRASKA
Omaha
Blue Cross-
Semi-private for
480.00
Single operation
12.00
1st day in hospital
[$100.001
Deductible/yr.
Basic cov-
Hospital care
None
Individual
Blue Shield,
major medical4/
150 days per
illness
180.00 Appendectomy
60.00 Tonsillectomy
6.00
Thereafter to 150
days
807.
$10,000.00
Coinsurance
erage
Per lifetime
$100.00
Normal delivery
9.20
employee
None
system
Family
20.95
employee
None
system
NEVADA
Clark Co. (Las
DALAI
United Benefit
$15.00/day for
300.00 Single operation
5.00
Per day in hospital
[$100.00]
Deductible/yr.
100.00
Lump sum
Same coverage
Individualk/
Life Ins. Co.
31 days per
150.00 Appendectomy
55.00
Maximum
807.
Coinsurance
4.18
employee
illness
45.00 Tonsillectomy
$10,000.00
Per lifetime
4.18
systea
Family
20.77
employee
4.18
system
NEW MEXICO
Albuquerque
Equitable Life
Assurance Society
Major medical
Major medical
Major medical
1$50.001
Deductible/yr.
150.00
less than
Normal delivery
Same coverage
Individual
6.57
employee
$5,000 earning
207.
system
[$75.001
$5,000 less than
Family
$10,000
16.87
employee
[$100.001
$10,000 or more
earning
Part
system
807
Coinsurance
$15,000.00
Per lifetime
NW YORK
Buffalo
Blue Cross-
Semi.-private for
500.00
Single operation
15.0D
1st day in hospi-
0No deductible
80.00
Normal delivery
Excludes ma-
Individual
Blue Shield
120 days per
150.00
Appendectomy
tal
80%
Coinsurance
jor medical
8.85
employee
extended benefits
illness
100.00 Tonsillectomy
10.00
2nd day
415,000.00
Per 3-year period
None
system
5.00
3rd thru 40th day
Family
3.0%
Thereafter to 120
days
20.97
employee
None
system
OHIO
455.0D
Maximum
Aon
Blue Cross -
2 or more bed
200.00 Single operatios
5.00
1st and 2n4 day in
[$75.00]:
Deductible/yr.
Basic cov-
Hoh.pital care
Excludes ma-
Individual
Blue Shield,
wards for 120
100.00 Appendectomy
hospital
75%
Coinsurance
erage
jor medical
11.02
employee
Poulson Insurance
days per ill-
ness-
35.00 Tonsillectomy
.3.00
Therafter to 70
day;
$5,000,00
Per lifetime
50.00
Normal delivery
None
system
Fully
22.72
employee
None
system
9tBeinnati
Blue Cross-
2 or more bed
3C0.00 Single:operation
10.00
1st day in hospi-
None
Basic cov-
Hospital care
Same coverage
Individual
Blue Shield
wards for 365
125.00 Appendectomy
tal.
erase
7.35
employee
days per ill-
&Loa Tonsillectomy
5.00
2nd thru 4th
50.00
Normal delivery
None
system
ness
4.00
Thereafter to 120
days
Family
18.00
employee
None
system
DIGESTS OF GROUP HEALTH INSURANCE PLANS FOR PUBLIC-SCHOOL PERSONNEL, 1964-65, MAXIMUM
ALLOWANCES AND BENEFITS (Continued)
Dollar amounts shown in () are charges to the individual for the specified benefit.
Dollar amounts shown in [
I are deductibles which must be satisfied by
the individual before coinsurance can be applied or benefits received.
School system and
Hospitalization:
Surgical
Medical
Major medical
underwriter of
Daily rom
Allow-
health plan
and board
ances
Benefits
Allowances
Benefiei
Allowances
Benefits
12
34
56
78
Stratum 2--enrollment 50,000-99,999 (Cont.)
OHIO (Cont.)
121,Ylc-LI
Blue Cross-
2 or more bed
$200.00
Blue Shield
wards for 120
100.00
Single operation
Appendectomy
$5.00
1st and 2nd day in
hospital
None
days per ill-
35.00
ness
Tonsillectomy
3.00
Thereafter to 70
days
Toledo
Blue Cross-
Semi-private for
200.00
Blue Shield,
70 days per
Single operation
5.00
1st and 2nd days in
hospital
($100.00j
Deductible/yr.
with basic
Phoenix Mutual
illness
3.00
Thereafter to 70
coverage
Life Insurance
days
80%
Coinsurance
Co.
$10,000.00
Per lifetime
OKLAHOMA
Tulsa
Blue Cross-
Semi-private for
300.00
Single operation
5.00
1st thru 15th day in
$7,000.00
Over 2 years
Blue Shield
90 days per
100.00
Appendectomy
hospital
for specified
illness after
40.00
025.00] de-
ductible
Tonsillectomy
4.00
Thereafter to 90
days
diseases
OREGON
Portland
Blue Cross
4 bed ward or
350.00
$22.00/day for
150.00
Single operation
Appendectomy
4.00
Per day for 100 days
in hospital
NonR
100 days per
50.00
Tonsillectomy
3.00
Office visit
illness
4.50
Home call, home and
office visits for
employee only,
starts 2nd day of
O.P.S. Blue
Shield
Kaiser Founda-
tion
$13.00/day for
70 days per
year, after
($15.001 de-
ductible
Full coverage
for 111 days
per illnesl,
70 days for
dependents
Full coverage
Full coverage
illness, $225.00
maximum
Maternity provisions
for normal delivery
Allowances
Benefits
910
Coverage
after
retirement
11
Financing
Cost per
Contributor
month
12
13
Basic cov-
Hospital care
N.I.
erage
$50.00
Normal delivery
Individual
$ 6.72
employee
None
system
Family
16.62
employee
None
system
Basic cov-
Hospital care
Major medical
Individual
erage
reduced
All
employees
Fee sched-
Normal delivery
benefits
None
system
ule
Family,
All
employees
None
system
10 days
60.00
Hospital care
N.I.
Normal delivery
100.00
Hospital care
N.I.
50.00
Normal delivery
Full cover-
For 70 days in hos-
None
60.00
Hospital care
N.I.
age
pital
50.00
Normal delivery
Full cover-
age (1.00)
(2.00)
In hospital
None
Full cov-
After 10 months' N.I.
erage
membership
Office visit
(120.00)
Before 10 months'
Home call, no limit
membership
Individual
507.
employee
50%
system
Family
Part
employee
Part
system
Individual
5.75
employee(M)
7.60
employee(W)
None
system
Family
15.70
employee(M)
16.25
employee(W)
None
system
Individual
6.37
employee(M)
6.94
employee(w)
None
system
Family
16.53
employee
None
system
Individual
7.75
employee
None
system
Family
19.95
employee
None
system
2
PENNSYLVANIA
Pittsburgh
Blue Cross-
Blue Shielde
SOUTH CAROLINA
Greenville Co.
Blue Cross-
Blue Shield
TENNESSEE
Nashville-
Davidson Co.
Provident Life
and Accident
Insurance Co.
TEXAS
El Paso
Blue Cr.ed-
Blue -41eld,
major medical
Fort Worth
Blue Cross-
Blue Shield,
major medical
San Antonio
Blue Cross-
Blue Shield,
major medical
UTAH
Semi-private or
85% of private
room for 70
days per ill-
ness
Semi-private for
70 days per
illneas after
[$20.00) deduct-
ible
$8.00/day for 31
days per ill-
ness
$12.00/day for 70
days per ill-
ness
$12.00/day for 70
days per ill-
ness
$12.00/day for 70
days per ill-
ness
Granite School Dist.
(P.O. salt Lake City)
Utah Teachers
Welfare Associa-
tion
3 bed ward for
70 days per
illness, there-
after 807 of
charges
45
$300.00
Single operation
$ 15.00
150.00
Appendectomy
10.00
50.00
TonsillectomY
4.00
3.00
5.00
7.00
250.00
Single operation
4.00
90.00
Appendectomy
35.00
Tonsillectomy
300.00
Single operation
115.00
Appendectomy
50.00
Tonsillectomy
300.00
Single operation
5.00
150.00
Appendectomy
300.00
Single operation
5.00
150.00
Appendectomy
40.00
Tonsillectomy
150.00
300.00
Single operation
5.00
150.00
857.
Of fee schedule
[25.00]
by Utah State
100%
Medical Associa-
tion
80%
6
1st day in hospital
2nd daY
3rd thru 10th day
Thereafter to 70
hospital days
Office visit
Home call, office
or home calls, for
employee only,
starts 4th visit
to 21 visits/yr.
Per day, start 3rd
day to 70 days in
hospital
Major medical
Per day, starts
4th day to 30
days in hospital
Per day, starts
4th day to 30
days in hospital
Maximum
Per day, starts
4th day to 30
days in hospital
Maximum
Deductible/illness
Next $75.00
Thereafter
78
910
1112
13
0100.00]
Deductible/3
10 days
Hospital care
Major medical
Individual
months
$90.00
Normal deliv-
reduced
$ 3.08
employee
807.
Coinsurance
ery
benefits
8.94
system
$10,000.00
Per illness
Family
26.02
employee
8.94
system
$10,000.00
For specified
10 days
Hospital care
N.I.
Individual
illnesses or
diseases
55.00
Normal delivery
4.85
employee
None
system
Family
11.70
eaployee
None
system
[$500.00]
Deductible/yr.
80.00
Hospital care
N.I.
Individual
75%
Coinsurance
60.00
Normal delivery
4.95
employee
$10,000.00
Per lifetime
None
systes
Family
15.21
employee
None
system
0100.001
Deductible/yr.
Basic coy-.
Hospital care
N.I.
Individual
807.
Coinsurance
erage
All
employee
$5,000.00
Per year
75.00
Normal delivery
None
system
$10,000.00
Per lifetime
Family
N.I.
[000.00)
Deductible/yr.
10 days
Hospital care
Same coverage
Individual
807.
Coinsurance
75.00
Normal delivery
5.16
employee
$5,000.00
Per year
None
system
$10,000.00
Per lifetime
Family
13.57
employee
None
system
[$100.00]
Deductible/yr.
10 days
Hospital care
same coverage
Individual
80%
Coinsurance
75.00
Normal delivery
All
employee
$5,000.00
Per year
None
system
$10,000.00
Per lifetime
Family
N.I.
$5,000.00
Per three yrs.
10 days
Hospital care
Seise coverage
Individual
for hospital,
surgical and
medical
100.00
Normal delivery
None
employee
All
system
family
DIGESTS OF GROUP HEALTH INSURANCE-PLANS FOR. PUBLIC-SCHOOL PERSONNEL, 196445, MAXIMUM ALLOWANCES AND BENEFITS (Continued)
Dollar amounts shown in () are charges to the imdividual for the specified benefit.
Dollar amounts shown in [
I are deductibles which must be satisfied by
the individual before coinaurance can be applied or benefits received.
School system and
Hospitalization:
Suroical
underwriter of
Daily room
Allow-
Benefita
health plan
and board
ances
12
34
Medical
Allowances
Benefita
Stratum 2--enrollment 50,000-99,999 (Cont.)
VIRGINIA
Fairfax Co.
Blue Cross-
Blue Shield
6s_
Major medical
Allowances
Benefits
78
Maternity provisions
for normal delivery
Allowances
Benefits
10
Coverage
after
retirement
11
Financing
Cost per Contributor
month 12
13
Semi-private for
$300.00
Single operation
$5.00
Per day, starts 4th
[$50.00]
Deductible/9G
$100.00
Hospital care
Same coverage
Individual
180 days per
day to 177 days in
days
85.0G
Normal delivery
$ 3.44
employee
illness
hospital
807.
Coinsurance
3.44
system
885.00
Maximum
$10,000.00
Per illness
Family
13.93
employee
3.44
system
Stratum 3--enralment 25,000-49,999
ALABAMA
Montgomery Co.
Blue Cross-
Blue Shield
ARIZONA
Tucson,
Blue Cross-
Blue Shield2/
CALIFORNIA
Anaheim Union High
School Dist.
Aetna Life
Fremont
Semi-private for
70 days per
illness
Major medical
Semi-private for
350.00
Single operation
120 days per
124.00 Appendectomy
illness
53.00 Tonsillectomy
Major medical
California Phy-
3 or more bed
sicians' Service
ward for 31
and Guardian
days per ill-
Life Insurance
ness
Co.
Kaiser Founda-
tion
Full coverage
for 111 days ,
per illness
Major medical
160.00 Appendectomy
80.00 Tonsillectomy
Full Coverage
7.00
4.00
Major medical
Per day, starts 3rd
day to 7th day in
hospital
Thereafter to 120
days
Major medical
4.00
Per day for 31 days
in hospital
4.00
Office visit
8.00
Home call.-routine,
office or home
visits, start
3rd day for ill-
ness to 100 visits
per year
Full cover..
age (1.00)
(3.50)
In hospital
Office visit
Home call..-routine,
no charge after
first two visits
[$100.00]
Deductible/yr.
10 days
Hospital care
N.I.
807.
Coinsurance
Major med-
Normal delivery
$5,000.00
Per year
ical
and physi-
$10,000.00
Per lifetime
cian's visits
None
Individual
All
employee
None
system
Family
N.I.
80.00
Hospital care
Same coverage
Individual
100.00
Normal delivery
8.30
employee
None
system
Family
18.32
employee
None
system
j$50.00]
Deductible/yr.
100.0Q
Lump sum, no
lione
1007.
Of next $500.00
deductibles
for hospital
expense
807.
Coinsurance
$10,000.00
Per lifetime
[$500.001
Deductible/90
days (basic
coverage ap-
plies
100%
Coverage
41moo.oa Per illness
Sone
50.00
Hospital care
Reduced
50.0G
Normal delivery
benefits
(60.00)
Full coverage
Individual
3.80
employee
3.80
system
Family
20.37
employee
3.80
system
Individual
1.56
employee
8.16
system
Family
10.39
employee
16.32
system
Individual
0.19
employee
8.16
system
Family
5.73
employee
16.32
system
12
7
Hayward
Full coverage
for 111 days
per illness
Full coverage
Full coverage
$ (1.00)
(3.50)
In hospital
Office visit
Home call--routine,
no charge after
first two visits
Kaiser Founda-
tion
B/ue Cross
3 or more bed
$300.00 single operation
3.00
Per day for 180
f$100.00
ward for 18O
150.00 Appendectomy
days in hospital
80%
days per ill-
50.00 Tonsillectomy
3.00
Office visit
$10,000.00
ness
4.50
Home call, office
or home visits for
employee only,
start 3rd visit
for illness,
$225.00 per year
Mt. Diablo School
Dist.,(Concord)
Blue Cross
3 or more bed
300.00
Single operation
3.00
Per day for 180
[$100.00]
ward for 180
150.00 Appendectomy
days in hospital
80%
days per ill-
50.00 Tonsillectomy
3.00.
Office visit
$10,000.00
ness
4.50
Home call, office or
home visits for em-
ployee only, starts
3rd day of illness
$225.00 per year
Kaiser Founds-
Full coverage
Full coverage
Full coverage
In hospital
tir
for 111 days
(1.00)
Office visit
per illness
(3.50)
Home call--routine,
no charge after
first two visits
Pasadena
910
1112
13
Koss Loos and
$20.00/day,
Full coverage
Full coverage
In hospital
[$100.001
Independent Life
$5,000.000
(25.00)
For dependents
(1.25)
Office visit
807
maximum for
hospital care
(5.00)
Home call, no limits
$5,000.00
Blue Cross
3 bed ward for
300.00
Single operation
3.00
Per day for 180 days
($100.001
180 days per
150.00
Appendectomy
in hospital.
80%
illness
50.00
Tonsillectomy
3.00
Office visit
$20,000.00
4.50
Home call, office or
home visits for em-
ployee only,starts
3rd day of illness,
$225.00 per year
Occidental Life
Major medical
Major medical
Major medical
($200.001
807.
Richmond
Kaiser Founds,-
Full coverage
tion
for 111 days
per illness
Full coverage
Full coverage
Full coverage
(3.50)
In hospital
Office visits
Home call--routine,
no charge after
first two visits
100%
$20,000.00
None
Deductible/yr.
Coinsurance
Per lifetime
Deductible/yr.
Coinsurance
Per lifetime
None
Deductible/yr.
Coinsurance
Per lifetime
Deductible/yr.
Coinsurance
Per lifetime
Deductible/yr.
Coinsurance for
hospital
Of scheduled
surgical and
medical
Per lifetime
None
$(60.00)
Full coverage
N.I.
after 10
months mem-
bership
(140.00)
After 10 months
membership
50.00
Hospital care
N.I.
Individual
$ 7.95
employee
None
system
Family
22.70
employee
None
system
Individual
8.64
employee(M)
10.88
employee(W)
None
system
Family
21.63
employee
None
system
50.00
Hospital care
Major med-
Individual
ical re-
3.70
employee(M)
duced ben-
6.01
employee(W)
efits
5.00
system
Family
16.92
employee
5.00
system
(60.00)
Full coverage
after 10
months' mem-
bership
(140.00)
Before 10
months' mem-
bership
Basic cov-
Hospital care
erage
(50.00)
Normal delivery
Basic cov-
Physicians vis-
erage
its
50.00
Hospital care
None
(60.00)
Full coverage
Same coverage
Reduced ben-
efits
Reduced ben-
efits
Individual
3.20
employee
5.00
system
Family
17.95
employee
5.00
system
Individual
4.45
employee
5.00
system
Family
16.78
employee
5.00
system
Individual
3.10
employea(M)
5.18
employee(W)
5.00
system
Family
15.77
employee
5.00
system
Reduced ben-
Individual
efits
1.37
employee
5.00
system
Family
12.48
employee
5.00
system
Same coverage
Individual
All
employee
None
system
Family
N.I.
DIGESTS OF GROUP HEALTH INSURANCE PLANS FOR
PUBLIC-SCHOOL PERSONNEL, 1964-65, MAXIMUM:ALLOWANCES AND BENEFITS
(Continued)
Dollar amounts shown in () are charges to the individual
for the specified benefit.
Dollar amounts shown in [
] are deductibles which must be satisfied by
the individual before coinsurance can be applied or
benefits received.
School system and
underwriter of
health
lan
Hospitalization:
VII
.,Surgical
Medical
Major medical
Maternity provisions
for normal delivery
Coverage
after
retirement
Financing
Daily room
and board
Allow-
ances
Benefits
Allowances
Benefits
Allowances
Benefits
Cost per Contributor
month
Allowances
Benefits
12
34
67
89
10
11
12
13
Stratum 3- -enrollment 25,000-49,999
(Cont.)
CALIFORNIA (Cont.)
Richmond (Cont.)
Blue Cross
3 or more bed
$ 300.00
Single operatiou
$ 3.00
Per day for 180 days
[$100.00]
Deductible/yr.
$50.00
Hospital care
N.I.
Individual
ward for 180
150.00
Appendectomy
in hospital
$80.00
Coinsurance
Non7---WOWyee
days per ill-
50.00
Tonsillectomy
3.00
Office visit
$5,000.00
Per illness
All
system
ness
4.50
Home call, office
and home visits
for employee only,
starts 3rd day of
illness, $225.00
per year
$10,000
Per lifetime
Family,
N.I.
Sacramento.
Equitable Life
$22.00/day for
400.00
Single operation
5.ca
A day for 31 days
5% of an-
Deductible/6
None
None
Individual
Assurance
31 days per
200.00
Appendectomy
in hospital
nual
months (not
None
employee
Society
illness
60.00
Tonsillectomy
155.00
Maximum
earnings
less than
loox
systemh/
$200.00 or
more than
Family
$12.45
employee
$600.00)
Emp. cov. system
757.
Coinsurance
$10,000.00
Per lifetime
San Bernardino
Kaiser Founda-
tion
Full coverage
for 125 days
per year, 240
days at 1/2
Full coverage
Full coverage
(5.00)
In hospital and
office visits
Home call, no limit
None
(100.00)
Full coverage
after 10
months' mem-
bership
Same coverage
Individual
1.15
employee
8.20
system
Family
rate
(175.00)
Before 10
months' mem-
bership
19.25
employee
8.20
system
California
3 bed ward for
1,100.00
Single operation
120 days in hospital
[$100.00)
Deductible/yr.
None
Same coverage
Individual
Physicians
120 days per
660.00
Maximum
807
Coinsurance
1.31
employee
Service
illness
330.00
Maximum per year
for office and
home visits, starts
$20,000.00
Per illness
8.20
system
Family,
18.42
employee
3rd day of illness
8.20
system
San Jose
Occidental Life
$16.00/day,
300.00
Single operation
4.50
Per day in hospital
$3,000.00
For specified
None
N.I.
Individual
$496.00 max-
150.00
Appen&xtomy
139.50
Maximum
diseases
5.95
employee(M)
imum per ill-
ness, $14.00-
52.50
Tosillectomy
$4.00-$124.00 for
dependents
8.22
employee(W)
None
fystem
$434.00 for
dependents
Family
16.74
empioyee
None
system
Kaiser Founda-
tion
Full coverage
for 111 days
per illness,
60 days for
Full coverage
Full coverage
(1.00)
(3.50)
In hospital
Office visit
Home call--routine,
no charge after
None
(60.00)
Full coverage
after 10
months' mem-
bership
Same coverage
Indivinual
7.95
employee
None
systems
Family
dependents
first two visits
(95.00)
Dependents
19.45
employee
(140.00)
Before 10
months' mem-
bership
None
sy.-itea
12
34
67
89
10
11
12
13
San Juan School
Dist. (Carmichael)._
California
3 bed ward
$200.00
Appendectomy
$5.00
Per day, routine for
($100.001
Deductible/yr.
$100.00
Hospital care
Reduced ben-
Individual
Physicians
for 180 days
100.00
Tonsillectomy
180 days in hospi-
80%
Coinsurance
efits
$ 3.16
employee
Service
per illness
tal
$10,000.00
Per lifetime
7.75
system
5.00
Office visit--routine
Family
10.00
Home call--routine,
office and home
visit for employee
only, starts 3rd
day of illness,
100 visits per
year
16.20
employee
7.75
system
Stockton
Continental
$20.00/day
1,000.00
Single operation
5.00
Per visit for hospi-
($100.001
Deductible/6
50.00
Hospital care
Same coverage
Individual
Casualty Co.
for 120 days
200.00
Appendectony
tal and office
months
50.00
Normal delivery
...
employee
per illness
100.00
Tonsillectcmy
7.50
Home call
807.
Coinsurance
7.86
system
350.00
Maximum per year for
all visits, home
and office visits
for employee only
$5,000.00
Per illnees
Family
13.86
employee
7.86
system
Torrance
Blue Cross
3 or more bed
300.00
Single operation
3.00
Per day for 180 days
[$100.00]
Deductible/yr.
50.00
Hospital care
Excludes ma-
Individual
ward for 180
150.00
Appendectomy
in hospital
807
Coinsurance
jor medical
All
employee
days per ill-
50.00
Tonsillectomy
$5,000.00
Per illness
None
system
ness
$10,000.00
Per lifetime
r=mily
N.I.
Kaiser Founda-
Full coverage
Full coverage
Full coverage
In hospital
None
(100.00)
Full coverage
Individual
tion
for 125 days
(2.00)
Office visit
after In
All
employee
per year, 240
days at 1/2
(5.00)
Home call, no limit
aonths mem-
bership
None
system
Family
rate
(17i.00)
,lefore 10 months
membership
N.I.
COLORADO
Colorado Springs
Equitable Life
Major medical
Major medical
Major medical
($50.00]
Deductible/yr.
200.00
Lump sum, no
Same coverage,
Individual
Assurance Society
1007.
First $500.00
of hospital
care
deductible
no reinstate-
sent
4.68
employee
6.64
system
Family
807
Coinsurance or
scheduled
surgical
fees which-
ever higher
13.92
employee
12.30
system
$10,000.00
Per lifetime
Jefferson Co.,
(P.O., Denver)
Insurance
$24.00/day for
150.00
Appendectomy
5.00
Per day for first
Basic cov-
Hospital care
Sane coverage
Individual
Services
365 days per
50.00
Tonsillectomy
50 days in hos-
erage
11.60
employee
Commission!!
illness
plus 807. of
pital
100.00
Normal delivery
None
system
excess of
scheduled
fees
4.00
Thereafter to 365
Family
28.90
employee
Non2
system
Insurance
Services
Major medical
Major medical
najor medical
($100.00]
Family deduct-
ible/yr.
Major medical
Same coverage
Individual
10.00
employee
Commission!!
807
Coinsurance
None
system
$10,000.00
Per year
Family
$20,000.00
Per lifetime
24.00
employee
None
system
DIGESTS OF GROUP HEALTH INSURANCE PLANS FOR PUBLIC-SCHOOL PERSONNEL, 1964-65, MAXIMUM
ALLOWANCES AND BENEFITS (Continued)
Dollar amounts shown in () are charges to the individual for the specified benefit.
Dollar amounts shown in [
] are deductibles which must be satisfied by
the individual before coinsurance can be applied or benefits received.
School system and
underwriter of
health plan
1
Hospitalization:
Daily room
Allow-
and board
ances
23
Stratum 3--enrollment 25 000-49
CONNECTICUT
Hartford
Blue Cross-
Blue Shield
FLORIDA
999 (Cont.)
$15.00/day for
$350.00
120 days per
illness, ex-
tended cover-
age for 1 year
or $7,500
Rrevard Co. (Titusville)
Fidelity and
Semi-private for
330.00
Guaranty Life Ins.
120 days per
165.00
illness
Polk Co. (Bartow)
Aetna Life
Insurance Co.
Volusia Co. (DeLand)
Provident Life
and Accident
Insurance Co.
GEORGIA
Col
lari
etta
$15.00/day for
300.30
31 days per
110.00
illness after
40.00
[$25.001 deduct-
ible
$14.00/day for
70 days per
illness,
$980.00 maxi-
mum
300.00
110.00
40.00
Protective Life
Semi private for
350.00
Insurance Co_
21 days per
175.00
illness, there-
52.50
after 80% of
semi private to
120 days
Fulton Co.
(excl. Atlanta)
Home Life
Insurance Co.
Major medical
Surgical
Medical
Major medical
Maternity provisions
for normal delivery
Coverage
after
retirement
Financing
Benefits
Allowances
Benefits
Allowances
Benefits
Cost per
Contributor
month
Allowances
Benefits
45
67
89
10
11
12
13
Single operation
$6.00
Per day for 4th-8th
[$100.00]
Deductible/dis-
$125.00
Hospital care
None
Individual
day in hospital
ability
75.00
Normal deliv-
None
employee
5.00
Next 10 days
807.
Coinsurance
ery
1007.
system
4.00
Thereafter to 120
days per year
$5,000.00
Per lifetime
Family
$15.35
employee
Emp. soy. system
Single operation
12.00
1st day in hospital
[$100.00]
Deductible/yr.
80.00
Hospital care
Excluded ma-
Individual
Appendectomy
5.00
Thereafter to 120
80%
Coinsurance
75.00
Normal deliv-
jor med-
6.20
employee
days
$5,000.00
Per year
ery
ical
None
system
600.00
Maximum
$10,000.00
Per lifetime
Family
18.40
employee
None
system
Single operation
5.00
Per day for 31 days
[$100.00]
Deductible/yr.
150.00
Lump sum
Sgme coverage
Individual
Appendectomy
in hospital
807.
Coinsurance
1.70
employee
Tonsillectomy
155.00
Maximum
$7,500.00
Per lifetime
3.52
system
Family
12.68
employee
3.52
system
Single operation
Major medical
[$100.00]
Deductible/yr.
150.00
Lump sum
Reduced ben-
Individual
Appendectomy
807.
Coinsurance
efits
5.42
employee
Tonsillectomy
$5,000.00
13..r. lifetime
None
system
Family.
14.17
zmployee
None
system
Single operation
Appendectomy
5.00
Per day for 70 days
in hospital
None
200.00
Lump sum
N.I.
6.74
employee
Tonsillectomy
1.00
system
Family
15.93
employee
1.00
system
Major medical
Major medical
[$100.00]
Deductible/90
days
100%
First $300.00
for hospital
care
80%
Coinsurance
$5,000.00
Per illness
None
None
Individual
5.20
emplGyee
1.67
system
Family
8.75
empllyee(M)
8.10
employe(W)
6.18
system
23
45
67
89
10
11
12
13
Muscogee Co.
(Columbus)
Blue Cross-
$20.00/day for
$300.00
Single operation
Fee schedule
According to illness
0No deductible
7 days
Hospital care
N.I.
Individual
Blue Shielda/
120 days per
illness
150.00
Appendectomy
68.00
Tonsillectomy
1007.
Hospital and
medical (non-
surgical)
care
$90.00
Normal deliv-.
ery
$ 8.85
employee
None
system
Family
22.15
enployee
80%
Nursing, phys-
ical therapy
and drugs
None
system
$10,000.00
Per lifetime
ILLINOIS
Rockford
Woodmen Accident
$20.00/day for
300.00
Single operation
$5.00
Per day for 31 days
[$100.00]
Deductible/yr.
100.00
Hospital care
Same coverage
Individual
and Life Co.
31 days per
150.00
Appendectomy
in hospital
807.
Coinsurance
100.00
Normal deliv-
None
emplovgc
(Custodial Per-
sonnel)
illness
40.00 Tonsillectomy
350.00
Maximum
$10,000.00
Per lifetime
ery
6.45
systemEV
Family
10.26
employee
6.45
system
Blue Cross-
Semi-private
300.00
Single operation
8.00
1st day in hospital
None
75.00
Hospital care
Same coverage
Individual
Blue Shield
for 120 days
150.00
Appendectomy
5.00
2nd-7th day
75.00
Normal deliv-
5.15
employee
per illness
($1.50) per
day members
payment
40.00 Tonsillectomy
3.00
Thereafter to 70
days
ery
None
system
Family
13.61
employee
None
system
Illinois Hos-
Semi-private for
200.00
Single operatioa
5.0.0
1st day in hospital
None
10 days
Hospital care
Same coverage
Individual
pital Service
70 days per
100.00
Appendectomy
3.00
2nd-7th day
50.00
Normal deliv-
3.40
employee
illness
27.00 Tonsillectomy
2.00
Thereafter to 70
days
ery
None
system
Family
9.80
employee
None
system
INDIANA
Ft. Wayne
Blue Cross-
2 or more bed
300.00
Single operation
15.00
1st day in hospital
None
Basic cov-
Hospital care
None
individual
Blue Shield
ward for 365
150.00
Appendectomy
10.00
2nd day
erege
2.27
employee
days per ill-
60.00 Tousillectomy
4.00
Next 3 days
100.00
Normal deliv-
4.17
system
ness
3.00
Thereafter to 120
days
ery
Fam
ily13.17
employee
al x
4.17
system
Blue Cross-
Semi-private
500.00 Single operation
15.00
1st day in hospital
[$100.00]
Deductible/3
Basic cov-
Hospital care
N.I.
Individual
Blue Shield,
major medical
for 120 days
per illness
150.00
Appendectomy
60.00
Tonsillectomy
10.00
4.00
2nd day
Next 8 days
80%
months
Coinsurance
erage
100.00
Normal deliv-
7.49
employee
None
system
3.00
Thereafter to 120
days
$10,000.00
Per illness
ery
Family,
14.91
employee
387.00
Maximum
None
system
KANSAS
Kansas City_
Continental
Casualty Co.2!
$20.00/day for
70 days per
illness
300.00
Single operation
5.00
Per day for 70 days
in hospital
[$500.00]
757.
Deductible/
illness
(basic plan
applies)
Coinsurance
10 days
Fee sched-
ule
Hospital care
Normal deliv-
ery
Same coverage
Individual
13.98
employeeti
None
system
Family,
28.21
employee
$10,000.00
Per lifetime
None
system
DIGESTS OF GROUP HEALTH INSURAMEPLANSFOR PUBLIC-SCHOOL PERSONNEL, 1964-65, MAXIMUMALLOWANCES AND BENEFITS (Continued)
Dollar amounts shown in () are charges tothe individual for the specified benefit.
Dollar amounts shown in [
I are deductibles which must be satisfiedby
the inlividual before coinsurance can
be applied or benefits received.
School system and
Hospitalization:
underwriter of
Daily roam
Allow-
health plan
and board
ances
12
3
Stratum 3--enrollment 25,000-49.999 (Cont.)
LOUISIANA
Calcasieu Parish
(Lake Charles)
John Hancock
$14.00/day for
$200.00
Mutual Life
120 days per
100.00
Insurance Co.
illness
30.00
MASSACHUSETTS
Springfield
Blue Cross-
Semi-private for
500.00
Blue Shield
120 days per
125.00
illness after
50.00
($25.001 deduct-
ible
MICHIGAN
Grand Rapids
Metropolitan
Ward for 365 days
450.00
Life Insurance
per illness
(semi-private
coverage paid by
employee)
Lansing
Blue Cross-
Semi-private for
157.50
Blue Shieldl/
365 days per
67.50
illness
MEA Health
$300.00 plus 75%
300.00
Care Insurance!!
of $5_000.00
after ($25.00]
deductible
MINNESOTA
St. Paul
Blue Cross, St.
2 or more bed
200.00
Paul Fire and
ward for 365
133.35
Marine Insurance
days per ill-
33.35
Co.
ness
Surgical
Medical
Major medical
Maternity provisions
for normal delivery
Coverage
after
retirement
Financing
Benefits
Allowances
Benefits
Allowances
Benefits
Cost per
Contributor
month
Allowances
Benefits
45
67
89
10
1112
13
single operation
$5.00
Per day for 70 days
[$100.00]
Deductible/6
$140.00
Hosp.,tal care
Reduced ben-
Individual
Appendectomy
in hospital
months
50.00
Normal deliv-
efits ex-
$10.22
employeek!
Tonsillectomy
350.00
Maximum
80%
Coinsurance
ery
eludes major
None
system
$10,000.00
Per lifetime
medical
Family
22.62
employee
None
system
Single operation
10.00
1st day in hospital
0No deductible
Basic cov-
Hospital care
Same coverage
Individual
Appendectomy
5.00
Thereafter to 120
100%
Hospital and
erage
3.16
employee
Tonsillectomy
days
medical care
75.00
Normal deliv-
3.16
system
80%
Appliances,
nursing
ery
Family
9.45
employee
$5,000.00
Per lifetime
9.45
system
Single operation
5.00
Per day for 365 days
in hospital
None
300.00
75.00
Hospital care
Normal deliv-
ery
Same coverage
Individual
.32
employee
(semi)
8.85
systemti
Family
14.50
eaployee
8.85
system
Appendectomy
15.00
1st day in hospital
None
Basic cov-
Hospital care
Same coverage
Individual
Tonsillectomy
6.00
Next 22 days
erage
9.09
employee
4.80
Thereafter to 365
days
Fee ached-
ule
Normal deliv-
ery
10.00
system
Family
23.50
employee
Single operation
Major medical
($50.00]
Deductible/
illness
$200.00
plus 757.
Hospital care
Reduced ben-
efits
10.00
system
b/
Individual-
6.10
employee
80%
Coinsurance
of
10.00
system
$10,000.00
Per lifetime
$1,000.00
Family
Fee sched-
ule
Normal deliv-
ery
23.65
employee
10.60
system
Single operation
4.00
Per day for 120 days
[$50.00]
Deductible/yr.
Basic cov-
Hospital care
N.I.
Individual
Appendectomy
in hospital
80%
Coinsurance
erage
None
employee
Tonsillectomy
480.00
Maximum
$10,000.00
Per illness
50.00
Normal deliv-
ery
11.88
systemk/
Family,
19.10
employee
17.26
system
12
37
89
1011
12
1:3
NEW JERSEY
Jersey City
Semi-private for
120 days per
illness and 245
part days
$350.00
175.00
75.00
Single operation
Appendectomy
Tonsillectomy
$ 10.00
7.00
6.00
5.00
1st day in hospital
2nd-7th day
8th-14th day
Thereafter to 365
days
None
7 days
$150.00
Hospital care
Normal deliv-
ery
Reduced bea-
efits
Individual
Blue Cross-
Blue Shielda/
$ 6.02
employee
None
system
Family
17.81
employee
None
system
NEW YORK
Rochester
Blue Cross-
Semi-private for
Fee
Single operations
10.00
1st day in hospital
[$50.00]
Deductible/yr.
$10.00/day
Hospital care
Same coverage
Individual
Blue Shield,
120 days per
sched-
5.00
Thereafter to 120
807.
Coinsurance
foz 120
5.06
employee
Aetna Major
illness
ule
days
$7,500.00
Per year
days
5.08
system
Medical
$15,000.00
Per lifetime
75.00
Normal deliv-
ery
Family
11.27
employee
11.27
system
Syracuse
Blue Cross-
Semi-private for
410.00
Single operation
12.30
1st day in hospital
[$100.00]
Deductible/yr.
80,00
Hospital care
Same coverage
Individual
Blue Shield,
70 days per
147.00
Appendectomy
8.20
2nd day
757.
Coinsurance
75.00
Normal deliv-
8.05
employee
Trav9lers Ins.
Co.21
illness
61.00
Tonsillectomy
4.10
Thereafter to 120
days
$5,000.00
Per lifetime
ery
Maj. med.
system
Family
17.70
employee
Maj. med.
system
Yonkers
State-wide Plan
Semi-private for
500.00
Single operation
7.00
lst-7th day
[$50.00]
Deductible/yr.
75.00
Hospital care
Same coverage
Individual
120 days per
175.00
Appendectomy
6.00
8th-14th day
807.
'coinsurance
75.00
Normal deliv-
4.62
employee
illness
75.00
Tonsillectomy
5.00
15th-70th day
$7,500.00
Per year
ery
4.62
system
4.00
719t-201st day in
hospital
$15,000.00
Per lifetime
Fa^111
12.75
employee
9.00
system
Health Insurance
Semi-private for
Full coverage
Full coverage for
($50.00]
Deductible/yr.
Full coverage
Same coverage
Individual
Plan
120 days per
hospital,office
807.
Coinsurance
5.79
employee
illness
and home visits
$15,000.00
Per lifetime
4.62
system
Family
16.49
employee
9.00
system
NORTH CAROLINA
Winston-Salem/
Forsythe Co.
(P.O., Winston-Salem)
Blue Cross-
Semi-private for
200.00
Single operation
Major medical
0No deductible
Basic cov-
Hospital care
Same coverage
Individual
Blue Shield
70 days per
100.00
Appendectomy
807.
Coinsurance
erage
5.15
employee
extended
benefitsa/
illness, ex-
tended coverage
to 730 days
35.00
Tonsillectomy
except for
certain
scheduled
fees
60.00
Normal deliv-
ery
None
system
Family
12.89
employee
None
system
$10,000.00
Per lifetime
OHIO
Youngstown
Blue Crossa/-
2 or more bed
200.00
Single operation
5.00
1st 2 days in hospi-
($100.001
Deductible/
Basic cov-
Hospital care
N.I.
Individual
Blue Shield, Con-
ward for 120
100.00
Appendectomy
tal
illness
erage
8.96
employee
necticut General
days per ill-
35.00
Tonsillectomy
3.00
Thereafter to 70
80%
Coinsurance
50.00
Normal deliv-
None
system
Life Insurance Co.
ness
days
$10,000.00
Per illness
ery
1.1111X
21.06
employee
None
system
DIGESTS OF GROUP HEALTH INSURANCE PLANS FOR PUBLIC-SCHOOL PERSONNEL, 1964-65, MAXIMUMALLOWANCES AND BENEFITS (Continued)
Dollar amounts shown in () are charges to the individual for the specified benefit.
Dollar amounts shown in [
I are deductibles which must be satisfied by
the individual before coinsurance can be applied or benefits received.
School system and
underwriter of
health plan
Hospitalization:
Surgical
Medical
Ma or medical
Maternity provisions
for normal delivery
Coverage
after
retirement
Financing
Daily room
and board
Allow-
ances
Benefits
Allowances
Benefits
Allowances
Benefits
Cost per
Contributor
month
Allowances
Benefits
12
34
67
89
10
11
12
13
Stratum 3--enrollment 25,000-49,999 (Cont.)
RHODE ISLAND
Providence
Blue Cross and
$22.00/day for
$404.00
Single operation
$5.00
1st 14 days in hospi-
($100.00]
Deductible/yr.
$110.00
Hospital care
None
Individual
Physicians
120 days per
150.00
Appendectomy
tal
80%
Coinsurance
75.00
Normal deliv-
None
employee
Service./
illness
67.00
Tonsillectomy
4.00
Thereafter to 102
$10,000.00
Per year
ery
$ 7.05
system
days
$20,000.00
Per lifetime
Family
406.00
Maximum
7.05
employee
7.05
system
TENNESSEE
Hamilton Co.
(Chattanooga)
Tennessee Hospi-
$8.00/day for 70
300.00
Single operation
None
$3,000.00
Or 3 years for
10 days
Hospital care
N.I.
Individual
tal Service Assoc.
days per ill-
115.00
Appendectomy
specified
60.00
Normal deliv-
All
employee
ness
50.00
Tonsillectomy
diseases
ery
None
system
Family
N.I.
Knoxville
Provident Life
and Accident
$12.00/day for
31 days per
300.00
115.00
Single operation
Appendectomy
Major medical
[$500.00]
757.
Deductible/yr.
Coinsurance
80.00
60.00
Hospita]. care
Normal deliv-
NJ,
Individual
7.29
employee
Insurance Co.
illness
50.00
Tonsillectomy
$10,000.00
Per year
ery
None
system
Family
14.95
employee
None
system
$helbv Co.
(excl. Memphis"
Memphis Hospi-
$14.00/day for
200.00
Single operation
Major medical
[$100.00]
Deductible/
Basic cov-
Hospital care
N.I.
Individual
tal Service
31 days per
100.00
Appendectomy
illness
erage
507
employee
and Surgical
illness
40.00
Tonsillectomy
80%
Coinsurance
50.00
Normal deliv-
50%
system
Association
$10,000.00
Per 36 months
ery
Family
N.I.
TEXAS
Amarillo
Inter-Ocean
$10.00/day for
300.00
Single operation
5.00
Per day for 120
None
125.00
Hospital care
Same coverage
Individual
Insurance Co.
120 days per
100.00
Appendectomy
days in hospital
75.00
Physicians vis-
4.58
employee
illness
50.00
Tonsillectomy
600.00
Maximum
its
None
system
Family
16.73
employee
None
system
Austin
Blue Cross-
$12.00/day for
300.00
Single operation
5.00
Per day, starts
($100.00]
Deductible/yr.
10 days
Hospital care
N.I.
Individual
Blue Shield,
major medical
70 days per
illness
4th day for 30
days in hospital
80%
$5,000.00
Coinsurance
Per year
6.01
employeal
Nerc
system
$10,000.00
Per lifetime
Family
14.74
employee
None
system
Corpus Christi
Blue Cross-
$12.00/day for
300.00
Single operation
150.00
Maximum in hospital
[$100.00]
Deductible/yr.
10 days
Hcspital care
N.I.
Individual
Blue Shield,
major medical
70 days per
illness
80%
$5,000.00
Coinsurance
Per year
All
employee
None
system
$10,000.00
Per lifetime
Family
N.I.
12
37
910
1112
13Lubbock
Blue Cross-
$12.00/day for
$300.00
Single operation
$5.00
Per day, starts 4tn
[$100.00]
Deductible/yr.
10 days
Hospital care
Same coverage
Individual
Blue Shield,
major medical
70 days per
illness
day for 30 days in
hospital
807.
$5,000.00
Coinsurance
Per year
$ 5.69
employee
None
system
150.00
Maximum
$]0,000.00
Per lifetime
Family
14.86
employee
None
system
UTAH
Davis Co. (Farmington)
Utah Teachers
3 bed ward for
857.
Of fee schedule
[25.00]
Deductible/illness
$5,000.00
Per three years
10 days
Hospital care
Same coverage
Individual
Welfare Asso-
ciation
70 days per
illness, there-
after 80% of
charges
by Utah State
Medical Asso-
ciation
100%
80%
Next $75.00
Thereafter
for hospital,
surgical,and
medical
$100
Normal deliv-
ery
1.96
employee
4.58
system-
Family
12.92
employee
5.54
systom
Salt Lake City
Equitable Life
3 bed ward fc.
637.50
siz:gle operation
Major medical
[$100.00]
Deductible/yr.
180.00
Hospital care
Excludes ma-
Individual
Assurance Society
70 days per
127.50
Appendectosly
80%
Coinsurance
100.00
Normal deliv-
jor medical
None
employee
illness
63.75
Tonsillectomy
$15,000.00
Per lifetime
ery
6.93
system
Family
None
employee
15.40
system
VIRGINIA
Arlington Co.
Blue Cross-
Semi-private for
300.00
Single operation
5.00
Per day, starts 4th
[$50.00]
Deductible/yr.
100.0P
Hospital care
None
Individual
Blue Shield,
major wedtcal
180 days per
illness
day to 177 days
in hospital
807.
$10,000.00
Coinsurance
Per illness
105.1J
Normal deliv-
ery
7.60
employee
5.07
system
885.00
Maximum
ramily
20.87
employee
13.91
system
Henrico cc.
Blue Cross-
Semi-private for
150.00
Appendectomy
15.00
1st day in hospital
[$100.00]
Deductible/ill-
80.00
Hospital care
N.I
.Individual
Blue Shield.!
365 days per
67.00
Tonsillectomy
10.00
2nd
day
ness
100.00
Normal deliv-
7.62
employee
major medical
illness
5.00
Thereafter to 70
80%
Coinsurance
ery
None
system
days
$10,000.00
Per year
Family
$20,000.00
Per 2 or more
years
18.97
employee
None
system
Newport News
Blue Cross-
Semi-private for
150.00
Appendectomy
15.00
1st day in hospital
[$100.00]
Deductible/yr.
80.00
Hospital care
N.I
.Individual
Blue Shieldp./
365 days per
67.00
Tonsillectomy
10.00
2nd day
80%
Coinsurance
100.00
Normal deliv-
All
employee
major medical
illness
5.00
Thereafter to 70
$10,000.00
Per year
ery
None
system
days
$20,000.00
Per lifetime
Family
WASHINGTON
N.I.
Seattle
Group Health
Cooperative
Full coverage for
180 days per
Full coverage
Full coverage
[$25.001
Deductible/out
of area
(150.00)
Full coverage
Same coverage
Individual
5.00
employee
illness
100%
Next $500.00
5.00
system
807.
Coinsurance
Family
$9,500.00
Per lifetime
25.00
employee
5.00
system
Blue Cross
$25.00/day for
300.00
Single operation
3.00
Per day in hospital
[6g0.00]
Deductible/yr.
100.00
Hospital care
Same coverage
Individual
Occidental Life
100 days per
150.00
Appendectomy
3004:0000
Maximum
Coinsurance
75.00
Normal deliv-
5.90
employee
Ins. Co.a/
illness
6.00
Office visit
Home call, office and
home call visits for
employee only, start
$10,000.00
Per lifetime
ery
5.00
system
Family
18.20
employee
5.00
systeal
2nd cail for illness,
DIGESTS OF GROUP HEALTH INSURANCE PLANS FOR PUBLIC-SCHOOL PERSONNEL, 1964-65, MAXIMUM ALLOWANCES AND BENEFITS (Continued)
Dollar amounts shown in () are charges to the individual for the specified benefit.
Dollar amounts shown in [
] are deductibles which must be satisfied by
the individual before coinsurance can be applied or benefits received.
School system and
underwriter of
health plan
Hospitalization:
Surgical
Medical
Major medical
Maternity provisions
for normal delivery
Coverage
after
retirement
Financlng
Daily room
Allow-
and board
ances
Benefits
Allowances
Benefits
Allowances
Benefits
Cost per
Contributor
month
Allowances
Benefits
12
34
56
78
910
1112
13
Stratum 3--enrollment 25,000-49,999
(Cont.)
WASHINGTON (Cont.)
Seattle (Cont.)
Mutual of
Omaha
$25.00/4ay for
120 days per
illness
$375.00
Single operation
$3.00
150.00
3.00
3.00
Per day in hospital
Maximum
Office visit
Home call, office and
home visits for em-
ployee only, 33 vis-
its maximum
$5,000.00
Or 3 years for
specified
dread dis-
eases
$250.00
Lump sum
Same coverage
Individual
$ 3.83
employee(M)
4.84
employee(W)
5.00
system
Family
23.28
employee
5.00
system
King County
$25.00/day for
Full
70 days in hospi- Full cover-
70 days in hospital
[$100.00]
Deductible/yr.
100.00
Hospital care
N.I.
Individual
Medical
70 days per
cover-
tal per year
age
per year
80%
Coinsurance
75.00
Normal deliv-
5.00
employee
year
age
Full cover-
age
35 office and home
calls for employee
only, starts 2nd
call for illness
$10,000.00
Per lifetime
ery
5.00
system
EEELLE
19.60
employee
5.00
system
Tacoma
Pierce County
Industrial
Medical Bureau
$24.50/day for
90 days per
illness, 30
days for de-
pendents
Full coverage
Full coverage
$2,000.00
Extended cov-
erage
10 days
Hospital care
Same coverage
Individual
All
employee
None
system
EEE224
N.I.
Western
4 bed ward for
Full coverage
Full coverage
None
30 days
Hospital care
Reduced ben-
Individual
ClinicJ
1 month per
illness, 50%
for next 5
months
(25.00)
Normal deliv-
ery
efits
8.65
employee(M)
9.15
employee(W)
None
system
Family
20.65
employee(M)
21.15
employee(W)
None
system
WISCONSIN
Madison
Biue Cross-
Blue Shield
)Semi-private
1,000.00
Maximum per
;for 365 days
illness for
per illness
surgical and
medical
Stratum 4--enrollment 12,000-24,999
ALABAMA
Gadsden
Blue Cross-
Blue Shield
Semi-private
for 70 days
per illness
after [$25.00]
deductible
200.00
Single operation
1,000.00
Maximum per illness
[$100.00]
for surgical and
medical
100%
80%
$10,000.00
3.00
Per day for 70
days in hospital
10C%
80%
$10,000.00
Deductible/90
days
Of hospital
room and
board and
physicians
charges
Coinsurance
Per lifetime
No deductible
Of scheduled
hospital and
medical care
Coinsurance
Per lifetime
10 days
100.00
10 days
Hospital care
Normal deliv-
ery
N.I.
Hospital care
N.I.
after [$25.00]
deductible
Individual
None
employee
All
system
Family
Dep. cov.
employee
Emp. cov.
system
Individual
All
employee
None
system
Family
N.I.
12
34
56
78
910
1112
13
Protective Life
$12.00/day for
$200.00
Single operation
Insurance Co.
70 days per
illness,
$7.00/day
for 70 addi-
tional days
Calhoun Co.,
Anniston
Blue Cross-
Semi-private
200.00
Single operation
B3.00
Blue Shield
for 70 days
per illness
after [$25.00]
deductible
ALASKA
Anchorage
United Benefit
Major medical
Major medical
Life Ins. Co.
CALIFORNIA
Alum Rock Elem.
Sch. Dist. (San Jose)
Kaiser Founda-
Full coverage
Full coverage
Full cover-
tion
for 111 days
age
per illness,
(1.00)
60 days for
(3.50)
dependents
Guardian Life
Insurance Co.
Berkeley
$20.00/day for
21 days per
illness
Xaiser Founda-
Full coverage
tion
for 111 days
per illness
Blue Cross
3 or more bed
ward for 180
days per ill-
ness
350.00
Single operation
175.00
Appendectomy
61.25 Tonsillectomy
Full coverage
500.00
single operation
175.00 Appendectomy
75.00
Tonsillectomy
None
Per day for 70
days in hospi-
tal
Major medical
In hospital
Office visit
Home call--routine,
no charge after
first 2 visits
4.00
Hospital visit
4.00
Office visit
4.00
Home call, 50 visits
per year, office
1007.
and home visits
Full cover-
age
Full cover-
age (1.00)
(3.50)
5.00
3.00
4.50
None
[$100.00]
Deductible/yr.
807.
Coinsurance
$5,000.00
Per year
$10,000.00
Per lifetime
[$50.00]
Deductible/yr.
807.
Coinsurance
$10,000.00
Per lifetime
None
[B500.00]
Deductible/yr.
(basic plan
applies)
Of scheduled
care
for employee only,
757.
Private nursing
start 3rd day for
$10,000.00
Per illness
sickness
In hospital
Office visit, employ-
ee
Office visit, depend-
ent
Home call--routine, no
charge after first
2 visits
Per day for 180 days
in hospital
Office visit
Home call, office
and home visits
for employee only,
start 3rd visit
for illness,
$255.00 per year
None
[$50.00]
Deductible/6
months
807.
Coinsurance
$10,000.00
Per illness
$20,000.00
Per lifetime
$100.00
Lump sum
N.I.
10 days
Hospital care
N.I.
None
(60.00)
Full coverage
after 10
months' mem-
beLship
For dependents
Before 10
months' mem-
bership
(95.00)
(140.00)
None
N.I.
Same coverage
Individual
$ 5.95
employeet/
None
system
Family
12.95
employee
None
system
Individual
8.70
employee(M)
11.20
employee(W)
None
system
Family
25.80
employee
None
system
Individual
2.68
employee
2.68
system
Family
11.51
employee
2.68
system
Individual
7.95
employee
None
system
Family
19.45
employee
None
system
Individual
b/
950
employee-
None
system
Family
25.88
employee
None
system
(60.00)
Full coverage
Same coverage
Individual
after 10
3.15
employee
months'
5.55
system
bership
family
(140.00)
After 10 months'
18.20
employee
membership
5.55
system
50.00
Hospital care
Same coverage
Individual
5.82
employee
5.55
system
Family
22.72
employee
5.55
system
DIGESTS OF GROUP HEALTH INSURANCE PLANS FOR PUBLIC-SCHOOL PERSONNEL, 1964-65, MAXIMUM ALLOWANCES AND BENEFITS (Continued)
Dollar amounts shown in () are charges to the individual for the specified benefit.
Dollar amounts shown in [
] are decuctibles which must be satisfied by
the individual before coinsurance can be applied or benefits received.
School system and
Hospitalization:
Surgical
underwriter of
Daily room
Allow-
Benefits
aealth Ian
and board
ances
Medical
Allowances
Benefits
Major medical
Allowances
Benefits
12
34
56
78
Maternfty provisions
for normal dolivem__
Allowances
Benefits
910
Coverage
Financing
after
Cost per
Contributor
retirement
month
11
12
13
Stratum 4--enrollment 12,000-24,999 (Cont.)
CALIFORNIA (Cont.)
Burbank
Roos-Loos and
$25.00/day after
Independence Life
($50.00] de-
ductible per
year, with
807 coinsurance
to $10,000.00
North American
807 of 3 bed
Life and Casualty
ward or $18.00
Co.
for 31 days
per illness
Cupertino
Blue Cross
3 or mure.bed
ward for 180
days per ill-
ness
Kaiser Founda-
Full coverage
tion
for 111 days
per illness,
60 days for
dependents
Downey
Blue Cross, Se-
3 bed ward for
curity Life and
180 days per
Accident Co.
illness
Garden Grove
New England
Mutual Life
Glendale
Blue Cross
Major medical
$25.00/day for
365 days per
illness
Full cov-
For employee
Full cover-
age
For enployee
None
Full cover-
age
For employee
Same coverage
erage
Serv-
ice
fees
807. of
$400.00
200.00
60.00
For dependents
Single operation
Appendectomy
Tonsillectomy
Service
fee
807. of
$5.00
For dependents
Per day for 31 days
in hospital
($200.00]
Deductible/
yr. (20%
under basic
plan does
not apply)
Service fee
For dependents
None
..one
807.
Coinsurance
$10,000.00
Per lifetime
300.00
Single operation
3.00
Per day for 180
[$50.00]
Deductible/yr.
$ 50.00
Hospital care
Reduced ben-
15n.00
Appendectomy
days in hospital
807
Coinsurance
efits
50.00
Tonsillectomy
3.00
Office visit
$10,000.00
Per lifetime
4.50
Home call, office
and home visits for
employee only,
starts 3rd day for
illness, $255.00
per year
Full coverage
Full cover-
age (1.00)
(3.50)
In hospital
Office visit
Home call--routine,
no charge after
first 2 visits
None
(60.00)
(140.00)
Full coverage
after 10
months nem-
bership
Before 10
months mem-
bership
Same coverage
300.00
Single operation
3.00
Per day for 180 days
($100.00i
Deductible/yr.
50.00
Hospital care
N.I.
200.00
Appendectomy
in hospital
807.
Coinsurance
50.00
Tonsillectomy
3.00
Office visit
$5,000.00
Per illness
4.50
Home call, officeand
home visits for em-
ployee only, starts
$10,000.00
Per lifetime
3rd day for illness,
$225.00 a year
Major medical
Major medical
[$100.00]
Deductible
None
N.I.
807.
Coinsurance
$10,000.00
Per 3 years
750.00
Single operat:Ion
Major medical
[$100.00]
Deductible/yr.
None
N.I.
200.00
Appendectomy
80%
Coinsurance
75.00
Tonsillectomy
$10,000.00
Per lifetime
Individual
None
employee
$ 7.87
system
Famil/
12.03
employee
7.87
system
Individual
None
employee
8.08
system
Family
15.18
employee
8.08
system
Individual
8.19
employee(M)
10.34
employee(W)
None
system
Family
20.84
employee
None
system
Individual
7.95
employee
None
system
Family
19.45
enployee
None
system
Individual
Part
employee
Part
systen
Family
N.I. Individual
All
employee
None
system
Family
N.I. Individual
None
employee
6.00
system
Family
13.99
employee
7.20
system
14
56
79
1011
12
13
Palo Alto
Kaiser Founda-
Full coverage
tion
for 111 days
per illness,
60 days for
dependents
Riverside
California
Physicians
Service21
3 or more bed
ward for 100
days per ill-
ness
Kaiser Founda-
Full coverage
tion
for 125 days
per year, 240
days at 1/2
San Leandro
Kaiser Founda-
Full coverage
tion
for 111 days
per illness
Blue Cross
Full coverage
Full coverage
Full coverage
Full coverage
3 or more bed
$300.00 Single operation
ward for 180
150.00 Appendectomy
days per ill-
50.00 Tonsillectomy
ness
Sweetwater %.S. Dist.
SCLIpla Vista),
Blue Cross
3 or more bed
ward for 180
days per ill-
ness
San Diego
3 or more bed
Health Associa-
ward--$24.00
tion
maximum--for
70 days per
illness
CONNECTICUT
Bridgeport
Blue Cross-
Blue Shield,
Travelers In-
surance Co.
$12.00/day for
100 days per
illness
300.00
Single operation
150.00 Appendectomy
50.00 Tonsillectomy
Full coverage
350.00
Single operation
Full cover-
age (1.00)
(3.50)
In hospital
Office visit
Home call--routine,
no charge after
first two visits
Full cover-
For 100 days in
age
hospital, 30 of-
fice or home
visits per year,
starts 3rd day
for illness
Full cover-
In hospital and of-
age
fice visits
(5.00)
Home call, no lim-
its
Full cover-
age (1.00)
(3.50)
In hospital
Office visit
Home call--routine,
no charge after
first two visits
None
($100.00]
Deductible/yr.
807.
Coinsurance
$20,000.00
Per lifetime
None
None
3.00
Per day for 180 days
[$100.00]
Deductible/yr.
in hospital
80%
Coinsurance
3.00
Office visit
$10,000.00
Per lifetime
4.50
Home call, office
and home visits
for employee only,
start 3rd day for
illness, $225.00
per year
3.00
Per day for 180 days
[$100.00]
Deductible/yr.
in hospital
80%
Coinsurance
$5,000.00
Per illness
$10,000.00
Per lifetime
Full cover-
age (1.00)
(5.00)
In hospital
Office visit
Home call
6.00
Per day for 1st 4
[$100.00]
days,starts 4th day
in hospital
5.00
Next 10 days
4.00
Thereafter to 120days
807.
00.00
Maximum
5 000.00
None
Deductible/ill-
ness, varies
with basic cov-
erage
Coinsurance
Per illness
$(60.00)
Full coverage
after 10
months' mem-
bership
.
(95.00)
For dependents
(140.00)
Before 10
months' mem-
bership
50.00
Hospital care
(100.00)
Full coverage
after 10
months' mem-
bership
(175.00)
Before 10
months' mem-
bership
(60.00)
(140.00)
Full coverage
after 10
months' mem-
bership
Before 10
months' mem-
bership
50.00
Hospital care
Same coverage
Individual
$ 7.95
employee
None
system
Family
15.45
employee
None
system
Reduced ben-:'
efits
Same coverage
Same coverage
Individual
3.21
employee
7.39
system
Family
19.27
employee
7.39
system
Individual
1.96
employee
7.39
system
Family
20.06
employee
7.39
system
Individual
None
employee
8.35
system
Family
14.75
employee
8.35
system
Reduced ben-
Individual
efits
Part
employee
Part
system
Family
N.I.
50.00
Hospital care
N.I.
Full cover-
After 10 monchs' Same coverage
age
membership
(100.00)
Before 10
months' mem-
bership
125.00
75.00
Hospital cs._
Normal dOiv-
ery
N.I.
Individual
7.J3
employee(M)
8.74
esployee(W)
None
system
Family
18.80
employee
None
system
Individual
All
employee
None
system
Family
N.I. Tndividual
None
employee
All
system
Family
Dep. cov, employee
Em .
cov. s stem
DIGESTS OF GROUP HEALTH INSURANCE PLANS FOR PUBLIC-SCHOOL PERSONNEL, 1964-65, MAXIMUM ALLOWANCES AND BENEFITS
(Continued)
Dollar amounts shown in () are charges to the individual for the specified benefit.
Dollar amounts shown in [
] are deductibles which must be satisfied by
the individual before coinsurance can be applied or benefits received.
School system and
underwriter of
health plan
Hospitalization:
Surgical
Medical
Major medical
Maternity provisions
r normal delivery
Coverage
after
retirement
Financing
Daily room
and board
Allow-
Benefits
ances
Allowances
Benefits
Allowances
Benefits
Cost per
Contributor
month
pa
ces
Benefits
12
34
56
78
10
11
12
13
Stratum 4--enrollment 12,000-24,999
(Cont.)
-CONNECTICUT (Cont.)
Waterbury
Blue Cross-
$15.00/day for
$350.00
Single operation
$6.00
Per day for 1st 4
[$100.00]
Deductible/yr.
$125.0J
Hospital care
Same coverage
Individual
Blue Shield,
major mecical
120 days per
illness
135.00
50.00
Appendectomy
Tonsillectomy
days, starts 4th
day in hospital
807
$10,000.00
Coinsurance
Per lifetime
75.00
Normal deliv-
ery
$ 6.21
employee
None
system
5.00
Next 10 days
Family
4.00
Thereafter to 120
days
15.73
employee
None
system
500.00
Maximum
FLORIDA
Sarasota Co.
Blue Cross.11-
$16.00/day for
333.00
Single operation
12.00
First day in hospi-
($100.00]
Deductible/yr.
80.00
Hospital care
N.I.
Individual
Blue Shield,
major medical
/0 days per
illness
5.00
tal
Thereafter to 70
80%
$5,000.00
Coinsurance
Per year
80.00
Normal deliv-
ery
6.75
employee
None
system
days
$10,000.00
Per lifetime
Family,
20.37
employee
None
system
GEORGIA
Daugherty Co. (Albany)
Provident Life
and Accident
Insurance Co.
$15.00/day for
70 days per
illness
300.00
Single operation
Nona
None
100.00
Lump sum
None
Individual
5.46
employeeti
None
system
FalF:It
tire
ILLINOIS
Peoria
Blue Cross
Poulsen Plan
Semi-private for
Fee
120 days per
sched-Single operation
5.00
Per day for 90 days
in hospital
None
80.00
Hospital care
Same coverage
Individual
8.62
employee
illness
ule
450.00
Maximum
None
system
757.
Of unexpected
charges to
Family,
24.30
employee
$5,000.00
None
system
INDIANA
Vigo Co.,
(P.O., Terre Haute)
Blue Cross-
Semi-private for
200.00
Single operation
15.00
1st day in hospital
None
Basic cov-
Hospital care
None
Individual
Blue Shield
120 days per
100.00
Appendectomy
10.00
2nd day
erage
5.44
employee
illness
35.00
Tonsillectomy
4.00
Next 8 days
50.00
Normal deliv-
None
system
3.00
Thereafter to 30 days
ery
Family
117.00
Maximum
14.61
employee
Washington Twp.
None
system
(Indianapolis)
Blue Cross-
2 or more bed
Fee
Single operation
15.00
1st day in hospital
None
Basic cov-
Hospital care
N.I.
Individual
Blue Shield
ward for 120
sched-
10.00
2nd day
erage
All
employee
days per ill-
ule
4.00
Next 8 days
Fee ached-
Normal deliv-
None
system
ness
3.00
Thereafter to 120 days
ule
ery
Family
N.I.
c:)
12
34
56
78
910
11
12
13
Waterloo
Blue Cross-
Blue Shield
LOUISIANA
Lafa ette Parish
Semi-private for
$400.00
Single operation
$8.00
lst day in hospital
70 days per
120.00 Appendectomy
4.00
Thereafter to 70
illness
60.00 Tonsillectomy
days
Washington Na-
Major medical
tional Insurance
Co.
MARYLAND
Harford Co. (Bel Air)
Blue Cross-
Blue Shield!!
Semi-private for
30 days per
illness
MASSACHUSETTS
New Bedford
Blue Cross-
Semi-private for
Blue Shield
120 days per
illness after
[$25.001 deduct-
ible
MICHIGAN
Lincoln Park
Blue Crosse
Blue Shield
Semi-private for
365 days per
illness
Saginaw
Blue Crossli-
Semi-private tor
Blue Shield
365 days per
illness
MINNESOTA
Bloomin ton
Blue Cross-
Blue Shield
2 bed ward for
365 days per
illness
None
Basic cov-
Hospital care
N.I.
Individual
erase
$ 5.50
employee
$ 80.00
Normal deliv-
None
system
ery
Family
12.25
employee
None
system
Major medical
Major medical
100%
First $500.00
hospital
care
80%
For 3 days
hospita/
care (no
Same coverage
Individual
8%
employee
92%
system
($50.001
Deductible/yr.
deductible)
!really
807
Coinsurance
100.00
Normal deliv-
N.I.
$10,000.00
Per lifetime
ery
340.00
Single operation
20.00
1st day in hospital
None
75.00
Hospital care
Same coverage
Individual
150.00 Appendectomy
8.00
2nd and 3rd
100.00
Normal oeliv-
6.12
employee
75.00 Tonsillectomy
6.00
The...!eafter to 30
days
ery
None
system
Family
16.10
employee
None
system
500.00
Single operation
10.00
1st day in hospital
$5,000.00
For hospital
Basic cov-
Hospital care
Same coverage
Individual
125.00
Appendectomy
5.00
Thereafter
and medical
erase
2.70
employee
50.00 Tonsillectomy
500.00
Maximum
care for
specified
illnesses
75.00
Normal deliv-
ery
2.70
system
Family
7.10
employee
7.10
system
450.00
Single operation,
fee schedule
Fee ached-
365 days in hospital
related to annual
None
Basic cov-
erage
Hospital care
N.I.
Individual
10.89
employeei/
related to an-
nual income
ule
income
Fee ached-
ule
Normal deliv-
ery
None
system
Family
27.98
employe&
None
syster
450.00
single operation,
fee schedule
Fee sched-
365 days in hospital
related to annual
None
Basic cov-
erage
Hospital care
N.I.
Individual
10.89
employed!
related to an-
nual income
ule
income
Fee sched-
ule
Normal deliv-
ery
None
system
Family
27.98
employe&
None
system
675.00
Single operation
16.50
1st day in hospital
[$100.00)
Deductible/
Basic cov-
Hospital care
N.I.
Individual
180.00
Appendectomy
5.50
Thereafter to 180
illness
erage
3.21
employeed/ -
67.50 Tonsillectomy
days
80%
Coinsurance
115.00
Normal deliv-
5.00
system
$10,000.00
Per illness
ery
$20,000.00
Per lifetime
12.95
employee!,
8.33
systea
DIGESTS OF GROUP HEALTH INSURANCE PLANS FOR PUBLIC-SCHOOL
PERSONNEL, 1964-65, MAXIMUM ALLOWANCES AND BENEFITS (Continued)
Dollar amounts shown in () are charges to the individual for the
specified benefit.
Dollar amounts shown in [
I are deductibles which must be satisfied by
the individual before coinsurance can be applied or benefits received.
School system and
underwriter of
health plan
Hospitalization:
Surgical
Medical
Major medical
Maternity provisions
for normal delivery
Coverage
after
retirement
Financing
Daily room
and board
Allow-
ances
Benefits
Allowances
Benefits
Allowances
Benefits
Cost per Contributor
month
Allowances
Benefits
12
34
56
78
910
11
12
13
Stratum 4--enrollment 12,000-24,999 (Cont.)
MINNESOTA (Cont.)
Duluth
Travelers In-
$18.00/day to
$350.00
Single operation
$4.00
Per day in hospital
[$100.00]
Deductible/
Basic cov-
Hospital care
N.I.
Individual
surance Co.
$6,750.00
175.00
Appendectomy
to $1,460.00 per
illness
erage
None
employee
per illness
52.50
Tonsillectomy
illness
807.
Coinsurance
$ 87.50
Normal deliv-
Emp. cov.
system
$5,000.00
Per lifetime
ery
Family
16.00
employee
Emp. cov. system
MISSOURI
Springfield
Continental
$18.00/day for
400.00
Single operation
5.00
Per day Lc:- 70 days
($500.00]
Deductible/
Basic cov-
Hospital care
Excludes ma-
Individual
Casualty Cc).E/
70 days per
illness
in hospital
illness,
basic plan
applies
erage
Fee sched-
ule
Normal deliv-
ery
jor medical
9.03
employee
None
system
Family
757.
Coinsurance
28.38
employee
$10,000.00
Per illness
None
system
MONTANA
Billings
Equitable Life
Major medical
Major medical
Major medical
[$50.00]
Deductible/yr.
100.00
Lump sum
Same coverage
Individual
Assurance Society
1007
First $300.00
hospital
care
No deductible
1.57
employee
4.57
system
Family
807.
Coinsurance
12.97
employee
$10,000.00
Per lifetime
4.57
system
NEVADA
Washoe Co., (P.O., Reno)
Major medical
Major medical
($50.00]
Deductible/yr.
100.00
Lump sum
N.I.
Individu41
California West-
Major medical
ern State Life
Ins. Co.
100%
First $500.00
hospital care
No deductible
5.74
employee
4.11
system
807.
Coinsurance
Family
$10,000.00
Per lifetime
22.96
employee
4.11
system
NEW JERSEY
Paterson
Blue Cross-
Semi-private for
175.00
Appendectomy
10.00
1st day in hospital
None
7 days
Hospital care
N.I.
Individual
Blue Shield
120 days per
75.00
Tonsillectomy
7.00
2nd-7th days
150.00
Normal deliv-
6.81
employee
year, 240 part
6.00
8th-14th days
ery
None
system
day's care
5.00
Thereafter 365 days
Family
19.82
employee
None
system
NEW MEXICO
Las Cruces
Business Men's,
$12.00/day for
375.00
Single operation
7.50
lst-7th day in hos-
None
75.00
Hospital care
N.I.
Individual
Assurance Co.2V
90 days per
165.00
Appendectomy
pital
50.00
Normal deliv-
4.35
employee
illness
67.50
Tonsillectomy
4.50
Thereafter to 50 days
ery
1.09
system
246.00
Maximum
Fauna
17.50
employee
1.09
system
12
34
56
78
910
11
12
13
NEW YORK
Niagara Falls
Blue Cross-
Semi-private for
$500.00
Single operation
$ 15.00
1st day in hospital
No deduct-
Basic cov-
Hospital care
Same coverage
Individual
Blue Shield
730 days per
150.00
Appendectomy
10.00
2nd day
ible
erage
$ 5.30
employee
illness
1C0.00
Tonsillectomy
5.00
3rd to 40th day
80%
Of speci-
$100.00
Normal deliv-
5.30
system
3.00
Thereafter to 120
fied care
cry
Family.
days
$15,000.00
Per lifetime
19.88
employee
4.00
Office visit
5.30
system
5.00
Home call, office
and home visits
only following
hospital care,
Maxim= 3 per
week
OHIO
Middletown
Blue Cross-
2, 3 or 4 bed
300.00
Single operation
10.00
1st day in hospital
None
Basic cov-
Hospital care
Same coverage
Individual
Blue Shield
ward for 365
125.00
Appendectomy
5.00
Next 3 days
erage
7.35
employee
days per ill-
ness
60.00
Tonsillectomy
4.00
Thereafter to 120
days
50.00
Normal deliv-
ery
None
system
Feeily
18.00
employee
None
system
Warren
Blue Shield-
2 or more bed
300.00
Single operation
10.00
1st day In hospital
None
Basic cov-
Hospital care
N.I.
Individual
Blue Cross
ward for 120
125.00
Appendectomy
5.00
Next 3 days
erage
7.75
employee
days per year
60.00
Tonsillectomy
4,00
Thereafter to 120
days
50.00
Normal deliv-.
ery
None
system
Family.
18.01
employee
None
systole
OREGON
Beaverton
4 bed ward,
$22.00/day
maximum, for
350.00
Single operation
4.00
Per day for 100 days
None
100.00
50.00
Hospital care
Normal deliv-
ery
N.I.
Individual
Blue Cross
4.70
employee(M)
6.00
employee(W)
100 days per
illness
None
system
Family
14.65
employee
None
system
Kaiser Founda-
tion
OPS-Blue Shield
PENNSYLVANIA
Altoona
Blue Cross
Blue Shield
Full coverage
Full coverage
Full cov-
In hospital
for 111 days
erage
per illness,
(1.00)
Office visit
70 days for
(5.00)
Home call
dependents
$14.00/day for
Full coverage
Full cov-
For 70 days in hos-
70 days per
erage
pital
year
No charge
For 35 office or
home visits per
year, starts 2nd
visit, for employ-
ee only
Semi-private
for 120 days
per illness
300.00
Single operation
150.00
Appendectomy
50.00
Tonsillectomy
Major medical
None
Full cov-
After 10
Same toverage
Individual
erage
months' mem-
7.75
employee
bership
None
system
(120.00)
Before 10
Family
months'
19.95
employee
None
system
None
60.00
Hospital care
Same coverage
Individual
50.00
Normal deliv-
7.30
employee(M)
ery
7.69
employee(W)
None
system
16.84
employee
None
system
[$100.00]
Deductible/yr.
Basic cov-
Hospital care
Reduced ben-
Individual
80%
Coinsurance
erage
efits
None
employee
$5,000.00
Per lifetime
90.00
Normal deliv-
5.68
system
ery
Family.
11.02
employee
5.68
system
DIGESTS OF GROUP HEALTH INSURANCE PLANS FOR PUBLIC-SCHOOL
PERSONNEL, 1964-65, MAIIMUM ALLOWANCES AND BENEFITS (Conanued)
Dollar amounts shown in () are charges to the individual for the
specified benefit.
Dollar amounts shown in [
] are deductibles which must be satisfied by
the individual before coinsurance can be applied or
benefits received.
School system and
underwriter of
health plan
Hospltalization:
Surgical
Medical
MA or medical
Maternity provislons
for normal delivery
Coverage
after
retirement
Financing
Daily roam
and board
Allow-
ances
Benefits
Allowances
Benefits
Allowances
Benefits
Cost per Contributor
month
Allowances
Benefits
12
34
56
78
910
11
12
13
Stratum 4--enrollment 12,000-24,999 (Cont.)
PENNSYLVANIA (Cont.1
Bethlehem
Blue Cross-
Semi-private for
$300.00
Single operation
$ 15.00
1st day in hospital
[$100.001
Deductible/yr.
Basic cov-
Hospital care
Excludes ma-
Individual
Blue Shield,
major medical
120 days per
illness
150.00
50.00
Appendectomy
Tonsillectomy
10.00
4.00
2nd day
Next 8 days
807.
$25,000.00
Coinsurance
Per lifetime
erage
$ 90.00
Normal deliv-
jor medical
None
employee
All
system
3.00
Thereafter to 70
days
ery
Family
Dep. cov. employee
5.00
Office visit
Emp. cov. system
7.00
Home call, office
and home visits
for employee only,
starts 4th day of
illness to 21 days
a year
SOUTH CAROLINA
Darlington Co.
Plan A.
Major medical
Major medical
Major medical
1007.
First $500.00
hospital
care
200.00
Lump sum
N.I.
Individual
7.35
employee
None
system
[$100.001
Deductible
Family
807
Coinsurance
18.15
employee
$10,000.00
Per lifetime
None
system
Plan B.
$11.50/day for
150.00
Single operation
None
None
50.00
Lump sum
N.I.
Individual
70 days, $4.50/
day for 70 addi-
tional days per
year
4.31
employeehl
None
system
Family
13.32
employee
None
system
Plan C.
Semi-private for
70 days per
illness after
250.00
Single operation
None
None
56.25
Normal deliv-
ery
N.I.
Individual
4.50
employeeh/
None
system
($25.001 de-
ductible
Family
9.05
employee
None
system
Spartanburg
Protective Life
$16.00/day for
400.00
Single operation
4.00
Per day for 70 days
None
160.00
Hospital care
Same coverage
Individual
Insurance Co.
70 days per
illness
in hospital
100.00
Normal deliv-
ery
except per
year rather
than illness
7.50
employeet/
None
system
Family
15.00
employee
None
system
Blue Cross-
Semi-private far70
325.00
Single operation
5.00
Per day for 70 days
$10,000.00
For speci-
10 days
Hospital care
N.I.
Individual
Blue Shield
days per illness
117.00
Appendectomy
in hospital,
fied dis-
71.50
Normal deliv-
All
employee
after [$20.00]
deductiblq
48.75
Tonsillectomy
starts 3rd day
eases
ery
None
system
Family
SOUTH DAKOTA
N.I.
Rapid City
United Bene-
$11.00/day for
300.00
Single operation
3.00
Per day for 70 days
[$100.00]
Deductible/yr.
110.00
Hospital care
Same coverage
Individual
fit Life In-
70 days per
150.00
Appendectomy
in hospital
807
Coinsurance
75.00
Normal deliv-
1.41
employee
surance Co.
illnesr after
45.00
Torsillectomy
210.00
Maximum
$10,000.00
Per lifetime
ery
Basic cov. system
[$25.00] de-
ductible
Family
3.27
employee
Basic cov. system
12
34
56
78
910
1112
13
TENNESSEE
Knox Co.
'excl. Knoxville)
Blue Cross-
$14.3f_Vdti Zor
$300.00
Single operation
$4.00
Per day for 70 days
None
10 days
Hospital care
Same coverage
Individual
Blue Shield
70 days per
115.00
Appendectomy
in hospital,
$ 60.00
Normal deliv-
$ 5.20
employee
illness
50.00
Tonsillectomy
starts 4th day
ery
None
system
Family
14.60
employee
None
system
TEXAS
Ector Co.,(Odessa)
Blue Cross-
$12.00/day for
300.00
Single operation
5.00
Per day for 30 days
0100.001
Deductible/
10days
Hospital care,
N.I.
Individual
Blue Shield
70 days per
150.00
Appendectomy
in hospital,
illness
deductible
5.67
employee
illness, after
starts 4th day
807.
Coinsurance
applies
4.17
system
($25.00) de-
$5,000.00
Per year
75.00
Normal deliv-
Family
ductible
$10,000.00
Per lifetime
ery
14.55
employee
4.17
system
Goose Creek,
(Baytown)
Blue Cross-
$12.00/day for
300.00
Single operation
5.00
Per day for 70 days
($100.00]
Deductible/yr.
120.00
Hospital care
N.I.
Individual
Blue Shield
70 days per
150.00
Appendectomy
in hospital
807.
Coinsurance
75.00
Normal deliv-
5.06
employee
illness, after
40.00
Tt-disiliectomy
$10,000.00
Per year
ery
4.17
system
[$35.00] de-
ductible
Family
15.56
employee
Port Arthur
4.17
system
Business Men's
Assurance Co.
$12.00/day for
100 days per
300.00
150.00
Single opera..ion
Appendectomy
3.00
Per day for 50 days
in hospital
None
10 days
Hospital care
Same coverage
Individual
bAll
employeel
-,
illness
37.50
Tonsillectomy
None
system
Family
N.I.
MTAR
9Rden
Metropolitan Life
$18.00/day for
350.00
Single operation
5.00
Per day to $155.00
None
150.00
Normal deliv-
Same coverage
Individual
Insurance Co.
70 days per
175.00
Appendectomy
in hospital
ery
1.44
employee
illness
70.00
Tonsillectomy
3.00
Office visit
5.76
system
5.00
Home call, office
and home visits
for employee only,
starts 3rd day
for illness,
$250.00 maximum
Family
4.60
employee
13.80
system
VIRGINIA
Chesapeake
Connecticut Gen-
$18.00/day to
300.00
Single operation
3.00
Per day in hospital
[$100.00]
Deductible/
100.00
Hospital care
N.I.
Individual
eral Life In-
$1,260.00
150.00
Appendectomy
350.00
Maximum
illness
75.00
Normal deliv-
2.44
employee
surance Co.
per illness
45.00
Tonsillectomy
807.
Coinsurance
ery
Part
system
$10,000.00
Per lifetime
Family
13.29
employee
Part
system
WASHINGTON
Clover Park (P.O., Tacoma)
Full
For 1 year for
Full cover-
For 1 year for any
$2,000.00
Extended cov-
10 days
Hospital care
Same coverage
Individual
Pierce County
$24.50/day for
Medical Bureau
90 days per
coy-
any 1 illness
age
1 illness
erage per
8.30
employee(M)
year
erage
illness
9.60
employee(W)
None
system
Family
21.45
employee(M)
22.55
employee(W)
None
system
DIGESTS OF GROUP HEALTH INSURANCE PLANS FOR PUBLIC-SCHOOL PERSONNEL, 1964-65, MAXIMUM ALLOWANCESAND BENEFITS (Continued)
Dollar amounts shown in () are charges to the individual for the specified benefit.
Dollar amounts shown in [
] are deductibles which must be satisfied by
the individual before coinsurance can be applied or benefits received.
School system and
Hospitalization:
Sur ical
Medical
Major medical
Maternity provisions
Coverage
Financing
underwriter of
Daily room
Allow-
Benefits
Allowances
Benefits
Allowances
Benefits
for normal delivery
after
Cost per
Contributor
health plan
and board
ances
Allowances
Benefits
retirement
month
12
34
56
78
910
11
12
13
Stratum 4--enrollment 12,000-24,999 (Cont.)
WASHINGTON (Cont.)
Edmonds
Snokomish Co.
$18.00/day for
Full coverage
Full cover-
For 12 months in
$5,000.00
Or 2 years ex-
$ 80.00
Hospital care
Same coverage
Individual
Physicians
90 days per
age
hospital
tended bene-
Full cov-
Normal deliv-
$ 6.75
employee(M)
Corporation
illness, 30
fits for one
erage
ery and phy-
9.50
employee(W)
days for de-
illness
sician's vis-
None
system
pendents
its in hos-
Family
pital
25.45
employee(M)
26.20
employee(W)
None
system
Blue Cross,
$20.00/day for
$300.00 Single operation
$3.00
Per day for 100 days
[$100.00]
Deductible/yr.
100.00
Hospital care
same coverage
Individual
Occidental Life
100 days per
150.00
Appendectomy
in hospital
80%
Coinsurance
75.00
Normal deliv-
8.66
employeeki
Insurance Co.
illness
3.00
Office visit
$10,000.00
Per 5 years
ery
None
system
5.00
Home call, office
Family
and home visits
19.66
employee
for employee only,
None
system
start 2nd day of
illness, to
$250.00 a year
WEST VIRGINIA
Mingo Co.
a/
Blue Cross- -
$15.00/day for
125.00 Appendectomy
10.00
1st day, starts 3rd
Blue Shield
70 days per
50.00
Tonsillectomy
day in hospital
illness
5.00
Thereafter to 30
days
145.00
Maximum
WISCONSIN
Kenosha
Blue Cross-
Semi-private
100% of "usual, customary, and unreasonable" charges to a maximum
Blue Shield
for 120 days
of fi,000.00 per illness
per illness
Casper-Midwest
(Casper)
Equitable Life
Assurance
Society
Major medical
Major medical
Major medical
None
None
[$50.00]
Deductible/yr.
807.
Coinsurance
$10,000.00
Per lifetime
10 days
75.00
Hospital care
Normal deliv-
ery
Same coverage
Individual
6.60
employee
None
system
Family
15.50
employee
None
system
Basic cov-
Hospital care
Same coverage
Individual
erage
7.82
employee
Basic cov-
Normal deliv-
None
system
erage
ery
Family
21.74
employee
None
system
200.00
Lump sum
Reduced ben-
-b/A/
Individual-:zy
No deductible
efits
8.85
employee
None
sylcqm
11111.1.11.
19.40
employee(M)
18.70
employee(W)
None
system
4.4
0%
23
45
67
.8
910
11
12
13
Suburban school districts (varies enrollments)
CALIFORNIA
Arcadia
Occidental
Life
$12.00/day to
$372.00 per
illness
Fmploy-
ee
$400.00
200.00
60.00
Depend-
ent
Single operation
Appendectomy
Tonsillectomy
Employee
$4.50
3.00
4.50
225.00
Dependent
Per day, hospital
Office visit
Home call
Maximum start 3rd
day of illness
($100.00]
80%
$10,000.00
Deductible/yr.
Coinsurance
Per 5 years
None
N.I.
Individual
$ 4.38
employee
None
system
Family
19.56
employee
None
system
300.00
Single operation
4.50
Per day in hospital
150.00
Appendectomy
225.00
Maximum
45.00
Tonsillectomy
Beverly Hills
Blue Cross
3 or more bed
300.00
Single operation
3.00
Per day for 180 days
($100.00]
Deductible/yr.
$ 50.00
Hospital care
N.I.
Individual
ward for 180
150.00
Appendectomy
in hospital
80%
Coinsurance
8.64
employee(M)
days per ill-
50.00
Tonsillectomy
3.00
Office visit
$5,000.00
Per illness
10.93
employee(W)
ness
4.50
Home call, office
and home visits
for employee only,
start 3rd day of
illness to $225.00
a year
$10,000.00
Per lifetime
None
system
Family
27-21
employee
None
system
CONNECTICUT
Wethersfield
Blue Cross-
$23.00/day for
350.00
Single operation
15.00
1st day in hospital
[$100.00]
Deductible/yr.
125.00
Hospital care
N.1.
b/d/
Individual-:='
Blue Shield,
120 days per
10.00
2nd day
80%
Coinsurance
75.00
Normal deliv-
None
employee
Travelers In-
illness
6.00
Next 5 days
$10,000.00
Per lifetime
ery
8.10
system
surance Co.
5.00
Next 10 days
Family
4.00
Thereafter to 120
days
10.61
employee
8.10
system
ILLINOIS
Skokie
Blue Cross-
2 or more bed
300.00
Single operation
6.00
1st 5 days in hospi-
[$100.00]
Deductible/
Basic cov-
Hospital care
None
Individual
Blue Shield,
major medical
ward for 120
days per ill-
125.00
Appendectomy
4.00
tal
Thereafter to 120
807
illness
Coinsurance
erage
80.00
Normal deliv-
4.24
employee
3.50
system
ness
days
$10,000.00
Per lifetime
ery
Family
13.38
employee
11.00
system
Highland Park Elem.
Blue Cross-
Major medical
Major medical
Major medical
[$100.00]
Deductible/yr.
100.00
Hospital care
N.I.
Individual
.Blue Shield
807
Of $2)000.00
50.00
Normal deliv-
None
employee
1007.
Thereafter
ery
8.52
system
$10,000.00
Per lifetime
Family
14.83
employee
8.52
system
Wilmette
Blue Cross-
Semi-private
300.00
Single operation
6,00
1st 5 days in hospi-
($100.00]
Deductible/yr.
Basic cov-
Hospital care
N.I.
Individual
Blue Shield,
for 120 days
125.00
Appendectomy
tal
807.
Coinsurance
erage
90%
employee
Washington Na-
tional In-
surance Co.
per illness
4.00
Thereafter to 120
days
$10,000.00
Per lifetime
80.00
Normal deliv-
ery
10%
system
Family
90%
employee
10%
system
DIGESTS OF GROUP HEALTH INSURANCE PLANS FOR PUBLIC-SCHOOL PERSONNEL, 1964-65,
MAXIMUM ALLOWANCES AND BENEFITS (Continued)
Dollar amounts shown in () are charges to the individual for the specified benefit.
Dollar amounts shown in [
] are deductibles which must be satisfied by
the individual before coinsurance can be applied or benefits received.
School system and
underwriter of
health_plan
1
Hospitalization:
Daily room
and board
2
Surgical
Allow-
ances
3
Benefits
Medical
Allowances
Benefits
Major medical
Allowances
Benefits
Maternity provisions
for normal delivery
45
67
8
Allowances
Benefits
910
Coverage
after
retirement
1.1
Financing
Cost per
Contributor
month12
13
Suburban school districts (varies enrollments) (Cont.)
MASSACHUSETTS
Brookline
Blue Cross-
Blue Shield
MICHIGAN
Trenton
$24.00/day for
120 days per
illness
Full
Based on annual
Full cov-
cov-
income
erage
erage
For 120 days in hos-
pital based on an-
nual income
$5,000.06
Extended cov-
Basic cov-
Hospital care
Same coverage
Individual
erage for
erage
$ 3.64
employee
specified
$ 75.00
Normal deliv-
3.64
system
illnesses
ery
Family
10.76
employee
10.76
system
Blue Crossai-
Blue Shield
Semi-private for
365 days per
illness
450.00
Single operation
fee schedule
related to an-
nual income
Fee sched-
ule
365 days in hospital
related to annual
income
None
Basic cov-
erage
Fee bched-
ule
Hospital care
Normal deliv-
ery
N.I.
Individual
2.56
employee
8.33
system
Family
19.65
employee
8.33
system
MINNESOTA
Roseville (St. Paul)
Blue Cross,
2 or more 'led
400.00
Single operation
4.00
Per day in hospital
($75.00]
Deductible/yr.
Basic cov-
Hospital care
None
Individual
United Benefit
ward for 365
200.00 Appendectomy
$1,460.00
Maximum
80%
Coinsurance
erage
None
employee
Life Insurance
Co.
days per ill-
ness, after
60.00
Tonsillectomy
$5,000.00
Per year
100.00
Normal deliv-
ery
8.30
system
Family
($25.00] de-
ductible
13.59
employee
8.30
system
NEW JERSEY
Teaneck
Blue Cross-
Semi-private for
175.00
Appendectomy
10.00
1st day in hospital
($100.001
Deductible/yr.
7 days
Hospital care
Reduced ben-
Individual
Blue Shield,
120 days per
75.00 Tonsillectomy
7.00
2nd day-7th day
80%
Coinsurance
150.00
Normal deliv-
efits
7.34
employee
Prudential In-
year, 245 part-
6.00
8th-14th day
$10,000.00
Per lifetime
ery
None
system
surance Co.
days
5.00
Thereafter to 365
days
Family
21.36
employee(M)
20.80
employee(W)
None
system
NEW YORK
Scarsdale
Connecticut
Semi-private for
300.00
Single operation
5.00
Per day for 70 days
($100.001
Deductible/2
150.00
Hospital care
Reduced cov-
Individual
Life Insurance
70 days peT
150.00
Appendectomy
in hospital
yrs.
75.00
Normal deliv-
erage
3.54
employee
Company
illness
45.00 Tonsillectomy
350.00
Maximum
80%
Coinsurance
ery
3.54
system
$10,000.00
Per illness
Family
11.65
employee
11.65
system
Williamsville
Blue Cross-
Semi-private for
500.00
Single operation
15.00
1st day in hospital
[$100.00]
Deductible/yr.
10 days
Hospital care
Reduced ben-
Individual
Blue Shield,
120 days per
150.00
Appendectomy
10.00
2nd day
80%
Of $2,000.00
80.00
Normal deliv-
efits
Bas. cov.
employee
Massachusetts
illness
100.00
Tonsillectomy
5.00
3rd-40th
100%
Over $2,000.00/
ery
Maj. med.
system
Mutual Life
3.00
Thereafter to 120
'year
Family
Insurance Co.
days
$10,000.00
Per lifetime
N.I.
12
OHIO
Beachwood
Blue Cross-
Blue Shield
Westlake
Blue Cross-
Blue Shield
PENNSYLVANIA
Cheltenham Twp.
(Elkins Park)
Semi-private for
120 days per
illness
Semi-private for
120 days per
illness
Blue Cross-
Semi-private for
Blue Shielde,
120 days per
I.N.A. Life In-
illness
surance Co.
Fox Chapel
Blue Cross-
Blue Shield!!
Semi-private for
30 to 70 days
per illness
depending on
years of con-
tinuous cover-
age
WISCONSIN
Wauwatosa
Blue Cross-
Semi-private for
Blue Shield
120 days per
illness
Whitefish Bay
Blue Cross-
Semi-private for
Blue Shield
365 days per
illness
34
56
89
1011
12
13
$500.00
Single operation
165.00 Appendectomy
75.00 Tonsillectomy
$15.00
5.00
4.00
675.00
1st day in hospital
2nd to 30th day
Thereafter to 120
days
Maximum
None
Basic cov-
erage
$ 60.00
Hospital care
Normal deliv-
ery
N.I.
Individual
$11.35
employee
None
system
Family
22.70
employee
None
system
500.00
Single operation
15.00
1st day in hospital
None
Basic coy-
Hospital care
N.I.
Individual
165.00 Appendectomy
5.00
2nd-30th day
erage
11.85
employee
75.00 Tonsillectomy
4.00
Thereafter to 120
days
60.00
Normal deliv-
ery
None
system
Family
675.00
Maximum
23.70
employee
None
system
30U.00
Single operation
15.00
1st day in hospital
[$100.00]
Deductible/
6 days
Hospital care
N.I.
Individual
150.00 Appendectomy
10.00
2nd day
6 months
90.00
Normal deliv-
Part
employee
50.00 Tonsillectomy
4.00
Next 8 days
807
Coinsurance
ery
Part
system
3.00
Thereafter to 70
days
$10,000.00
Per lifetime
Family
N.I.
5.00
Office visit
7.00
Home call, office
and home visits
for employee only,
start 4th visit
for illness to 21
visits per year
300.00
Single operation
15.00
1st day in hospital
None
10 days
Hospital care
Reduced cov-
Individual
150.00 Appendectomy
10.00
2nd day
90.00
Normal deliv-
erage
None
employee
50.00 Tonsillectomy
4.00
Next 8 days
ery
6.53
system
3.00
Thereafter to 70
days
Family
11.69
employee
5.00
Office visit
6.53
system
7.00
Home call, office
and home visits
for employee only,
start 4th visit
for illness to 21
visits per year
Full coverage to
Full coverage to
1$100.00]
Deductible/90
Basic cov-
Hospital care
Sane coverage
.Individual
$1,000.00 per
$1,000.00 per
days
erage
Maj. med. employee
illness
illness
807.
Coinsurance
75.00
Normal deliv-
Bas. cov. system
$10,000.00
Per illness
ery
Family
N.I.
700.00
Single operation
6.00
Per day, starts 4th
0100.001
Deductible/yr.
Basic cov-
Hospital care
N.I.
Individual
125.00
Appendectomy
day for 6 days
807 .
Coinsurance
erage
8.05
employee
50.00 Tonsillectomy
in hospital
$10,000.00
Per lifetime
65.00
Normal deliv-
None
system
3.00
Thereafter to 70
days
ery
Family
21.47
employee
None
system
N.I.--No information.
a/ More than one plan or schedule of
6/ The cost per month includes other
2/ Cost per month varies with age; t
41 Cost per month varies with annual
benefits is offered by the same underwriter.
benefits such as life insurance, accidental death and dismemberment, and income protection from
accident or sickness.
See the table following this listing.
he cost at age 40 is reported.
income; the cost at $6,700 is reportd.
BENEFITS INSEPARABLE FROM PACKAGE COST OF INSURANCE PLANS
School system
Life
insur-
ance
Acciden-
tai death
and dis-
memberment
Income
protec-
tion
23
4
Stratum 1
FLORIDA
Duval Co
$1,000
$2,500
MARYLAND
Baltimore
1,000
$100 monthly
TEXAS
Dallas
2,500
Houston
2,000
Stratum 2
ALABAMA
Mobile Co
1,000
1,000
100 monthly
FLORIDA
Orange Co
1,000
2,500
LOUISIANA
Caddo Parish
5,000
5,000
MASSACHUSETTS
Boston
2,000
2,000
MINNESOTA
Minneapolis
2,000
Stratum 3
CALIFORNIA
Sacramento
2,000
2,000
GEORGIA
Cobb Co.
1,000
1,000
25 weekly
ILLINOIS
Rockford
2,000
2,000
KANSAS
Kansas City
1,000
50 weekly
LOUISIANA
Calcasieu Parish,
Employee:
2,000
2,000
Spouse:
500
Child:
500
MICHIGAN
Grand Rapids
1,00
0
School system
Life
insur-
ance
Acciden-
tal death
and dis-
memberment
Income
protec-
tion
23
4
Stratum 3
,(Continued),
MICHIGAN (Continued)
Lansing (MEA Health)
$100 weekly
MINNESOTA
St. Paul
$1,000
$2,000
NEVADA
Clark Co.
1,000
TEXAS
Austin
1,000
1,000
Stratum 4
ALABAMA
Gadsden
2,000
3,000
CALIFORNIA
Alum Rock Elan
1,000
2,000
GEORGIA
Dougherty Co.
1,000
60 monthly
SOUTH CAROLINA
Darlington, Plans B and C
1,000
2,500
Spartanburg
1,00
0TEXAS Port Arthur
500
WASHINGTON
Edmonds
1,759
1,750
WYOMING
Casper-Midwest, Employee:
8,000
8,000
Spouse:
2,000
Children:
Varies
with
age
Suburban
CONNECTICUT
Wethersfield
7,000
81
VI. SELECTED REFERENCES ON GROUP HEALTHINSURANCE
1. Allen, Clifford H. School Insurance Administration. New York: Macmillan Co., 1965. 133 p.
2. Angell, Frank J. Health Insurance. New York: Ronald Press Co., 1963. 541 p.
3. Campen, Palmer G. The Selection, Administration, and Content of Health Insurance Plans forPublic School Districts Personnel. Evanston, Association of School Business Officials,
1962. 72 p.
4. Dickerson, 0. D. Health Insurance. Revised edition. Homewood, Ill.: Richard D. Irwin,
1963. 686 p.
5. Egley, Edgar C. Fringe Benefits for Classified Employees in Cities of 100,000 Population or
Greater. Bulletin No. 19. Evanston, Ill.: Association of School Business Officials of theUnited States and Canada, 1959. 79 p.
6. Eilers, Robert D. Regulation of Blue Cross and Blue Shield Plans. S. S. Huebner Foundation
for Insurance Education-Studies. Homewood, Ill.: Richard D. Irwin, 1963. 359 p.
7. Eilers, Robert D., and Crowe, Robert M., editors. Group Insurance Handbook. Homewood, Ill.:
Richard D. Irwin, 1965. 600 p.
8. Faulkner, Edwin J. Health Insurance. New York: McGraw-Hill Book Co., 1960. 636 p.
9. Ferguson, Wayne S. Non-Wage Benefits for Teachers. Research Bulletin No. 132. Burlingame:
California Teachers Association, 1960. 69 p.
LO. Finchum, Ralph N. School Insurance: Managing the Local Program. U. S. Department of Health,Education, and Welfare, Office of Education, Bulletin 1959, No. 23. Washington, D. C.:Government Printing Office, 1959. 97 p.
11. Follmann, J. F., Jr. Medical Care and Health Insurance: A Study in S ecial Pro
wood, Ill.: Richard D. Irwin, 1963. 503 p.
re ss. Home-
12. Gregg, Davis W., editor. Life and Health Insurance Handbook. Second edition. Homewood, Ill.:
Richard D. Irwin, 1964. 1348 p.
13. Klarman, Herbert E. The Economics of Health. New York: Columbia University Press, 1965.
200
14. Kleinmann, Jack H. Fringe Benefits for Public School Personnel. New York: Teachers College,
Columbia University, 1962. 178 p.
15. National Association of Secretaries of State Teachers Associations. Insurance Programs of
State Education Associations. Information Service Report No. 99. Washington, D. C.: the
Association, a department of the National Education Association, October 30, 1963. 19 p.
16. National Education Association, Research Division. Employer Cooperation in Group InsuranceCoverage for Public-School Personnel, 1964-65. Research Report 1966-R4. Washington, D. C.:
the Association, March 1966. 192 p.
17. National Education Association, Research Division. "Group Insurance Programs for Teachers."NEA Research Bulletin 39: 92-93; October 1961.
18. National Education Association, Research Division. School Districts That Pay Part of the Pre-miums for Certain Insurance Programs Covering School Employees. Research limo 1961-23. Wash-
ington, D. C.: the Association, June 1961. 13 p.
82
19. National Education Association, Salary Consultant Service and Department of Classroom Teach-
ers. The Place of Fringe Benefits. Guidelines for Effectivr Work To Improve nacher Salary
Programa, No. 9. Washington, D. C.: the Association. 6 p.
20. Pickrell, Jesse F. Group Heallb_Igagreme. Homewood, Ill.: Richard D.Irwin, 1961. 221 p.
21. Reed, Louis S. "Privats Health Insurance in the United States: An Overview." Social Securitv
Bulletin 28: 3-21, 48; December 1965.
22. Reed, Louis S., and Hanft, Ruth S. "National Health Expenditures, 1950-64." Social Securitv
lulletiA 29: 3-19; January 19664
23. Somers, Herman M., and Somers, Anne R. Doctors. Patients and Health Insurance: The Organisa-
tion and Financing of Medical cam. Washington, D. C.: Brookings Institution, 1961. 576 p.
24. U. S. Department of Labor, Bureau of Labor Statistics. Digest of 50 Selected Health and In-
surance Plans for Salaried Employees. Spring 1963. Bulletin No. 1377. Washington, D. C.:
Government Printing Office, February 1964. 161 p.
25. U. S. Department of Labor, Bureau of Labor Statistics. Digest of One Hundred Selected Hea1t4
and Insurance Plans Under Collective Bargaining, Winter 1961-62. Bulletin No. 1330. Wash-
ington, D. C.: Government Printing Office, June 1962. 215 p.
26. U. S. Department of Labor, Bureau of Labor Statistics. Health and Insurance Benefits and
Pension Plans for Salaried EmPlAwses. Spring 1963. Bulletin No. 1405. Washington, D. C.:
Government Printing Office, May 1964. 13 p.
27. U. S. Department of Labor, Bureau of Labor Statistics. Supplementary Compensation for Non-
Production Workers. 1963. Bulletin No. 1470. Washington, D. C.: Government Printing Office,
December 1965. 110 p.