TRADITIONPLUS HOSPITAL PROGRAM

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1 PO Box 1407, Church Street Station New York, NY TRADITIONPLUS HOSPITAL PROGRAM PAID-IN-FULL COVERAGE 365 DAYS A YEAR For people who want real value in a hospital program, Empire BlueCross BlueShield offers the TraditionPLUS Hospital Program. This program covers you and your covered dependent s hospital-related costs all year round. That s right, 365 days coverage a year, starting with the very first day. And no qualifying medical questionnaire is required. Plus, you ll get important benefits, including: - Maternity care in birthing centers of hospitals - Hospital care for newborns - Outpatient physical therapy - Radiation therapy - Care in Skilled Nursing Facilities Coverage extends to your spouse, and to covered dependents to the end of the calendar year of the 23 rd birthday. PROTECTION YOU CAN RELY ON At Empire, you will also get peace of mind. When you carry the Empire BlueCross BlueShield identification card, your hospital needs are covered, even if you re away from home. That s because the Empire BlueCross BlueShield ID card is accepted without question at over 9,000 hospitals and other facilities nationwide. No other insurance company provides such complete protection across the U.S. There s another advantage to Empire BlueCross BlueShield: unlike some other insurance companies, we re in this business to stay. We ve proven that by providing health coverage to millions of New Yorkers over the past 65 years. Empire has the knowledge and experience to give you the coverage and options you want, along with the security you need. 1

2 REAL VALUE IN A HOSPITAL PROGRAM 365 days of Paid-In-Full Inpatient Hospital Protection: - Semiprivate rooms and board (paid in full in participating hospitals) - Full range of hospital services, facilities, equipment and supplies - Maternity care in birthing centers or hospitals - Hospital care for newborns, up to 30 days - Inpatient physical therapy and rehabilitation, up to 30 days - In-hospital mental and nervous care, up to 30 days Extensive Outpatient Benefits: - Emergency care for sudden, serious illness or accidental injury - Ambulatory surgery (in approved ambulatory surgery centers or hospitals) - Chemotherapy - Radiation therapy - Physical therapy up to 90 visits per year following surgery or hospitalization - Kidney dialysis in a hospital or free-standing facility, or at home Important Additional Benefits: - Pre-surgical testing and second surgical opinions days at a Skilled Nursing Facility, when pre-approved, for admissions occurring within 10 days of hospital discharge days of hospice care visits by a certified home health care agency professional No prior hospitalization may be required, even for away-from-home care 2

3 Please note: The benefits described are subject to Empire Managed Benefits provisions and to the terms and limitations of your Empire BlueCross BlueShield contract. For certain services, benefits must be pre-authorized. This contract may limit the number of days, visits or dollar amounts to be reimbursed. All Empire BlueCross BlueShield contracts require an 11-month waiting period for coverage of pre-existing conditions, unless that period has been met under similar coverage provided by Empire or another insurer. The TraditionPLUS Hospital program meets the minimum standards for basic hospital insurance as defined by the New York State Insurance Department. This contract does NOT provide basic medical or major medical insurance. The expected benefits ratio for this contract is 92%. This ratio is the portion of future premium which the Plan expects to return as benefits, when averaged over all individuals with this contract. Services provided by Empire HealthChoice Assurance Inc., a licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. 3

4 Summary of Limitations and Exclusions 1. We will not pay for transplants of artificial or animal organs or parts of such organs. 2. Our reimbursement for transplant services is secondary to any and all government or institutional sources of funding except Medicaid. A. newborn child may receive routine hospital service during the mother s hospitalization B. Each calendar year you may receive up to thirty (30) days of hospital services for the diagnosis and treatment of mental and nervous disorders C. Each calendar year you may receive benefits for up to a maximum of thirty (30) days of inpatient hospital service for physical medicine or rehabilitation D. Unnecessary Services are not covered E. Pre-Existing Conditions Limitations 11 month exclusion, 6 month back and credit given if prior coverage within last 63 days. F. Procedures That Are Not Of Proven Benefit Or Have Not Been Recognized By The Medical Profession As Appropriate For Diagnosis Or Treatment And Procedures Which Are Obsolete G. We will not cover an inpatient hospital stay or any part of it that is primarily for diagnosis H. Cosmetic Surgery I. Workers Compensation, No-Fault Automobile Insurance And Similar Legislation J. Government Hospital Services K. Services Covered Under Government Programs L. Non-Acute Or Chronic Hospital Care M.Services Usually Given Without Charge N. War O. No benefits are provided for travel expenses, even if the doctor recommends it. P. Limit On Payment

5 Detailed Limitations and Exclusions Organ Transplant Specific Limits 1. We will not pay for transplants of artificial or animal organs or parts of such organs. 2. Our reimbursement is secondary to any and all government or institutional sources of funding except Medicaid. A. Limit On Benefits For Routine Hospital Care For Newborn Children Your newborn child may receive routine hospital service during the mother s medically necessary and appropriate hospitalization which is directly related to the birth of the newborn. However, this benefit ends thirty (30) days from the date of birth. B. Limit On Benefits For Mental And Nervous Care Each calendar year you may receive up to thirty (30) days of hospital services for the diagnosis and treatment of mental and nervous disorders, whether or not such disorders are organically caused or related, in a hospital as defined in Article III, Section A that is: 1. an acute care general Participating Hospital; 2. an acute care general hospital located outside our Plan Area; or 3. any other hospital with which we have a participation agreement for providing this service. There are no benefits in hospitals that are not acute care hospitals as defined in Article III, even if they have a Participation Agreement with another Blue Cross or Blue Shield Plan, unless they have an agreement with us. C. Limit On Benefits For Inpatient Physical Medicine And Rehabilitation Each calendar year you may receive benefits for up to a maximum of thirty (30) days of inpatient hospital service for physical medicine or rehabilitation or a combination of these services; in a hospital or rehabilitation facility approved by us or which has a Participation Agreement with us or another Blue Cross or Blue Shield Plan. D. Unnecessary Services No benefits are available for any services or items or any portion of a stay in a facility covered by this Contract that, in our judgment, are not needed for proper medical care. If services or items or any portion of a stay are provided that cost more than other types of care, which, in our judgment, are equally or more beneficial, benefits may be limited to the cost of the less expensive type of care. For example, we will not pay for an inpatient admission for surgery if, in our judgment, the surgery could have been performed in an ambulatory surgery facility. We will not provide any benefits for any day or part of any day that you are out of the hospital. Nor will we provide any benefits for any day when, in our judgment, inpatient care was not necessary.

6 E. Pre-Existing Conditions Limitations TBD F. Procedures That Are Not Of Proven Benefit Or Have Not Been Recognized By The Medical Profession As Appropriate For Diagnosis Or Treatment And Procedures Which Are Obsolete We will not cover any procedure or any hospitalization in connection with such procedure if, in our judgment, it is: 1. not of proven benefit; or 2. experimental or investigational and not generally recognized by the medical community in our Plan Area as effective or appropriate for the diagnosis or treatment of your condition: or 3. obsolete or ineffective and not used by the medical community in our Plan Area for the diagnosis and treatment of your condition. Governmental approval of a particular drug, medical device or procedure is not necessarily sufficient to render it of proven benefit, or appropriate or effective for a particular diagnosis or condition under this Section. G. Diagnostic Services We will not cover an inpatient hospital stay or any part of it that is primarily for diagnosis unless the diagnostic services are performed in connection with specific symptoms which if not treated on an inpatient basis could reasonably result in deterioration of the condition so as to cause serious impairment to your bodily functions or jeopardy to your life and the services cannot be safely received, in our judgment, outside a hospital. We do not cover a general physical examination or check-up, or any service in connection with them. H. Cosmetic Surgery No benefits are provided for elective cosmetic surgery or for any complications arising from - such surgery, or - any hospitalization in connection with such surgery or its complications. However, benefits may be available for reconstructive surgery if it is necessary to treat an infection or injury, provided that such infection or injury does not arise from cosmetic surgery. With respect to a covered child, benefits are available for cosmetic surgery to treat a functional defect that is present from birth. I. Workers Compensation, No-Fault Automobile Insurance And Similar Legislation No benefits will be provided for services covered in whole or in part under a Workers Compensation Act, the Federal Employers Liability Act, the Longshoremen s and Harbor Workers Compensation Act, Jones Act or similar law, and/or the mandatory portion of a no-fault automobile insurance policy unless and until you have exhausted all of the benefits available under these laws. This applies even if

7 1. you do not claim benefits under the above laws or policies or 2. after any of the above benefits are paid, you repay them because you recover that money in a related lawsuit or other proceeding. J. Government Hospital Services No benefits are provided for services received in a government or a public benefit corporation hospital unless we have a Participation Agreement or special agreement with that hospital (and then only for the specific services to which the special agreement applies). However, this exclusion shall not apply to United States Veteran s Administration or Department of Defense Hospitals except for services in connection with a service related disability. In addition, if you are hospitalized in a government or public benefit corporation hospital due to an emergency, benefits are provided as described in Article III, Section A, until such time as you can, in our judgment, be safely transferred to a Participating Hospital. K. Services Covered Under Government Programs No benefits are provided for services you are eligible to receive under any Federal, State, County or Municipal Law or the laws of any other Country except for Medicaid. L. Non-Acute Or Chronic Hospital Care There are no benefits for any part of a hospital stay that is primarily custodial or for a rest cure or for convalescent or sanitarium type care. There is no coverage for care in a hospital, or in a separate division of a hospital, where half or more of the days of care provided by that hospital or that separate division of the hospital are during stays of more than ninety (90) days in length. M.Services Usually Given Without Charge We will not cover any service if it is usually provided without charge. For example, when a provider does not usually collect payment in the absence of insurance coverage, no benefits are provided. This applies even if charges are billed. N. War No benefits are provided for any injury or illness received as a result of war, declared or undeclared, or any act of war. O. Travel No benefits are provided for travel expenses, even if the doctor recommends it. P. Limit On Payment We will not pay an amount that is more than a provider charged for covered care or that is more than the Customary Charge.