Chicago Police Sergeants Association Police Benevolent & Protective Association 1616 W. Pershing Road - Chicago, Illinois 60609 Phone 773-376-7272 - Fax 773-376-7344 www.chicagosergeants.org November 28 th, 2016 Dear Retired Member of the Chicago Police Sergeants' Association, With the input of many retirees, the Association is able to provide a Group Medicare Supplement for its eligible members. This plan differs from Medicare Advantage Plans and is another option for you to consider. The "Retiree Medical Program for Chicago Police Sergeants Retirees Association plan is ready for your review. This program is for Medicare eligible retirees who are age 65 and over. Medical Plan United American Insurance Company is the provider for the Group Retiree Medical coverage. Highlights of this plan include: Freedom to choose providers and hospitals for medical care anywhere within the United States Over 94% of providers and more than 99% of hospitals accept Medicare Members can self-refer to any medical provider that accepts Medicare Plans cover Medicare excess charges Foreign travel benefits No medical questions on the application, and guaranteed renewable No paperwork or claim forms United American works seamlessly with Medicare; claims are processed electronically so you will never need to submit claim forms. This proposed program is a traditional Medicare Supplement plan (similar to what you have today) and not a Medicare Advantage plan. Open enrollment in the plan for our members begins November 28 th, 2016 and you may enroll until March 1 st, 2017. This proposed medical plan will be available for all Medicare eligible members and their Medicare eligible family members. United American is providing coverage for numerous police and fire retirees throughout our United States. Rated an A+ insurer by A.M. Best rating service, United American has been committed to the senior retiree market since Medicare was introduced in 1966. United American is recognized as a leading provider of Medicare Supplement insurance.
Rx Plan Members who need a prescription drug plan can utilize GoHealth, a Chicago-based insurance broker recommended by the City of Chicago in a previous mailing. GoHealth can help you with your prescription drug insurance options as well as other health insurance related questions. Their number is 1-855-785-7841. Resources and Enrollment for the Medical Plan For questions about the plan or to enroll, call United American at 1-855-454-5623 Monday through Friday 7am to 5pm CST. We have also enclosed an application that can be completed and submitted by mail or fax (630) 834-2297. Enclosed are more details on the plans and enrollment information. In addition, our local broker for this program is MAF Companies of Oak Brook, IL. MAF is expert in the specific challenges and obstacles that police officers and their families face. MAF can be reached at (800) 979-9393 and will be available to answer any and all questions that you may have concerning this plan. To learn more, you are encouraged to attend an informational meeting; the schedule is below. Date Time Location December 12, 2016 11 a.m. Sergeants Association 1616 W. Pershing Rd. Chicago, IL December 17, 2016 11 a.m. MAF Companies 1200 Harger Rd., Suite 718 Oak Brook, IL December 19, 2016 11 a.m. Sergeants Association 1616 W. Pershing Rd. Chicago, IL Sincerely, James Ade President Chicago Police Sergeants' Association Police Benevolent & Protective Association
Enrollment Questions and Directions 1. How do I enroll in this plan? The easiest and best way to enroll is by calling 1-855-454-5623. Call the United American dedicated line for the Chicago Police Sergeants Association at 1-855-454-5623 and enroll over the phone. Enrollment by phone is available Monday Through Friday from 7am CST until 5pm CST. If you wish you may also mail a paper application to United American. Complete and sign the attached form on pages 4 and 5. Be sure to indicate which Plan Option each enrollee desires. If a spouse is applying, he or she must complete his/her own separate application. If you prefer to enroll by mail send the completed enrollment document to United American at: UNITED AMERICAN INSURANCE CO. ATTN: GROUPS/SPECIAL MARKETS PO BOX 8080 MCKINNEY, TX 75070-9922 2. What do I need to do to qualify for this plan? To qualify for this plan, you must be age 65 or older and enrolled in Medicare Parts A and B. 3. When can I enroll in this plan? The plan will be available for our members for enrollment beginning November 28 th through March 1st. Your coverage through the City of Chicago ends January 1 st 2017; you have a special enrollment period lasting until March 1 st 2017. 4. What if my spouse is under 65? If your spouse is under 65, he/she is not eligible for this plan. Check with your current carrier for more details. 5. How do I pay for this plan? Payment for the plan can be accomplished through an Electronic Funds Transfer from your checking or savings account or you can be billed at home. We are working to allow you to be able to pay for the plan out of your pension sometime in 2017. 6. Who can I contact with questions? For any questions regarding enrollment, coverage, eligibility, please contact United American directly at 1-855-454-5623 from 7am CST to 5pm CST. MAF Companies is the local broker for the Chicago Police Sergeants Association; they can be reached at 630-834-2210. 7. Will my rates remain the same throughout the year? Yes. The plan rates enclosed are effective through December 31 st 2017. 3
CHICAGO POLICE SERGEANTS' ASSOCIATION INDIVIDUAL ENROLLMENT FORM SPONSORED GROUP PLAN ADMINISTERED BY UNITED AMERICAN Mail To: UNITED AMERICAN INSURANCE CO. ATTN: GROUPS/SPECIAL MARKETS PO BOX 8080 MCKINNEY, TX 75070-9922 LAST name: FIRST Name: Middle Initial: Mr. Mrs. Ms. Birth Date: ( / / ) Sex: M F Social Security Number: Home Phone Number: ( ) (M M / D D / Y Y Y Y) Permanent Residence Street Address: City: State: ZIP Code: Mailing Address (only if different from your Permanent Residence Address): Street Address: City: State: ZIP Code: Emergency contact: [Optional] Phone Number: [Optional] Relationship to You [Optional] E-mail Address: [Optional] Please Provide Your Medicare Insurance Information Please take out your Medicare Card to complete this section. Please fill in these blanks so they match your SAMPLE ONLY red, white and blue Medicare card. Name: - OR - Attach a copy of your Medicare card or your Medicare Claim Number Sex letter from the Social Security Administration or Railroad Retirement Board. - - Is Entitled To Effective Date You must have Medicare Part A or Part B to HOSPITAL (Part A) join a Medicare supplement plan. MEDICAL (Part B) Signature: Today s Date: SEE REVERSE TO SELECT YOUR PLAN BOTH SIDES MUST BE SIGNED AND COMPLETED 4
2017 Plan Offerings Designed Exclusively for Chicago Police Sergeants Association 2017 Medical Options and Rates Option 1 (Plan G) * Option 2 (Plan F) * You Pay Part A Deductible Part B Deductible $183 Part B Coinsurance Amount Annual Maximum Out of Pocket 0% $183 You Pay Part A Deductible Part B Deductible $183 Part B Coinsurance Amount Annual Maximum Out of Pocket 20% $1000 Monthly Premium Schedule: Ages 65-69 $190 Ages 70-74 $206 Ages 75-79 $262 Ages 80+ $284 Monthly Premium Schedule: Ages 65-69 $131 Ages 70-74 $147 Ages 75-79 $203 Ages 80+ $225 *See Enclosed Benefit Grids for Complete Description Please select your plan option: [ ] Option 1 (Plan G) [ ] Option 2 (Plan F) Print Name Signature: Today s Date: FOR PREFERRED AND EXPEDITED ENROLLMENT: ENROLL WITH UNITED AMERICAN VIA PHONE BY CALLING 1-855-454-5623 SEE SIDE ONE TO COMPLETE ENROLLMENT. BOTH SIDES MUST BE COMPLETED. 5
OPTION 1 - PLAN G MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD 2017 * A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION * Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1316 $1316 (Part A Deductible) 61st thru 90th day All but $329 a day $329 a day 91st day and after: While using 60 lifetime reserve days All but $658 a day $658 a day Once lifetime reserve days are used: Additional 365 days 100% of Medicare Eligible ** Expenses Beyond the Additional 365 days All Costs SKILLED NURSING FACILITY CARE * You must meet Medicare s requirements, including having been in a hospital for at least 3 days and entered a Medicare approved facility within 30 days after leaving the hospital First 20 days All approved amounts 21st thru 100th day All but $164.50 a day Up to $164.50 a day 101st day and after All Costs BLOOD First 3 pints 3 pints Additional Amounts 100% HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care Medicare copayment/ coinsurance ** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy s Core Benefits. During this time the hospital is prohibited from billing you the balance based on any difference between its billed charges and the amount Medicare would have paid. Plan Code H37 6
SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $183 of Medicare Approved Amounts* Part B Excess Charges (Above Medicare Approved Amounts) BLOOD First 3 pints Next $183 of Medicare Approved Amounts* OPTION 1 - PLAN G MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR 2017 * Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. Generally 80% 80% until you reach your Part B deductible, then 100% of the amount not paid by Medicare All Costs until you reach your Part B deductible, then 100% of the amount not paid by Medicare CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES 100% PARTS A & B HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% Durable medical equipment First $183 of Medicare Approved Amounts* 80% OTHER BENEFITS NOT COVERED BY MEDICARE FOREIGN TRAVEL NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA until you reach your Part B deductible, then 100% of the amount not paid by Medicare First $250 each calendar year $250 Remainder of Charges 80% to a lifetime maximum benefit of $50,000 100% until you reach your Part B deductible, then 100% until you reach your Part B deductible, then 100% until you reach your Part B deductible, then 20% and amounts over the $50,000 lifetime maximum Plan Code H37 7
OPTION 2- PLAN F MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD 2017 * A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION * Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1316 $1316 (Part A Deductible) 61st thru 90th day All but $329 a day $329 a day 91st day and after: While using 60 lifetime reserve days All but $658 a day $658 a day Once lifetime reserve days are used: Additional 365 days 100% of Medicare Eligible ** Expenses Beyond the Additional 365 days All Costs SKILLED NURSING FACILITY CARE * You must meet Medicare s requirements, including having been in a hospital for at least 3 days and entered a Medicare approved facility within 30 days after leaving the hospital First 20 days All approved amounts 21st thru 100th day All but $164.50 a day Up to $164.50 a day 101st day and after All Costs BLOOD First 3 pints 3 pints Additional Amounts 100% HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care Medicare copayment/ coinsurance ** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy s Core Benefits. During this time the hospital is prohibited from billing you the balance based on any difference between its billed charges and the amount Medicare would have paid. Plan Code HC2 8
OPTION 2 - PLAN F MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR 2017 * Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), Medicare Part B Deductible will have been met for the calendar year. (1) Your certificate has a $1,000 deductible on Medicare Part B services. Depending upon the order in which the claims are submitted to us, your calendar year certificate deductible may be met by the Medicare Part B Deductible, Medicare Part B Coinsurance, and/or Excess Charges. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $183 of Medicare Approved Amounts* Part B Excess Charges (Above Medicare Approved Amounts) Generally 80% until your $1,000 per calendar year deductible is met (1), then 100% of the amount not paid by Medicare BLOOD First 3 pints All Costs Next $183 of Medicare Approved Amounts* until your $1,000 per calendar year deductible is met (1), then 100% of the amount not paid by Medicare CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES 100% PARTS A & B HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% Durable medical equipment First $183 of Medicare Approved Amounts* 80% until your $1,000 per calendar year deductible is met (1), then 100% of the amount not paid by Medicare OTHER BENEFITS NOT COVERED BY MEDICARE FOREIGN TRAVEL NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 $250 Remainder of Charges 80% to a lifetime maximum benefit of $50,000 100% until your $1,000 per calendar year deductible is met(1), then 100% until your $1,000 per calendar year deductible is met(1), then 100% until your $1,000 per calendar year deductible is met (1), then 20% and amounts over the $50,000 lifetime maximum Plan Code HC2 9