Catastrophe Major Medical

What It Is

Catastrophe Major Medical Insurance supplements your basic hospitalization and major medical insurance, including Medicare, as well as long-term care insurance. After the deductible has been met, the plan pays up to 100% of eligible expenses not recovered by other insurance for up to 5 years or $2 million.

NYSUT Member Benefits Trust-endorsed Catastrophe Major Medical Insurance is underwritten by The United States Life Insurance Company in the City of New York and is administered by Marsh Affinity Group Services.

The United States Life’s Catastrophe Major Medical Plan is a NYSUT Member Benefits Trust (Member Benefits)-endorsed program. Member Benefits has an expense reimbursement/endorsement arrangement of 2.9% of earned premiums for this program. All such payments to Member Benefits are used solely to defray the costs of administering its various programs and, where appropriate, to enhance them. The Insurer pools the premiums of Member Benefits participants who are insured for the purposes of determining premium rates and accounting. Coverage outside of tihs plan may have rates and terms that are not the same as those obtainable through Member Benefits. The Insurer or Member Benefits may hold premium reserves that may be used to offset rate increases and/or fund such other expenses related to the plan as determined appropriate by Member Benefits. Member Benefits acts as your advocate; please contact Member Benefits at (800) 626-8101 if you experience a problem with any endorsed program.

Agency fee payers to NYSUT are eligible to participate in NYSUT Member Benefits Trust-endorsed programs.

Eligibility

Members and agency fee payers who are age 79 or younger, in-service or retired, are eligible to apply. Basic health insurance (or Medicare) is required, and a member may add coverage for a spouse or certified domestic partner, dependents to age 21 (27 if full-time students), parents and parents-in-law, as long as each person applying is age 79 or younger, covered under a basic medical plan and has not been treated or diagnosed in the last 5 years for a condition listed on the application.

Features

The plan includes a $25,000 deductible, and you have 3 full years from the date your first eligible expense is incurred to satisfy this deductible. All reasonable and customary eligible expenses count toward your deductible, including those paid by your basic health insurance policy, as well as those you pay out of pocket. “Reasonable and customary” means the normal charge for a certain procedure or service performed by medical providers in your area. For example, if your doctor charges $3,000 for a surgical procedure, basic medical insurance allows $2,400 and you pay the $600 balance, the entire $3,000 will likely be considered reasonable and customary. If, however, your doctor charges $5,000 for a procedure for which most doctors only charge $3,000, the extra amount may not be considered reasonable and customary and therefore will not count toward your deductible.

After your deductible is met, eligible expenses under the plan include:

• Hospital charges for daily semi-private room and board and intensive care.
• Miscellaneous hospital services and operating room charges.
• Treatment by licensed physicians, whether in a hospital, at home or in the office.
• Dental treatment if natural teeth are injured by a covered non-job related accident.
• X-ray, physiotherapy or laboratory services for diagnosis and treatment.
• Anesthetic and its administration.
• Medically necessary ambulance service to and from any hospital, up to a $2,000 lifetime maximum.
• Prescription drugs, casts, splints, braces, trusses and crutches.
• Oxygen and rental of equipment for its administration, rental of wheelchairs or hospital beds.
• Rental of iron lung or other mechanical equipment for treatment of respiratory paralysis; rental of other mechanical equipment for medical or surgical treatment.
• Reasonable and customary expenses for room and board, general convalescent care services, and supplies for custodial or convalescent care as an inpatient in a convalescent/nursing home, up to $500 per week, up to 3 years per benefit period ($80,000 lifetime maximum). Benefits begin on the 6th day of confinement.
• Up to 300 home health care visits per calendar year per benefit period.
• 85% of reasonable and customary private duty nursing services while in a hospital or at home--$120 maximum per 8-hour shift ($360 maximum per day) up to a lifetime maximum of $35,000 per insured.
• Charges for a Hospice Care Program -- 210 consecutive days of confinement per benefit period are covered, including drugs and medical supplies, and 5 visits per benefit period for bereavement counseling services for the family of a terminally ill insured, either before or after the insured’s death.

If more than 1 insured family member is injured in the same accident or contracts the same contagious disease within 30 days, only 1 deductible needs to be satisfied, and each insured member will still be eligible for up to $2 million in benefits for up to 5 years during the benefit period.

An insured’s benefit period begins on the date the first eligible expense toward the deductible is incurred. The benefit period ends at the earliest of:

• 5 years from the day eligible expenses toward the deductible were first incurred.
• $2 million have been paid.
• The insured recovers.
• 12 consecutive months during which no charge for sickness or injury was incurred. If after these 12 months, the insured is again treated for the same or related condition, the plan considers this as a new illness with a new deductible and benefit period.
• 24 consecutive months from the date the first eligible expense was incurred, if 90 consecutive days pass without at least $150 of eligible expenses being incurred.

Catastrophe Major Medical Insurance coverage continues for insured dependents of a deceased member as long as the dependents meet the normal eligibility requirements and the premiums are paid.

Pre-existing conditions will not be covered until 12 consecutive months (6 months if age 65 or over) from the effective date of coverage. Pregnancy that exists on the effective date is considered a pre-existing condition. All covered accidents and sicknesses that occur after the effective date of insurance are covered immediately.

Premiums are based on the member’s age when insurance becomes effective and increase when the member enters a new age category.

Your satisfaction with the plan is 100% guaranteed. If, when you receive your Certificate of Insurance, the plan is less than what you expected, just mail it back to the Plan Administrator within 30 days, your money will be promptly refunded and your insurance canceled.

Payment Options

If payroll or pension deduction of NYSUT Member Benefits Trust is available to you and you choose to pay your premiums through this option, you save 10% on annual premiums. You can also be billed directly on a semi-annual basis.

How To Apply

You must complete the Catastrophe Major Medical Insurance Plan application. The plan is medically underwritten. To receive a brochure and application, call the Plan Administrator, Marsh Affinity Group Services, toll-free at (888) 38-NYSUT (888-386-9788), weekdays from 9:15 a.m. to 6 p.m. Eastern Time. You can click on the Marsh Affinity link below to download a brochure and application.

Or call Member Benefits toll-free at (800) 626-8101, weekdays from 9 a.m. to 5 p.m. Eastern Time, or e-mail us at Member Benefits.

For more information, please visit Marsh Affinity Group Services.

Contact

For more information on eligibility, plan benefits and exclusions, billing rates or to receive an application, call the Plan Administrator toll-free at (888) 38-NYSUT (1-888-386-9788), weekdays from 9:15 a.m. to 6 p.m. Eastern Time.

Or for a brochure and application, call Member Benefits toll-free at (800) 626-8101, weekdays from 9 a.m. to 5 p.m. Eastern Time, or e-mail us at Member Benefits.

For more information or to view or print a brochure and application, please visit Marsh Affinity Group Services.

NYSUT Member Benefits Trust-endorsed Catastrophe Major Medical Insurance is underwritten by The United States Life Insurance Company in the City of New York and is administered by Marsh Affinity Group Services.