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CAP Home > CAP Members > Group Insurance Coverage for Members > Group Health Insurance

  Group Health Insurance
  PPO Plan

 

 

 

Updated December 11, 2008

Who May Apply

All CAP Junior Members and Fellows of the College who reside in the U.S. and who are under age 64 are eligible to apply for coverage. You may also apply for coverage for your lawful spouse (not legally separated) and dependent children under age 25. This plan is not like those whose eligibility is based on employment. This plan is designed exclusively for CAP members regardless of employment.

This plan is not available to members residing in Idaho, Kentucky, Maine, Massachusetts, New Hampshire, New Jersey, North Carolina, North Dakota, Vermont, and Washington.

Preferred Provider Network Savings

In many parts of the country, discounted fees are offered by hospitals, physicians, and other medical care providers participating in a preferred provider organization (PPO) developed and managed by Private Healthcare Systems, Inc. (PHCS). You can find the network provider nearest you by calling 1-800-239-5523. Please indicate that you are interested in a PPO provider.

In-Network vs. Out-of-Network Provider

An in-network provider is a physician or facility which has contracted with PHCS to provide care to a group of insureds at a pre-determined rate. Out-of-network providers are those physicians and facilities that do not have a contracted relationship with PHCS. If an in-network provider is utilized, out-of-pocket expenses will be lower. However, the choice of providers is always up to you. There are no gate keepers and a primary physician does not have to be pre-designated.

Deductibles, Co-Insurance, Maximum Benefit Level

There are two deductibles available: the $1,200 or $2,400 deductible plan. After the deductible has been satisfied the plan will pay benefits at 90 percent* of the next $10,000 of eligible expenses incurred in that calendar year for those eligible expenses charged by a PHCS PPO provider, and 70 percent* for those expenses charged by providers outside of the PHCS network. Thereafter, the plan will pay 100 percentof any additional eligible expenses incurred in that calendar year up to the plan maximum of $5,000,000.

Family Deductible — Regardless of the number
of insureds in a family, the CAP plans limit the deductible amounts a family must pay. All insured family members will be considered to have satisfied their deductibles for any calendar year when the amount of eligible expenses applied to their individual deductible totals two times the amount of the individual deductible.

Prescription Drugs — Eligible expenses for out-of-hospital prescription drugs will be paid at 80 percent up to a $2,500 calendar year maximum.

Common Accident Deductible — If two or more insured members of a family are injured in the same accident, only one cash deductible applies with respect to all medical expenses resulting from the accident in that and the next calendar year regardless of the number of family members injured.

*Eligible expenses incurred in connection with convalescent nursing home care, private duty nursing, and mental and nervous illnesses while the person is not a hospital bed-patient are paid at 50 percent under all plans. Please refer to the Exclusions and Limitations for an explanation.

$5,000,000 Individual Maximum

Each insured family member is eligible to receive up to $5,000,000 in maximum benefits for eligible expenses when insured. Additionally, an insured may reinstate the full maximum — after $10,000 in benefits has been paid — by furnishing satisfactory evidence of insurability to New York Life. Furthermore, regardless of physical condition, the amount of any benefits paid up to $1,000 will be restored to the remaining maximum, each January 1st. The mental and nervous conditions maximum is not subject to this reinstatement and restoration provision.

Pre-Certify Hospital Stays with Utilization Review (UR) Provided by PHCS

Prior to a hospital confinement, it will be necessary to call PHCS at their toll-free number, 1-800-239-5523, to receive pre-certification. Failure to notify PHCS and receive the necessary certification will result in the first $500 of hospital expenses for such confinement not being covered under this plan (this is in addition to the deductible), and it 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). In the event of an emergency admission, the member or somebody they appoint must notify PHCS 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 insured and his or her physician. In addition, UR does not guarantee benefit payment under the plan.

Wellness Benefits

Annual Gynecological Exam Benefit
Charges for an annual gynecologic examination will be considered eligible expenses. These expenses include charges for one gynecological examination and X-ray or laboratory services given or ordered as part of the examination, subject to an annual maximum benefit of $100. Benefits are not subject to the deductible and are payable at 100 percent up to the maximum benefit.

Adult Physical Exam
Charges for a routine adult physical examination, once a year, will be considered eligible expenses. Insureds age 18 or over may submit charges for a physical, routine immunizations (except those required for foreign travel), and X-ray or laboratory services ordered as part of the examination subject to an annual maximum benefit of $250. Benefits are not subject to the deductible and are payable at 100 percent up to the maximum benefit.

Child Health Care to Age 18
Eligible expenses for insured children under age 18 for eligible child health supervision services will include 18 physician visits at the following approximate age intervals: birth, 2, 4, 6, 9, 12, 15, and 18 months; and 2, 3, 4, 5, 6, 8, 10, 12, 14, and 16 years. The eligible expenses include those for physical examinations, development assessment, anticipatory guidance, appropriate immunizations, and laboratory tests. Benefits are not subject to the deductible and are paid at 100 percent.

Eligible Expenses

The following expenses are covered while insured when they are incurred at a physician's direction as being necessary to treat an illness or accident:

  • Hospital semi-private room and board charges.
  • Miscellaneous charges while a bed-patient.
  • Intensive care unit charges.
  • Charges incurred as an outpatient to treat an accidental bodily injury.
  • Charges incurred as an outpatient in connection with surgery.
  • Physicians' charges in the hospital, office, or home. (For correcting body distortion, benefits are limited to $35 per visit and a $500 calendar year maximum. This limit does not apply to open surgery on the vertebral column or to treatment for arthritis, scoliosis, fractures, or herniated discs.)
  • Charges for X-ray examinations and microscopic or laboratory tests, anesthesia, oxygen and its administration, X-ray, or radioactive isotope therapy.
  • Charges for blood or blood plasma and their administration, casts, splints, braces, crutches, surgical dressings, artificial limbs, or eyes for initial replacement.
  • Charges for outpatient prescription drugs or medicines up to $2,500 in a calendar year.
  • Services of a registered nurse or a licensed physical therapist (other than a member of the insured person's family or household). Private duty nursing charges are eligible up to 50 percent of the expense with a calendar year maximum of $10,000.
  • Rental of wheelchair, hospital-type bed, or equipment for the administration of oxygen if used solely for treating an illness.
  • Ambulance and transportation charges to the nearest hospital within the U.S. and Canada equipped to furnish required treatment.
  • Charges for surgical procedures.
  • Charges for surgery and related medical care required for caesarean section, extrauterine pregnancy, complications requiring interabdominal surgery after termination of pregnancy, and pernicious vomiting or toxemia and convulsions while hospitalized.
  • Charges by a hospital or home health agency for up to $40 per visit and up to 100 home care visits (four hours considered one visit) in a period of 12 consecutive months, if the visits begin within 14 days after a hospital or nursing home stay, and if the insured's physician certifies that the home care was necessary to treat the illness which caused the stay or are in lieu of a hospital confinement.
  • Hospice — After the deductible, benefits will be payable for certain covered expenses for services of physicians, nurses, health aides, and social for care of a terminally ill patient.
  • Charges for pre-admission testing
  • Charges for one routine mammography in a calendar year.
  • Charges for one routine Pap smear in a calendar year.
  • Charges for foot care, provided such charge is for:
    1. an open cutting operation of metatarsalgia or bunion;
    2. a partial or complete removal of a nail root;
    3. medical care of the feet, if it is not for
      1. treatment of weak, strained or flat feet; or instability or imbalance of the feet,
      2. treatment of any metatarsalgia or bunion, or
      3. orthopedic shoes and any other supportive device;
    4. other treatment of the feet, if it is not a cutting, removal or other treatment of a corn, callus or toenail, unless such treatment is needed because of diabetes or other similar disease.
  • Convalescent nursing home room and board charges for up to 120 days each calendar year if confinement begins within 14 days after a minimum three day hospitalization for the same cause. Maximum eligible charge is the lesser of the expense incurred or 50 percent of the semi-private room rate of the hospital from which the covered person was transferred.
  • Charges for treatment of infertility: the plan will pay benefits up to a maximum of $5,000 while insured under the plan.
  • Charges to restore speech loss and to correct speech impairments due to a congenital malformation for which corrective surgery has been performed.
  • Charges by a speech therapist for correcting an impairment due to an accident or sickness will be covered only if therapy is restorative or rehabilitative in nature. Charges for correcting a speech impairment following an accident or sickness will be covered only if speech was normal prior to the accident or illness.

Exclusions and Limitations

No benefit is provided unless the expense is incurred upon recommendation of a legally qualified physician. Charges which the insured is not legally obligated to pay and those in excess of what is customary and reasonable are not eligible expenses. Benefits are not payable in connection with:

  1. War or military service.
  2. Dental work, eye examinations, eyeglasses, hearing aids, and cosmetic surgery, except for dental charges to treat an accidental injury which is incurred within 24 months after the accident provided such treatment begins within 24 months after the accident.
  3. Elective termination of pregnancy, sterilization, or reversal of sterilization.
  4. Alcoholism or narcotism except for charges incurred while a bed-patient for no more than 30 days in each calendar year in a hospital or state-approved alcoholism/drug treatment facility, up to a maximum of $10,000.
  5. Mental or nervous conditions after a maximum of $50,000 is reached.
  6. Out-of-hospital consultations with a physician for psychiatric conditions, except the plan will pay 50 percent of charges (maximum eligible charges $60) for up to 50 home or office visits each calendar year to the extent they exceed the cash deductible.
  7. Pregnancy, except certain complications of pregnancy such as are indicated under Eligible Expenses.
  8. Charges on behalf of a newborn child not yet discharged from the hospital, unless the charges are in connection with premature birth, congenital sickness, or injury sustained during or after birth or an examination as indicated in the Child Health Care to Age 18 section of this brochure.
  9. Immunizations required for travel.
  10. Health or check-up examinations in excess of one per calendar year or $250 per calendar year (except for children under age 18; see Wellness Benefits section).
  11. Those losses for which benefits are payable under any Workman's Compensation Law orsimilar legislation.
  12. Confinement in a convalescent nursing home after the 120th day of any one period of confinement.
  13. Charges for vision or occupational therapy.
  14. Charges for out-patient prescription drugs in excess of $2,500 per calendar year.
  15. Charges for experimental surgery or research.
  16. Custodial care charges.
  17. Any charges made by the insured or by his or her immediate family.
  18. Charges for sexual transformations.
  19. Charges which would not be made in the absence of this insurance.
  20. Charges for treatment of jaw joint conditions when total benefits of $1,000 have already been paid to the insured for such treatment.
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, individual 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.

Hospital and Nursing Home Defined

"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 a mental illness or nervous disorder or for rehabilitative treatment after an injury or illness.)

"Nursing home" means an institution for skilled nursing care with 24-hour supervision by a legal qualified physician or graduate registered nurse (R.N.), the services of a physician available at all times, the necessary nursing personnel to provide continuous patient care, and maintenance of daily medical records for each patient. It does not include any institution (or part thereof) used mainly as a facility for custodial care, drug addicts, alcoholics, the aged, or remedial education training.

Effective Date of Coverage

Your insurance will take effect on the first day of the month following 30 days after the date of receipt of your application provided the initial contribution is paid to the CAP group insurance office within 31 days of that date.

Coverage will be issued regardless of health status; however, applicants who would have been issued modified coverage based on former underwriting guidelines will pay the standard plus 15 premium rates, which are 15 percent higher than the standard health insurance rates. Applicants who would have been declined will be charged the standard plus 50 premium rates, which are 50 percent higher than the standard health insurance rates. In order to ascertain which premium rate applies to an individual, the CAP group insurance office will review medical history. Do not send the premium with your application. You will be notified of the appropriate charges upon the completion of the review of your application.

PPO Premiums (PDF, 49 K)

PPO Plan Quarterly Premium Rates for California (PDF, 54 K)

Additional Dependents

If you have any dependent medical care insurance in force, newborn children are automatically covered from birth for 31 days. This coverage will be continued if there is medical care insurance in force on other dependent children. You must inform the CAP group insurance office in writing of the child's name and date of birth.

If there is no dependent coverage in force and if you want to continue this automatic medical coverage, you must notify the CAP Group Insurance Office within 31 days and remit the extra premium needed.

Coordination of Benefits

If you are insured under more than one group or franchise policy or governmental plan, benefits under this CAP plan will be coordinated with the other coverage so that you will not receive more than 100 percent of the total allowable medical expenses insured from all such policies and plans.

When you or your insured dependent spouse attain age 65 your coverages will coordinate benefits with Medicare as if you are insured for both Medicare Parts A and B.

Certificate of Insurance

Once insured, you will be issued a Certificate of Insurance evidencing your coverage which is provided under Master Policy No. G-5387-1 (Policy Form GMR). The master policy is on file with the College and may be inspected at any reasonable time upon request.

How to File a Claim

The plan administrator will furnish claim forms upon request with instructions for their completion.

Change in Status

If a member ceases to be a CAP member, the insured's major medical coverage can be automatically continued but his or her premium class will change. Premium rates for this class of insureds will be significantly higher than the CAP active member rates.

Also, the change in status applies to dependent coverage (1) for a spouse upon divorce; (2) for a dependent child when he or she becomes self-supporting, marries, or reaches age 25 (In this case any coverage that is continued will be charged at the child's actual attained age.); (3) upon change in the member's premium class.

When Insurance Ends

New York Life cannot terminate coverage or change benefits or premiums on an individual basis; it may do so only on a class-wide basis.

CAP major medical coverage ends when:

  • an insured fails to pay insurance charges on time; or
  • an insured requests the coverage to end; or
  • the master policy terminates AND replacement coverage is provided.
The 30 Day Free Look

The College of American Pathologists has thoroughly analyzed this plan and monitors its administration. When you receive your certificate, examine it carefully. If you are not completely satisfied with your CAP major medical coverage, simply return your certificate, without claim, within 30 days with your request for a full refund.

No questions will be asked, and there will be no further obligation.

Important Notice: How New York Life Underwrites Your Request for CAP Coverage

Information regarding insurability for standard rate classifications will be treated as confidential. In considering whether the persons in your request for insurance qualify for standard rates, we will rely on medical information you provide, and on the information you authorize us to obtain from your doctor, other medical practitioners and facilities, other insurance companies for which you applied for insurance, and MIB, Inc. (Medical Information Bureau). New York Life will not disclose such information to anyone except those you authorize or where required by law. We may make a brief report to MIB; however, we will not disclose our underwriting decision. Information in our files may be seen by New York Life and plan administrator employees, but only on a "need to know" basis in considering your request. Upon receipt of all requested information we will make a determination as to whether your request for insurance can be approved.

MIB is a non-profit membership organization of life insurance companies which operates an information exchange on behalf of its members. When you apply for insurance or submit a claim for benefits to an MIB member company, medical or non-medical information may be given to the bureau, which may then be furnished to member companies. Upon written request, MIB will arrange disclosure of any information it may have about you in its file. MIB's information office is PO Box 105, Essex Station, Boston, MA 02112; phone 617-426-3660.

If we cannot provide you with standard rates, we will tell you why. In all cases medical records information will be given to a medical professional designated by you (except for certain types of medical information in specified jurisdictions you may choose to receive such information directly). If you feel our information is inaccurate, you will be given a chance to correct or complete the information in our files.

For New Mexico residents, in addition, protected persons** have a right of access to certain confidential abuse information*** we maintain in our files and they may choose to received such information directly. You have the right to register as a protected person by sending a signed request to the administrator at the address listed on the application. Please include your full name, date of birth, and current address.

For U.S. residents, your request is handled in accordance with the Fair Credit Reporting Act procedures. If we can provide the coverage you requested, we will inform you as to when such coverage will be effective. Under no circumstances will coverage be effective prior to this date.

Payment of premium contribution with your application does not mean that there is any insurance in force before the effective date is determined by New York Life.

**Protected person means a victim of domestic abuse who has notified us that he or she is or has been a victim of domestic abuse and who is an insured or prospective insured.

***Confidential abuse information means information about acts of domestic abuse status, the work or home address or telephone number of a victim of domestic abuse or the status of an applicant or insured as family member, employer, or associate of a victim of domestic abuse or a person with whom an applicant or insured is known to have a direct, close personal, family, or abuse-related counseling relationship.

How to Apply

  1. Simply indicate the deductible you want on the enrollment form. (PDF, 58.3 K)
  2. Complete, date, sign, and return the application to the Plan Administrator. Send no money now.
  3. Send to:
    Affinity Insurance Services, Inc.
    159 E. County Line Road
    Hatboro, PA 19040-1218
Do you have any questions? Call toll-free: 1-800-509-6023

Administered By:
 
Affinity Insurance Services, Inc.
159 E. County Line Road
Hatboro, PA 19040-1218
(California License #: 0795465)
(Massachusetts License #: 1554442)
(Louisiana License #: 192615)

Underwritten By:
 
New York Life Insurance Company
51 Madison Avenue
New York, NY 10010
(NAIC #66915)

 
 

 

 

   
 
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