Group Excess Major Medical Insurance

Even if your basic health insurance policy has a large lifetime maximum benefit, your dollar benefits may be limited per year and may be limited again as to what will and won’t be covered. A catastrophic illness or injury can quickly exceed the lifetime limit of many basic medical plans. This plan takes over when your basic health insurance reaches its limits, paying up to $2,000,000 in benefits.

Enhance your current basic medical coverage with the ACS Group Excess Major Medical Plan which includes convalescent home care, home health care, private duty nursing coverage and more.

Eligibility	All ACS Members and Society Affiliates are eligible to apply for member or spouse/domestic partner coverage, regardless of age, as well as for any unmarried dependent children under age 21 (27 if full-time student). Each applicant must be covered by a basic major medical plan (including HMO, PPO, or by Medicare Parts A and B) that provides benefits at least as great as the following: semiprivate room and board for 70 days; $10,000 for extra services other than room and board; $25,000 for physician services; and a lifetime maximum benefit of $1,000,000. For insureds who are not covered by a basic plan at the time of claim, the following charges will not be covered: hospital charges incurred during the first 70 days of each confinement; the first $10,000 of charges for chemotherapy, radiation therapy, physical therapy, or speech therapy that would otherwise be covered; the first $25,000 of charges for physician services that would otherwise be covered; and the first $2,500 of charges for prescription drugs while not hospitalized that would otherwise be covered. (Subject to the Pre-Existing Conditions limitations below.) The plan is not available in AZ, KY, MA, ME, NJ, NY, OR, VT, WA, Canada, or other foreign countries. New York residents may call the Plan Administrator at 1-800-752-0179 for information on a separate New York plan. Subject to state variations.
How the Plan Works	This Plan helps pay for extraordinary medical expenses—resulting from non-job-related illnesses or injuries—beyond the limits of your basic hospitalization, major medical insurance, HMO, PPO, or Medicare. To help keep the Plan affordable, it includes a $25,000 deductible. All reasonable and customary expenses count toward your deductible, including those paid for by your basic health plan or out of your own pocket. The deductible amount is the greater of the cash amount of $25,000 or the benefits provided by your basic health insurance plan. Since this deductible is based on the total accumulation of eligible hospital, surgical, medical, and convalescent expenses, you may include all eligible expenses regardless of whether or not the claims are related. In other words, once your first eligible expense is incurred, all additional eligible expenses immediately count toward satisfying your deductible. You will have up to 36 months to satisfy your deductible. After your $25,000 deductible is met, the Plan will pay up to 100% of all reasonable and customary eligible expenses, up to a $2,000,000 maximum benefit, for up to five years from the date your first eligible expense is incurred.
What the Plan Covers	Hospital charges including daily semiprivate room and board or intensive care. Miscellaneous hospital services and supplies. Charges by a currently licensed physician, for diagnosis, treatment, and surgery. Medically necessary private-duty nursing services from a registered LPN or RN private-duty nurse while in a hospital or at home—$120 maximum per eight-hour shift ($360 maximum per day) up to a lifetime maximum of $35,000 per insured. Dental care, treatment, or surgery if natural teeth are injured in a non-job-related injury caused by an accident that occurs while insured. X-ray, physiotherapy (by a licensed physiotherapist) or laboratory tests and services for diagnosis and treatment. Ambulance service to and from a hospital for treatment prescribed by a licensed physician—up to a $2,000 lifetime maximum per insured. Anesthetic and its administration. Prescription drugs, casts, splints, braces, trusses, and crutches both in and out of the hospital. Oxygen and rental of equipment for its administration and rental of other medical equipment such as wheelchairs or hospital beds. Psychiatric, mental, emotional or nervous disorders, or alcoholism or drug addiction treated in a hospital are covered up to a $25,000 lifetime maximum. A lifetime maximum benefit of $5,000 is provided for outpatient treatment, with a maximum eligible charge of $100 per visit. Rental of mechanical equipment for the treatment of respiratory paralysis and rental of other mechanical equipment for medical or surgical treatment. Up to 100 visits per calendar year for Home Health Care treatment.
Convalescent Home Benefit	Should any insured family member become confined as an inpatient in a convalescent home facility for custodial care due to a non-job-related injury or illness, the Plan will pay eligible expenses for room and board, general nursing care services, and supplies up to $600 per week for up to three full years ($93,600 lifetime maximum), after satisfaction of the Plan deductible. Benefits will begin on the seventh day of a convalescent home confinement that is prescribed by your doctor. Convalescent home means a licensed institution that has on its premises organized facilities to care for and treat its patients, a staff of physicians to supervise such care and treatment, and a registered nurse on duty at all times. Convalescent home does not mean a place, or part of one, which is used mainly for the aged; alcoholics; drug addicts; or persons with mental, nervous, or emotional disorders.
Home Health Care Benefit	A value-added benefit of this Plan is home health care coverage—up to 100 visits per benefit period for part-time or intermittent home nursing care or home health aide service. Each visit by a member of a home health care team will be considered one home health care visit. Four hours of home health aide services will be considered one home health care visit. The visits must be set up and approved by the Insured’s physician and a certified home health care agency. Home health care is in lieu of a hospital or skilled nursing facility stay.
Common Disaster Provision	If more than one insured family member is injured in the same accident, or contracts the same contagious disease within 30 days, only one deductible needs to be satisfied, and each insured family member will still be eligible for up to $2,000,000 in benefits for up to five years from the date the first expense is incurred against the deductible.
Reasonable and Customary Charges	Reasonable and customary charges are those charges that are not more than the usual charge for medical treatment in the locality where it is received.
Recurrent Illnesses	You are eligible for the maximum benefit of up to $2,000,000 during one benefit period. If a period of 12 consecutive months passes with no covered expenses, treatment for the same or a related condition will be treated as a new illness with a new deductible and benefit period. Otherwise, the same or related condition will be treated as continuation of the first.
Effective Date	Insurance will become effective on the date specified by United States Life, provided the appropriate premium is paid. The insured must give evidence of insurability to United States Life, unless prohibited by state law. The effective date for insurance will be delayed if the insured is hospitalized or unable to perform the normal activities of a person of like age and sex with like occupation or retired status. Insurance will become effective upon the date the insured is no longer hospitalized and/or resumes such normal activities. Dependents must be able to perform the normal activities of a person of like age and sex, with like occupation or retired status on the date insurance is to take effect. If not, such insurance will take effect on the day the dependent resumes such normal activities.
Termination of Benefit Period	Your benefit period will cease at the earlier of: completion of five years from the day the first eligible expense is incurred and used to satisfy the deductible; $2,000,000 has been paid, except as stated for Convalescent Care/Home Health Care Benefits, or psychiatric, mental, nervous, or emotional disorders, alcoholism or drug addition treatment while hospital confined; the end of a period of 12 consecutive months during which no charge is incurred for the injury or sickness; or after 24 months from the date the first covered charge is used to satisfy the deductible, if a period of 90 consecutive days passes without at least $150 of covered charges being incurred.
Pre-Existing Conditions	Pre-existing conditions will not be covered until 12 continuous months have passed without incurring charges, receiving medical treatment, consulting a physician, or taking prescribed drugs for such condition; or until the insured has been covered under the group policy for 24 continuous months. Any condition for which the insured incurred charges, received medical treatment, consulted a physician, or took prescribed drugs during the 12-month period prior to the date his/her insurance took effect is considered a pre-existing condition. All covered, non-job-related accidents and illnesses, which originate after the effective date of insurance, are covered immediately.
Exclusions	This Plan does not cover loss caused by or resulting from any one or more of the following: intentionally self-inflicted injuries; war or act of war; eye examinations to prescribe or fit corrective lenses or eyeglasses, unless they result from a non-job-related injury and the injury is caused by an accident which occurs while insured; dental care, treatment, or surgery except to the extent that it is necessary to treat a non-job-related injury to natural teeth caused by an accident which occurs while the person is insured and services are rendered within 12 months of the accident or they are made by a hospital while the person is hospitalized; treatment for temporomandibular joint dysfunction (TMJ) will be covered except to the extent for charges for crowns or bridgework; cosmetic treatment or surgery, unless such charges are the result of a non-job-related injury or illness or are necessitated by congenital defects in a dependent child which have resulted in a functional defect; any treatment given by an insured’s spouse or the insured’s or spouse’s father, mother, son, daughter, brother, sister, or employer or an employee of the employer; treatment that would be given free if the person was not insured; treatment which is not essential for the necessary care or treatment of the injury or illness involved; or treatment for psychiatric, mental, emotional, or nervous disorders, alcoholism, and drug addiction except as provided. The Plan also excludes charges to buy or rent air conditioners, air purifiers, motorized transportation equipment, escalators or elevators in private homes, eyeglass frames or lenses, hearing aids, swimming pools or supplies for them, general exercise equipment, or for a routine physical exam, except charges for preventive mammography and cytologic screening, and for persons who are not covered under a basic plan at the time of claim, the following charges will not be covered: hospital charges incurred during the first 70 days of each confinement; the first $10,000 of charges for chemotherapy, radiation therapy, physical therapy, or speech therapy that would otherwise be covered; the first $25,000 of charges for physician services that would otherwise be covered; and the first $2,500 of charges for prescription drugs while not hospitalized that would otherwise be covered.
Continuation of Coverage	Coverage will continue as long as your premiums are paid when due, you remain an eligible member, and the group policy remains in force. Coverage for dependents continues as long as: 1) your coverage remains in effect; 2) premiums are paid when due; 3) dependents’ insurance continues to be available under the group policy; 4) with respect to spouses, marriage does not end by divorce or annulment; and 5) with respect to children, the child does not reach the limiting age.
Certificate of Insurance	This brochure is a brief summary of benefits only and is subject to the terms, conditions, exclusions, and limitations of Group Policy Number E-610,345, Form No. G-19000. For a complete description of the benefits, limitations, and exclusions, refer to the Certificate of Insurance you will be sent. In the event of any conflict or inconsistency between the information on this site and the information contained in the underlying plan documents, the plan documents will in all respects control and govern. If any provision is not explained or only partially explained, your rights will always be determined under the provisions of the underlying plan documents. Insurance coverage and availability may differ by state.
30-Day Free Look	If you are not completely satisfied with the terms of your Certificate of Insurance, you may return it, without claim, within 30 days. Your coverage will be invalidated and you will receive a full refund—no questions asked!
Rates	Rates
Important Notices	Important Notice about the Medical Information Bureau (MIB) Retain for your records. Information given in your application may be made available to other insurance companies to which you make application for life or health insurance coverage or to which a claim is submitted. Information regarding your insurability will be treated as confidential except that the Company may, however, make a brief report thereon to the Medical Information Bureau, Inc., a non-profit membership organization of life insurance companies, which operates an information exchange on behalf of its members. Upon request by another member insurance company to which you have applied for life or health insurance coverage or to which a claim is submitted, the Medical Information Bureau, Inc., will supply such company with the information it may have in its files. Upon receipt of a request from you, the Bureau will arrange disclosure of any information it may have in your file. If you question the accuracy of information in the Bureau’s file, you may contact the Bureau and seek a correction in accordance with the procedures set forth in the Federal Fair Credit Reporting Act. The address of the Bureau's information office is 50 Braintree Hill Park, Suite 400, Braintree, Massachusetts 02184-8734, telephone number (866) 692-6901 [TTY (866) 346-3642]. The Company may also release information in its file to other life insurance companies to whom you may apply for life or health insurance or to whom a claim for benefits may be submitted. Important Notice to Persons on Medicare: This Insurance Duplicates Some Medicare Benefits This is not Medicare Supplement Insurance. This insurance pays limited reimbursement for expenses if you meet the conditions listed in the policy. It also pays a fixed amount, regardless of your expenses, if you meet other policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement Insurance. This Insurance duplicates Medicare benefits when: Any expenses or services covered by the policy are also covered by Medicare. It pays the fixed dollar amount stated in the policy and Medicare covers the same event. Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include: Hospitalization Physician services Hospice care Other approved items and services BEFORE YOU BUY THIS INSURANCE Check the coverage in all health insurance policies you already have. For more information about Medicare and Medicare Supplement Insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company. For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.
Disclaimers	This ACS Group Excess Major Medical Insurance is underwritten by: The United States Life Insurance Company in the City of New York 3600 Route 66 P.O. Box 1580 Neptune, NJ 07754-1580 The underwriting risks, financial, and contractual obligations, and support functions associated with the products issued by The United States Life Insurance Company in the City of New York are its responsibility. The most prominent independent ratings agencies continue to recognize The United States Life Insurance Company in the City of New York in terms of insurer financial strength. For current insurer financial strength ratings, please consult the website at www.aigag.com/ratings. The ACS Member Insurance Program is self-supporting. ACS member dues are not used in any way to maintain or promote ACS insurance plans.