MCA&F TRICARE Supplement - mca

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TRICARE Supplement Insurance Plan

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TRICARE Supplement Insurance Plan

For members covered by TRICARE, MCA&F provides an excellent, affordable supplement which pays your cost share after deductibles have been met.

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Overview

As an MCA&F member, you qualify for affordable group rates for the MCA&F TRICARE Supplement. The plan helps cover the cost of civilian medical care for you, your spouse and eligible dependent children who are under age 21, or 23 if they’re a full time student.

After you have met the TRICARE and this plan’s deductibles, the supplement pays your cost share for services covered by TRICARE. It also pays the additional 15% above the TRICARE allowable that providers who do not accept TRICARE assignment may charge you.

 

Who Is Eligible?

Active Duty Family Plan – Your spouse, under age 65. Your unmarried dependent children, under age 21, or age 23 if they’re a full-time student.

TRICARE Select and TRICARE Prime Supplements for Retirees – You and your spouse, under age 65. Your dependent children under age 21, or age 23 if they’re a full-time student.

Of course, each person must be covered by TRICARE.

 

When Does Coverage Start?

The first day of the month following receipt of your Enrollment Form and first premium payment, subject to the 12-month pre-existing condition limitation. If on the date that you are to become covered under the Policy and you are confined in a Hospital, your coverage will be deferred until the first day after you are discharged.

 

When Does Coverage End?

On the first of these to occur:

  • The date the Policy terminates with MCA&F;
  • After the Grace Period if premium is not paid;
  • The first day of the month after you cease being an MCA&FMember;
  • The date coverage for your Class is cancelled;
  • The date you cease to be covered by TRICARE;
  • The date you turn age 65 and become eligible for Medicare, unless you’re not eligible for Medicare and have a Notice of Disallowance;
  • For Spouse and Children: 
    • The first premium due date on or next following the date he or she ceases to be an Eligible Spouse or Eligible Child;
    • The date the Member ceases to be covered;
    • The date they are no longer eligible due to age (age 65 for Spouse, 21 or 23 for children).

Termination of coverage will be without prejudice to any claim which originated before the effective date of termination.

Benefits

How does the MCA&F TRICARE Supplement Work?

TRICARE has its own deductibles. See the TRICARE website at https://tricare.mil/Costs/HealthPlanCosts to determine your TRICARE Deductible.

The MCA&F TRICARE Supplement has a deductible – you choose either a $200 or $350 deductible.

After you have met the TRICARE and Supplement’s deductibles, the supplement pays your cost share for services covered by TRICARE up to the TRICARE allowed amount. If you see a provider that does not accept TRICARE assignment, they are limited to charging 115% of the TRICARE allowable. The MCA&F TRICARE Supplement also pays this additional 15% above the allowed amount.

In many instances you now simply make a co-payment. The supplement pays this co-payment for TRICARE covered services.

 

Rates

Group Rates make this coverage affordable

Please see your appropriate TRICARE classification to determine your rates.

QUARTERLY RATES* FOR TRICARE STANDARD / Extra Active Duty Family Plan
  Member Spouse Each Child
Inpatient Only Plan N/A $4.74 $1.90
In & Outpatient Plan N/A $29.87 $23.76
QUARTERLY RATES* FOR TRICARE STANDARD / Extra Retiree Plans
Age Inpatient Only
$0 Deductible
In & Outpatient
$75 Deductible
In & Outpatient
$150 Deductible
In & Outpatient
$250 Deductible
Member Spouse Member Spouse Member Spouse Member Spouse
Under 50  $30.86 $37.79 $119.65 $143.67 $84.04 $108.05 $50.37 $64.82
50 to 54  $45.71 $53.66 $166.97 $205.32 $131.36 $169.71 $78.72 $107.70
55 to 59  $73.19 $81.68 $214.06 $266.05 $178.44 $230.44 $106.96 $138.18
60 to 64  $97.61 $103.22 $266.68 $302.05 $231.07 $266.44 $138.49 $159.74
Each Child  $22.87 $129.90 $85.72 $56.58

 

QUARTERLY RATES* FOR TRICARE PRIME with Point of Service Benefits
Age Member Spouse
Under 50 $26.30 $35.94
50 to 54 $40.16 $54.42
55 to 59 $55.41 $71.21
60 to 64 $63.62 $83.09
Each Child $36.93

 

 

 

Rates and/or benefits may be changed on a class basis. Rates are based on the attained age of the Insured Person and increase as you enter each new age category.

 

 

Why add MCA&F TRICARE Supplement if my family already uses TRICARE?

To help reduce your family's out-of-pocket medical costs. As generous as TRICARE can be, it doesn't pay for everything. That's why a TRICARE Supplement Insurance Plan is so important. MCA&F TRICARE Supplement helps protect your family budget by paying the covered expenses TRICARE leaves behind.

My family uses TRICARE Prime. What can MCA&F TRICARE Supplement do for us?

It can help reduce medical bills from your family's budget. MCA&F TRICARE Supplement pairs up with TRICARE Prime to help cover your co-payments for any inpatient or outpatient care you get from a TRICARE Prime physician. Then MCA&F TRICARE Supplement gives you an extra layer of protection by taking care of any cost-shares you incur if you need to see a specialist or another doctor besides your Primary Care Manager. It's an important safety net for your family and your finances.

Terms

Pre-existing Conditions Limitation

During the first 12 months of coverage, losses incurred from Pre-Existing Conditions are not covered. A Pre-existing Condition means any injury or sickness, diagnosed or undiagnosed, for which you have received medical care within the 12-month period prior to your coverage effective date or the date of an increase in coverage. During that time, benefits for all other accidents or illnesses will be paid according to the policy provisions. You are urged to consider this limitation before dropping any coverage you may currently have.

Exclusions and Limitations

The Policy does not covered:

1. injury or sickness resulting from war or act of war, whether war is declared or undeclared; 2. intentionally self-inflicted injury; 3. suicide or attempted suicide, whether sane or insane (in Missouri, while sane); 4. the following services: a) routine physical exams, unless required for school enrollment (but not sports physicals) by a Covered Child aged 5 through 11; and b) immunizations; except that these services are covered when: a) rendered to a Covered Child who is less than 6 years of age; or b) ordered by a Uniformed Service for a Covered Spouse or Child of an Active Duty Member for such spouse or child's travel outside the United States due to the Member's assignment; 5. domiciliary or custodial care; 6. eye refractions and routine eye exams except when rendered to a Covered Child who is less than 6 years of age; 7. eyeglasses and contact lenses; 8. prosthetic devices, except those covered by TRICARE/CHAMPUS; 9. cosmetic procedures, except those resulting from covered Sickness or Injury; 10. hearing aids; 1 orthopedic footwear; 12. care for the mentally incapacitated or physically handicapped if: a) the care is required because of the mental incapacitation or physical handicap; or b) the care is received by an Active Duty Member's child who is covered by the "Program for the Handicapped" under TRICARE/CHAMPUS; 13. drugs which do not require a prescription, except insulin; 14. dental care unless such care is covered by TRICARE/CHAMPUS, and then only to the extent that TRICARE/CHAMPUS covers such care; 15. any confinement, service, or supply that is not covered under TRICARE/CHAMPUS; 16. Hospital nursery charges for a well newborn, except as specifically provided under TRICARE/CHAMPUS; 17. any routine newborn care except Well Baby Care, as defined, for a Covered Child who is less than 6 years of age; 18. expenses in excess of the TRICARE/CHAMPUS Cap; 19. expenses which are paid in full by TRICARE/CHAMPUS; 20. any expense or portion thereof which is in excess of the Legal Limit; 21. any expense or portion thereof applied to the TRICARE/CHAMPUS Outpatient Deductible; 22. that part of any Covered Expense which is in excess of the TRICARE/CHAMPUS Allowed Amount, except as otherwise stated in the Supplement Benefits; 23. treatment for the prevention or cure of alcoholism or drug addiction except as specifically provided under TRICARE/CHAMPUS and this Policy; 24. any part of a covered expense which the Covered Person is not legally obligated to pay because of payment by a TRICARE/CHAMPUS alternative program.

Nervous, Mental, Emotional Disorders, Alcoholism and Drug Addiction Limitation

MCA&F's TRICARE Supplement Insurance Plans do not cover: Inpatient Benefits for Confinement due to nervous, mental, or emotional disorders (including alcoholism and drug addiction) which exceed the lesser of: 90 days for any period of Confinement; the number of days payable by TRICARE; or outpatient benefits for expenses in excess of $500 per person per Calendar Year.

Qualified Hospital

To qualify for these benefits, hospitals must operate pursuant to law: primarily and continuously provide medical care on an inpatient basis: have facilities for medical and surgical diagnosis and treatment under supervision of legally qualified physicians; and provide 24-hour nursing services. Convalescent homes, skilled nursing facilities or places which primarily care for drug addiction, alcoholism or mental illness are not qualified hospitals.

Effective Date

This coverage is effective on the first day of the month (subject to the Pre-existing Condition Limitation), following receipt of your signed Enrollment Form and your first premium payment. If you or one of your family members to be insured is in the hospital on the date that your MCA&F TRICARE Supplement Insurance Plan should become effective, that person's coverage will be deferred until the first of the month following their date of discharge from the hospital.

Insured Person Termination: Your coverage under the Policy will cease on the first to occur of:

  1. the date the Policy terminates;
  2. the date the required premium is not paid, subject to the Grace Period provision;
  3. the first day of the month on or next following the date you cease to be a Member;
  4. the date coverage for your class is cancelled;
  5. the date you cease to be covered under TRICARE or TRICARE Reserve Select;
  6. the date you become eligible for Medicare;
  7. the date you attain age 65 (unless you are not eligible for Medicare and have a Notice of Disallowance for Benefits under Medicare Part A from the Social Security Administration).

Termination of your coverage will be without prejudice to any claim which originated before the effective date of termination. The Member must notify the Plan Administrator in writing within 31 days of the change in TRICARE status.

Dependent Termination: Your dependent's coverage under the Policy will cease on the first to occur of:

  1. the date the Policy terminates;
  2. the date the required premium is not paid, subject to the Grace Period provision;
  3. the first premium due date on or next following the date he or she ceases to be an Eligible Spouse or an Eligible Child (except that a spouse who remains eligible for TRICARE after divorce or legal separation from the Member may continue his or her coverage until he or she remarries, subject to payment of the required premium);
  4. the date coverage is cancelled for the class to which he or she belongs;
  5. the date the Member ceases to be covered, subject to the Covered Dependent Continuation provision; (This will not apply to the Spouse or Child of an Active Duty Member or a Service Disabled Member.)
  6. the date he or she becomes eligible for Medicare;
  7. if a spouse, the date he or she attains age 65 (unless he or she is not eligible for Medicare and has a Notice of Disallowance for Benefits under Medicare Part A from the Social Security Administration);
  8. if a child, the date he or she attains age 21 or age 23 if he or she is enrolled full-time at a school of higher learning.

Termination of coverage will be without prejudice to any claim which originated before the effective date of termination.

TRICARE means the Department of Defense regional managed care program for members of the Uniformed Services and their families, and survivors and retired members and their families. TRICARE provides choices for health care delivery: TRICARE Select, a preferred provider organization (PPO) option which offers cost share discounts; and TRICARE Prime, a health maintenance organization (HMO) option.

Confined or Confinement means being an inpatient in a Hospital (or Skilled Nursing Facility) due to sickness or injury. A Confinement begins on the date the covered person is admitted to the hospital as an inpatient and ends on the date he or she is discharged.

A Hospital or a Skilled Nursing Facility does not mean any institution or part thereof used principally as a rest home, a home for the aged, or a place for custodial care; or a place for the care of drug addicts, alcoholics, or the mentally ill.

 

This website explains the general purpose of the insurance described, but in no way changes or affects the policy AGP-5516 as actually issued. In the event of a discrepancy between this website and the policy, the terms of the policy apply. All benefits are subject to the terms and conditions of the policy. Policies underwritten by Hartford Life and Accident Insurance Company and Hartford Life Insurance Company detail exclusions, limitations and terms under which the policies may be continued in full or discontinued. Complete details are in the Certificate of Insurance issued to each insured individual and the Master Policy issued to the policyholder. This program may vary and may not be available to residents of all states.

 

Approved by:
MCA&F Group Benefit Program,

P.O. Box 26610, Phoenix, AZ 85068-6610


Administered by:
A.G.I.A., Inc.
PO Box 9947, Phoenix, AZ 85068

A.G.I.A., Inc. is the Plan Administrator and Insurance broker that administers the insurance plan on behalf of the Hartford Life and Accident Insurance Company and Hartford Life Insurance Company for the benefit of the Group Policyholder. A.G.I.A., Inc. is compensated for the placement of insurance and for the services it provides to customers on behalf of the insurance company, in addition to other compensation it may receive. A.G.I.A., Inc. is licensed/authorized to transact business in all 50 United States, and the District of Columbia. Their state of domicile is California. J. Christopher Burke California Agent license number is 0F70947. J. Christopher Burke Arkansas Agent License Number is 8876308.

 

 

Questions? Call MCA&F's Customer Service and Claims Phone number at 1 (888) 611-6010.

 

Download, print and mail in your Enrollment Form today!

  1. Use the link below to download and print the form.
  2. Please complete all fields on the Enrollment Form.
  3. Mail in your form to the MCA&F Group Benefit Program, P.O. Box 26610, Phoenix, AZ 85068-6610

 

Questions? Call MCA&F's Customer Service and Claims Phone number at 1 (888) 611-6010.

 

Download Printable Enrollment Form

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