83
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-R10 Pub Date Jul 66 Note- 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 health insurance coverage for public school personnel. A general overview is given of (1) group heAlfh insurance coverage. (2) patterns of group health insurance. (3) group health i ince organizations. (4) eligibility and enrollment practices. and (5) continuout: .alth insurance coverage. Developing specifications for group health insurance 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 group insurance plans are included and maximum allowances and benefits of these plans are presented by State and school district. A short bibliography lists relevant background material. A related document is EA 001 801. (TT)

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Page 1: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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)

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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

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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

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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.

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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

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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

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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:

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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/

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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%

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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.

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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.

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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

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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.

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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

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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.

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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.

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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.

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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.

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Mem

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ual c

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cred

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ds $

he c

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rsu

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ervi

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bscr

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a n

on-m

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for

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s de

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Mem

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S r

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to a

bove

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% o

f the

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sual

cha

rges

, as

acr

edit

tow

ards

the

char

ges

for

such

ser

vice

s.

(v)

Eac

h of

the

abov

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bpar

agra

phs

are

subj

ect t

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ecia

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visi

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if a

ny, s

how

n on

par

ticul

arm

embe

r-sh

ip c

ards

.

(b)

FO

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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

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er fo

r bo

th R

OU

-T

INE

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RV

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S A

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SP

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IAL

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RV

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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

.

Page 20: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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.

Page 21: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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

Page 22: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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

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Page 23: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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1100

8100

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A n

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hysi

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n) a

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eA

pplic

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e ap

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atio

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re-

ceiv

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e be

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and

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se n

ame

and

iden

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atio

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mbe

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the

mem

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hip

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ishe

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e su

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appl

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ereo

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RO

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The

Cor

pora

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s pr

ovid

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PA

RT

III b

elow

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the

follo

win

g su

rgic

al a

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edic

al s

ervi

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n re

nder

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phys

icia

n en

title

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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

Page 24: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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.

Page 25: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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

Page 26: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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

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ysto

scop

y, d

iagn

ostic

, ini

tial

1725

Enc

epha

logr

aphy

Ven

tric

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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

Page 27: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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

Page 28: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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.

Page 29: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

(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,

Page 30: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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

.

Page 31: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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

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ch p

ay-

men

t to

the

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ican

t for

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self

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his

depe

nden

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bscr

iber

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r to

the

subs

crib

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r re

tired

sub

scrib

er.

(b)

Thi

s rid

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mad

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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)

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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

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ereu

nder

if th

ere

had

been

note

rmin

atio

n.

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of th

e te

rms,

con

ditio

ns a

nd d

efin

ition

sof

said

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ic C

ontr

acts

not

inco

nsis

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term

san

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nditi

ons

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is r

ider

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ply

to a

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e an

dbe

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part

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rider

as

fully

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as c

ompl

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gh s

peci

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et fo

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here

in; t

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rovi

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ic C

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rel

atin

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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

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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

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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.

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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.

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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.

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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.

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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

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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

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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.

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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-

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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:

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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.

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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.

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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.

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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.

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V. D

IGE

STS

OF

GR

OU

P IN

SUR

AN

C2

PLA

NS

FOR

PUB

LIG

SCH

OO

L P

FRSO

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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

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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

Page 49: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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

Page 50: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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)

Page 51: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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

Page 52: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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

Page 53: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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

Page 54: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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

Page 55: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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

Page 56: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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

Page 57: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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

Page 58: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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.

Page 59: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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

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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

Page 61: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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

Page 62: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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

Page 63: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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

Page 64: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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

Page 65: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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.

Page 66: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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,

Page 67: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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.

Page 68: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

12

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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

Page 69: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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

Page 70: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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

Page 71: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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:)

Page 72: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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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

Page 73: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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

Page 74: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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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

Page 75: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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

Page 76: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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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

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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%

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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

Page 79: DOCUMENT RESUME Descriptors-Employer Employee Relationship ... · Descriptors-Employer Employee Relationship, Frin9e Benefits, ... Project Directors: ... This report is designed to

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.

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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.

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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

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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.

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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.