The SPE Group Insurance Program

Catastrophic Major Medical Group Insurance Plan

Underwritten by New York Life Insurance Company

Did you know that many health plans have a maximum benefit that limits the amount they will pay for your care? In many cases that could mean that you or your loved ones will have to pick up the extra cost if you come down with a catastrophic illness or require extended care.

Many of these plans also have "gaps" in their coverage: deductibles, co-pays and exclusions for certain conditions or services that may again result in significant out-of-pocket expenses.

With the Catastrophic Major Medical Insurance Plan, you can help reduce your worry about being "priced-out" of the care you may need should you fall victim to a covered catastrophic illness or accident. In many cases, this coverage also helps preserve your freedom of choice by allowing you to select health care providers who may not be a part of your current plan’s network of approved facilities and physicians.

And unlike some other plans, this valuable insurance covers certain prescription drugs, and even certain expenses for home health care services and private duty nursing.

As an association member, you and your immediate family have access to $2,000,000 worth of additional medical insurance for covered expenses while insured though the plan. After the deductible has been satisfied, this plan is designed to provide an additional layer of protection over your basic health insurance plan by:

Paying for a variety of services that might not otherwise be covered – both in and out of the hospital.
Extending the length of certain provided services.
Paying for services rendered by health care providers and facilities that may not be part of your current plan’s approved network.
Paying up to 100% of all co-pays and deductibles associated with your existing plan, after the deductible has been satisfied for each injury or illness. (See below for further details.)

The Plan pays up to $2,000,000 in benefits for eligible expenses once the deductible is met.

Plan Information

Eligibility Requirements

You are eligible to apply for the SPE Catastrophic Major Medical Group Insurance Plan if:

you are a member of the Society of Petroleum Engineers,
you are under age 65, and
you are covered by a basic health insurance plan.

For coverage issued on or after November 1, 2007, a basic plan is defined as a single plan that provides benefits that are at least equal to or the actuarial equivalent of all of the following:

Inpatient hospital coverage for a minimum of 70 consecutive days on an expense-incurred basis as opposed to an indemnity basis; and
Medical coverage that includes surgical or anesthetic services; and
A cash deductible of $5,000 or less; and
Coinsurance of 70% or greater; and
A lifetime maximum benefit of $500,000 or greater.

Once you reach age 65, Medicare Parts A and B will be considered your basic health insurance plan in determining benefits under the Catastrophic Major Medical Plan.

You can also apply for coverage for your spouse (if under age 65) and any unmarried dependent children through age 21 (through age 27 if attending school full-time).

The SPE Catastrophic Major Medical 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 Dakota, Vermont, or Washington. Filing approval is pending for Florida, Indiana, Minnesota, North Carolina, and Tennessee. For additional information, please contact the Administrator at 800-337-3140 or e-mail speinsurance@agia.com.

Guaranteed Acceptance

You cannot be declined for this coverage, regardless of your medical condition. The same is true for your spouse and dependent children. Coverage will be issued regardless of your health history. However, the Catastrophic Major Medical Plan application contains questions about your and your dependents’ health histories. The insurance company will determine the premium rate classification for you and your family based on your answers to these questions. It is also possible that additional medical information may be requested before making this determination. Pre-existing conditions may not be covered immediately.

Here’s How the Catastrophic Major Medical 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.

Deductible

You have a choice of deductibles, either $25,000 or $50,000. The deductible must be satisfied for each illness or injury and will be the greater of the benefits of your basic plan or the deductible you select. You have two years from the date of the first covered charge to satisfy the deductible. A new deductible will apply to each illness or injury.

For persons who do not remain insured under a basic plan after their effective date, all hospital charges for the first 70 days of hospital confinement and the first $50,000 of eligible charges for out-of-hospital care within a benefit period will be excluded.

Benefit Period

The Plan will pay up to 100% of eligible expenses for up to three years from the date the first expense used to satisfy the deductible was incurred, subject to a $2,000,000 maximum benefit while insured. The benefit period ends on the earliest of any of the following to occur:

the maximum benefit amount is paid,
three years from the date of the first expense used to satisfy the deductible,
the end of any period of 12 consecutive months during which no covered expenses were incurred for that condition.
when your coverage under the plan ends.

At the end of the benefit period, the deductible must be satisfied again in order to establish a new benefit period.

How the Deductible Works

John Smith is diagnosed with a serious illness that requires extensive treatment. He visits the hospital and incurs initial charges of $200,000 in medical expenses. John’s Basic Plan will pay 80% of the usual and customary charges for these expenses ($160,000). John is responsible for the remaining 20% ($40,000). Once John reaches his $25,000 deductible, the Catastrophic Major Medical Plan will reimburse him for covered expenses due to this illness for which his basic plan does not provide benefits, up to the plan maximum. John will be reimbursed $40,000 for this claim.

Jane Doe suffers a severe accident, and needs to see a specialist. Unfortunately, her basic plan limits her choice of physicians and will not pay for the one who comes most highly recommended. Rather than select from the choices available on her plan, Jane pays the first $25,000 out of her own pocket (or $50,000 depending on the deductible selected). Once her costs for this specialist exceed $25,000 in covered expenses (or $50,000), Catastrophic Major Medical Insurance steps in and pays for her continued care from this specialist for this injury up to the plan maximum.

Common Disaster Provision

If family members are injured in the same accident or contract the same contagious disease within 30 days, only one deductible will need to be met.

Eligible Expenses

Following is a summary of all of the expenses and services the plan is designed to cover once your deductible has been met. Unless otherwise stated, you will be reimbursed 100% of the reasonable and customary charges for the following expenses incurred during the benefit period:

Room and board for a semi-private room in a hospital;
Unit charges for intensive care in a hospital;
Miscellaneous charges incurred while receiving care and treatment in a hospital;
Doctor fees for diagnosis and treatment, anesthesiologist fees, treatment by a licensed physical therapist;
Doctor fees for surgery;
Charges for x-ray, lab tests, radiation treatment, anesthetics, blood and blood plasma, artificial limbs and eyes, surgical dressings, casts, splints, braces, trusses and crutches;
Drugs prescribed by a physician for treatment and the relief of pain associated with your illness or injury;
Dental care, treatment and surgery if natural teeth are injured in a non-workplace accident;
Oxygen and rental of necessary equipment;
Rental of other necessary medical equipment such as wheelchairs and hospital beds;
Private duty nursing up to $120 per 8 hour shift not to exceed $360 per day up to a maximum of $35,000 while insured;
Ambulance fees to and from the hospital;
Home health care treatment up to 100 visits per year (maximum 4 hours per visit) when prescribed by a doctor to treat an illness or injury immediately following a hospitalization for the same cause;
Charges by a nursing home starting on the 7^th day of confinement for room and board, custodial and general nursing care, for up to $500 per week for a maximum of up to three years while insured;

A nursing home is defined as a certified institution that is primarily engaged in providing skilled nursing services or custodial care for the sick or injured inpatients and which has clinical records for all patients, continuous nursing service supervised by a full-time doctor or RN and the service of a doctor available. It does not include a rest home, an assisted living facility, or a place for the care of the aged, alcoholics or drug addicts. Note: This is not long-term care insurance.

Hospice care for up to 210 days of confinement per benefit period and hospice care charges for 5 visits per benefit period for bereavement counseling to the family of the insured person;
Charges for in-patient and out-patient treatment and/or diagnosis of alcoholism; alcohol abuse or substance dependency; psychiatric, mental, nervous or emotional disorders, aliments or illness are limited to a $35,000 overall combined maximum while insured.

Prescription Drug Coverage

Once your deductible is satisfied, this plan will pay 100% of all covered drugs prescribed to treat your illness or injury or pay the difference between what your current health insurance provides.

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.

Exclusions

Eligible expenses do not include:

Charges for abortions unless medically necessary as certified by a doctor; charges for sexual transformations; charges for non-prescription medicines, oral contraceptives, vitamins, nutrient and food supplements even if prescribed by a doctor; charges for drugs not approved by the FDA; experimental treatment; treatment of specified foot care; hearing aids unless the hearing loss is due to an accident and charges for the hearing loss occur within 24 months after the accident; immunizations (except for Child Health Supervision Services); charges for the treatment of infertility; charges for care which is not medically necessary or inappropriate; injury or sickness which is compensable under any Workers’ Compensation or Occupational Disease Act or Law; routine dental work or vision care; cosmetic surgery that does not involve restoration work required by an illness or injury; injuries as a result of war or an act of war; charges that exceed the plan maximum; treatment that would be free if you were not insured; and treatment performed by a member of the insured’s immediate family or by the insured’s employer or by the employee of the insured’s employer; a pre-existing condition as defined in the Pre-Existing Condition Exclusion section; and, for coverage issued on or after November 1, 2007, all charges for the first 70 days of confinement per benefit period and the first $50,000 of eligible charges for out-of-hospital care for persons who are not insured by a basic plan on the date a covered expense is incurred.

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 Catastrophic Major Medical Plan. A certificate of creditable coverage or some other satisfactory proof will be required as evidence that Catastrophic Major Medical creditable coverage was in force. This certificate should be secured from the Plan Administrator of your current or last health plan.

When Insurance Ends

New York Life Insurance Company cannot terminate coverage or change benefits or premiums on an individual basis; it may do so on a classwide basis. 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.

Survivor’s Benefit

If an insured member passes away, insured dependents will retain their coverage as long as they continue to meet all other eligibility requirements and the group policy remains in force. However, rates may be adjusted depending on the survivor’s age.

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 21 (or 27 if a full-time student). 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 later of the date the administrator receives your application or the date 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 date.

Understanding Your Certificate of Insurance—30-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 30104-0 (Policy Form GMR). 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.

2008 Current Semiannual Standard Premiums

$25,000 Deductible

Member’s Age	Member	Member & Spouse	Member, Spouse & Child	Member & Child

Under 40	60.28	114.81	179.97	125.44
40-49	114.95	224.18	289.34	180.11
50-59	182.70	359.66	424.82	247.86
60-64	274.84	543.94	609.10	340.00

$50,000 Deductible

Member's Age	Member	Member & Spouse	Member, Spouse & Child	Member & Child

Under 40	45.21	86.12	135.00	94.09
40-49	86.23	168.13	217.01	135.11
50-59	137.03	269.74	318.62	185.91
60-64	206.14	407.95	456.83	255.02

Important Rate Information: Please note that all premiums are based on the member’s age at the time of applying. Once covered under the plan, premiums will automatically increase on the policy anniversary date after the member reaches the next higher age bracket. New York Life reserves the right to increase rates on any premium due date and on any date on which benefits are changed. 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.

Rates may also be affected by your health status at the time of application. Rates will be 25% higher in cases where modified coverage would have been issued based on medical underwriting and 50% if coverage would have been declined.

You may pay your premiums annually, semiannally, or quarterly. The annual premium is twice the semiannual premium. If you wish to pay quarterly, your premium will be half the semiannual premium.

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

How To Apply for Coverage

It is important to read the General Information section of this website before applying for coverage. Complete application instructions and the Plan application for the SPE Catastrophic Major Medical Plan are available online.

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