The SPE Group Insurance Program

SPE Comprehensive HealthCare Group Insurance Plan

Underwritten by New York Life Insurance Company

Plan Information

Eligibility Requirements

You are eligible to apply for the SPE Comprehensive HealthCare Group Insurance Plan if:

you are a member of the Society of Petroleum Engineers, and
you are under age 65

You can also apply for coverage for your lawful spouse and any unmarried dependent children through age 25.

If you and your spouse are age 65 or over and eligible for Medicare, you may request coverage under the Medicare Supplement Plan, underwritten by Monumental Life Insurance Company.

The SPE Comprehensive HealthCare Plan is available to residents of the United States only. Please note, due to state regulations, the Plan is not currently available to residents of Idaho, Kentucky, Maine, Massachusetts, New Hampshire, New Jersey, New York, North Carolina, North Dakota, Oregon, Vermont, or Washington. Filing approval is pending for Florida, Indiana, Minnesota, and Tennessee. For additional information, please contact the Administrator at 800-337-3140.

Note: The Comprehensive Healthcare Plan application contains questions about you and your dependents' health history. Although you cannot be declined for coverage based on your health history, the Insurance Company will determine the premium rate classification for you and your family based on the answers to these questions. It is also possible additional medical information may be requested before making this determination.

Here's How the Comprehensive HealthCare Plan Works

$2,000,000 Maximum Benefit

The Plan can provide up to $2,000,000 in benefits for you and each of your covered dependents for eligible medical expenses incurred while insured under the Plan.

Choice of Calendar Year Deductibles to Help Meet Your Needs and Budget

You may select a deductible of $1000 or $5000 for both individual and family coverage. A $2000 deductible is also available but only for members who are covering their families, too (no member-only coverage). The higher the deductible you select, the lower your premium payments.

When eligible expenses for two or more insured family members equal twice the selected deductible for a calendar year, all insured family members will be considered to have satisfied their deductibles for that year.

The Plan also includes a carryover provision that permits you to apply eligible expenses incurred during the last three months of the calendar year to the next year's deductible. The deductible must be satisfied within 12 consecutive months after the first eligible expense was incurred rather than in the same calendar year.

Limited Out-of-Pocket Expenses

After the deductible has been satisfied, the Plan will pay 80%* for in-network providers and 70%* for out-of-network providers of your first $15,000 of covered expenses ($30,000 for family coverage) in a calendar year. Thereafter, the Plan will pay 100% of most of your covered expenses during the balance of that calendar year.

*Different benefits and limits apply to hospitalizations without pre-certification, alcohol/drug abuse and mental/nervous disorder treatment, ambulance charges, and out-patient prescription drugs.

In-Network vs. Out-of-Network Providers

An in-network provider is a physician who has contracted with the preferred provider network to provide care to a group of insureds at a pre-determined discount. Out-of-network providers are those physicians who do not have a contracted relationship with the preferred provider network.

To find out if your physician is a member of the PPO network or if you are looking for a new physician within the network, please call PHCS (part of the larger network Multiplan) at 1-800-239-5523 or visit their website at www.multiplan.com. A few areas do not have providers in the PPO Network. If you live more than 30 miles from the nearest PPO provider, eligible expenses will be payable at the PPO provider level.

Payment Made Directly to In-Network Provider

If you visit an in-network provider, the physician can file your claim and be reimbursed directly by New York Life Insurance Company. You will then be billed for any remaining balance. If you visit an out-of-network physician, you are responsible for submitting the claim directly to the insurance Administrator.

Discount Drug Card

You will receive an Express Scripts drug card as part of the Plan. By presenting the card at one of the Express Scripts network pharmacies, you will enjoy a discount from the usual retail price on most prescription drugs. Please note that the discount from the usual retail price is given on most, but not all, prescription drugs.

Coverage for Newborn Children

Newborn children are automatically covered from birth through the first 31 days of life. If the newborn is the first child, you must notify the Administrator of your request to add dependent coverage and pay the additional premium to extend coverage beyond 31 days. All other children are then automatically covered at no additional cost. Simply notify the Administrator of each childs name and date of birth.

In the event of multiple births, only one deductible will be applied for all such children born of the same pregnancy for treatment of an illness contracted or sustained within 30 days after birth, premature birth, congenital defect, or birth abnormality.

Coordination of Benefits

To avoid duplicate payments, payments under this Plan will be coordinated with benefits you receive or are eligible to receive from any other group or blanket insurance plan, Medicare, or any similar government plan, so that total payments do not exceed the covered medical expenses actually incurred.

Eligible Medical Expenses

Unless otherwise indicated, eligible expenses are subject to the deductible. Benefits begin once the insured's calendar year deductible is satisfied. The following expenses are covered when they are incurred while insured at a physicians direction as being necessary to treat an illness or accident.

Hospital Coverage: Eligible hospital charges are covered 80% (in-network), 70% (out-of-network) and include the following:

charges for room and board (up to the semi-private room rate);
care in the Intensive Care unit;
operating room charges;
outpatient services;
lab tests;
x-rays;
diagnostic and laboratory tests;
radiation and chemotherapy treatment;
cost of anesthetic and its administration;
charges for artificial limbs, eyes and other prosthetic devices (except for replacement);
casts, splints, trusses, crutches and braces (except dental braces);
private duty nursing when prescribed by a physician;
oxygen and rental of equipment for the giving of oxygen;
approved organ transplant services, including immunosuppressive medication, limited to a maximum benefit amount of $300,000 while insured under the Plan;
organ donor procurement expenses limited to a benefit amount of $10,000 (amount reduced by expenses payable under any other Plan) while insured under the Plan;
prescription drugs;
blood and blood plasma, except when replaced.
charges for a skilled nursing facility in lieu of hospitalization.

Convalescent Care: Room and board charges up to the standard semi-private room rate, not to exceed 60 days per calendar year. Confinement must follow a period of hospitalization within 14 days after a minimum 3-day hospitalization for the same cause.

Emergency Care: Charges for in-network and out-of-network emergency room treatment and/or emergency office visits are covered at 80% after deductible, unless hospital confinement immediately follows; then charges fall under hospital covered expenses. You must notify PHCS within two business days after an emergency admission.

Ambulance Service: Charges for licensed ambulance service to a local hospital or a skilled nursing facility are covered at 70%.

Surgical and Medical Services: Charges by a doctor, surgeon, radiologist, professional anesthesiologist, physiotherapist, or laboratory, when the charge is not made by a hospital for the same medical care.

Nursing Care: Charges for private duty services when prescribed by your doctor.

Physical and Occupational Therapy: Charges by a doctor for physical and occupational therapy treatment.

Speech Therapy: Charges for a qualified speech therapist for treatment of speech loss or impairment due to illness or injury or for surgery to correct a congenital anomaly.

Out-Patient Prescription Drugs: Medications prescribed by your physician and dispensed by a licensed pharmacist are covered at 70%. Charges for Viagra are limited to no more than 6 pills per 30 days.

Cosmetic Surgery: Charges for reconstructive surgery incidental to or following surgery resulting from trauma, infection or other diseases while insured and for a congenital disease or anomaly of a covered person.

Dental Care: Dental treatment is covered for injury or illness of the jaw, facial bones, teeth or gums if performed by a doctor and not for periodontal disease or in connection with the extraction of teeth. Removal of cysts or malignant tissue; correction of harelip, cleft palate, or protruding mandible; and freeing of a muscle attachment are covered. Injuries to sound, natural teeth are covered if the injury occurred while the patient was under this Plan and treatment is rendered within one year of the injury.

Home Health Care: Eligible expenses charged by a hospital or home health care agency for appropriate home health care will be payable up to a maximum of 100 visits during any calendar year. The visits must begin within 14 days of a hospital confinement.

Hospice Care Program: Hospice charges for a 31-day period and each 31-day period following as prescribed by the patients doctor for in-patient or home health care of a terminally ill patient are covered. Covered charges include private duty nursing when the doctor or hospice certifies it is necessary; medical supplies (including medications and durable medical equipment); services by a licensed social worker; and 3 counseling sessions with a professional for family members within one year after the terminally ill persons death.

Mental and Nervous Disorders; Alcoholism and Drug Abuse: For confinement ordered by a doctor in a hospital or state approved alcoholism/drug treatment facility, the Plan will pay 80% of eligible expenses (in-network) and 70% (out-of-network). Benefits will be paid after the deductible is met and for up to 30 days per year. Utilization review (pre-certification) is required.

Eligible expenses for outpatient treatment will be reimbursed at 50% after the deductible is met, up to a maximum of $1,000 per year.

Common Disaster Provision: If more than one insured family member is injured in the same accident or contracts the same contagious disease within 60 days, only one deductible shall apply for all such persons for treatment resulting from that accident or contagious disease.

Preventive Care for Children: Charges for medical examinations, immunizations and routine tests not incident to the treatment of an injury or sickness are covered from birth up to age 24 months and are not subject to the deductible.

Preventive Care for Women: Annual gynecological examinations, mammograms, and Pap tests are covered at 100% of usual and customary amounts in-network and out-of-network, and are not subject to the deductible amount.

Preventive Care for Men: Annual prostate examinations and tests are covered at 100% of usual and customary amounts in-network and out-of-network, and are not subject to the deductible amount.

Preventive Care for Insureds Over Age 30: Charges for colorectal cancer screening, including sigmoidoscopy or fecal occult blood testing, are covered once every three years for insureds over age 30.

Normal Maternity Expenses: The Plan covers all eligible pregnancy expenses once you have met your deductible.

Infertility Treatment: Charges for treatment of infertility for those unable to conceive or sustain a successful pregnancy. These treatments include, but are not limited to, in vitro fertilization and artificial insemination. Limitations apply

Definitions

"Convalescent care facility" means a licensed institution which provides (a) post-hospital care or rehabilitation services; (b) room and board; (c) 24-hour-a-day nursing service by registered professional nurses on duty or call, with at least one full-time nurse, and (d) doctor on duty or call. It may be a section of a hospital. Convalescent care facility does not include: a rest home; a place for the care of the aged, alcoholics, mentally ill or drug addicts; and/or place for custodial care.

"Hospital" means an institution (other than federal or state) with 24-hour nursing, diagnostic and major surgical facilities and does not include an institution (or part thereof) used mainly as a facility for rest, nursing, convalescence, the aged or remedial education or training. (The hospital need not possess surgical facilities if the individual is confined for treatment of mental illness or nervous disorder or for rehabilitative treatment after an injury or illness.)

Exclusions and Limitations

No benefit is provided unless the expense is medically necessary and is incurred upon a physicians recommendation to treat an injury or sickness. The fact that a doctor may prescribe, order, recommend or approve a service or supply does not automatically make the service or supply a necessary expense.

No coverage is provided for a loss caused by or resulting from:

abortions unless medically necessary as certified by a doctor;
injury or sickness which is compensable under any Workers Compensation or Occupational Disease Act or Law;
declared or undeclared war or act of war;
expenses which are not approved by a physician;
charges which are inappropriate and/or not medically necessary as defined in the policy;
cosmetic surgery except as stated in the Eligible Medical Expenses section;
expenses incurred for routine eye tests, eyeglasses, contact lenses or their fitting except eyewear after surgery;
radial keratotomy or similar surgery;
immunizations except as defined in the Preventive Care for Children section;
charges related to treatment of infertility except as defined in the Eligible Expenses section;
sterilizations;
sexual transformations;
hearing aids unless the hearing loss is due to an accident and charges for treatment of the hearing loss occur within 24 months after the accident;
weekend admissions (Friday or Saturday) unless the admission is due to an accident or medical emergency;
pregnancy where the person consulted a physician or received treatment prior to the date the person became insured except for specified complications of pregnancy;
charges for non-prescription medicines, oral contraceptives, vitamins, nutrients and food supplements even if prescribed or administered by a doctor;
charges for drugs unapproved by the FDA;
custodial care, except by a hospice for eligible expenses;
dental care and treatment except as stated in the Eligible Medical Expenses section;
a charge for care provided mainly for educational, training, or vocational rehabilitation purposes;
treatment of specified foot conditions, including bunions (except open cutting), corns, calluses, and flat feet;
transportation except as defined under Ambulance Charges in the Eligible Medical Expenses section;
experimental treatment;
nursing home charges;
routine physical examinations except as stated in the Preventive Care for Men/Women/Children section;
a pre-existing condition as defined below.

Pre-Existing Condition Exclusion

Benefits will not be paid for an illness or injury due to a pre-existing condition as indicated below until the end of 12 consecutive months during which the person has been insured under the Plan.

Pre-existing condition means a condition, whether physical or mental, regardless of the cause of the condition for which medical advice, diagnosis, care or treatment was recommended or received within the six-month period immediately preceding the coverage effective date.

However, the pre-existing condition exclusion will not apply if the applicant can prove that this coverage is replacing creditable coverage that was in force on him/herself or any other person applying for coverage for at least 18 months without a break in coverage of more than 63 days.

Creditable coverage is coverage provided under a group health Plan or government health Plan. Hospital indemnity coverage does not qualify as creditable coverage. A certificate of creditable coverage or some other satisfactory proof will be required as evidence that creditable coverage was in force. This certificate should be secured from the Plan Administrator of your current or last health Plan.

Benefits at Age 65

When you or your spouse reach age 65, benefits will be based on the portion of medical charges left unpaid after Medicare benefits. It is important the insured is enrolled in both Parts A and B of Medicare.

Utilization Review (UR)

Provided by American Health Holding, Inc. Prior to a hospital confinement, it will be necessary to call American Health Utilization Review toll-free at 866-343-4087 to receive pre-authorization. Failure to notify American Health and receive the necessary certification will result in the first $500 of hospital expenses for that confinement not being covered under the Plan. (This is in addition to the deductible and will not count toward the out-of-pocket maximum.)

For a non-emergency hospital admission, UR must be requested at least seven days prior to the planned admission (or as soon as possible if scheduled less than seven days prior to admission). For maternity admissions, you are asked to notify American Health during the first trimester, but UR must be requested at least seven days prior to admission. In the event of an emergency admission, the member or somebody they appoint must notify American Health within two business days, or as soon as reasonably possible after the admission.

Please note that UR is the program utilized by New York Life to determine if in-patient treatment is medically necessary and appropriate under the terms of the Plan. This determination is not medical advice. The final decision regarding hospitalization rests with the member and their physician. In addition, UR does not guarantee benefit payment under the Plan.

How to Calculate Your Premium

Please refer to the Comprehensive HealthCare rate sheet. (See the "Search" option below.) Locate your age on the table and note the premium for your selected deductible. The premium for dependents should be added to your premium.

The cost for a member, spouse and all children is based on the member's age when the insurance becomes effective, and will increase each year on the renewal date following the members birthday. In cases where a spouse only is insured because the member is over 65 and covered by Medicare, the rates are based on the insured spouse’s age.

The ratesheet shows the standard rates in your area. Rates will be 25% higher in cases where modified coverage would have been issued based on medical underwriting. In cases where coverage would have been declined based on medical underwriting, rates will be 50% higher.

You may pay your premiums monthly, quarterly, semi-annually or annually.

Note: A $2.00 administrative fee is added for billing modes other than annual.

Premium Adjustments

On the first of the month during which the insured reaches 65, premiums are reduced to correlate with the benefits available under the Federal Medicare Program. When either member or spouse reach age 65, premiums are then based on the age of each insured person.

This Plan is subject to rate changes on any premium due date and on any date on which benefits are changed. Once you are enrolled in this Plan, your premium renewal payments are due on each renewal date.

The costs of medical services, such as those covered under this Plan, are directly affected by inflation. As medical costs rise, so does the amount paid for claims. As a result, New York Life Insurance Company reserves the right to increase premiums on a classwide basis to maintain Plan stability. However, your rates may change only if they are changed for all others in the same class of insureds under this group policy. For example, a class of insureds is a group of people with all the same issue age and gender. Increases are reviewed with the Committee on Group Insurance.

When Insurance Ends

New York Life cannot terminate coverage or change benefits or premiums on an individual basis; it may do so on a classwide basis. A class is a group of people with the same age or gender. Medical coverage ends if the master policy terminates, provided replacement coverage is provided or when an insured fails to pay insurance premiums on time or requests that coverage end.

Change in Status

If you cease to be a member of AAPG or one of the cooperating societies, coverage for you and your covered dependents will be automatically continued, but your premium class will change. Your premium rates will be significantly higher than the member rates.

The change in status applies to dependent coverage:

for a spouse upon divorce;
for a dependent child who becomes self-supporting, marries or reaches the limiting age of 26 (in this case, any coverage that is continued will be charged at the child's actual age and as a primary insured);
upon change to the member's premium class.

Effective Date

Your insurance will become effective on the date later of a) the date the application is received at the administrator's office or b) a later date if specified by you on your application, provided the initial contribution is paid within 31 days after the date you are billed and you are eligible for coverage.

If all information requested to complete the review of your application is not received prior to the date coverage is effective, the standard premium rate plus 50% will be charged. If information is received after the effective date which would enable the Insurance Company to charge the standard premium rate or the standard rate plus 25%, a credit will be applied to your next premium contribution due.

Understanding Your Certificate of Insurance30 Day Free Look

This website contains only a partial description of the provisions of this insurance coverage. Once approved, you will receive a Certificate of Insurance as evidence of coverage provided under the Group Policy of 29065 (Policy Form GMR). The Texas form numbers are GMR-FACE/G29065. It is important that you understand your coverage. Please read your Certificate thoroughly when it arrives and contact us with any questions.

We want you to get the coverage that's right for your insurance needs. That's why we give you a thirty day period to review your Certificate. If you return your Certificate within thirty days, we will refund your full premium and the Certificate will be null and void, as if it were never issued.

Toll-Free Plan Assistance

If you have a question, need more information or you need to file a claim, please do not hesitate to call your SPE Customer Service Representative, toll-free at 1-800-337-3140.

Or email to: speinsurance@agia.com

Or write to:

SPE Program

P. O. Box 189

Santa Barbara, CA 93102-0189

The Broker of Record is:
F. Michael Strunk
P. O. Box 511385
Punta Gorda, FL 33951-1385
Phone: 941-639-3333
CA License #0C30823