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Updated December 11, 2008

Insurance Enrollment Form (63k PDF)
The Health Savings Account (HSA) Concept
Choice of Deductible Plans
Out Of Pocket Maximums Per Calendar Year
Eligible Members
Individual Maximum
Wellness Benefits
Eligible Expenses
Exclusions and Limitations
Pre-Existing Condition Exclusion
Pre-Certify Hospital Stays
Hospital and Convalescent Care Facility Defined
When Your Coverage Becomes Effective
Coordination of Benefits
Certificate of Insurance
How to File a Claim
Change In Status
When Insurance Ends
30-Day Free Look
How to Apply

The Health Savings Account (HSA) Concept
The basic concept of an HSA is that it should make it more affordable for people to buy health insurance because they are required to purchase a higher deductible (less expensive) plan and the significant tax advantages help offset the higher out-of-pocket costs. Plus HSAs are now available to everyone, not just those who are self- employed as stated under the Medical Savings Account (MSA).

You first buy the insurance plan that is HSA-qualified, then you go to the bank or an investment firm and you open your private Health Savings Account with your own money (just like an IRA). You can then withdraw your own money at any time to pay for all medical expenses not covered by your insurance plan (dental, eyeglasses, deductible, elective procedures, even long term nursing care premiums).

If you decide not to use your annual HSA deposits and just accumulate the funds, you have now developed another retirement fund. Below are the names of two Trustees providing HSAs.

American Health Value
6477 Fairview Avenue Suite H
Boise, ID 83704
800-914-324
CNA Trust
3080 South Bristol Street
Costa Mesa, CA 92626
800-778-1288

The CAP Endorsed HSA Qualified Health plan is a High Deductible Insurance Plan that meets the federal government's requirements for Health Savings Accounts.

New York Life Insurance Company (51 Madison Avenue, New York, NY 10010), the underwriter of the High Deductible Health Plan and the College of American Pathologists bear no responsibility for the establishment or the administration of the Health Savings Account. Any information (including this summary of benefits) concerning an HSA is not intended as legal or tax advice. We strongly urge you to consult with your accountant or tax advisor before opening an HSA to determine if this savings vehicle is available and appropriate for you.

Your bank ('trustee') should provide you with guidelines and the procedures on what constitutes qualified expenses for reimbursement and what submissions are necessary to obtain reimbursement.

If you determine that an HSA is not appropriate for you, you may still enroll for this High Deductible Health Plan, which will simply operate as a medical insurance plan.

Choice of Deductible Plan (Qualify for use with an HSA)
PLAN1 $3,000 Individual $6,000 Family
  Under the Individual Deductible plan, the insured member must incur $3,000 of eligible expenses in a calendar year before benefits will be paid. The individual plan is available to member only. Under the Family Deductible plan, the member and his/her insured family members must incur $6,000 of eligible expenses in a calendar year before benefits will be paid. The family deductible plan is available to member and spouse, member and children; and member/spouse and children. The individual deductible does not apply under the Family deductible plan.
PLAN2 $5,000 Individual $10,000 Family
  Under the Individual Deductible plan, the insured member must incur $5,000 of eligible expenses in a calendar year before benefits will be paid. The individual plan is available to member only. Under the Family Deductible plan, the member and his/her insured family members must incur $10,000 of eligible expenses in a calendar year before benefits will be paid. The family deductible plan is available to member and spouse, member and children; and member/spouse and children. The individual deductible does not apply under the Family deductible plan.

COINSURANCE: After the deductible (either individual or family) has been satisfied, then the plan pays:
Plan 1: In-Network
80%*
Out-of-Network
60%*
Plan 2: In-Network
100%*
Out-of-Network
80%*

OUT OF POCKET MAXIMUMS PER CALENDAR YEAR
$3,000 Individual $6,000 Family
In-Network benefits are payable at 100% for the remainder of the calendar year once the Individual pays $5,000 of covered expenses, including the deductible.
Out of Network benefits are payable at 100% for the remainder of the calendar year once the Individual pays $7,500 of covered expenses, including the deductible.
In-Network benefits are payable at 100% for the remainder of the calendar year once the Family pays $10,000 of covered expenses, including the deductible.
Out of Network benefits are payable at 100% for the remainder of the calendar year once the Family pays $15,000 of covered expenses, including the deductible.
$5,000 Individual $10,000 Family
In-Network benefits are payable at 100% for the remainder of the calendar year once the Individual pays $5,000 of covered expenses, including the deductible.
Out of Network benefits are payable at 100% for the remainder of the calendar year once the Individual pays $7,500 of covered expenses, including the deductible.
In-Network benefits are payable at 100% for the remainder of the calendar year once the Family pays $10,000 of covered expenses, including the deductible.
Out of Network benefits are payable at 100% for the remainder of the calendar year once the Family pays $15,000 of covered expenses, including the deductible.

Note: Under all HSA-qualified plans, out-of-hospital drug expenses are payable at 80%, after the deductible is satisfied, until the overall applicable out-of-pocket limit has been satisfied.

Eligible Members
All CAP Members 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 under age 64 (not legally separated) and dependent children under age 25.

Important Notice -The CAP Major Medical Group Insurance plan is not available to residents of Idaho, Kentucky, Maine, Massachusetts, New Hampshire, New Jersey, North Carolina, North Dakota, Vermont and Washington. These programs are not available in Canada.

Individual Maximum
Each insured family member is eligible to receive up to $5,000,000 in maximum benefits payable for covered expenses while insured. Additionally, each January 1st. New York Life will automatically restore up to $1,000 of the used portion of a covered person's maximum not previously restored.

Wellness Benefits

Annual Gynecological Benefits
Charges for an annual gynecological examination will be considered eligible expenses. These expenses include charges for one gynecological examination and one or more pap smears given or ordered as part of the examination subject to an annual maximum benefit of $100. Benefits are subject to the deductible and co- insurance provisions.

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 immunization (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 subject to the deductible and co- insurance provisions.

Child Health Care
To Age 18 Eligible expenses for insured children under age 18 for eligible child health supervision services will include 18 physician's visits at the following approximate age intervals: birth, 2, 4, 5, 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 subject to the deductible and coinsurance provisions.

Eligible Expenses (Subject to applicable co-insurance and calendar year deducible)

The following expenses are covered when they are incurred while insured and at a physician's direction as being medically 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 - 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 vertebra) column or to treatment for arthritis, scoliosis, fractures or herniated discs
  • Charges for X-ray examination 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 dressing, artificial limbs or eyes for initial replacement
  • Charges for prescription drugs or medicines
  • Services of a registered nurse or licensed physical therapist (other than a member of the insured person's family or household)
  • 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 local hospital within the U.S. and Canada equipped to furnish required treatment
  • Charges for surgery and related medical care required for nonelective caesarean section, extrauterine pregnancy, complications requiring inter-abdominal surgery after termination of pregnancy, and pernicious vomiting or toxemia and convulsions while hospitalized
  • Charges for surgical procedures
  • Home Health Care - Charges by a hospital or home health agency for up to $40 per visit and up to 100 home care visits (up to 4 hours considered one visit) in a period of twelve 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 - benefits will be payable for certain Covered Expenses for services of physicians, nurses, health aides and social workers for care of a terminally ill patient for up to 365 days while insured.

Additional Eligible Expenses

  • Charges for Pre-Admission Testing
  • Mammography - Charges for one (or more if recommended by doctor) routine mammography per calendar year
  • Charges for Foot Care, provided such charge is for:
    • (a) an open cutting operation of metatarsalgia or bunion;
    • (b) a partial or complete removal of a nail root;
    • (c) medical care of the feet, if it is not for;
      • (i) treatment of weak, strained or flat feet; or instability or imbalance of the feet,
      • (ii) treatment of any metatarsalgia or bunion, or
      • (iii) orthopedic shoes and any other supportive device;
    • (d) 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.
  • 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 the therapy is restorative or rehabilitative in nature.
  • Charges for correcting a speech impairment following an accident or sickness will be covered only if the 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.

Exclusions and Limitations
No benefit is provided unless the expense is incurred upon recommendation of a legally qualified physician. Charges while the insured is not legally obligated to pay and those in excess of what is customary and reasonable are not eligible expenses. Benefits are also not payable in connection with: War or Military Service; 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; Elective termination of pregnancy, sterilization, or reversal of sterilization; Alcoholism or narcoticism - 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 while insured; Mental or nervous conditions after a maximum of $50,000 is reached while insured; Out-of-hospital consultations with a physician for psychiatric conditions, are limited to 50% 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; Pregnancy except certain complications of pregnancy such as are indicated under Eligible Expenses; 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; Immunizations required for travel; Adult routine physical exam in excess of one per calendar year or $250 per calendar year (except for children under age 18 as indicated in "Child Health Care to Age 18" section); Those losses for which benefits are payable under any workmen's compensation law or similar legislation; Confinement in a Convalescent Care Facility after the 120th day of any one period of confinement; Charges for vision or occupational therapy; Charges for experimental surgery or research; Custodial care charges; Any charges made by the insured or by his or her immediate family; Charges for sexual transformations; Charges which would not be made in the absence of this insurance; Charges for treatment of jaw joint conditions when total benefits of $2,500 have already been paid to the insured for such treatment; Charges due or related to a pre-existing condition as detailed 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. 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.

Pre-Certify Hospital Stays with Utilization Review (UR) Provided by The Private Healthcare Systems, Inc. (PHCS) Prior to a hospital confinement, it is necessary to call The Private Healthcare Systems, Inc. (PHCS)
Network toll-free at 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 the 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 inpatient 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.

Hospital and Convalescent Care Facility defined
Hospital means an institution (other than federal or state) with 24 hour nursing diagnostic and major surgical facilities and does not include any 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).
Convalescent Care Facility means a licensed institution for skilled nursing care with 24 hour supervision by a legally 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 or training.

When Your Coverage Becomes Effective
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 on behalf of New York Life to the CAP Group Insurance Office within 31 days of the date billed and all proposed insureds are still eligible on the date insurance becomes effective.

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% 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% higher than the Standard Health Insurance rates.* In order to ascertain which premium rate applies to an individual New York Life will review medical history. Do not send premium with your enrollment form. You will be notified of the appropriate charges upon the completion of the review of your application.

*Current "Standard" Health Insurance Rates are illustrated in the rate chart. California residents, reference this rate chart.

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 Insurance Plan will be coordinated with the other coverage so that you will not receive more than 100% of the total allowable medical expenses insured from all such policies and plans. When you or your insured dependent spouse attain age 65 your coverage 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 evidencing your coverage and will have complete details of all terms, conditions and exclusions, 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 his/her member and dependent coverage will not end, but will transfer to premium class Q. Premium rates for this class of insureds will be significantly higher than the CAP active member rates. You will be advised of the applicable Class Q cost at the time of transfer.

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 as a primary insured.) (3) upon change in the member's premium class.

Right to Change Benefits or Rates
New York Life cannot change benefits or premiums on an individual basis; it may do so only on a class-wide basis. Benefits may be changed by agreement between New York Life and the policyholder.

CAP Major Medical Coverage ends when:
an insured fails to pay insurance charges on time; or an insured requests the coverage to end; or Master Policy terminates AND replacement coverage is provided.

The 30-Day Free Look
When you receive your certificate, examine it carefully. If you are not completely satisfied, 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 obligations.

Although this plan has been designed to qualify for Health Savings Accounts, it may not do so in all states. The College of American Pathologists and New York Life Insurance Company (New York, NY 10010) bear no responsibility for the establishment and administration of any Health Savings Accounts.

How to Apply

  1. Simply indicate the deductible you want on the enrollment form.
  2. Complete, date, sign, and return the application to the Plan Administrator. Send no money now.
  3. Send to:
    Affinity Insurance Services, Inc.
    159 East County Line Road
    Hatboro, PA 19040-1218

How New York Life Underwrites Your Request for CAP Coverage
Information regarding insurability will be treated as confidential. In considering whether the persons in your request for insurance qualify for standard rates, we will rely on the medical information you provide, and on the information you authorize us to obtain from your doctor, other medical practitioners and facilities, other insurance companies to which you have 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 or permitted by law. New York Life may use or disclose information as described in the HIPAA Notice of Privacy Practices in Protected Health Information. 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 can be approved for standard rates. MIB is a nonprofit, 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 a 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 to New York Life or MIB, you will be provided with non-medical information, generally medical information will be given either directly to the proposed insured or to a medical professional designated by the proposed insured. (NOTE: In certain jurisdictions, you may choose to receive medical information directly) If you question the accuracy of the information provided by MIB you may contact MIB and seek a correction. If we cannot provide the standard rates you request, we will tell you why. If you feel our information is inaccurate, you will be given a chance to correct or complete the information in our files. For U.S. Residents, your request is handled in accordance with the Fair Credit Reporting Act Procedures. MIB's information office is P.O. Box 105, Essex Station, Boston, MA 02112, telephone 617-426-3660. For Canadian residents, the address is 330 University Avenue, Suite 403, Toronto, Canada MSG 1R7, telephone (416) 597-0590. For NM Residents, PROTECTED PERSONS (1) have aright of access to certain CONFIDENTIAL ABUSE INFORMATION (2) we maintain our files and they may choose to receive 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 address. (1) PROTECTED PERSON means a victim of domestic abuse who has notified us that he/she is or has been a victim of domestic abuse; and who is an insured or prospective insured. (2) CONFIDENTIAL ABUSE INFORMATION means information about: acts of domestic abuse of 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 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 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.