In the EBG section entitled, “Medical Benefit Options Comparison” (pages 46-53), the comparison chart’s “What You Pay Under the Point-of-Service Option/Network” column is revised to reflect the increase in physician’s visits copayments from $17 for PCP/$20 for Specialist to $20 for PCP/$30 for Specialist. All other sections of the chart are not changed, and therefore not reflected in this Summary of Material Modifications. See the revisions noted in the chart below:
Features What you Pay Under the Standard Medical Option
What You Pay Under the Point-of-Service Option
Network Out-of-Network
Annual routine physical exams
(page 46)
No changes to the contents of this column
$20 per visit to PCP No changes to the contents of this column
Well-child care
(page 46)
$20 per visit to PCP, with no age limit
Physician’s office visit
(including x-ray and lab work)
(page 47)
$20 per visit to PCP
Specialist’s office
(including x-ray and lab work) (page 47)
$30 per visit
Urgent care clinic
(page 47)
$30 per visit
Gynecological care
(page 47)
$20 per visit to an
OB/GYN (same as visit to a Primary Care Physician, whether the OB/GYN is treating you in the capacity of a Specialist or a Primary Care Physician
care during pregnancy are subject to the $150 copayment) Second surgical opinions (page 47)
$30 per visit, if elected by participant
Chiropractic care
(page 47)
$30 per visit
Maximum 20 chiropractic visits per person per year combined network and out-of-network Speech, physical, occupational, restorative, and rehabilitative therapy (page 48) $30 per visit Allergy care
Physician’s office visit
(page 48)
PCP—$20 per visit Specialist—$30 per visit
Allergy testing, shots, or serum
(page 48)
No cost if administered in physician’s office; $20
copayment if PCP office visit is charged; $30 for specialist visit
Outpatient surgery in physician’s office (pre- authorization is
recommended to ensure medical necessity; see QuickReview) (page 48)
$30 per visit
Tubal ligation or
vasectomy (Reversals are not covered) (page 50)
$30 copayment in physician’s office, 10% coinsurance in hospital
Outpatient mental health care (page 51)
$30 per visit
Out patient chemical dependency
rehabilitation
(page 51)
$30 per visit if approved by EAP
Under the “Covered Expenses” section, the second paragraph of “Outpatient mental health care” (page 66) is revised as follows:
For outpatient mental health care through a network provider under the Point-of-Service Option, the copayment is $30 per visit.
In the “Point-of-Service Option” section, “How the Point-of-Service Option Works” (page 76), the fourth bullet is revised as follows:
• Covered preventive care from network providers, including a $20 copayment for OB/GYN care
visits (same as primary care physician visits), regardless of whether the OB/GYN is treating in the capacity of a specialist or a PCP. (OB/GYN visits related to care during pregnancy continue to be subject to the $150 copayment.)
In the “Point-of-Service Option” section, “Special Provisions”, the first bullet under “Preventive care” (page 77) is revised as follows:
• Well-woman exams (includes a $20 copayment for OB/GYN care visits, same as Primary Care Physician visits , regardless of whether the OB/GYN is treating in the capacity of a specialist or a PCP). OB/GYN visits related to care during pregnancy continue to be subject to the $150 copayment.
In the “Flexible Spending Accounts” section, “Using the UnitedHealthcare Consumer Account Card” (page 167), the amounts of copayments in the second paragraph change from “$17 or $27” to
$20 or $30
III. Addition of TriCare Supplement Insurance Option as a Medical Benefit Option for Active and Leave
of Absence Employees
In the “Contact Information” section (page 1), the following information is added: TriCare Supplement Insurance
Option
Enrollment, member services, etc. inquiries ASI 2301 Research Blvd., Ste 300 Rockville, MD 20850-6265 (800) 638-2610, Ext. 255 (800) 311-3124 (fax) Web site: www.asicorptricaresupp.com Email: [email protected]
TriCare Supplement Insurance Option Claim inquiries ASI PO Box 2510 Rockville, MD 20847 (800) 638-2610, Ext. 255 (800) 310-5514 (fax) DEERS
(Eligibility for TriCare)
Defense Manpower Data Center Support Office (DMDC) Attn: COA 400 Gigling Road Seaside, CA 93955-6771 (800) 538-9552 (800) 866 363-2883 (for TTY/TTD)
(831) 655-8317 (Attn: CSO) (fax)
Email: addrinfo @osd.pentagon.mil
Online: https://www.dmdc.osd
In the “Benefits at a Glance” section, “Medical Benefit Options” (page 5), a fourth bullet is added to the list of medical benefit options:
• TriCare Supplement Insurance
In the “Benefits at a Glance” section, “Medical Benefit Options” (page 6), the following text is added: TriCare Supplement Insurance Option
Military retirees under age 65, retired military reservists under age 65, and their eligible dependents may be eligible for TriCare health coverage sponsored by the federal government. TriCare-enrolled employees may elect to enroll in TriCare Supplement Insurance Option as a new Medical Benefit Option for 2006. TriCare Supplement Insurance Option coordinates with your TriCare coverage and reimburses many out- of-pocket expenses not paid by TriCare. For more details about the TriCare Supplement Insurance Option, see page 86.
Under “Retiree Benefits” (page 12) a third bullet is added to the “Retiree Medical Benefits” listing, as follows:
- TriCare Supplement Insurance Option (for under age 65 retirees)
In the “Eligibility” section, “Common Law Spouse/Domestic Partners” (page 20), a fifth bullet is added to the statement, “Domestic Partners are not eligible to participate in”, as follows;
• TriCare Supplement Insurance Option
In the “Eligibility” section, “Eligibility for Retiree Benefits, “Retiree Medical Benefits” (page 19), the first paragraph is revised as follows:
There are three options for medical coverage under the Retiree Medical Benefits—the Retiree Standard Medical Option, the Retiree Point-of-Service Option, and the TriCare Supplement Insurance Option.
In the “Eligibility” section, “Eligibility for Retiree Benefits, “Retiree Medical Benefits” (page 23), the following material is added:
Additional Eligibility Requirements for the TriCare Supplement Insurance Option
In addition to meeting the Retiree Medical Benefits requirements outlined in the “Retiree Medical Benefits” section, if you voluntarily elect to participate in the TriCare Supplement Insurance Option, you must also meet all the following eligibility requirements:
• Be under age 65 (unless ineligible for Medicare)
• Meet all other eligibility requirements, as set forth in the provisions of the Retiree Medical Benefits • Have not reached your maximum medical benefit under a Company-sponsored medical coverage • Did not terminate under Article 30 for Flight Attendants
• Did not elect to waive, or elect to voluntarily and permanently opt out of Retiree Medical Benefits • Did not retire under the 1995 SVEOP (Special Voluntary Early Out Program)
• Are not a TransWorld Airlines, Inc. (TWA) retiree
• Are enrolled in the Defense Enrollment Eligibility Reporting System (DEERS—see Contact Information Section) the database of beneficiaries, worldwide, who are entitled to TriCare benefits, including
- Spouse or surviving spouse of an active duty member
- Retirees of the uniformed services or their spouses and surviving spouses
- Spouses of reservists who are ordered up to active duty for more than 30 days (they are covered only during the reservist’s active-duty tour), or a reservist who died while on active-duty tour
- Former spouses of active-duty or retired military who were married to a service member or former service member who had performed at least 20 years of creditable service for retirement purposes at the time a divorce or annulment occurred
- Spouses or surviving spouses of 100% disabled veterans. Such spouses would be eligible for CHAMP/VA)
- Unmarried dependent children of TriCare-eligible employees
To determine your TriCare eligibility, contact the Defense Manpower Data Center Support Office (see Contact Information section in this Guide).
In the “Enrollment” section, “Paying for Coverage, “Company-Provided Benefits” (page 27), “Medical Benefits”, the first sentence is revised as follows:
• Medical Benefits. You can choose from one of four Standard Medical Options, the Point-of-Service Option, an HMO (if available in your area), or the TriCare Supplement Insurance Option (if you are eligible for TriCare). . . .
In the “Enrollment” section, “Taxation of Benefits” (page 29), the chart outlining options, taxability, etc., “Medical Benefit Options” is revised as follows:
Type of Benefits Before Tax? May Waive?
Medical Benefit Options
• Four Standard Medical Options • Point-of-Service Option (POS)
• Health Maintenance Organizations Option (HMOs) • TriCare Supplement Insurance Option (not available to DomesticPartners)
Yes Yes
In the “Life Events” chart (page 34), the first bullet under “You get married or declare a Domestic Partner” is revised as follows:
Medical and Dental Options: Add coverage for your spouse and eligible dependents; stop coverage for a dependent or yourself. Although you can add or drop coverage for dependents or yourself, you cannot change benefit options at this time. Domestic Partners and their dependents are not eligible for the TriCare Supplement Insurance Option. You may add or drop dental coverage but you may not switch between Dental Option 1 and Dental Option 2.
In the “Life Events” chart (page 37) the first bullet under “You move to a new home address” is revised as follows: Medical Option: May select from medical options available in new location if you are covered under the Point-of-Service Option or an HMO and you moved out of the service area to any area with different options available. For example, you may change from a Standard Option or TriCare Supplement Insurance Option to the Point-of-Service Option or an HMO; or from the Point-of-Service or HMO Option to a Standard Option or TriCare Supplement Insurance Option, but you may not choose among Standard Options or between Standard Options and TriCare Supplement Insurance Option. Contact HR Employee Services for more information.
Under “Special Life Event Considerations” (page 39), the “Relocation” first paragraph is revised as follows:
If you are enrolled in the Point-of-Service (POS) Option and you move to a location where POS is available, you will stay enrolled in POS, or you may elect coverage that was not available in your prior location, such as an HMO. If POS is not available, you must choose another medical option, or you may waive coverage if you have other coverage (such as your spouse’s employer-sponsored plan). If you are enrolled in an HMO and you move out of that HMO’s service area, you must choose another medical option. However, if you change to another medical option, your deductibles and out-of-pocket maximums do not transfer to the new option. If you are enrolled in one of the Standard Medical Options or in TriCare Supplement Insurance Option, you may stay in that option or elect POS Option or an HMO, if available. You may not choose among Standard Options or between the Standard Options and TriCare Supplement Insurance Option because of relocation.
Under “Benefit Coverages Not Affected by Life Events” (page 40), the “Medical Options” paragraph is revised as follows:
Medical Options: You may change medical options only if you relocate (see the chart beginning on page 34). However, if you are enrolled in a Standard Medical Option or TriCare Supplement Insurance Option, you may not choose among the Standard Medical Options or between the Standard Medical Options and TriCare Supplement Insurance Option due to relocation. . . .
Under the “Medical Benefit Options”, “Overview” (page 42), a fourth bullet is added, as follows:
TriCare Supplement Insurance Option is a fully insured option with covered services insured and underwritten by Hartford Life and Accident Insurance Company, and administered by the Association and Society Insurance Corporation (ASI). This Option is available to employees who are eligible for TriCare.
In the “Maximum Medical Benefit” section (page 45), the last sentence of the first paragraph is revised as follows:
All benefits paid under the Standard Medical Options, the Point-of-Service Option, the Medical Benefits’ prescription drug coverage (both retail and mail order), HMO Options, and TriCare Supplement Insurance Option are included in the maximum medical benefit.
In the “Maximum Medical Benefit” section (page 45) the fifth paragraph is revised as follows:
If your selected medical coverage (for both the employee and covered eligible dependents) is one of the self-funded medical coverages (Standard or Point-of-Service Options), and you and/or your covered eligible dependents exhaust the maximum medical benefit under the self-funded medical coverage, neither you nor your covered eligible dependents who exhaust the maximum medical benefit can elect any other medical coverage (including an HMO or TriCare Supplement Insurance Options) under the Plan.
TriCare Supplement Insurance Option
For those employees who are eligible for TriCare medical coverage,
- Spouse or surviving spouse of an active-duty member,
- Retirees of the uniformed services or their spouses and surviving spouses,
- Spouses of reservists who are ordered up to active duty for more than 30 days (they are covered only during the reservist’s active-duty tour), or a reservist who died while on active-duty tour,
- Former spouses of active-duty or retired military who were married to a service member or former service member who had performed at least 20 years of creditable service for retirement purposes at the time a divorce or annulment occurred,
- Spouses or surviving spouses of 100% disabled veterans. Such spouses would be eligible for CHAMP/VA), and
- Unmarried dependent children of TriCare-eligible employees,
TriCare medical coverage (offered through the federal government) may be a preferred option for you and your family. If you (or you and your family) are enrolled in TriCare, you have the option of electing the TriCare Supplement Insurance Option as your Medical Benefit Option under the Plan. TriCare Supplement Insurance Option, insured by the Hartford Life and Accident Insurance Company and administered by ASI, is designed to coordinate with your federal government-sponsored TriCare medical coverage, and may provide an overall richer coverage than the Standard Options, the POS Option, or the HMO Option.
TriCare and the TriCare Supplement Insurance Option include a network of physicians, hospitals, and other medical service providers; TriCare and the TriCare Supplement Insurance Option determine your medical coverage. If you elect TriCare Supplement Insurance Option, your TriCare Supplement Insurance Option replaces medical coverage offered through the Standard Medical Options, the POS Option, or the HMO Option. Your benefits, including prescription drugs prescribed by physicians and dentists, as well as mental health care, treatment for alcohol/chemical dependency, are determined according to the terms and provisions of TriCare and the TriCare Supplement Insurance Option. Some of the TriCare Supplement Insurance Option features are:
• No preexisting condition exclusion
• No plan deductibles
• Protection from excess charges
• Guaranteed acceptance in the TriCare Supplement Insurance
• Freedom of choice to utilize any TriCare authorized civilian doctor or specialist
• Comprehensive coverage
• Prompt processing of claims
• Portability—you may choose to continue your TriCare Supplement Insurance if you leave your employment for any reason
• No claim forms required
• Administration services provided by Association and Society Insurance Corporation (ASI) • No separate precertification or preauthorization requirement
• Between TriCare and TriCare Supplement Insurance, most eligible charges are reimbursed in full
TriCare Supplement Insurance Option offered through the benefit program for Flight Attendants is completely independent of American Airlines, Inc. and as such, American Airlines, Inc. cannot influence or dictate the coverage provided under this option. While this section of the Guide has provided you with overview information about the TriCare Supplement Insurance Option, you must carefully review the ASI/Hartford TriCare Supplement Insurance documents to determine the provisions, limitations, and exclusions of this insurance, as those documents govern your coverage and benefits under the TriCare Supplement Insurance Option. If you elected this as your Medical Benefit Option, ASI/Hartford will provide you with the plan document/summary plan description that will detail the coverages, terms, and provisions of the TriCare Supplement Insurance Option. (See Contact Information for ASI and Hartford.)
In the “Additional Rules” section (page 87), the first sentence is revised as follows:
The following sections apply to the Standard Medical Options, Point-of-Service Option, Dental Benefits, HMO Option, TriCare Supplement Insurance Option, and HCFSA Benefit (except as noted). In the “Qualified Medical Child Support Order” section (page 81), a sixth bullet is added after the third paragraph, as follows:
TriCare Supplement Insurance Option
In the “Continuation of Coverage” section (page 93), the second paragraph is revised as follows:
Several of American Airlines, Inc. benefits or plans (Standard Medical Options, Point-of-Service Option, Dental Benefits, HMOs, TriCare Supplement Insurance Option, and the HCFSA Benefit) provide for continuation of coverage under the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA) in case of certain qualifying events. . . .
In the “Continuation of Coverage” section (page 93), the following subsection is added: Portability of the TriCare Supplement Insurance
You have the ability to continue your TriCare Supplement Insurance after you separate from the Company. For information on portability, contact ASI/Hartford (see Contact Information).
In the “Retiree Benefits” section, “Retiree Medical Benefit” (page 175), the first two paragraphs are revised as follows:
There are three medical options available to eligible retirees:
• Retiree Point-of-Service (RPOS) Option (you must pay ongoing monthly contributions to maintain coverage under this Option)
• Retiree Standard Medical (RSM) Option (Since you prefund for this benefit while you are an active employee, this option generally does not require you to pay ongoing monthly contributions to maintain coverage during retirement. However, there are situations in which you might be required to pay for this coverage during retirement—see the Retiree Benefits Guide in the “Paying for Coverage” section for information.
• TriCare Supplement Insurance Option (for retirees under age 65) (you must pay ongoing monthly contributions to maintain coverage under this Option)
You must meet the age and Company years of service requirements to be eligible for participation in Retiree Medical Benefits, irrespective of whether you select the RSM, RPOS, or TriCare Supplement Insurance Option. . . .
In the “Article 30” section (page 176-177), the last bullet is revised as follows:
• You are not eligible for the Retiree Point-of-Service (RPOS) Option or the TriCare Supplement Insurance Option
In the “Circumstances that Affect Prefunding” section, “Retirement” (page 180), the last paragraph is revised, and a new paragraph is added, as follows:
When you retire and elect Retiree Point-of-Service Option (RPOS) or TriCare Supplement Insurance Option coverage, the value of your prefunding contributions will be refunded to you, and you must pay ongoing monthly contributions for the RPOS Option or for TriCare Supplement Insurance Option. If you later elect Retiree Standard Medical Option (RSM), you must pay ongoing monthly contributions for RSM.
At that time, your coverage changes to RSM Option for age 65 and over participants, and you must pay ongoing monthly contributions for this coverage.
If you are covered under TriCare and are enrolled in TriCare Supplement Insurance Option, upon your attainment of age 65, these coverages terminate, as you become eligible for Medicare and TriCare for Life (a federal government-sponsored supplement to Medicare for age 65 and over individuals who participated in TriCare). Since Medicare and TriCare for Life generally provide a richer coverage than the combination of Medicare and the RSM Option, you have the opportunity to voluntarily and permanently opt out of the RSM Option (in favor of TriCare for Life). See the Retiree Benefit Guide on Jetnet, or contact HR Employee Services for more information (see Contact Information).
In the “Plan Administration” section (page 183), “Plan Information”, a fourth bullet is added to the chart for the Group Life and Health Benefits Plan for Employees of Participating AMR Corporation Subsidiaries, and “Medical Benefits” is revised as follows:
• Medical Benefits
- Standard Medical Option (four options)
- Point-of-Service Option
- Health Maintenance Organizations