1 04/12/2007 CT RE: A Health Insurance Proposal - OneDeductible PPO with an HSA Dear Mr. Sample: Enclosed is the information you requested on Health Plans for Individuals and Families from Time Insurance Company. Please review the attached proposal carefully. Our OneDeductible HSA provides extensive coverage while offering the simplicity and convenience of a single, common deductible for all members of the family. This plan protects you from the large medical bills that accompany a serious accident or illness, and the Health Savings Account (HSA) lets you pay everyday medical expenses with tax-free funds. Our commitment to the individual health insurance business makes Assurant Health a leader and innovator in the industry. Our commitment to protecting customers makes Assurant Health the best choice for those who pay for their own health insurance coverage. Sincerely, Alston Balkcom INSURANce P.O. Box 6055 Bridgeport, CT (800) Assurant Health is the brand name for products underwritten and issued by Time Insurance Company, John Alden Life Insurance Company and Union Security Insurance Company.
2 Prepared for: ZIP Code: Your personal representative: Individual Medical Your Plan Summary Alston Balkcom Phone: (800) Fax: (888) The kind of protection you need for the peace of mind you deserve. Health Plans for Individuals and Families Your total monthly amount $ Individual Medical Major Medical - for your healthcare protection OneDeductible PPO with Health Savings Account (HSA) Features: -First-year rate guarantee. -$3,000,000 lifetime benefit for each covered person. -Worldwide Coverage. -Ground or air ambulance service to the nearest hospital that is able to treat the condition. -$500 per calendar year wellness benefit, subject to deductible and coinsurance. Refer to State Variations for any state specific wellness benefits. -Health Savings Account (HSA) custodial account feature. -Reduced renewal rates with the HealthyDiscount feature - offered with OneDeductible PPO. -Additional non-network deductible encourages network usage. -Prescription drug discount card with no separate deductible and no copay. Save up to 25% off the retail price of prescription drugs. Here are some examples: Prescription - Use Sample Retail Price* Discount Card Price* Monthly Savings Flonase - Allergy Nasal Spray $98 $78 $20 Levaquin - Antibiotic (10 days) $139 $115 $24 Lipitor - Cholesterol $131 $115 $16 Nexium - Antiulcer $167 $134 $33 Singulair - Allergic Rhinitis $116 $92 $24 Zoloft - Antidepressant $98 $77 $21 *Actual prices and savings will vary depending on the pharmacy and location. This is a brief description of coverage. Your personal representative can provide materials that include more details. This plan summary is not an insurance contract. In the event there are discrepancies with the information here, the terms and conditions of the coverage documents will govern. This plan is available to members of the Health Advocates Alliance. Chosen Medical Benefits and Options: -$2,800 individual annual deductible. -100% coinsurance. PPO Networks available in the Enrollee's ZIP code: Private Healthcare Systems (PHCS), , HealthChoice/HMC (HCT), , Northeast Direct Health (NEDH), , Assurant Health markets products underwritten by Time Insurance Company.
3 501 W. Michigan Milwaukee, WI Date: Version: 04/12/ LA Form/Plan ID: Area: 225/BASE 0.69 Enrollee(s) Address CT Agency INSURANce Information P.O. Box 6055, Bridgeport, CT Business Number: w , Telephone: (800) , Fax: (888) Writing Agent Alston Balkcom Information P.O. Box 6055, Bridgeport, CT OneDeductible PPO Plan Selected with HSA Fundamentals Health Savings Account (HSA) Effective Date: 04/12/2007 Payment Mode: Monthly Annual HSA Plan: OneDeductible PPO Deductible: $2,800 HSA Acct Type: HSAFUND Annual OON Ded: $500 Coinsurance/ Out-of-pocket: 100% after deductible Individual Out-ofpocket Maximum: PPO Network $2,800 (includes in-net deductible only) Out-of-Network Lifetime Maximum: $3,000,000 Differential: 20% PPO Network: Private Healthcare Systems (PHCS) (CON) Association: Health Advocates Alliance Enrollee(s) Sex Age Class Base No Off Copay Misc Fees Optional Benefits Totals Primary Male 63 Standard $ $ HAA Fees $4.00 $4.00 Total Recurring Amount $ $4.00 $ Processing Fee (one-time) $20.00 Total Amount $ You may choose to add a $300 Accidental Medical Expense benefit for $7.30 in addition to the premium amount above. These rates are only valid for policies issued with effective dates from 4/01/2007 to 4/28/2007 when quoted using the most current version of software. Rates quoted more than 30 days in advance of the effective date are subject to change and are not guaranteed. This proposal is not an insurance contract. Only the actual contract provisions will apply. Final rates may vary slightly due to the rounding process. Assurant Health markets products underwritten by Time Insurance Company.
4 Time Insurance Company 501 West Michigan, Milwaukee, WI Date: Version: Enrollee(s): Address: 04/12/ LA CT Form/Plan ID: 225/BASE OneDeductible PPO with HSA Alternate Quote Report By Deductible PPO Network: Private Healthcare Systems (PHCS) Annual Deductible Coinsurance/OOP OneDeductible PPO Lifetime Max: $3,000,000 First Year Maximum HSA Contribution* $1,100 50% (OOP: $2,500) $ tbd** $1,100 80% (OOP: $2,000) $ tbd** $1,600 50% (OOP: $2,500) $ tbd** $1,600 80% (OOP: $2,000) $ tbd** $1, % after deductible $ tbd** $2,100 50% (OOP: $2,500) $ tbd** $2,100 80% (OOP: $2,000) $ tbd** $2, % after deductible $ tbd** $2,800 50% (OOP: $2,500) $ tbd** $2,800 80% (OOP: $2,000) $ tbd** $2, % after deductible $ tbd** $3, % after deductible $ tbd** $5, % after deductible $ tbd** Based on contribution limits for this year, the maximum allowable HSA contribution for next year is: Monthly Quarterly Semi-annual Lump Sum (Annual) tbd** tbd** tbd** tbd** Maximum contribution amount assumes no prior qualifying coverage during the calendar year. *The above HSA contribution calculation is based on an effective date of 04/12/2007. If the health plan is effective on the first of the month, the HSA is effective on the same day. If the policy is effective on a date other than the first of the month, the HSA will be effective the first day of the following month. **HSA contribution amount information for effective dates of 1/1/2007 and later is not yet available. This information will be updated on the next version of software. To find the latest forms, please go to Find A Form on the Assurant Health Sales website, Insureds age 55 or older may make an additional deductible contribution of up to $800 per person per calendar year to their HSA. For the OneDeductible PPO plan, an additional non-network deductible of $500 ($1000 if family) applies if services are rendered outof-network. The above rates do NOT include the $20 processing fee.
6 Time Insurance Company 501 West Michigan, Milwaukee, WI Date: Version: Enrollee(s): 04/12/ LA Form/Plan ID: 225/BASE State Maximum Out-of-Pocket Table OneDeductible PPO with HSA 100% after deductible Network Annual Network Deductible Maximum Coinsurance Network Out-of-pocket Total Network Out-of-pocket Individual Family Individual Family Individual Family $1,600 $3,200 $0 $0 $1,600 $3,200 $2,100 $4,200 $0 $0 $2,100 $4,200 $2,800 $5,600 $0 $0 $2,800 $5,600 $3,750 $7,500 $0 $0 $3,750 $7,500 $5,000 $10,000 $0 $0 $5,000 $10,000 Non-Network Annual Non-Network Deductible Maximum Coinsurance Non-Network Out-of-pocket Total Non-Network Out-of-Pocket Individual Family Individual Family Individual Family $2,100 $4,200 $1,000 $2,000 $3,100 $6,200 $2,600 $5,200 $1,000 $2,000 $3,600 $7,200 $3,300 $6,600 $1,000 $2,000 $4,300 $8,600 $4,250 $8,500 $1,000 $2,000 $5,250 $10,500 $5,500 $11,000 $1,000 $2,000 $6,500 $13,000 These tables are meant only as a general cost guide. Please refer to the state variations or brochure for state-specific information.
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