Monthly Premiums Chart / Rate Sheet

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Eligibility Requirements

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

Limited Out-of-Pocket Expenses

In-Network vs. Out-of-Network Providers

Payment Made Directly to In-Network Provider

Coverage for Newborn Children

Coordination of Benefits

Eligible Medical Expenses

Hospital Coverage

Definitions

Exclusions and Limitations

Pre-Existing Conditions

Benefits at Age 65

Utilization Review

Premium Adjustments

When Insurance Ends

Change in Status

Effective Date

Understanding Your Certificate of Insurance30 Day Free Look

Important Note

Toll-Free Plan Assistance

Have A Question or Need Additional Information? Call Toll-Free

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HSA Qualified Health Group Insurance Plan

Underwritten by New York Life Insurance Company

Plan Information

Eligibility Requirements

You are eligible to apply for the SPE HSA Qualified Health Group Insurance Plan if:

You can also apply for coverage for your lawful spouse if under age 65 and any unmarried dependent children through age 25.

The SPE HSA Qualified Health Insurance 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 California, 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 1-800-337-3140 or email speinsurance@agia.com.

Note: The HSA Qualified Health Insurance Plan application contains questions about you and your dependent's 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 HSA Qualified Health Insurance 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 $1750, $2250, or $5000, for individual coverage. If you will be covering dependents as well as yourself, the deductible choices are $3500, $4500 and $10,000. The higher the deductible you select, the lower your premium payments.

Different benefits and limits apply to hospitalizations without pre-certification.

Limited Out-of-Pocket Expenses

After you satisfy your deductible within the calendar year, the plan pays 100% of eligible expenses for in-network providers and 80% for out-of-network providers.

For individuals with the $1,750 and $2,250 deductibles, the annual out-of-pocket maximum is $3,000 including your deductible. For families with the $3,500 and $4,500 deductibles, the annual out-of-pocket is $6,000 including your deductible.

For individuals with the $5,000 deductible, the annual out-of-pocket maximum is $5,000 for eligible expenses from in-network providers and $7,500 for expenses from non-network providers, including your deductible.

For families with the $10,000 deductible, the annual out-of-pocket maximum is $10,000 for eligible expenses from in-network providers and $15,000 for expenses from non-network providers, including your deductible.

Please note that, regardless of your selected deductible, eligible expenses for medical emergencies and prescription drugs are paid at 100% once your deductible has been satisfied.

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 American Health at 800-239-5523 or visit their website at www.phcs.com.

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.

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 child's name and date of birth.

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

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

Hospital Coverage: Eligible hospital charges include the following:

Convalescent Care: The maximum allowable charge is the lesser of the facility's regular semi-private room rate, or 50% of the semi-private room rate at the hospital from which the patient was transferred not to exceed 30 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 100% after the deductible. You must notify American Health within two business days after an emergency admission.

Ambulance Service: Charges for licensed ambulance service to a local Hospital are covered.

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.

Out-Patient Private Duty Nursing Care: Charges for private duty services for one 8-hour shift per 24-hour period, up to $50 per hour are covered 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 100%. Charges for Viagra are limited to no more than 6 pills per 30 days.

Body Distortion: Eligible charges for treatment of body distortion are covered.

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.

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.

Preventive Care for Women: Charges for an annual gynecological examination, mammogram, and Pap test.

Complications of Pregnancy: Charges for surgery and related medical care required for non-elective caesarean section, extrauterine pregnancy, complications requiring inter-abdominal surgery after termination of pregnancy, and pernicious vomiting or toxemia and convulsions while hospitalized.

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 subject to a $50 per day, 40 visit per calendar year limit if the visits 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 patient's 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 6 counseling sessions with a professional for family members within one year after the terminally ill persons death.

Mental Disorders and Chemical Dependency:

Alone or in any combination, the maximum benefit for treatment of mental disorders and/or chemical dependency is $25,000 for expenses incurred while insured under the Plan.

For confinement ordered by a doctor in a hospital or state approved alcoholism/drug treatment facility for the treatment of mental/nervous disorders or chemical dependency, eligible expenses are limited to 30 days per calendar year after the deductible is met. Utilization review (certification) is required.

Eligible expenses for outpatient treatment of mental disorders are reimbursed at a maximum of $50 per day after the deductible is met, up to a maximum of 30 days per calendar year.

Benefits for outpatient treatment of chemical dependency are limited to 60 days per calendar year.

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 physician's 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:

Pre-Existing Conditions

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 with 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 coveragethat 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. Prior to a hospital confinement, it will be necessary to call American Health toll-free at 1-800-343-4087 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 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.) 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 HSA Qualified Health Insurance Plan ratesheet. (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 member's birthday.

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.

Search for the rate in your area by inputting your zip code.

Zip:

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 reaches age 65, premiums are then based on the age of each insured person.

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, the Insurance Company reserves the right to increase premiums on a classwide basis to maintain Plan stability. Rates may be changed on any premium due date and any date on which benefits are changed. However, 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. 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. 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 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:

  1. for a spouse upon divorce;
  2. 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;
  3. upon change to the member's premium class.

Effective Date

Your insurance will become effective on the 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, providing 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 Insurance-30-Day Free Look

This brochure is 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 Group Policy 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 30-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.

We will advise you of your rate classification and let you know when coverage will become effective. Under no circumstances will coverage be effective prior to this date. Payment of a premium contribution with your application does not mean that there is any insurance in force before the effective date as determined by New York Life.

Important Note

Although this Plan has been designed to qualify for Health Savings Accounts, it may not do so in all states. Consult with your accountant or tax advisor to determine if this Plan is appropriate for your needs. New York Life Insurance Company bears no responsibility for the establishment and administration of any Health Savings Accounts.

Toll-Free Plan Assistance

For assistance or questions regarding the Plan, your benefits, your rates, or how to file a claim, please call your SPE Customer Service Representative, toll-free at 1-800-337-3140.

Have A Question or Need Additional Information? Call Toll-Free

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 at: 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


Health Savings Account

HSA's Save Money

Quite simply, an HSA helps you build a tax-deferred fund to cover high medical insurance deductibles. You couple the tax savings of a tax-deductible savings account with the cost savings of high-deductible health insurance to achieve more complete protection for you and your family.

The Advantages

For complete details, please consult your tax advisor.

Special Note: Insureds between the ages of 55 and 65 may make "catch up contributions." Consult your tax advisor for details.

Eligibility

Current federal law provides that individuals may open a Health Savings Account any month in which they:

  1. are covered under a high deductible health plan (HDHP) on the first of that month;
  2. are not also covered by any other health plan that is not an HDHP (with certain exceptions for plans providing certain limited types of coverage);
  3. are not entitled to benefits under Medicare, and
  4. may not be claimed on another person's tax return.

How the Health Savings Account Works

You begin by applying for a federally qualified high deductible health insurance plan (HDHP) as described in the section about the SPE HSA Qualified Health Insurance Plan. Once your coverage is in force, you establish a Health Savings Account through a financial institution to cover medical costs. The funds you put in the account are tax deductible, FDIC insured, and the interest on those funds is tax-deferred subject to federal guidelines.

Four Important Notes

One, to be eligible for tax savings under Federal guidelines, an individual who is eligible for HSA contributions must be covered under a qualifying high deductible health plan and no other health plan (other than described as follows):

  1. Other insurance if substantially all of the coverage relates to:
    1. Liabilities incurred under workers compensation law;
    2. Tort liabilities;
    3. Liabilities relating to ownership or use of property (e.g. auto insurance), or
    4. Such other similar liabilities as the Secretary of the Treasury may prescribe by regulations.
  2. Insurance for specified disease or illness.
  3. Insurance that provides a fixed payment for hospitalization.
  4. Medicare supplement insurance.

Two, the Health Savings Account is established as a separate arrangement between the financial institution and the individual. Such financial institutions fees are not included in any premium remitted to your administrator. Please contact your administrator for additional information.

Three, since everyone's situations are different, please consult your tax advisor should you have further questions regarding tax treatment.

Four, this plan is not an employer-sponsored health plan.

Note

We cannot give, and this brochure is not intended as, legal or tax advice. We strongly urge that you consult with your accountant or tax advisor before opening an HSA to determine if this savings vehicle is available to and appropriate for you.

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