Compare what you’re currently paying to MOAA MEDIPLUS
®
monthly rates:
MEDIPLUS
®
TRICARE Standard Retiree Supplement Monthly Rates MEDIPLUS
®
Retired
Under 45 45–49 50–54 55–59 60–64 TRICARE Prime Supplement
Inpatient
Member Nonsmoker $13.62 $15.33 $21.29 $28.96 $36.73
Member or
and
(or Auxiliary
Spouse Age Nonsmoker Smoker
Outpatient
Member) Smoker $14.48 $17.03 $23.00 $30.66 $40.41
Each
Plan Child
Under 50 $ 8.45 $ 8.88
—$300 Nonsmoker $18.74 $23.00 $28.10 $31.52 $38.57 $12.78
Per Person Spouse
50–54 $12.90 $13.55
Deductible
Smoker $21.29 $25.55 $31.52 $35.77 $43.17
55–59 $15.24 $15.99
Under 45 45–49 50–54 55–59 60–64
60–64 $19.48 $20.46
Inpatient Member
Nonsmoker $23.88 $26.87 $37.32 $50.75 $65.14
and (or Auxiliary
Each Child — $10.99
Outpatient Member)
Smoker $25.38 $29.85 $40.30 $53.74 $71.65
Each
Plan
Child Other MEDIPLUS TRICARE Standard Supplement
—$150 Nonsmoker $32.84 $40.30 $49.26 $55.23 $68.39
$22.39
Plans are available. For more information, call
Spouse
TOLL-FREE 1-800-247-2192. Premiums are based on
Per Person
each person’s age when coverage becomes effective,
Deductible Smoker $37.32 $44.78 $55.23 $62.69 $76.53
and increase on January 1 after the next highest age
bracket is reached. Premiums may be increased or
decreased on a class-wide basis. For your convenience,
You qualify as a nonsmoker if you have not smoked cigarettes, cigars, or used a pipe, chewing tobacco, nicotine chewing gum or snuff in the past 12 months.
you will be billed quarterly.
Switching To MEDIPLUS From Other Plans? baby care and immunizations, except that these services are
Preexisting Conditions Limitation: If you or your covered
Employer Plans: You won’t have to satisfy a waiting covered when rendered to a child who is less than 6 years of
dependents received medical treatment or advice for a health
period on current health conditions if you sign up for age; hospital nursery charges for a well newborn; domiciliary
condition (including pregnancy) during the six months before the
MEDIPLUS within 30 days after your employer-sponsored or custodial care; eye refractions and routine eye exams,
date the coverage takes effect, that health condition won’t be
protection ends because you are no longer an eligible unless required for school; eyeglasses and contact lenses
covered until the person has been enrolled in the plan for six months.
participant in that program (if you change jobs, move or retire, (except that surgically implanted contact lenses are covered if
We urge you to consider this limitation before dropping any other
for example). If you’ve voluntarily ended your employer- approved by TRICARE); prosthesis (except that artificial limbs
health insurance you may have.
sponsored plan while you are still an eligible participant, the and eyes, and devices which must be implanted by surgery,
Important Information Regarding Veterans’
six-month waiting period for current health conditions will are covered); breast implants except when covered by
Administration (VA) Hospitals: TRICARE Supplement
apply. TRICARE for reconstructive surgery due to cancer; hearing aids;
insurance policies pay benefits only after TRICARE has first reviewed
Active Duty: Officers who enroll within 30 days of the date orthopedic footwear; care for the mentally incapacitated or
and approved the expense. A review by TRICARE results in a
their active duty medical coverage ends or within 30 days of physically handicapped if a) the care is required because of
TRICARE Explanation of Benefits (“EOB”). Many VA Hospitals
their initial eligibility for TRICARE benefits are also covered for the mental incapacitation or physical handicap; or b) the care
currently do not submit their claims through TRICARE. Only claims
all health conditions right away. is received by an Active Duty Member’s child who is covered
TRICARE processes, resulting in an EOB, are subject to benefits under
by the “Program for Persons with Disabilities” under TRICARE; The Hartford’s TRICARE Supplement insurance policies. If you use VA
30-Day, No-Risk Coverage: If for any reason you are not nursing service, unless it is for the full-time service of a
facilities for your care, please be aware of this TRICARE Supplement
completely satisfied with your MEDIPLUS Certificate of Insurance registered graduate nurse or a licensed practical nurse;
policy requirement. VA Hospitals also can charge the veteran a
after you have examined it for 30 days, you may cancel it with no purchase of a wheelchair, Hospital type bed, iron lung or other
Category C copayment based on a means test, per Public Law 99
questions asked. Simply write “Cancel” on your Certificate and durable equipment unless approved by TRICARE (the rental of
Section 272. This law specifically applies only to the veteran and
return it within 30 days to MOAA Insurance Plans. such equipment is covered); ambulance service in excess of
not the insurance company. The Hartford is not liable for payment
Effective Date: Your MEDIPLUS coverage begins on the first day $100 per trip unless approved by TRICARE; any expenses
of these charges.
of the month following receipt of your Enrollment Form and first paid in full by TRICARE; drugs which do not require a
premium payment, provided you are an MOAA member. prescription (except that insulin is covered); dental care,
This brochure explains the general purpose of the insurance
Qualified Hospital: A hospital must be engaged primarily in except that it is covered when it is needed to treat another
described, but in no way changes or affects the Master Policy (Policy
medical care and treatment of sick and injured persons on an (not dental) injury or sickness; any confinement, service, or
# AGP-1134; Policy Form 7318-5 [3rd Rev][HLA][1134]) as
inpatient basis, have full surgical facilities, be under the supervision supply that is not covered under TRICARE; any expense
actually issued. In the event of a discrepancy between this brochure
of legally qualified physicians and provide 24-hour nursing services applied to the TRICARE Outpatient Deductible or the TRICARE
and the policy, the terms of the policy apply. All benefits are subject
by R.N.s to qualify. A sanitarium operated by or certified by the First Prime Point of Service Deductible; any expense applied to the
to the terms and conditions of the policy. Policies underwritten by the
Church of Christ Scientist, Boston, Massachusetts, also qualifies. A Retiree Inpatient Only Supplement $200 Deductible; any
Hartford Life and Accident Insurance Company detail exclusions,
convalescent home; skilled nursing facility; a place for rest, custodial expense applied to the Retiree Inpatient/Outpatient
limitations, reduction of benefits and terms under which the policies
care or care for the aged; or a place primarily caring for mental Supplement $300/$150 per person Deductibles; any
may be continued in full or discontinued. Complete details are in the
illness, drug addiction or alcoholism does not qualify. In certain portion of the cost-share amount which the Insured Person is
Certificate of Insurance issued to the insured individual and the
situations, an institution for the treatment of nervous, mental or not legally obligated to pay because of payment by a TRICARE
Master Policy issued to the policyholder, MOAA. This program may
emotional disorders is considered a hospital under the MEDIPLUS alternative program; expenses for which TRICARE makes full
vary and may not be available to residents of all states.
TRICARE Standard Supplements. Confined or Confinement means payment for the TRICARE-allowed amount (this exclusion
Marsh Affinity Group Services, a service of Seabury & Smith,
being an inpatient in a Hospital or Skilled Nursing Facility due to does not apply to coverage expressly provided for expenses in
receives compensation for services to provide this program; these
sickness or injury. excess of the TRICARE allowable amount); any portion of a
services may include enrollments, ongoing servicing, billing,
Termination: Your coverage, as well as your dependents’ TRICARE cost-share which we determine is payable by
marketing, brokerage, customer administrative and claim servicing
coverage, will terminate only if you are no longer eligible for TRICARE because the TRICARE cap has been met; under the
and communications. Refer to https://www.personal-
TRICARE, the Master Policy is canceled, your premiums are not paid Inpatient Only Plans, outpatient surgical benefits are limited to
plans.com/disclosure and enter in the security code i674009 or call
or you discontinue your MOAA membership. Your dependent $500 a year.
us at 1-888-206-5088 for specific details.
children’s coverage will continue as long as they maintain TRICARE Nervous, Mental, Emotional Disorders,
eligibility, are unmarried and are under age 21 (23 if full-time Alcoholism, and Drug Addiction Limitations: The
Your association shares a financial interest in this program that
student). Spouse coverage will continue as long as he/she coverage provided under the TRICARE Supplement does not
benefits the entire membership.
remains married to the MOAA member. cover inpatient treatment for mental, nervous, or emotional
General Exclusions and Limitations: These TRICARE disorders in excess of 45 days if under age 19, or in excess of
Supplements do not cover: injury or sickness resulting from war or 30 days if age 19 or older (or 90 days if approved by TRICARE
acts of war, whether declared or undeclared; intentionally self- Standard) in any one calendar year. Outpatient benefits for
inflicted injury; suicide or attempted suicide, whether sane or such disorders are limited to $500 during any period of 12
insane; the following services: a) routine physical exams, except consecutive months. In addition, for mental illness we will pay
when such services are rendered to a child who is less than 6 years up to 150 days of inpatient care for covered expenses for a
of age or when required for school enrollment (but not sports covered dependent child up to age 21.
Underwritten by:
physicals) for a covered child ages 5 through 11; b) routine or well
Hartford Life and Accident Insurance Company
Simsbury, CT 06089
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