2009-482-1-2-brochure-v8-noc7.qxp

STUDENT INJURY ANDSICKNESS INSURANCE PLAN Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Effective and Termination Dates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1How to Enroll or Waive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Extension of Benefits after Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Premium Refund Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Student Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Pre-Admission Notification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3Schedule of Basic Medical Expense Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4UnitedHealthcare Network Pharmacy Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Preferred Provider Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Maternity Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Optional Major Medical Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Accidental Death and Dismemberment Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Excess Provision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Continuation Privilege . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Mandated Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Benefits for Postpartum Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Benefits for Child Health Screening Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Benefits for Child Health Screening Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13Benefits for Habilitative Services for the Treatment of Congenital or Genetic Birth Defects. .13Benefits for Prostate Cancer Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13Benefits for Cytologic Screening and Mammographic Examinations . . . . . . . . . . . . . . . . . . . . . . .13Benefits for Colorectal Cancer Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13Benefits for Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13Benefits for Mental and Nervous Disorder, Alcoholism and Drug Dependency . . . . . . . . . . . . .14 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Exclusions and Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15Collegiate Assistance Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Scholastic Emergency Services: Global Emergency Medical Assistance . . . . . . . . . . . . . . . . . . . .17Online Access to Account Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17Claim Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 We know that your privacy is important to you and we strive to protect the confidentiality of yournonpublic personal information. We do not disclose any nonpublic personal information about ourcustomers or former customers to anyone, except as permitted or required by law. We believe wemaintain appropriate physical, electronic and procedural safeguards to ensure the security of yournonpublic personal information. You may obtain a copy of our privacy practices by calling us toll-freeat 800-767-0700 or visiting us at www.uhcsr.com.
All full-time domestic undergraduate and graduate students and International undergraduate andgraduate students (full and part-time), enrolled or attending classes, are automatically enrolled in theBasic Benefits Plan 1: 482-1 of this insurance Plan at registration unless proof of comparablecoverage is furnished.
All part-time domestic students are eligible to enroll in Plan 1: 482-1 of this insurance Plan.
Students attending the House of Studies, Washington Theological Union and John Paul II Instituteare eligible to enroll Plan 2: 482-2 of this insurance Plan.
All insured students may purchase Major Medical coverage on an optional basis.
Students must actively attend classes for the first 31 days after the date for which coverage ispurchased, or, if not required to physically attend classes in order to complete their course of study,must be enrolled for 31 days after the date for which coverage is purchased. Home study,correspondence Internet, and television (TV) courses do not fulfill the Eligibility requirements that thestudent actively attend classes. The Company maintains its right to investigate student status andattendance records to verify that the policy Eligibility requirements have been met. If the Companydiscovers the Eligibility requirements have not been met, its only obligation is to refund premium.
Eligible students who do enroll may also insure their Dependents. Eligible Dependents are the spouseand unmarried children under 19 years of age. Dependent Eligibility expires concurrently with that ofthe Insured Student.
Optional Coverage may only be purchased simultaneously and in conjunction with the purchase ofBasic coverage at the time of initial enrollment in the Plan. Only those students enrolled in BasicCoverage may purchase Optional Major Medical coverage. Students may purchase optionalcoverages for themselves or for themselves and all family members.
The Master Policy becomes effective August 14, 2009. The individual student’s Coverage becomeseffective on the first day of the period for which premium is paid or the date the enrollment form andfull premium are received by the Company (or its authorized representative), whichever is later. TheMaster Policy terminates August 13, 2010. Coverage terminates on that date or at the end of theperiod through which premium is paid, whichever is earlier. Dependent coverage will not be effectiveprior to that of the Insured Student or extend beyond that of the Insured Student.
You must meet the Eligibility requirements each time you pay a premium to continue insurancecoverage. To avoid a lapse in coverage, your premium must be received within 14 days after thecoverage expiration date. It is the student’s responsibility to make timely premium payments to avoida lapse in coverage.
Refunds of premiums are allowed only upon entry into the armed forces. The Policy is a Non-Renewable, One-Year Term Policy.
Students must go to www.srstudentcenter/cua.com to either enroll in the plan or waive out of the planby the deadline date for each semester. Students billed on a part-time basis are eligible to purchasethe CUA Student Medical Plan on a voluntary basis by enrolling online atwww.srstudentcenter/cua.com. Notification of the enrollment and waiver status will be supplied viaemail from UHCSR. The student’s account at CUA will be subsequently charged after acceptance ofenrollment.
For Dependent and Optional Major Medical coverage please go to www.uhcsr.com. All Students enrolling for the Fall Semester New Students enrolling for the Spring Semester New Students enrolling for the Summer Semester Late Enrol ment:Coverage for late enrollees may be possible only under certain conditions. After the enrollmentdeadline, only those students who have involuntarily lost health insurance coverage through a“Qualifying Life Event” such as (1) removal from a parent’s health insurance plan after achieving alandmark birthday that disqualifies them from a parent’s health insurance plan or (2) losing privateinsurance through loss of employment or divorce, may apply for late enrollment. A certificate ofcreditable coverage stating the date of the involuntary loss of health coverage must be submitted tothe CUA Insurance Administrator within 31 days of the qualifying life event. Please contact the CUAStudent Insurance Administrator at 202-319-6634 or e-mail [email protected] for moreinformation.
Extension of Benefits after Termination The coverage provided under the Policy ceases on the Termination Date. However, if an Insured isHospital Confined on the Termination Date from a covered Injury or Sickness for which benefits werepaid before the Termination Date, Covered Medical Expenses for such Injury or Sickness will continueto be paid as long as the condition continues but not to exceed 90 days after the Termination Date.
The total payments made in respect of the Insured for such condition both before and after theTermination Date will never exceed the Maximum Benefit.
After this “Extension of Benefits” provision has been exhausted, all benefits cease to exist, and underno circumstances will further payments be made.
Premium Refund Policy Except for medical withdrawal due to a covered Accident or Sickness, that occurs after the Policy isin force, any student withdrawing from school during the first 31 days of the period for which coverageis purchased shall not be covered under the Policy and a refund of the premium will be made.
Students withdrawing after such 31 days will remain covered under the Policy for the full period forwhich premium has been paid. No refund will be allowed.
Student Health Services Students’ health care needs can best be satisfied when an organized system of health care providersat Catholic University of America Student Health Services manages the treatment. If you are enrolledin the Student Injury and Sickness Insurance Plan, it is to your advantage to first seek treatment atStudent Health Services (SHS). It should be noted that the Student Health Service does not providecoverage for dependents even if they are insured under the CUA Student Medical Plan. Student Health Services provides primary health care to all students with emphasis on healthmaintenance and illness prevention. SHS is an integral part of the CUA Division of Student Life andas such subscribes to the mission of the Division of Student Life. Medical care and advice isconsistent with the teachings of the Catholic Church. Our primary care facility is conveniently locatedin the new Student Health and Fitness Center. The SHS is affiliated with Providence Hospital andother services (such as X-ray and Emergency Room Services) are readily available within a shortdistance from campus. The SHS provides professional medical care for the treatment of illness andinjury. In addition, health promotion and education programs are offered to help the student maintainand improve their health. Services include gynecological care, including sexually transmitted diseasetreatment and counseling; pregnancy testing; allergy injections (administered only when the physicianis on he premises); physical examinations; health education, preventive medicine, HIV testing andevaluation and treatment of eating disorders, substance abuse, depression, etc. In addition, SHSprovides evaluation and treatment of all commonly experienced illnesses and injuries. Referrals aremade to nearby medical specialists whenever medically necessary. Some on-site lab tests may bedone for a minimal charge which is billed through Student Accounts. Other lab work is obtained onthe premises and sent to a local lab. SHS has a limited on-site pharmacy. This service is available tostudents that are seen by a provider at the SHS. If medications are filled at the on-site pharmacy, thecharges will be billed to the Student’s Account. The pharmacy is unable to file prescription claims. If astudent requires a medication that is not available in the on-site pharmacy, a list of local pharmacieswill be given to assist the student.
SHS is open Monday through Friday from 9:00 am to 5:00 pm during the Fall and Spring semester.
SHS is closed during the undergraduate student's Christmas Break, Spring Break, Summer Break inAugust, CUA Holidays and whenever the CUA is closed. SHS is open on a limited schedule duringthe summer.
Avidyn should be notified of all Hospital Confinements prior to admission.
1. PRE-NOTIFICATION OF MEDICAL NON EMERGENCY HOSPITALIZATIONS: The patient, Physician or Hospital should telephone 1-877-295-0720 at least five working days prior to theplanned admission.
2. NOTIFICATION OF MEDICAL EMERGENCY ADMISSIONS: The patient, patient’s representative, Physician or Hospital should telephone 1-877-295-0720 within two working days of the admissionto provide the notification of any admission due to Medical Emergency.
Avidyn is open for Pre-Admission Notification calls from 8:00 a.m. to 6:00 p.m., C.S.T., Monday throughFriday. Calls may be left on the Customer Service Department’s voice mail after hours by calling 1-877-295-0720.
IMPORTANT: Failure to follow the notification procedures will not affect benefits otherwise payableunder the policy; however, pre-notification is not a guarantee that benefits will be paid.
Schedule of Basic Medical Expense Benefits $250,000 Basic Maximum Benefit (for Each Injury or Sickness) Deductible $200 (Per Insured Person Per Policy Year)Family Deductible $400 (Per Family) (Per Policy Year) Preferred Provider Coinsurance 80% except as noted below Out-of-Network Coinsurance 60% except as noted below The Policy provides benefits for the Usual & Customary Charges incurred by an Insured Personfor loss due to a covered Injury or Sickness up to the Maximum Benefit of $250,000 for eachInjury or Sickness.
Usual & Customary Charges are based on data provided by Ingenix using the 80th percentilebased on location of provider.
The Preferred Provider for this plan is UnitedHealthcare Options PPO. If care is received froma Preferred Provider, any Covered Medical Expenses will be paid at the Preferred Provider levelof benefits. If the Covered Medical Expense is incurred due to a Medical Emergency, benefitswill be paid at the Preferred Provider level of benefits. In all other situations, reduced or lowerbenefits will be provided when an Out-of-Network provider is used.
Preferred Provider Out-of-Pocket Maximum: After the Deductible of $200 Per Insured Person/$400 Per Family has been satisfied, benefits will be paid for 80% of Covered MedicalExpenses incurred up to $2,000 Per Insured Person/$3,000 Per Family. After $2,000 PerInsured Person/$3,000 Per Family has been paid, payment will be made for 100% of additionalCovered Medical Expenses incurred, not to exceed the Maximum Benefit of $250,000 PerInjury or Sickness.
Out-of-Network Out-of-Pocket Maximum: After the Deductible of $200 Per InsuredPerson/$400 Per Family has been satisfied, benefits will be paid for 60% of Covered MedicalExpenses incurred up to $4,000 Per Insured Person/$6,000 Per Family. After $4,000 PerInsured Person/$6,000 Per Family has been paid, payment will be made for 100% of additionalCovered Medical Expenses incurred, not to exceed the Maximum Benefit of $250,000 perInjury or Sickness.
All benefit maximums are combined Preferred Provider and Out-of-Network, unless notedbelow. Benefits will be paid up to the Maximum Benefit for each service as scheduled below.
Covered Medical Expenses include: Room and Board Expense, daily semi-private Preferred Allowance room rate; general nursing care provided by the Hospital Miscellaneous Expense includes Preferred Allowance Miscellaneous Expenses such as the cost of the operating room, laboratory tests, x-rayexaminations, anesthesia, drugs (excluding takehome drugs) or medicines, therapeutic services,and supplies. In computing the number of dayspayable under this benefit, the date of admissionwill be counted, but not the date of discharge.
Confined; and routine nursery care providedimmediately after birth.
(Up to 48 hours for vaginal delivery or 96 hoursfor cesarean delivery) (including circumcision) Surgeon’s Fees, in accordance with data Preferred Allowance provided by Ingenix. If two or more procedures are performed through the same incision or inimmediate succession at the same operativesession, the maximum amount paid will notexceed 50% of the second procedure and 50%of all subsequent procedures.
(Expenses for removal of moles, warts and lesionsare covered the same as any other Sickness.) Anesthetist, professional services in connection Preferred Allowance Registered Nurse’s Services, private duty nursing Physician’s Visits, benefits are limited to one visit Preferred Allowance per day and do not apply when related to surgery.
Pre-Admission Testing, payable within 3 working Psychotherapy, benefits are limited to one visit See Benefits for Mental and Nervous Disorder, (Semi Private Room Rate) (In lieu of confinement in a hospital as a full time inpatient, or within 24hours following a hospital confinement and for thesame or related causes, such as hospitalconfinement.) (50 days of treatment maximum. Confinement must follow within 24 hours of and be for thesame or related causes as a period of hospital orskilled nursing facility confinement). Surgeon’s Fees, in accordance with data Preferred Allowance provided by Ingenix. If two or more procedures are performed through the same incision or inimmediate succession at the same operativesession, the maximum amount paid will notexceed 50% of the second procedure and 50%of all subsequent procedures.
(Expenses for removal of moles, warts andlesions are covered the same as any otherSickness.) Day Surgery Miscel aneous, related to scheduled Preferred Allowance surgery performed in a Hospital, including the cost of the operating room; laboratory tests and x-ray examinations, including professional fees;anesthesia; drugs or medicines; and supplies.
Usual and Customary Charges for Day SurgeryMiscellaneous are based on the OutpatientSurgical Facility Charge Index.
Anesthetist, professional services administered Preferred Allowance in connection with outpatient surgery.
Physician’s Visits, benefits are limited to one visit Preferred Allowance per day. Benefits for Physician’s Visits do not apply when related to surgery or Physiotherapy.
Physiotherapy, (10 visits maximum Per Policy Preferred Allowance Year) Benefits are limited to 1 visit per day.
Outpatient Physiotherapy benefits payable onlyfor a condition that required surgery or HospitalConfinement: 1) within the 30 days immediatelypreceding such Physiotherapy; or 2) within the30 days immediately following the attendingPhysician’s release for rehabilitation OR; whenprescribed by the Attending Physician andtreatment is not following surgery. Coveredmedical expenses are paid on the same basis asany expense up to a maximum of one visit perday, and up to a maximum of 10 visits per year.
(Includes Chiropractic expenses). Medical Emergency Expenses, use of the Preferred Allowance Tests and Procedures, diagnostic services and medical procedures performed by a Physician, other than Physician’s Visits, Physiotherapy, x-rays and lab procedures. (Includes allergy testing) Prescription Drugs, Mail order Prescription Drugs are available through UHPS at 2.5 times the retail copay up to a 90 day supply. (Contraception covered only when medically necessary) prescription for Tier 1$25 copay perprescription for Tier 2Up to a 31 day supplyper prescription Psychotherapy, includes all related ancillary See Benefits for Mental and Nervous Disorder, charges incurred as a result of a Mental and Nervous Disorder. Benefits are limited to one visitper day.
Durable Medical Equipment, a written prescription must accompany the claim when submitted.
Replacement equipment is not covered.
Consultant Physician Fees, when requested and approved by the attending Physician.
Dental Treatment. made necessary by Injury to Women’s Health Benefit (Policy Deductible waived.) (Covered Medical Expenses for an annual GYN exam and mammogram or more frequently, ifrecommended by a Physician. Includes expensesincurred for all lab and x-ray expenses inconnection with an annual pap smear andmammogram.) Home Health Care (40 visit maximum Per Policy Year for Medically Necessary Home Health Care services when ordered and supervised by theattending Physician.)Reconstructive Breast Surgery (Charges incurred by the Insured person who is receiving benefits for Medically Necessary mastectomy and whoelects breast reconstruction after a mastectomy.) High Cost Procedures (Includes CAT Scan, MRI, Laser Treatment; any Outpatient procedures (Includes testing for Attention deficit disorder, attention deficit hyperactivity disorder anddyslexia). The Exclusion for learning disabilitieswill be waived and benefits paid for learningdisability testing only. No benefits are payablefor learning disability treatment, except asspecifically provided under Benefits for Mentaland Nervous Disorder, Alcoholism and DrugDependency; and under Benefits forHabilitative Services For The Treatment ofCongenital or Genetic Birth Defects.) Temporomandibular Joint Dysfunction (Non- Surgical Treatment Only ) (The exclusion for TMJ will be waived and benefits paid for non-surgicaltreatment of Temporomandibular JointDysfunction.) Routine Physical Examination (Includes lab, x-ray and other tests given in connection with the exam, and materials for the administration ofimmunizations for infectious disease & testing fortuberculosis. Benefits for materials for theadministration of immunizations are covered,except as otherwise mandated.) UnitedHealthcare Network Pharmacy Benefits Benefits are available for outpatient Prescription Drugs on our Prescription Drug List (PDL) whendispensed by a UnitedHealthcare Network Pharmacy. Benefits are subject to supply limits andcopayments that vary depending on which tier of the PDL the outpatient drug is listed. There arecertain Prescription Drugs that require your Physician to notify us to verify their use is covered withinyour benefit.
You are responsible for paying the applicable copayments. Your copayment is determined by the tierto which the Prescription Drug is assigned on the PDL. Tier status may change periodically andwithout prior notice to you. Please access www.uhcsr.com or call 1-877-417-7345 for the most up-to-date tier status.
$10 copay per prescription order or refill for a Tier 1 Prescription Drug up to a 31 day supply $25 copay per prescription order or refill for a Tier 2 Prescription Drug up to a 31 day supply Mail order Prescription Drugs are available at 2.5 times the retail copay up to a 90 day supply.
Your maximum al owed benefit is $2,000 Per Policy Year.
Please present your ID card to the network pharmacy when the prescription is filled. If you do notpresent the card, you will need to pay the prescription and then submit a reimbursement form forprescriptions filled at a network pharmacy along with the paid receipt in order to be reimbursed. Toobtain reimbursement forms, or for information about mail order prescriptions or network pharmacies,please visit www.uhcsr.com and log in to your online account or call 1-877-417-7345.
If you do not use a network pharmacy, you will be responsible for paying the full cost for theprescription.
In addition to the policy Exclusions and Limitations, the following Exclusions apply to NetworkPharmacy Benefits: 1. Coverage for Prescription Drug Products for the amount dispensed (days' supply or quantity limit) 2. Experimental or Investigational Services or Unproven Services and medications; medications used for experimental indications and/or dosage regimens determined by the Company to beexperimental, investigational or unproven.
3. Compounded drugs that do not contain at least one ingredient that has been approved by the U.S.
Food and Drug Administration and requires a Prescription Order or Refill. Compounded drugs thatare available as a similar commercially available Prescription Drug Product. Compounded drugs thatcontain at least one ingredient that requires a Prescription Order or Refill are assigned to Tier 2.
4. Drugs available over-the-counter that do not require a Prescription Order or Refill by federal or state law before being dispensed, unless the Company has designated the over-the counter medicationas eligible for coverage as if it were a Prescription Drug Product and it is obtained with aPrescription Order or Refill from a Physician. Prescription Drug Products that are available in over-the-counter form or comprised of components that re available in over-the-counter form orequivalent. Certain Prescription Drug Products that the Company has determined areTherapeutically Equivalent to an over-the-counter drug. Such determinations may be made up tosix times during a calendar year, and the Company may decide at any time to reinstate Benefits fora Prescription Drug Product that was previously excluded under this provision.
5. Any product for which the primary use is a source of nutrition, nutritional supplements, or dietary management of disease, even when used for the treatment of Sickness or Injury.
DefinitionsPrescription Drug or Prescription Drug Product means a medication, product or device that has beenapproved by the U.S. Food and Drug Administration and that can, under federal or state law, bedispensed only pursuant to a Prescription Order or Refill. A Prescription Drug Product includes amedication that, due to its characteristics, is appropriate for self-administration or administration by anon-skilled caregiver. For the purpose of the benefits under the policy, this definition includes insulin.
Prescription Drug List means a list that categorizes into tiers medications, products or devices thathave been approved by the U.S. Food and Drug Administration. This list is subject to the Company’speriodic review and modification (generally quarterly, but no more than six times per calendar year).
The Insured may determine to which tier a particular Prescription Drug Product has been assignedthrough the Internet at www.uhcsr.com or call Customer Service at 1-877-417-7345.
“Preferred Providers” are the Physicians, Hospitals and other health care providers who havecontracted to provide specific medical care at negotiated prices. Preferred Providers in the localschool area are Hospitals and Physicians of UnitedHealthcare Options PPO.
The availability of specific providers is subject to change without notice. Insured’s should alwaysconfirm that a Preferred Provider is participating at the time services are required by calling theCompany at 1-800-767-0700 and/or by asking the provider when making an appointment forservices.
“Preferred Al owance” means the amount a Preferred Provider will accept as payment in full forCovered Medical Expenses.
“Out of Network” providers have not agreed to any prearranged fee schedules. Insured’s may incursignificant out-of-pocket expenses with these providers. Charges in excess of the insurance paymentare the Insured’s responsibility.
Regardless of the provider, each Insured is responsible for the payment of their Deductible. TheDeductible must be satisfied before benefits are paid. The Company will pay according to the benefitlimits in the Schedule of Benefits.
PREFERRED HOSPITALS - Eligible inpatient Hospital expenses at a Preferred Hospital will be paidat the coinsurance percentages specified in the Schedule of Benefits up to any limits specified in theSchedule of Benefits. Call (800) 767-0700 for information about Preferred Hospitals.
OUT-OF-NETWORK HOSPITALS - If care is provided at a Hospital that is not a Preferred Provider,eligible inpatient Hospital expenses will be paid according to the benefit limits in the Schedule ofBenefits.
Outpatient Hospital ExpensesPreferred Providers may discount bills for outpatient Hospital expenses. Benefits are paid accordingto the Schedule of Benefits. Insureds are responsible for any amounts that exceed the benefitsshown in the Schedule, up to the Preferred Allowance. Benefits for Covered Medical Expenses provided by Hospitals and Physicians of UnitedHealthcareOptions PPO will be paid at the coinsurance percentages specified in the Schedule of Benefits or upto any limits specified in the Schedule of Benefits. All other providers will be paid according to thebenefit limits in the Schedule of Benefits.
This policy does not cover routine, preventive or screening examinations or testing unless MedicalNecessity is established based on medical records. The following maternity routine tests andscreening exams will be considered, if all other policy provisions have been met. This includes apregnancy test, CBC, Hepatitis B Surface Antigen, Rubella Screen, Syphilis Screen, Chlamydia, HIV,Gonorrhea, Toxoplasmosis, Blood Typing ABO, RH Blood Antibody Screen, Urinalysis, Urine BacterialCulture, Microbial Nucleic Acid Probe, AFP Blood Screening; Pap Smear, and Glucose Challenge Test(at 24-28 weeks gestation). One Ultrasound will be considered in every pregnancy, without additionaldiagnosis. Any subsequent ultrasounds can be considered if a claim is submitted with the PregnancyRecord and Ultrasound report that establishes Medical Necessity. Additionally, the following tests willbe considered for women over 35 years of age: Amniocentesis/AFP Screening; and ChromosomeTesting. Fetal Stress/Non-Stress tests are payable. Pre-natal vitamins are not covered. For additionalinformation regarding Maternity Testing, please call the Company at 1-800-505-4160.
$100,000 Maximum Benefit (For Each Injury or Sickness) This optional benefit is subject to payment of an additional premium as specified on the enrollmentcard.
The Major Medical Benefit begins payment after the Basic Maximum Benefit of $250,000 has beenpaid by the Company. Optional benefits may only be purchased at the time of initial enrollment in thePlan and may not be added later.
The Company will pay 80% for Preferred Providers or 60% for Out-of-Network Providers foradditional Covered Medical Expenses incurred up to the Major Medical Maximum of $100,000. Thetotal benefit payable under Major Medical is $350,000 minus the Basic Benefits already paid.
No benefits will be paid under Major Medical for: 1. Room & Board / Hospital Miscellaneous Expenses which exceed the semi-private room rate;2. Dental treatment;3. Psychotherapy in excess of the mandated benefits specified in the Mandated Benefits section under Benefits for Mental and Nervous Disorder, Alcoholism and Drug Dependency; 4. Alcoholism and drug abuse in excess of the mandated benefits specified in the Mandated Benefits section under Benefits for Mental and Nervous Disorder, Alcoholism and Drug Dependency; 5. Services designated as "No Benefits" in the Basic Medical Expense Benefits Schedule of Benefits; 6. Pre-existing Conditions, except for individuals who have been continuously insured under the Optional Major Medical coverage for at least 6 consecutive months; If an individual: (1) hadcoverage under a Previous Plan as defined below; and (2) that coverage was continuous to a datenot more than 63 days prior to the person’s Effective Date under this Optional Major Medicalcoverage, the time under the Previous Plan will be credited toward the 6 consecutive monthsneeded to provide benefits for a Pre-existing Condition. A “Previous Plan” means any accident andhealth insurance policy or certificate, nonprofit hospital or medical service corporation, HMO,MEWA, or plan provided by another benefit arrangement, including a government plan or programproviding health benefits or health care. It does not include a Medicare Supplement.
Accidental Death and Dismemberment Benefits If such injury shall independently of all other causes and within 180 days from the date of injury solelyresult in any one of the following specific losses, the Insured Person or beneficiary may request theCompany to pay the applicable amount below. Payment under this benefit will not exceed the policyMaximum Benefit.
Member means hand, arm, foot, leg, or eye. Loss shall mean with regard to hands or arms and feet orlegs, dismemberment by severance at or above the wrist or ankle joint; with regard to eyes, entire andirrecoverable loss of sight. Only one specific loss (the greater) resulting from any one injury will bepaid.
No benefits are payable for any expense incurred for Injury or Sickness which has been paid or ispayable by other valid and collectible insurance or under an automobile insurance policy. However, this excess provision will not be applied to the first $100 of medical expenses incurred.
Covered Medical Expenses excludes amounts not covered by the primary carrier due to penaltiesimposed as a result of the Insured’s failure to comply with policy provisions or requirements.
Important: The Excess Provision has no practical application if you do not have other medicalinsurance or if your other insurance does not cover the loss.
All Insured Persons who have been continuously insured under the school's regular student Policy forat least 3 consecutive months and who no longer meet the Eligibility requirements under that Policyare eligible to continue their coverage for a period of not more than six months under the school'spolicy in effect at the time of such continuation. If an Insured Person is still eligible for continuationat the beginning of the next Policy Year, the insured must purchase coverage under the new policy aschosen by the school. Coverage under the new policy is subject to the rates and benefits selected bythe school for that policy year.
Application must be made and premium must be paid directly to Student Insurance and be receivedwithin 14 days after the expiration date of your student coverage. For further information on theContinuation privilege, please contact UnitedHealthcare StudentResources.
Benefits will be paid the same as any other Sickness for inpatient postpartum treatment inaccordance with the medical criteria outlined in the most current version of or an official update to theGuidelines for Perinatal Care prepared by the American Academy of Pediatrics and the AmericanCollege of Obstetricians or the Standards for Obstetric-Gynecologic Services prepared by theAmerican College of Obstetricians and Gynecologists, and such coverage must include an in-hospitalstay of a minimum of 48 hours after vaginal delivery, and 96 hours after a Cesarean delivery.
Benefits will be provided in all cases of early discharge for post-delivery care within the minimum timeperiods established above to be delivered in the Insured’s home, or in a Physician’s office, asdetermined by the Physician in consultation with the Insured. The at-home post-delivery care shall beprovided by a Physician which includes a registered professional nurse, nurse practitioner, nursemidwife, or physician assistant experienced in maternal and child health, and shall include: 1. Parental education;2. Assistance and training in breast and bottle feeding; and3. Performance of any medially necessary and clinically appropriate tests, including the collection of an adequate sample for hereditary and metabolic newborn screening.
Benefits shall be subject to all Deductible, coinsurance, copayments, limitations and any otherprovisions of the Policy.
Benefits for Child Health Screening Services Benefits will be paid the same as any other Sickness for uniform age-appropriate health screeningrequirements including childhood immunizations, consistent with the standards and schedules of theAmerican Academy of Pediatrics, for Insured’s from birth to age 21 years in the District and servicesoutside the state for Insured’s with special needs.
For the purposes of this benefit, Insured’s with special needs means Insureds: 1) With physical ormental, disabilities or illnesses who reside or receive care in other states, because the District ofColumbia does not have the facilities, resources, or services to appropriately treat the Insured’sphysical or mental, disability or illness; and 2) Whose parents or legal guardians reside in the Districtof Columbia.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any other provisionsof the policy.
Benefits for Child Health Screening Services Benefits will be paid the same as any other Sickness for uniform age-appropriate health screeningrequirements including childhood immunizations, consistent with the standards and schedules of theAmerican Academy of Pediatrics, for Insured’s from birth to age 21 years in the District and servicesoutside the state for Insured’s with special needs.
For the purposes of this benefit, Insured’s with special needs means Insureds: 1) With physical ormental, disabilities or illnesses who reside or receive care in other states, because the District ofColumbia does not have the facilities, resources, or services to appropriately treat the Insured’sphysical or mental, disability or illness; and 2) Whose parents or legal guardians reside in the Districtof Columbia.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any other provisionsof the policy.
Benefits for Habilitative Services for the Treatment of Congenital or Benefits will be paid the same as any other Sickness for Habilitative Services for the treatment ofCongenital or Genetic Birth Defects to age 21 years.
Congenital or Genetic Birth Defect means: a defect existing at or from birth including a hereditarydefect. Including autism or an autism spectrum disorder and cerebral palsy.
Habilitative Services means: services, including occupational therapy, physical therapy, and speechtherapy, for the treatment of a child with a Congenital or Genetic Birth Defect to enhance the InsuredPerson’s ability to function.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any other provisionsof the policy.
Benefits will be paid the same as any other Sickness for Prostate Cancer Screening in accordanceto the latest screening guidelines issued by the American Cancer Society.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any other provisionsof the policy.
Benefits for Cytologic Screening and Mammographic Examinations Benefits shall be provided as for any other Sickness for: 1) cervical cytologic screening for womenupon certification by the attending Physician that the test is a Medical Necessity; and 2) a baselinemammogram and an annual screening mammogram for women. All such services must be inaccordance with the standard practice of medicine. All benefits are subject to the terms andconditions of the policy exclusive of any Deductible and coinsurance provisions in the policy.
Benefits will be paid the same as any other Sickness for colorectal cancer screening for InsuredPersons. The screening shall be in compliance with American Cancer Society colorectal cancerscreening guidelines, as updated.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any other provisionsof the policy.
Benefits will be paid the same as any other Sickness for the equipment, supplies, and other outpatientself-management training and education, including medical nutritional therapy, for the treatment ofinsulin-dependent diabetes, insulin-using diabetes, gestational diabetes, and non-insulin usingdiabetes if prescribed by a Physician legally authorized to prescribe such item.
Benefits shall be subject to all Deductible, coinsurance, copayments, limitations and any otherprovisions of the policy.
Benefits for Mental and Nervous Disorder, Alcoholism and Drug Dependency Benefits will be paid the same as any other Sickness for Mental and Nervous Disorder, Alcoholismand Drug Dependency subject to all terms and conditions of the policy and the following limitations.
Covered Medical Expenses will be limited to inpatient, residential, and outpatient services provided bya Hospital, nonhospital residential facility, outpatient treatment facility, Physician, psychologist orindependent clinical social worker. Before an Insured may qualify to receive benefits under thisbenefit, a Physician, psychologist or independent clinical social worker must: 1) certify that theindividual is suffering from drug abuse, alcohol abuse or a Mental and Nervous Disorder; 2) certify thatthe treatment is medically or psychologically necessary; and 3) prescribe appropriate treatment whichmay include referral to other treatment providers.
Covered Medical Expenses will be limited to coverage of treatment of clinically significant substanceuse disorders or mental illness identified in the most recent edition of the International Classificationof Diseases of the Diagnostic and Statistical Manual of the American Psychiatric Association.
Benefits will be paid not to exceed a maximum of 12 days per policy year for the process whereby aperson who is intoxicated by or dependent on drugs or alcohol or both is assisted through the periodof time necessary to eliminate the intoxicating agent from the body, while keeping the physiologicalrisk to the patient at a minimum. Additional treatment for alcoholism and drug dependency will beprovided not to exceed 60 days per policy year for inpatient or residential care, and for a maximum of75% for the first 40 outpatient visits per policy year and a maximum rate of 60% for any outpatientvisits thereafter for that policy year.
Benefits will be paid for the treatment of Mental and Nervous Disorders not to exceed a maximum of60 days per policy year for inpatient or residential care, and for a maximum of 75% for the first 40outpatient visits per policy year and a maximum rate of 60% for any outpatient visits thereafter forthat policy year. The inpatient and outpatient benefits for Mental and Nervous Disorders will notexceed a maximum lifetime benefit of $250,000 or one third of the maximum lifetime benefit for anyother Sickness, whichever is greater.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any other provisionsof the policy.
INJURY means bodily injury which is: 1) directly and independently caused by specific accidentalcontact with another body or object; 2) unrelated to any pathological, functional, or structural disorder;3) a source of loss; 4) treated by a Physician within 30 days after the date of accident; and 5)sustained while the Insured Person is covered under this policy. All injuries sustained in one accident,including all related conditions and recurrent symptoms of these injuries will be considered one injury.
Injury does not include loss which results wholly or in part, directly or indirectly, from disease or otherbodily infirmity. Covered Medical Expenses incurred as a result of an injury that occurred prior to thispolicy's Effective Date will be considered a Sickness under this policy.
PRE-EXISTING CONDITION means any condition for which medical advice, diagnosis, care ortreatment was recommended or received within the 12 months immediately prior to the Insured’sEffective date under the policy. “Pre-existing condition” does not include pregnancy.
SICKNESS means sickness or disease of the Insured Person which causes loss, and originates whilethe Insured Person is covered under this policy. All related conditions and recurrent symptoms of thesame or a similar condition will be considered one sickness. Covered Medical Expenses incurred asa result of an Injury that occurred prior to this policy's Effective Date will be considered a sicknessunder this policy.
USUAL AND CUSTOMARY CHARGES means a reasonable charge which is: 1) usual andcustomary when compared with the charges made for similar services and supplies; and 2) made topersons having similar medical conditions in the locality of the Policyholder. No payment will be madeunder this policy for any expenses incurred which in the judgment of the Company are in excess ofUsual and Customary Charges.
No benefits will be paid for: a) loss or expense caused by, contributed to, or resulting from; or b)treatment, services or supplies for, at, or related to: Learning disabilities, attention deficit disorder, except as specifically provided under Benefits forMental and Nervous Disorder, Alcoholism and Drug Dependency; and under Benefits forHabilitative Services For The Treatment of Congenital or Genetic Birth Defects; Congenital conditions, except as specifically provided for Newborn or adopted Infants; andunder Benefits For Habilitative Services For The Treatment of Congenital or Genetic BirthDefects; Cosmetic procedures, except cosmetic surgery required to correct an Injury for which benefitsare otherwise payable under this policy or for newborn or adopted children; Dental treatment, except for accidental Injury to Sound, Natural Teeth; Eye examinations, eye refractions, eyeglasses, contact lenses, prescriptions or fitting ofeyeglasses or contact lenses, vision correction surgery, or other treatment for visual defects andproblems; except when due to a disease process; 10. Foot care including: flat foot conditions, supportive devices for the foot, subluxations of the foot, care of corns, bunions (except capsular or bone surgery), calluses, toenails, fallen arches, weakfeet, chronic foot strain and symptomatic complaints of the feet; 11. Health spa or similar facilities; strengthening programs;12. Hearing examinations or hearing aids; or other treatment for hearing defects and problems except as specifically provided in the Benefits for Child Health Screening Services or exceptwhen due to an Injury. "Hearing defects" means any physical defect of the ear which does orcan impair normal hearing, apart from the disease process; 13. Immunizations; except as specifically provided in the policy; preventive medicines or vaccines, except where required for treatment of a covered Injury; 14. Injury or Sickness for which benefits are paid or payable under any Workers' Compensation or Occupational Disease Law or Act, or similar legislation; 15. Injury sustained while (a) participating in any intercollegiate, or professional sport, contest or competition; (b) traveling to or from such sport, contest or competition as a participant; or (c)while participating in any practice or conditioning program for such sport, contest orcompetition; 16. Investigational services;17. Lipectomy; 18. Participation in a riot or civil disorder; commission of or attempt to commit a felony; or fighting;19. Pre-existing Conditions, except for individuals who have been continuously insured under the school’s student insurance policy for at least 6 consecutive months; If an individual: (1) hadcoverage under a Previous Plan as defined below; and (2) that coverage was continuous to adate not more than 63 days prior to the person’s Effective Date under this Policy, the time underthe Previous Plan will be credited toward the 6 consecutive months needed to provide benefitsfor a Pre-existing Condition. A “Previous Plan” means any accident and health insurance policyor certificate, nonprofit hospital or medical service corporation, HMO, MEWA, or plan providedby another benefit arrangement, including a government plan or program providing healthbenefits or health care. It does not include a Medicare Supplement; 20. Prescription Drugs, services or supplies as follows: Therapeutic devices or appliances, including: hypodermic needles, syringes, supportgarments and other non-medical substances, regardless of intended use; except asspecifically provided under the Benefits for Diabetes; Birth control and/or contraceptives, oral or other, whether medication or device, except asspecifically provided in the policy; Immunization agents, biological sera, blood or blood products administered on anoutpatient basis; Drugs labeled, “Caution - limited by federal law to investigational use” or experimentaldrugs; Drugs used to treat or cure baldness; anabolic steroids used for body building; Anorectics - drugs used for the purpose of weight control; Fertility agents or sexual enhancement drugs, such as Parlodel, Pergonal, Clomid, Profasi,Metrodin, Serophene, or Viagra; Refills in excess of the number specified or dispensed after one (1) year of date of theprescription; 21. Reproductive/Infertility services including but not limited to: family planning; fertility tests; infertility (male or female), including any services or supplies rendered for the purpose or withthe intent of inducing conception; premarital examinations; impotence, organic or otherwise;tubal ligation; vasectomy; sexual reassignment surgery, reversal of sterilization procedures; 22. Research or examinations relating to research studies, or any treatment for which the patient or the patient’s representative must sign an informed consent document identifying thetreatment in which the patient is to participate as a research study or clinical research study,except for Covered Medical Expenses incurred in connection with participation in approvedclinical trials; 23. Routine Newborn Infant Care, well-baby nursery and related Physician charges in excess of 48 hours for vaginal delivery or 96 hours for cesarean delivery; 24. Preventive testing or treatment; screening exams or testing in the absence of Injury or Sickness; except as specifically provided under “Benefits for Child Health Screening Services”; 25. Services provided normally without charge by the Health Service of the Policyholder; or services covered or provided by the student health fee; 26. Skeletal irregularities of one or both jaws, including orthognathia and mandibular retrognathia; temporomandibular joint dysfunction; deviated nasal septum, including submucous resectionand/or other surgical correction thereof; nasal and sinus surgery, except for treatment ofchronic purulent sinusitis; 27. Flight in any kind of aircraft, except while riding as a passenger on a regularly scheduled flight 28. Supplies, except as specifically provided in the policy;29. Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices, or 30. Treatment in a Government hospital, unless there is a legal obligation for the Insured Person to 31. War or any act of war, declared or undeclared; or while in the armed forces of any country (a pro-rata premium will be refunded upon request for such period not covered); and 32. Weight management, weight reduction, nutrition programs, treatment for obesity, surgery for Insured Students have access to nurse advice, health information, and counseling support 24 hoursa day, 7 days a week by dialing the number indicated on the permanent ID card. Collegiate AssistanceProgram is staffed by Registered Nurses and Licensed Clinicians who can help students determineif they need to seek medical care, need legal/financial advice or may need to talk to someone abouteveryday issues that can be overwhelming.
Scholastic Emergency Services: Global Emergency Medical Assistance If you are a student insured with this insurance plan, you and your insured spouse and minor child(ren)are eligible for Scholastic Emergency Services (SES). The requirements to receive these services areas follows: International Students, insured spouse and insured minor child(ren): You are eligible to receive SESworldwide, except in your home country.
Domestic Students, insured spouse and insured minor child(ren): You are eligible for SES when 100miles or more away from your campus address and 100 miles or more away from your permanenthome address or while participating in a Study Abroad program. SES includes Emergency MedicalEvacuation and Return of Mortal Remains that meet the Department of Homeland Securityrequirements. The Emergency Medical Evacuation services are not meant to be used in lieu of orreplace local emergency services such as an ambulance requested through emergency 911telephone assistance. All SES must be arranged and provided by SES, any services not arranged bySES will not be considered for payment.
• Medical Consultation, Evaluation and Referral • Care for Minor Children Left Unattended Due to a Medical Incident• Lost Luggage or Document Assistance Please visit your school’s insurance coverage page at www.uhcsr.com for the Scholastic EmergencyServices Global Emergency Assistance Services brochure which includes service descriptions andprogram exclusions and limitations.
To access services please call: (877) 488-9833 Toll-free within the United States, (609) 452-8570Collect outside the United States.
Services are also accessible via e-mail at [email protected].
When calling the SES Operations Center, please be prepared to provide: 1. Caller's name, telephone and (if possible) fax number, and relationship to the patient;2. Patient's name, age, sex, and Reference Number;3. Description of the patient’s condition;4. Name, location, and telephone number of hospital, if applicable;5. Name and telephone number of the attending physician; and6. Information of where the physician can be immediately reached.
SES is not travel or medical insurance but a service provider for emergency medical assistanceservices. All medical costs incurred should be submitted to your health plan and are subject to thepolicy limits of your health coverage. All assistance services must be arranged and provided by SES.
Claims for reimbursement of services not provided by SES will not be accepted. Please refer to yourSES brochure for Program Guidelines as well as limitations and exclusions pertaining to the SESprogram.
UnitedHealthcare StudentResources insureds have online access to claims status, Explanation ofBenefits, correspondence and coverage information via My Account at www.uhcsr.com. Insureds canalso print a temporary ID card, request a replacement ID card and locate network providers from MyAccount. If you don’t already have an online account, simply select the “Create an Account” link from the homepage at www.uhcsr.com. Follow the simple, onscreen directions to establish an online account inminutes. Note that you will need your 7-digit insurance ID number to create an online account. If youalready have an online account, just log in from www.uhcsr.com to access your account information.
In the event of Injury or Sickness, the student should: 1)Report to the Student Health Service or Infirmary for treatment or referral, or when not in school, to 2)Mail to the address below all medical and hospital bills along with the patient's name and insured student's name, address, social security number and name of the university under which the studentis insured. A Company claim form is not required for filing a claim.
3)File claim within 30 days of Injury or first treatment for a Sickness. Bills should be received by the Company within 90 days of service. Bills submitted after one year will not be considered forpayment except in the absence of legal capacity.
UnitedHealthcare StudentResourcesP.O. Box 809025Dallas, Texas [email protected]@uhcsr.com UnitedHealthcare StudentResources1-800-237-0903E-mail: [email protected] Please keep this Brochure as a general summary of the insurance. The Master Policy on file at theUniversity contains all of the provisions, limitations, exclusions and qualifications of your insurancebenefits, some of which may not be included in this Brochure. The Master Policy is the contract andwill govern and control the payment of benefits.
This Brochure is based on Policy #2009-482-1/2 NUMBER: 2009-482-1/2
NOTICE:The benefits contained within have been revised since publication. The revisions areincluded within the body of the document, and are summarized on the last page of thedocument for ease of reference.
NOC 7 02/01/2010
1. To clarify that allergy testing is covered under this policy, we need to add "includes allergy testing"under Test and Procedures in the Schedule of Benefits.
2. Add the following to Exclusion #20B: "except as specifically provided in the policy" NOC 6 02/01/2010
1. Remove Exclusion # 18 - OP Physiotherapy, in it's entirety.
2. Add to the parenthetical under the OP Physiotherapy benefit, the following wording, OR; whenprescribed by the Attending Physician and treatment is not following surgery. Covered medicalexpenses are paid on the same basis as any expense up to a maximum of one visit per day, and upto a maximum of 10 visits per year. (Includes Chiropractic expenses) 3. On the In and OP Anesthetist, please change FROM; covered under Surgery, TO; PA / U&C NOC 5 01/11/2010
1. Exclusion #15 has been removed. “Injury or Sickness outside the United States and its possessions, Canada or Mexico, except for a Medical Emergency when traveling for academicstudy abroad programs;” NUMBER: 2009-482-1/2
NOTICE:The benefits contained within have been revised since publication. The revisions areincluded within the body of the document, and are summarized on the last page of thedocument for ease of reference.
NOC 4 09/24/2009
FROM: All full-time domestic students and International students (full and part-time) enrolled orattending classes are required to participate in the plan on a hard-waiver basis. All full-time Graduatestudents enrolled in Dissertation Guidance, may participate in the plan on a voluntary basis. All part-time domestic students may participate in the plan on a voluntary basis. Eligible Dependents ofenrolled students may participate in the plan on a voluntary basis. Students must actively attendclasses for the first 31 days after the date for which coverage is purchased, or be enrolled formatriculation. TO: All full-time domestic undergraduate and graduate students and International undergraduate andgraduate students (full and part-time), enrolled or attending classes, are required to participate in theplan on a hard-waiver basis. All part-time domestic students may participate in the plan on a voluntarybasis. Eligible Dependents of enrolled students may participate in the plan on a voluntary basis.
Students must actively attend classes for the first 31 days after the date for which coverage ispurchased, or, if not required to physically attend classes in order to complete their course of study,must be enrolled for 31 days after the date for which coverage is purchased.
2. The Pre-existing exclusion (in the exclusions and limitations and in the Major Medical exclusions)have been changed 12/12 to 6/6. See below.
Pre-existing Conditions, except for individuals who have been continuously insured under the school’sstudent insurance policy for at least 6 consecutive months; If an individual: (1) had coverage under aPrevious Plan as defined below; and (2) that coverage was continuous to a date not more than 63days prior to the person’s Effective Date under this Policy, the time under the Previous Plan will becredited toward the 6 consecutive months needed to provide benefits for a Pre-existing Condition. A“Previous Plan” means any accident and health insurance policy or certificate, nonprofit hospital ormedical service corporation, HMO, MEWA, or plan provided by another benefit arrangement, includinga government plan or program providing health benefits or health care. It does not include a MedicareSupplement.
Added the language in red to Diagnostic Parenthetical benefit in the SOB: (Includes testing for Attention deficit disorder, attention deficit hyperactivity disorder and dyslexia. The Exclusion for learning disabilities will be waived and benefits paid for learning disability testing only.
No benefits are payable for learning disability treatment, except as specifically provided underBenefits for Mental and Nervous Disorder, Alcoholism and Drug Dependency; and under Benefits forHabilitative Services For The Treatment of Congenital or Genetic Birth Defects.) NOC 3 9/17/2009
FROM: All full-time domestic students and international students (full and part-time) enrolled or attending classes are required to participate in the plan on a hard-waiver basis. All part-timedomestic students may participate in the plan on a voluntary basis. Eligible Dependents ofenrolled students may participate in this plan on a voluntary basis; TO: All full-time domestic students and international students (full and part-time) enrolled or attending classes are required to participate in the plan on a hard-waiver basis. All full-timeGraduate students enrolled in Dissertation Guidance may participate in the plan on a voluntarybasis. All part-time domestic students may participate in the plan on a voluntary basis. EligibleDependents of enrolled students may participate in this plan on a voluntary basis. Students mustactively attend classes for at least the first 31 days after the date for which coverage ispurchased, or be enrolled for matriculation.
2. Inpatient Benefits added Skilled Nursing facility (semi-private room rate) 80/60, in lieu of confinement in a hospital as a full time inpatient, or within 24 hrs following a hospital confinementand for the same or related causes, such as hospital confinement. 3. Inpatient Benefits added Rehabilitation Facility (semi-private room rate) 80/60 50 Day Max (confinement must follow within 24 hours of and be for the same or related causes as a period ofhospital or skilled nursing facility confinement). 4. Diagnostic Learning Disability Testing – 80/60 – Includes testing for Attention deficit disorder, attention deficit hyperactivity disorder and dyslexia). The Exclusion for learning disabilities will bewaived and benefits paid for learning disability testing only. No benefits are payable for learningdisability treatment. 5. Temporomandibular Joint Dysfunction Non-Surgical Treatment only – 80/60, the exclusion for TMJ will be waived and benefits paid for non-surgical treatment of Temporomandibular Jointdysfunction. 7. Routine Physical Exam 80/60 Includes lab, x-ray and other tests given in connection with the exam, and materials for the administration of immunizations for infectious disease & testing fortuberculosis. Benefits for materials for the administration of immunizations are covered, except asotherwise mandated.
8. Removing “allergy testing” from the Acne & Allergy exclusion 9. Adding back attention deficit disorder to the Learning Disabilities exclusion 10. Adding back the Exclusion for Circumcision (and added “including circumcision” parenthetical under the Routine newborn care benefit in the SOB). 11. Deleting “Routine Physical examinations and routine testing” from the Routine and preventative 12. Adding “Contraception covered only when medically necessary” to the Rx benefit in the SOB.
13. Inpatient and Outpatient benefits adding “Second Surgical Opinion” – 80/60 to Schedule of 14. Adding to Other - “High Cost Procedures (Includes CAT Scan, MRI Laser Treatment; any Outpatient procedures costing over $200) – 80/60 15. Deleted from– Medical Emergency Expenses (Outpatient) “ Treatment must be rendered within 72 hours from time of Injury or first onset of Sickness.” FROM: Coverage for late enrollees may be possible only under certain conditions. Please contact the CUA Student Insurance Administrator at (202) 319-6634 or email [email protected] for more information.
Coverage for late enrollees may be possible only under certain conditions. After theenrollment deadline, only those students who have involuntarily lost health insurancecoverage through a “Qualifying Life Event” such as (1) removal from a parent’s healthinsurance plan after achieving a landmark birthday that disqualifies them from a parent’shealth insurance plan or (2) losing private insurance through loss of employment ordivorce, may apply for late enrollment. A certificate of creditable coverage stating thedate of the involuntary loss of health coverage must be submitted to the CUA InsuranceAdministrator within 31 days of the qualifying life event. Please contact the CUA StudentInsurance Administrator at 202-319-6634 or e-mail [email protected] formore information.
1. Optional Major Medical: the following statement should say "may NOT be added later.” The wordNOT was missing and has now been added: The Major Medical Benefit begins payment after the Basic Maximum Benefit of $250,000 has been paid by the Company. Optional benefits may only be purchased at the time ofinitial enrollment in the Plan and may not be added later.
1. Continuation changed from 3 to 6 months.

Source: http://studentinsurance.cua.edu/res/docs/2009-482-1-2-brochure-v8-noc7.pdf