CERTIFICATE OF INSURANCE

Transcription

1 AARP ESSENTIAL HEALTH INSURANCE PLAN CERTIFICATE OF INSURANCE Underwritten by United HealthCare Insurance Company Fort Washington, Pennsylvania Issued to: United HealthCare Insurance Company ( United HealthCare ) has issued Group Policy No. G to the TRUSTEES OF THE AARP INSURANCE PLAN, Washington, D.C. The Group Policy is delivered in and governed by the laws of the District of Columbia and provides insurance for the members of AARP. All benefits are subject to the entire Group Policy, which includes the group insurance certificates. This Certificate is an important document and should be kept in a safe place. Benefits are payable as shown in the SCHEDULE OF BENEFITS for the following: HOSPITAL INPATIENT STAYS LABORATORY/PATHOLOGY SERVICES EMERGENCY ROOM/OUTPATIENT OBSERVATION HEALTH CARE PRACTITIONER SERVICES CARE POST-HOSPITAL CARE SURGERY RADIOLOGY SERVICES THIS CERTIFICATE PROVIDES LIMITED BENEFITS AND DOES NOT MEET THE STANDARDS OF A MEDICARE SUPPLEMENT, A LONG TERM CARE, OR A MAJOR MEDICAL PLAN. If you are eligible for Medicare, you are not eligible for coverage under this plan. Please review the Guide to Health Insurance for People with Medicare available from United HealthCare. 30 DAY RIGHT TO EXAMINE YOUR CERTIFICATE If you decide you do not want this coverage, you may return this Certificate within 30 days after receiving it. Upon receipt, your insurance will be deemed void from its Effective Date and any Premium payments made will be returned to you. However, United HealthCare has the right to recover any claims paid during this period. Any Premium refund otherwise due to you will be reduced by the amount of any claims paid during this period. If you have received claim payment in excess of the amount of your Premium, no refund of Premium will be made and United HealthCare has the right to recover all excess amounts. The Certificate, together with a written request for such withdrawal, must be sent to: United HealthCare, P.O. Box 1000, Montgomeryville, PA PRE-EXISTING CONDITIONS LIMITATION A pre-existing condition is any Injury, Sickness, or other condition for which you received medical advice, or that was diagnosed or treated, or for which prescription medications or drugs were prescribed or taken, or which produced symptoms which would have caused an ordinarily prudent person to seek medical diagnosis or treatment within the 6 month period ending on your plan s Effective Date. Any stay which begins, or care received, within 6 months after the Effective Date is not covered if caused by or resulting from a pre-existing condition. GHESP2 GH PLEASE READ YOUR CERTIFICATE CAREFULLY

2 GUIDE TO YOUR CERTIFICATE Who Is Eligible To Be Covered-Effective Date... 2 General Matters... 8 What Certain Terms Mean... 2 When Your Coverage Stops... 9 What Is Covered... 4 Benefits After Your Coverage Stops... 9 What Is Not Covered... 6 Schedule Of Benefits When You Have A Claim... 7 WHO IS ELIGIBLE TO BE COVERED EFFECTIVE DATE To enroll for coverage under this plan, an individual must not be eligible for Medicare, and must be an eligible member of AARP age 50 to 64 or an eligible member s spouse under age 65. The person or persons named on the first page of this Certificate are covered from the Effective Date shown. The required Premium must be paid when due. The term you or your refers individually to each person named. If you request a change that affects this coverage, such change will be effective on the first day of the month following the date we receive your request for such change, subject to United HealthCare s approval. CAUTION: Statements made by you in the application were relied upon in the issuance of this coverage. If any statement is incorrect or untrue, United HealthCare may have the right to rescind this coverage, adjust Premiums or reduce benefits. If you are aware of any incorrect or incomplete information, you should contact United HealthCare now, before any claim arises. If, for any reason, any of your answers are incorrect, contact United HealthCare at: P.O. Box 1000, Montgomeryville, PA WHAT CERTAIN TERMS MEAN Ambulatory Surgical Center The following facilities qualify as an Ambulatory Surgical Center: a facility licensed as an ambulatory surgical center by the state in which it is located; or a freestanding facility, other than a clinic or Health Care Practitioner s office, where surgical and diagnostic services are provided on an ambulatory basis, and which has written agreements with local Hospitals for the immediate acceptance of patients who develop complications or require postoperative confinement. Calendar Year January 1 st through December 31 st. Covered Service(s) Stays or services incurred while your coverage is in force and determined by United HealthCare to meet all of the following: (1) the stay or service must meet United States medical standards; (2) the stay or service must be necessary for the prevention, diagnosis or treatment of a Sickness or Injury; (3) the stay or service must not be primarily for your convenience; (4) the stay or service must be certified by a Physician, upon United HealthCare s request, as being appropriate for the diagnosis and treatment of your Sickness or Injury; and (5) the stay or service must meet all other applicable terms and conditions of this plan. Current Procedural Terminology (CPT) - Current Procedural Terminology codes are identifying codes which are used nationwide for reporting medical services and procedures performed. A complete listing, entitled Physicians Current Procedural Terminology, is published by the American Medical Association. Experimental or Investigational Medical, surgical, diagnostic, psychiatric, substance abuse or other health care services, technologies, supplies, treatments, procedures, drug therapies or devices that, at the time United HealthCare makes a determination regarding coverage in a particular case, are determined to be any of the following: (1) not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use and not identified in the American Hospital Formulary Service or the United States Pharmacopoeia Dispensing Information as appropriate for the proposed use; (2) subject to review and approval by any institutional review board for the proposed use; or (3) the subject of an ongoing clinical trial that meets the definition of a Phase 1, 2 or 3 clinical trial set forth in the FDA regulations, regardless of whether the trial is actually subject to FDA oversight. 2

3 Health Care Practitioner A licensed Physician, physician s assistant, nurse practitioner, physical therapist, occupational therapist, speech therapist, chiropractor or mental health care provider acting within the scope of his or her license. Health Care Common Procedure Coding System (HCPCS) Level II National Codes A uniform method for health care providers and medical suppliers to report professional services, procedures and supplies. This coding system was developed and is updated by the Centers for Medicare and Medicaid Services (CMS). Home Health Aide A person whose main function is to provide personal care services. If state or local licensing or certification is required, the person must be licensed or certified as a home health aide where the service is performed. If licensing or certification is not required, any person who meets the minimum training qualifications recognized by the National Home Caring Council, National League of Nursing, or Centers for Medicare and Medicaid Services will be considered a home health aide, provided that they are employed through a licensed or Medicare-certified home health care agency. Hospital The following facilities will qualify as a Hospital: Medicare Approved Hospitals. An institution which, while you use it, has an agreement as a provider of inpatient hospital services under the Medicare program (i.e., Section 1866 of Title XVIII of the United States Social Security Act as amended). Christian Science Sanitoria. A Sanitorium operated by or certified by the Commission for Accreditation of Christian Science Nursing Organizations/Facilities. Other Institutions. An institution or unit thereof, other than those above, which meets fully all of the following requirements: (1) holds a state license as a hospital (if a license is required); (2) operates mainly for the medical care and treatment of sick or injured persons as inpatients; (3) provides on-duty 24 hour-a-day nursing service by registered or graduate nurses; (4) has a staff of one or more licensed Physicians available at all times; and (5) provides on its premises, or through contractual arrangement with another institution, organized facilities regularly used for diagnosis and major surgery. The unit of the institution in which you are confined must meet fully all five of these requirements. Note: Institutions or units thereof (by whatever name called), which might otherwise meet these requirements, will NOT be considered a covered hospital when functioning primarily as: (1) a clinic, rest home, convalescent home, home for the aged or assisted living center; (2) a nursing home unit or a facility or unit providing skilled nursing care, intermediate care, extended care or custodial care; (3) a domiciliary unit or a facility or unit providing housing or residential care; (4) a hospice; (5) an ambulatory surgical center or dialysis center; (6) a facility or unit providing scheduled classes, training, education or recreation; or (7) a facility or unit which provides treatment for alcohol, drug, or other substance abuse. Hospital Inpatient Stay The continuous period of time that begins on the day you: 1) enter a Hospital as an inpatient, or 2) enter an emergency room or observation room and are admitted to the Hospital as an inpatient directly from the emergency room or observation room, and ends when you have been out of a Hospital for at least 24 hours. This applies even if you move from one Hospital to another. Immediate Relatives Your spouse, child(ren), child s spouse, parent(s), spouse s parent(s), sibling(s), sibling s spouse, grandchild(ren), or stepchild(ren). Injury An accidental bodily injury which is the direct result of an accident, independent of disease or bodily infirmity or any other cause, and occurs while this plan is in force for you. Laboratory/Pathology Services Only those procedures designated as Pathology and Laboratory in the Physicians Current Procedural Terminology (CPT). 3

4 Medical Emergency The sudden and unexpected onset of symptoms, Sickness, Injury, or a condition that would be deemed, under appropriate United States medical standards, to carry substantial risk of serious medical complication or permanent damage to you if care or services are delayed or withheld. Mental Illness Those mental health or psychiatric diagnostic categories that are listed in the current Diagnostic and Statistical Manual of the American Psychiatric Association. Nurse For the purpose of the Post-Hospital Benefit, a professional nurse legally designated RN (registered nurse) or LPN (licensed practical nurse) who, where licensing is required, holds a valid license from the state in which the nursing service is performed. LPN shall include a licensed vocational nurse ( LVN ) and any other similarly designated nurse in those jurisdictions in which a professional nurse is designated as other than an LPN and for whom licensing is required. Period of Hospital Stay The total number of days of all successive Hospital Inpatient Stays. Such Hospital Inpatient Stays which are separated by more than 90 days are NOT part of the same Period of Hospital Stay. If you re-enter a Hospital after your coverage stops, that Hospital Inpatient Stay is NOT covered. Physician A licensed doctor of medicine or osteopathy acting within the scope of his or her license. Premium(s) The monthly payment required for each member in accordance with this plan. Primary Residence Your dwelling located in the state which is used as your state of residence for purposes of your federal income tax return. Radiology Services Only those procedures designated as Radiology in the Physicians Current Procedural Terminology (CPT). Sickness An illness or disease which first manifests itself after the Effective Date of this plan and while this plan is in force for you. Skilled Nursing Facility An institution (or unit of a Hospital) which: (1) is operated or licensed pursuant to state law or is approved for payment of Medicare benefits or is qualified to receive such approval if requested; (2) is primarily engaged in providing, in addition to room and board accommodations, skilled nursing care under a licensed Physician's supervision; (3) provides on-duty 24 hour-a-day nursing service under the supervision of registered or graduate nurses; and (4) maintains a daily record for each patient. The unit of the institution in which you are confined must meet fully all four of these requirements. Note: Institutions or units thereof (by whatever name called), which otherwise meet these requirements, will NOT be considered a Skilled Nursing Facility when functioning primarily: (1) as a clinic, rest home, or convalescent home; (2) as a domiciliary, residential or custodial care unit; (3) as an assisted living center; (4) as a home for the aged; (5) as an educational care unit; (6) for the treatment of substance abuse; or (7) for the convenience of the insured. Surgery Only those procedures designated as Cardiac Catheterization, Cardiovascular Therapeutic Services which require introducing, positioning or repositioning of catheters, and Surgery, as stated in the Physicians Current Procedural Terminology (CPT). Therapist A licensed physical therapist, occupational therapist, or speech therapist who is acting within the scope of his or her license where the services are performed. WHAT IS COVERED United HealthCare will pay the Applicable Benefit shown in the SCHEDULE OF BENEFITS for the following covered stays and services which are not otherwise excluded (see WHAT IS NOT COVERED). All stays must begin, and all services must be received, on or after the Effective Date of this Certificate. All stays and services must meet the definition of a Covered Service(s) and be ordered by a legally qualified Physician acting within the scope of his or her license. Benefits payable for covered stays or services under any and all AARP Essential Health Insurance Plans 4

5 underwritten by United HealthCare will be applied to the satisfaction of this policy s Calendar Year maximum, lifetime maximum or any other limitation described in this Certificate. When benefits are payable as described below, no more than one Applicable Benefit as shown in the SCHEDULE OF BENEFITS will be payable for any one covered service. Separate benefits will not be paid for the technical and professional components of a covered service. 1) Hospital Inpatient Stay Benefit If you are confined in a Hospital as an inpatient, the Hospital Inpatient Stay Benefit is payable beginning on the second day of a covered Hospital Inpatient Stay, for those days that the Hospital makes an inpatient room and board charge. The Hospital Inpatient Stay Benefit is subject to: a Calendar Year maximum of 45 days for Hospital Inpatient Stays when the primary diagnosis is for Mental Illness; a maximum of 365 days per Period of Hospital Stay for all Hospital Inpatient Stays; and a total lifetime maximum of 730 days for all Hospital Inpatient Stays. 2) Emergency Room/Outpatient Observation Care Benefit If you incur an emergency room charge or an outpatient observation care charge and you are not admitted to the Hospital as an inpatient, an Emergency Room/Outpatient Observation Care Benefit is payable. Your emergency room charge must be for services performed in an emergency room of a Hospital and must be due to a Medical Emergency. Outpatient observation care must be furnished by a Hospital on the Hospital s premises; and must provide the use of a bed and periodic monitoring to evaluate your condition to determine your need for an inpatient admission. The outpatient observation care must meet all of the following conditions: (1) you must receive medical advice, tests or treatment while confined in a Hospital on an outpatient basis for at least 12 hours; (2) a room charge (other than inpatient room and board charge) must be incurred; (3) such care must meet the definition of Covered Service(s); and (4) such care must be ordered by a Physician. Confinement in an outpatient surgical unit is not considered outpatient observation care. Only one Emergency Room/Outpatient Observation Care Benefit is payable for each emergency room stay or outpatient observation care stay. If you receive emergency room services and outpatient observation care during the same stay, only one Emergency Room/Outpatient Observation Care Benefit is payable for the entire stay. The Emergency Room/Outpatient Observation Care Benefit is subject to a Calendar Year Maximum of 1 benefit. Note: If you receive emergency room services or outpatient observation care and you are admitted to the Hospital as an inpatient directly from the emergency room or observation room, benefits will be considered under the Hospital Inpatient Stay Benefit and no Emergency Room/Outpatient Observation Care Benefit is payable. 3) Surgery Benefit If you incur a Physician charge for Surgery performed on an inpatient or outpatient basis, a Surgery Benefit is payable. The applicable Surgery Benefit is shown in the SCHEDULE OF BENEFITS, and will be determined based on the place where Surgery is performed, as reflected on the standard billing form. The Surgery Benefit is subject to a Calendar Year Maximum of, in total, 3 procedures. Only one Surgery Benefit is payable per day. Separate benefits will not be paid for the services of a primary surgeon, assistant surgeon, co-surgeon or anesthesiologist. 4) Radiology Benefit If you incur a charge for a Radiology Service performed in an outpatient setting, a Radiology Benefit is payable. The applicable Radiology Benefit is shown in the SCHEDULE OF BENEFITS, and is subject to a Calendar Year Maximum of 3 tests. Only one Radiology Benefit is payable for each Radiology Service performed. Separate benefits will not be paid for the technical and professional components of a Radiology Service. Note: If you are admitted to the Hospital as an inpatient directly from the emergency room or observation room, no Radiology Benefits are payable for services performed while you were confined in the emergency room or observation room. 5) Laboratory/Pathology Benefit If you incur a charge for a Laboratory/Pathology Service performed in an outpatient setting, a Laboratory/Pathology Benefit is payable. The applicable Laboratory/Pathology Benefit is shown in the SCHEDULE OF BENEFITS, and is subject to a Calendar Year Maximum of 3 tests. Only one Laboratory/Pathology Benefit is payable for each Laboratory/Pathology Service performed. Separate benefits will not be paid for the technical and professional components of a Laboratory/Pathology Service. 5

6 Note: If you are admitted to the Hospital as an inpatient directly from the emergency room or observation room, no Laboratory/Pathology Benefits are payable for services performed while you were confined in the emergency room or observation room. 6) Health Care Practitioner Services Benefit If you incur a charge for a service provided by a Health Care Practitioner which is not otherwise eligible for consideration under the Surgery, Radiology, or Laboratory/Pathology Benefits, and not otherwise excluded under this plan, a Health Care Practitioner Services Benefit is payable. The applicable Health Care Practitioner Services Benefit is shown in the SCHEDULE OF BENEFITS, and is subject to a Calendar Year Maximum of 3 visits. 7) Post-Hospital Care Benefit If you incur a charge for the following, within 90 days of a Hospital Inpatient Stay for which benefits are payable under this Certificate and due to the same or related condition for which you were hospitalized, benefits are payable as shown in the SCHEDULE OF BENEFITS. A) Skilled Nursing Facility Stay - If you incur a charge for a stay in an eligible Skilled Nursing Facility for skilled nursing care, benefits are payable for each day of such stay, up to a maximum of 30 days. B) Home Health Care Visit If you incur a charge for home health care as described below, benefits are payable for one visit per day, up to a maximum of 30 days. (i) Nurse Visit Nursing care provided by a Nurse. (ii) Therapist Visit Physical, occupational, or speech therapy by a qualified Therapist. Benefits are payable whether the visit is received at home or in the Therapist s office. (iii) Home Health Aide Visit Services which consist of the following: bathing, dressing, personal hygiene, preparing meals, feeding, administering prescribed drugs, or changing bandages and other dressings, when provided by a Home Health Aide. WHAT IS NOT COVERED Care or Services Provided Without Charge Stays or services for which no charge would be made to you in the absence of insurance are not covered. Care Provided by Immediate Relatives or Household Members Services provided by your Immediate Relatives or members of your household are not covered. Pregnancy Pregnancy will not be covered unless the pregnancy begins more than 12 months after the Effective Date of the mother s coverage under this plan. After 12 months, the applicable benefits will be payable for the care of the insured mother during antepartum, delivery and postpartum. Fertility Services Stays, services, or procedures performed for treatment related to fertility, infertility or contraception are not covered. Care or Services Prior to the Effective Date Charges for the following are not covered: (1) Stays which began prior to your Effective Date. (2) Services provided or expenses incurred: a) prior to your Effective Date; or b) in connection with a stay which began prior to your Effective Date. Governmental Programs Stays or services for which benefits are available under Medicare or other governmental programs (except Medicaid) are not covered unless required by law. 6

7 Inpatient Confinements That Are Not Covered An inpatient Hospital confinement is not covered if the primary purpose of the confinement is to provide any of the following types of care: (1) care of the type provided in a clinic, rest home, convalescent home, home for the aged or assisted living center; (2) skilled nursing care; (3) intermediate care, extended care or custodial care; (4) residential care or care of the type provided in a domiciliary unit; (5) care of the type provided in a hospice; (6) care of the type provided in an Ambulatory Surgical Center or dialysis center; or (7) care consisting primarily of scheduled classes, training, education and/or recreation. Such confinement is not covered even when the facility or unit in which such care is provided is part of or a unit of a Hospital. Dental Services Services involving one or more teeth, the tissue or structure around them, the alveolar process or the gums are not covered. This applies even if a condition requiring any of these services involves a body part other than the mouth such as treatment of Temporomandibular Joint Disorders (TMJD) or malocclusion involving joints or muscles by methods including, but not limited to, crowning, wiring or repositioning teeth. This exclusion does not apply to a charge made for treatment or removal of a malignant tumor. Self-Inflicted Injuries Stays or services caused, wholly or partly, by intentionally self-inflicted injury, or attempted suicide, while sane or insane, are not covered. Experimental Charges Stays or services that are educational, Experimental or Investigational, or are provided for research purposes, are not covered. Vision and Hearing Services Examinations to determine the need for, or the proper adjustment of, glasses, contact lenses, or hearing aids are not covered. Laser vision correction surgery solely for the purpose of eliminating the need for corrective lenses is not covered. War Stays or services for Injury or Sickness caused by or resulting from any future act of war are not covered, even if the war is not declared. Foot Conditions Any service performed for the treatment of the following is not covered: (1) a weak, strained, flat, unstable or unbalanced foot or for a metatarsalgia or bunion. This does not apply to a Physician charge for a Surgery that meets the qualifications of the Surgery Benefit. (2) one or more of the following: corns, calluses or toenails. This exclusion does not apply to a charge for: (a) removal of part or all of one or more nail roots; and (b) services in connection with treatment of a metabolic or peripheral vascular disease. Cosmetic Surgery Stays or services for cosmetic surgery performed mainly to change your appearance are not covered. This includes surgery to treat a mental, psychoneurotic or personality disorder through change in appearance. Cosmetic surgery does not include surgery to correct the result of an accidental Injury, surgery to treat a condition which impairs the function of a body organ, or surgery to reconstruct a breast after mastectomy. Ambulance Transportation by ambulance and related services are not covered. Supplies Medical and surgical supplies, including but not limited to dressings, prosthetics, orthotics, diabetic shoes, durable medical equipment, and enteral and parenteral therapies, are not covered. Outside the United States Stays and services received outside the United States and its possessions are not covered. WHEN YOU HAVE A CLAIM Filing Claims Instructions for filing claims were sent to you after you enrolled. Proof of Loss Satisfactory proof of loss must be furnished no later than 15 months from the date of loss, except in the absence of legal capacity. Satisfactory proof of loss includes an itemized bill that provides the name and address of the Hospital, facility or provider, CPT code(s) or HCPCS code(s), type(s) and date(s) of service(s), admission and discharge dates, and amounts charged. Proof of loss must be produced on a standard billing form which clearly identifies the provider of the service, place of service, as well as the type and dates of service. 7

8 Time of Payment of Claim Benefits will be paid when United HealthCare receives satisfactory proof of loss. Payment of Claim If you have signed an assignment of benefits, your benefits will be paid directly to the provider. Benefits not assigned will be paid to you. If any benefit remains payable after your death or while you are not competent to give a valid release, United HealthCare may pay a benefit up to $3,000 to any relative of yours whom United HealthCare decides to be justly entitled to it. Any payment made to your relative in good faith will fully release United HealthCare of its responsibility to the extent of the payment. Physical Examination When you submit a claim, United HealthCare, at its own expense, has the right to examine you as often as it may reasonably require. Medical Records When you submit a claim, United HealthCare may need to obtain your authorization to permit a provider who treated you to release medical records to United HealthCare in order to determine eligibility of the claim and/or for the plan. Failure to provide United HealthCare with such authorization in a timely manner may result in the loss of coverage. United HealthCare will treat any medical records or information it receives as confidential. Legal Actions You cannot bring any action at law or in equity for any benefits under the Group Policy until sixty (60) days after you have filed written proof of loss. No such action can be brought once three (3) years have passed from the date you were required to provide proof of your loss. Recovery of Claims Paid If United HealthCare makes a payment with respect to services and such payment or a portion thereof is not required according to the terms of this plan, United HealthCare shall have the right to recover such overpaid amounts from any of the following: any future claim payments; any person to or for or with respect to whom the payments were made; or any liable third party. GENERAL MATTERS Statements Made By You The Certificate, any riders which may be issued or attached, your application, and the Group Policy constitute the entire contract. Statements made by you to obtain insurance under this plan will be deemed representations and not warranties. These statements will not be used in a contest to avoid your insurance, adjust Premiums or reduce benefits unless: 1) it is in a written statement signed by you; and 2) a copy of that statement is or has been furnished to you or your legal representative. If you have misstated your age, eligibility, health conditions, or other material facts and this Certificate would not have been issued had that information been correctly stated, this Certificate is void. United HealthCare will refund all Premiums paid less the amount of any claims paid under this Certificate. If you have misstated your age, eligibility, health conditions, or other material facts and a different Premium would have been charged had that information been correctly stated, you are responsible for payment of the correct Premiums from the Effective Date of this Certificate within 30 days of notification by United HealthCare. In addition to other rights granted under this Certificate, United HealthCare shall have the right to offset against any claim amounts otherwise payable to recover that portion of Premiums owed by you but not paid as the result of your misstatement. These statements, except fraudulent misstatements, will not be used in a contest after your insurance has been in force, prior to the contest, for at least two years. After two years, only fraudulent misstatements may be used to contest your coverage. Grace Period Upon payment of your first Premium, you have 31 days after the Premium due date to pay any subsequent required Premium. Your coverage under this plan will stay in force until the end of this period. In any case, you must pay the Premium for coverage in force during the grace period. If you replace this plan with any other AARP health plan issued through United HealthCare, coverage under this plan will stop on the effective date of your new plan and this 31 day grace period will not apply. 8

9 Multiple Coverage You may not be covered at any one time under more than one of AARP s group hospital indemnity insurance plans, AARP Essential Health Insurance Plans or similar plans under Group Policy No. G , or AARP s Group Medical Advantage Plans or similar plans under Group Policy No. G This Certificate replaces any Certificate previously issued to you under the Group Policy. Effect of Change of Plan If, on the Effective Date shown, you have replaced any other AARP Essential Health Insurance Plan insured by United HealthCare (the prior plan) with this plan, the following will apply: (1) benefits for any stay or service not covered under this plan due to the Pre-Existing Conditions Limitation will be determined as if the prior plan were still in effect; (2) no benefits will be paid under this plan to the extent that a benefit is payable under the prior plan; and (3) benefits paid for covered stays or services under the prior plan will be applied to the satisfaction of this plan s Calendar Year maximum, lifetime maximum, or any other limitation. Premium and Benefit Changes The required Premium and benefits for this plan are subject to change. Premiums are based on the rate table in effect on the Premium due date. The plan type and level of benefits, your age, your class, and your Primary Residence on the Premium due date are factors in determining your Premiums. Inspection of Policy The Group Policy is on file at the office of the Trustees of the AARP Insurance Plan located at 601 E Street, N.W. Washington, DC It may be inspected during their normal business hours. Conformity With State Statutes Any provision in this Certificate which, on its Effective Date, conflicts with the applicable laws of the state in which it is delivered, is amended to meet the minimum requirements of such laws. WHEN YOUR COVERAGE STOPS Termination of Coverage Your coverage will stop when the first of these occurs: 1) the first day of the month in which you become eligible for Medicare; 2) the first day of the month in which you turn age 65; or 3) the date you are no longer an AARP member or a spouse of a member. Any Premium paid after your coverage stops will not continue your coverage in force and will be returned. If the member dies, or the member and spouse divorce, the spouse, if covered under the Group Policy, may elect to continue coverage by paying the required Premium. You must advise United HealthCare immediately upon becoming eligible for Medicare. Failure to Pay Premium Your coverage will stop at the end of the 31 day grace period after any Premium due date if you fail to pay the required Premium by the end of the grace period. If you request a change of your coverage from this plan to another AARP group health insurance plan, your coverage under this plan will stop on the effective date of the new plan and the 31 day grace period under this plan will not apply. Termination of Group Policy Your coverage will stop on the date the Group Policy is terminated. BENEFITS AFTER YOUR COVERAGE STOPS If your coverage stops while you are confined in a Hospital or Skilled Nursing Facility, the Hospital Inpatient Stay or Post- Hospital Skilled Nursing Care Benefits will continue to be paid as though your coverage had not stopped while you remain continuously confined; subject to all other terms and conditions of this plan. All other benefits will stop on the date coverage terminates. 9

10 SCHEDULE OF BENEFITS A separate and distinct benefit will not be paid under this plan for packaged services. Packaged services may include operating room, recovery room, anesthesia, pharmaceuticals, medical and surgical supplies, blood and blood storage, devices and equipment, intraocular lenses, costs to procure donor tissue (other than corneal), travel and/or transportation costs, and incidental services, such as venipuncture and introduction of a needle or catheter. COVERED BENEFIT APPLICABLE BENEFIT Hospital Inpatient Stay benefit From 2 nd day of stay (First day of each Hospital Inpatient Stay is not covered) Mental Illness Calendar Year Maximum Maximum per Period of Hospital Stay for all Hospital Inpatient Stays Hospital Inpatient Stay Lifetime Maximum Emergency Room/Outpatient Observation Care Benefit Calendar Year Maximum Surgery Benefit (Based on the place of service, as reflected on the standard billing form) performed in a Physician s office performed in a Hospital operating room or an Ambulatory Surgical Center Calendar Year Maximum for all Surgery procedures Radiology Benefit Calendar Year Maximum $300 per day 45 days 365 days 730 days $50 per stay 1 benefit $75 per procedure $150 per procedure A total of 3 procedures $50 per test 3 tests Laboratory/Pathology Benefit Calendar Year Maximum $15 per test 3 tests Health Care Practitioner Services Benefit Calendar Year Maximum $50 per visit 3 visits Post Hospital Care Benefits (For services provided within 90 days following a covered Hospital Inpatient Stay) Skilled Nursing Facility Stay $100 per day Maximum following each covered Hospital Inpatient Stay 30 days Home Health Care Visit (limited to one visit per day) $50 per visit Maximum following each covered Hospital Inpatient Stay 30 days 10