Student Health Insurance Plan Western Michigan University. Graduate Appointees/Teaching Assistants

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1 Student Health Insurance Plan Western Michigan University Graduate Appointees/Teaching Assistants Underwritten by: Aetna Life Insurance Company Policy Number

2 WHERE TO FIND HELP In case of an emergency, call 911 or your local emergency hotline, or go directly to an emergency care facility. For nonemergency situations please visit or call Sindecuse Health Center at (269) For questions about: Insurance Benefits Enrollment Claims Processing Pre-Certification Requirements Lost ID cards Please contact: Aetna P.O. Box El Paso, TX (877) Identification Cards: ID cards will be issued as soon as possible. If you need medical attention before the ID card is received, benefits will be payable according to the Policy. You do not need an ID card to be eligible to receive benefits. Once you have received your ID card, present it to the provider to facilitate prompt payment of your claims. For questions about: Sindecuse Health Center Referrals On Campus Support Locating Preferred Provider Sites Assistance with Benefits Enrollment Forms Brochures Please contact: Sindecuse Health Center Insurance Manager (269) Or For questions about: Status of Pharmacy Claim Pharmacy Claim Forms Excluded Drugs and Pre-Authorization Please contact: Aetna Pharmacy Management (800) (Available 24 hours) For questions about: Provider Listings To find a complete list of participating providers, you can use Aetna s DocFind Service at 2

3 For questions about: On Call International 24/7 Emergency Travel Assistance Services Please contact: On Call International at (866) (within U.S.). If outside the U.S., call collect by dialing the U.S. access code (001) plus (603) Please also visit and visit your school-specific site for further information. IMPORTANT NOTE Please keep this Brochure, as it provides a general summary of your coverage. A complete description of the benefits and full terms and conditions may be found in the Master Policy issued to Western Michigan University. If any discrepancy exists between this Brochure and the Policy, the Master Policy will govern and control the payment of benefits. The Master Policy may be viewed at the Insurance Office in Sindecuse Health Center during business hours. This student Plan fulfills the definition of Creditable Coverage explained in the Health Insurance Portability and Accountability Act (HIPAA) of At any time should you wish to receive a certification of coverage, please call the customer service number on your ID card. 3

4 TABLE OF CONTENTS Page Numbers Sindecuse Health Center... 5 Policy Period... 6 Rates... 6 Deductibles... 7 Student Coverage... 7 Enrollment & Waiver Deadlines... 7 Refund Policy... 8 Dependent Coverage Eligibility... 8 Continuously Insured... 9 Preferred Provider Network... 9 Referral Requirements... 9 Pre-Certification Program Pre-Existing Conditions Inpatient Hospitalization Benefits Surgical Benefits Outpatient Benefits Mental Health Benefits Substance Abuse Benefits Maternity Benefits Additional Benefits Additional Services and Discounts General Provisions Extension of Benefits Termination of Insurance Exclusions Definitions Claim Procedure Prescription Drug Claim Procedure On Call International Accidental death & Dismemberment Aetna Navigator Notice

5 SINDECUSE HEALTH CENTER The Sindecuse Health Center is a student oriented medical facility that exists to support and promote optimal health for the Western Michigan University community. The Health Center Physicians, Physician assistants, nurses, laboratory personnel, pharmacists, physical therapists, health educators, and staff work to assist students with a wide variety of health care concerns. Become familiar with the Sindecuse Health Center convenient, cost-effective, student-centered services. Hours: 8:00 a.m. 6:00 p.m. Monday* 8:00 a.m. 5:00 p.m. Tuesday, Wednesday and Friday* 9:00 a.m. 5:00 p.m. Thursday* 8:00 a.m. 12:00 p.m. Saturday (Pharmacy Only) *Pharmacy Drive Thru pick-up window open until 5:30 p.m. M-F Appointment and Clinician of Choice Medical services include: family practice, gynecology, internal medicine, psychiatry, dermatology, sports medicine, and nutrition counseling. Referrals to community specialists will be made when indicated. Same-Day Care Clinic For sudden problems that need immediate attention. Full-Service Pharmacy Provides prescriptions at a cost savings for students. Family Physician Prescriptions honored. Laboratory Services Performs most general diagnostic tests. Laboratory test results often evaluated while students wait for prompt treatment X-ray Services Provides general diagnostic X-rays. All X-rays available for immediate evaluation, then reviewed by radiologist. HIV Counseling and Testing Anonymous HIV counseling and testing are available to all students. For more information call (269) 387-4HIV. Allergy Injections Administered during conveniently scheduled hours. Student provides antigen and injection schedule from allergist. Immunizations and TB Testing Immunizations available upon request including hepatitis B, tetanus, and measles. Comprehensive travel immunizations program in place. TB testing is available and required for some classes and jobs. TB screening provided at the Sindecuse Health Center is covered at 100% under the Plan. HPV vaccinations are covered at 100% under the Comprehensive Plan only. Sports Medicine Clinic Provides comprehensive diagnosis and treatment of Injuries and joint pains. Complete physical therapy services are available at reduced rates. Health Promotion Opportunities for Students The Health Center offers a wide range of programs, information, and self-help resources to help you maintain and enhance your health. Our interactive Health Resources Center features computer assisted learning that provides a visual approach to skills and information that can help you enhance your health and quality of life. Annual Preventative Exam Covered Medical for an Annual Preventative Exam at Sindecuse Health Center are payable at 100% of the Negotiated Rate. 5

6 Important Information Please keep the following phone numbers for reference. For an appointment at the Sindecuse Health Center: (269) To talk to the Insurance Manager at the Sindecuse Health Center: (269) Or POLICY PERIOD 1. Students: Coverage for all insured students enrolled for the 2011/2012 Academic year, will become effective at 12:01 AM on August 24, 2011, and will terminate at 11:59 PM on August 23, Insured dependents: Coverage will become effective on the same date the insured student s coverage becomes effective. Coverage for insured dependents terminates in accordance with the Termination Provisions described in the Master Policy. For more information on Termination of Covered Dependents see page 38 of this Brochure. Examples include, but are not limited to: the date the student s coverage terminates, the date the dependent no longer meets the definition of a dependent. RATES Basic Plan Option A Annual Coverage 08/24/11-08/23/12 Fall 08/24/11-12/31/11 Option B: Tri-Annual Coverage Spring 01/01/12-05/02/12 Summer 05/03/12-8/23/12 Student Only* $1,986 $ 707 $ 664 $ 615 Spouse Only* $4,913 $1,750 $1,642 $1,521 Child Only $1,953 $ 696 $ 653 $ 604 All Children $3,410 $1,215 $1,141 $1,054 *The rates above include both premium for the Student Health Plan underwritten by Aetna Life Insurance Company, as well as Western Michigan University s administrative fee. Comprehensive Plan Option A Annual Coverage 08/24/11-08/23/12 Fall 08/24/11-12/31/11 Option B: Tri-Annual Coverage Spring 01/01/12-05/02/12 Summer 05/03/12-8/23/12 Student Only* $2,739 $ 976 $ 916 $ 847 Spouse Only* $6,794 $2,420 $2,271 $2,103 Child Only $2,706 $ 964 $ 905 $ 837 All Children $4,726 $1,684 $1,580 $1,462 *The rates above include both premium for the Student Health Plan underwritten by Aetna Life Insurance Company, as well as Western Michigan University s administrative fee. 6

7 DEDUCTIBLES The following Deductible are applied before Covered Medical are payable: Basic: Individual: $350 per Policy Year Comprehensive: Individual: $350 per Policy Year Deductible is waived at Sindecuse Health Center. WESTERN MICHIGAN UNIVERSITY STUDENT ACCIDENT AND SICKNESS INSURANCE PLAN This is a brief description of the Accident and Sickness Medical Expense benefits available for Western Michigan University Graduate Assistants, Teaching Assistants, and their eligible Dependents. The Plan is underwritten by Aetna Life Insurance Company (called Aetna). The exact provisions governing this insurance are contained in the Master Policy issued to the University. STUDENT COVERAGE ELIGIBILITY All Graduate Assistants and Teaching Assistants students are eligible to purchase either the Basic Student Health Insurance Plan or the Comprehensive Student Health Insurance Plan. To enroll for this insurance benefit and elect one of the two plans, go to the link to the health insurance enrollment website at: For you to be eligible to enroll, your department must have submitted your appointment form through the Office of Human Resources. You will need to enter your WIN and birth date for the system to verify your eligibility and allow you to proceed to the enrollment form. If the enrollment system advises you that verification failed, first contact your hiring department to determine when your appointment form was submitted to Human Resources and then you may contact the Graduate College for assistance at (269) , , or Online enrollments will be accepted through Friday, September 23, 2011 for Fall. After that date, enrollments will only be processed through the Graduate College on a case-by-case basis. You may contact the Graduate College at (269) for further information about the Graduate Appointee health insurance benefit. ENROLLMENT & WAIVER DEADLINES Enrollment and waiver deadlines are listed below. Category Waiver Deadline Date Annual or Fall 09/23/11 Spring or Spring/Summer 01/20/12 Summer 05/18/12 7

8 REFUND POLICY If you withdraw from school within the first 31 days of a coverage period, you will not be covered under the Policy and the full premium will be refunded, less any claims paid. After 31 days, you will be covered for the full period that you have paid the premium for, and no refund will be allowed. (This refund policy will not apply if you withdraw due to a covered Accident or Sickness). Exception: A Covered Person entering the armed forces of any country will not be covered under the Policy as of the date of such entry. In this case, a pro-rata refund of premium will be made for any such person and any Covered Dependents upon written request received by Aetna Student Health within 90 days of withdrawal from school. DEPENDENT COVERAGE ELIGIBILITY Covered students may also enroll their lawful spouse and children under age 26 years of age. Dependent eligibility expires concurrently with that of the insured students. To enroll the eligible dependent(s) of a Covered Student, go to Select Western Michigan University from the Find Your School drop down menu. Follow the prompts for dependent enrollment. (1) A Covered Dependent who will loose coverage due to his/her age (26) may stay on the Plan if the dependent is incapable of self support due to a mental or physical disability and is dependent on subscriber for support. Proof of dependency must be presented within 31 days of loss of coverage. (2) A Covered Dependent who is a Covered Dependent due to full or part-time student status must be allowed to continue coverage on the Plan while taking a leave of absence from school due to an illness or injury. The coverage for the dependent on a leave of absence shall continue for at least 12 months or until the dependent reaches the age which he or she would normally terminate from the Plan, Proof of illness or injury can be required. (Applies to any policy or contract for disability insurance). Insurance may be continued for incapacitated Dependent children who reach the age at which insurance would otherwise cease. The Dependent child must be chiefly dependent for support upon the Covered Student and be incapable of selfsustaining employment because of mental or physical handicap. NEWBORN INFANT AND ADOPTED CHILD COVERAGE A child born to a Covered Person shall be covered for Accident, Sickness, and congenital defects, for 31 days from the date of birth. At the end of this 31 day period, coverage will cease under the Western Michigan University Student Health Insurance Plan. To extend coverage for a newborn past the 31 days, the Covered Student must: 1) enroll the child within 31 days of birth, and 2) pay the additional premium, starting from the date of birth. Coverage is provided for a child legally placed for adoption with a Covered Student for 31 days from the moment of placement provided the child lives in the household of the Covered Student, and is dependent upon the Covered Student for support. To extend coverage for an adopted child past the 31 days, the Covered Student must 1) enroll the child within 31 days of placement of such child, and 2) pay any additional premium, if necessary, starting from the date of placement. For information or general questions on dependent enrollment, contact Aetna Student Health at (877)

9 CONTINUOUSLY INSURED Persons who have remained continuously insured under this Plan or other policies will be covered for any Pre-Existing Condition, which manifests itself while continuously insured, except for expenses payable under prior policies in the absence of this Plan. Previously Covered Persons must re-enroll for coverage, including Dependent coverage, in order to avoid a break in coverage for conditions which existed in prior policy years. Once a break in continuous coverage occurs, the Pre- Existing Conditions Limitation will apply. PREFERRED PROVIDER NETWORK Aetna Student Health has arranged for you to access a Preferred Provider Network in your local community. Acute care facilities and mental health networks are available nationally if you require hospitalization outside the immediate area of the Western Michigan University campus. To maximize your savings and reduce your out-of-pocket expenses, select a Preferred Provider. It is to your advantage to use a Preferred Provider because savings may be achieved from the Negotiated Charges these providers have agreed to accept as payment for their services. Preferred Providers are independent contractors, and are neither employees nor agents of Western Michigan University, Aetna Student Health, or Aetna. You may obtain information regarding Preferred Providers through the Internet by accessing DocFind at 1. Click on Enter DocFind 2. Select zip code, city, or county 3. Enter criteria 4. Select Provider Category 5. Select Provider Type 6. Select Plan Type Student Health Plans 7. Select Start Search or More Options 8. More Options enter criteria and Search Preferred providers are independent contractors and are neither employees nor agents of Aetna Life Insurance Company, Chickering Claims Administrators, Inc. or their affiliates. Neither Aetna Life Insurance Company, Chickering Claims Administrators, Inc. nor their affiliates provide medical care or treatment and they are not responsible for outcomes. The availability of a particular provider(s) cannot be guaranteed and network composition is subject to change. REFERRAL REQUIREMENTS Unless otherwise noted, a referral from Sindecuse Health Center (SHC) is necessary to access your health insurance coverage under the Plan. Without a referral, benefits are not payable, and you will be responsible for any cost incurred outside of Sindecuse Health Center. Prior referral is not necessary for the following: Treatment of an Emergency Medical Condition. A referral is required for follow-up care related to the emergency room visit; When Sindecuse Health Center is closed; When service is rendered at another facility during break or vacation periods; Medical care received when the student is more than 25 miles from campus; Medical care obtained when a student is no longer enrolled at the University due to a change in student status; Maternity and OBGYN; or Psychotherapy. Dependent children under age 12 are not eligible to use the SHC and therefore are exempt from the above limitations and requirements. NOTE: Only one referral per Covered Condition per Policy Year is required. 9

10 PRE-CERTIFICATION PROGRAM Pre-Certification means calling Aetna Student Health prior to treatment to obtain approval for a medical procedure or service. Pre-Certification may be done by you, your doctor, a hospital administrator, or one of your relatives. All requests for certification must be obtained by contacting Aetna Student Health at (877) (attention Managed Care Department). If you do not secure Pre-Certification for non emergency inpatient admissions, or provide notification for emergency admissions, your Covered Medical will be subject to a $200 per admission Deductible. If you do not secure Pre-Certification for partial hospitalizations, your Covered Medical will be subject to a $200 Deductible. The following inpatient and outpatient services or supplies require Pre-Certification: All inpatient admissions, including length of stay, to a hospital, convalescent facility, skilled nursing facility, a facility established primarily for the treatment of substance abuse, or a residential treatment facility. All inpatient maternity care, after the initial 48/96 hours. All partial hospitalization in a hospital, residential treatment facility, or facility established primarily for the treatment of substance abuse. Pre-Certification does not guarantee the payment of benefits for your inpatient admission. Each claim is subject to medical policy review, in accordance with the exclusions and limitations contained in the Policy, as well as a review of eligibility, adherence to notification guidelines, and benefit coverage under the student Accident and Sickness Plan. Pre-Certification of Non-Emergency Inpatient Admissions, Partial Hospitalization, Identified Outpatient Services and Home Health Services: The patient, Physician or hospital must telephone at least three (3) business days prior to the planned admission or prior to the date the services are scheduled to begin. Notification of Emergency Admissions: The patient, patient s representative, Physician or hospital must telephone within two (2) business day following inpatient (or partial hospitalization) admission. PRE-EXISTING CONDITIONS/ CONTINUOUSLY INSURED PROVISIONS Pre-Existing Condition A Pre-Existing Condition is an injury or disease that was present before your first day of coverage under a group health insurance plan. If you received treatment or services for that injury or disease or you took prescription drugs or medicines for that injury or disease during the 180 days prior to your first day of coverage, that injury or disease will be considered a Pre- Existing Condition. Limitation Pre-Existing Conditions are not covered during the first 180 days that you are covered under this Plan. However, there is an important exception to this general rule if you have been Continuously Insured. Continuously Insured You have been continuously insured if you (i) had creditable health insurance coverage (such as COBRA, HMO, another group or individual policy, Medicare or Medicaid) prior to enrolling in this Plan, and (ii) the creditable coverage ended within 63 days of the date you enrolled under this Plan. If both of these tests are met, then the pre-existing limitation period under this Plan will be reduced (and possibly eliminated altogether) by the number of days of your prior creditable coverage. You will be asked to provide evidence of your prior creditable coverage. Once a break of more than 63 days in your continuous coverage occurs, the definition of Pre-Existing Conditions will apply. 10

11 DESCRIPTION OF BENEFITS The Western Michigan University Graduate Assistants / Teaching Assistants Student Health Insurance Plans may not cover all of your health care expenses. The Plans exclude coverage for certain services and contain limitations on the amounts it will pay. Please read the 2011/2012 Western Michigan University Graduate Assistants / Teaching Assistants Student Health Insurance Plan Brochure carefully before deciding whether either Plan is right for you. While this document will tell you about some of the important features of the Plans, other features may be important to you and some may further limit what the Plans will pay. If you want to look at the full Plan descriptions which are contained in the Master Policy issued to Western Michigan University, you may view it at the Insurance Office of Sindecuse Health Center or you may contact Aetna Student Health at (877) The Plan will never pay more than $75,000 (Basic) or $100,000 (Comprehensive) per Condition per Policy Year. The Prescription Maximum is $750 (Basic) or $2,500 (Comprehensive) per Policy Year. Additional Plan maximums may also apply. Some illnesses may cost more to treat and health care providers may bill you for what the Plan does not cover. Subject to the terms of the Policy, benefits are available for you and your eligible Dependents only for the coverages listed below, and only up to the maximum amounts shown. Please refer to the Policy for a complete description of the benefits available. SUMMARY OF BENEFITS CHART DEDUCTIBLES The following per Policy Year Deductible is applied before Covered Medical are payable: Basic: Individual: $350 per Policy Year Comprehensive: Individual: $350 per Policy Year Deductible is waived at Sindecuse Health Center. COINSURANCE Covered Medical are payable at the Coinsurance percentage specified below, after any applicable Deductible, up to a maximum benefit of $75,000 (Basic) or $100,000 (Comprehensive) per Condition per Policy Year. All coverage is based on Recognized Charges unless otherwise specified. Basic Plan Inpatient Hospitalization Benefits Hospital Room and Board Covered Medical are payable as Preferred Care: 80% of the Negotiated Charge up to $25,000, then 100% thereafter. Charge for a semi-private room. Comprehensive Plan Covered Medical are payable as Preferred Care: 80% of the Negotiated Charge up to $25,000, then 100% thereafter. Charge for a semi-private room. Intensive Care Unit Covered Medical are payable as Preferred Care: 80% of the Negotiated Charge up to $25,000, then 100% thereafter. Charge for the Intensive Care Room Rate for an overnight stay. Covered Medical are payable as Preferred Care: 80% of the Negotiated Charge up to $25,000, then 100% thereafter. Charge for the Intensive Care Room Rate for an overnight stay. 11

12 Miscellaneous Hospital Covered Medical are payable as Preferred Care: 80% of the Negotiated Charge up to $25,000, then 100% thereafter. Covered Medical include, but are not limited to: laboratory tests, X-rays, surgical dressings, anesthesia, supplies and equipment use, and medicines. Covered Medical are payable as Preferred Care: 80% of the Negotiated Charge up to $25,000, then 100% thereafter. Covered Medical include, but are not limited to: laboratory tests, X-rays, surgical dressings, anesthesia, supplies and equipment use, and medicines. Physician Hospital Visit/ Consultation Covered Medical for charges for the non-surgical services of the attending Physician, or a consulting Physician, are payable as Preferred Care: 80% of the Negotiated Charge up to $25,000, then 100% thereafter. Benefit is limited to one visit per day. Covered Medical for charges for the non-surgical services of the attending Physician, or a consulting Physician, are payable as Preferred Care: 80% of the Negotiated Charge up to $25,000, then 100% thereafter. Benefit is limited to one visit per day. Surgical Benefits (Inpatient and Outpatient) Surgical Covered Medical for charges for surgical services, performed by a Physician, are payable as Preferred Care: 80% of the Negotiated Charge up to $25,000, then 100% thereafter. Covered Medical for charges for surgical services, performed by a Physician, are payable as Preferred Care: 80% of the Negotiated Charge up to $25,000, then 100% thereafter. Anesthesia Covered Medical for the charges of Anesthesia, during a surgical procedure, is payable up to 50% of the amount paid to the surgeon. Covered Medical for the charges of Anesthesia, during a surgical procedure, is payable up to 50% of the amount paid to the surgeon. Assistant Surgeon Covered Medical for the charges of an assistant surgeon, during a surgical procedure, are payable up to 25% of the amount paid to the surgeon. Covered Medical for the charges of an assistant surgeon, during a surgical procedure, are payable up to 25% of the amount paid to the surgeon. 12

13 Ambulatory Surgical Benefits are payable for Covered Medical incurred by a Covered Person for expenses incurred for outpatient surgery performed in an ambulatory surgical center. Covered Medical must be incurred on the day of the surgery or within 48 hours after the surgery. Preferred Care: 80% of the Negotiated Charge up to $25,000, then 100% thereafter. Benefit is payable to a maximum of $2,500 per Condition per Policy Year. Benefits are payable for Covered Medical incurred by a Covered Person for expenses incurred for outpatient surgery performed in an ambulatory surgical center. Covered Medical must be incurred on the day of the surgery or within 48 hours after the surgery. Preferred Care: 80% of the Negotiated Charge up to $25,000, then 100% thereafter. Benefit is payable to a maximum of $2,500 per Condition per Policy Year. Outpatient Benefits Physician s Office Visits Covered Medical are payable as Sindecuse Health Center: After a $10 per visit Copay, 100% of the Negotiated Preferred Care: After a $25 per visit Copay, 80% of the Negotiated Charge to $25,000, then 100% thereafter. Non-Preferred Care: After a $25 per visit Deductible, 60% of the Recognized Benefits are limited to 1 visit per day. Covered Medical are payable as Sindecuse Health Center: After a $10 per visit Copay, 100% of the Negotiated Preferred Care: After a $25 per visit Copay, 80% of the Negotiated Charge to $25,000, then 100% thereafter. Non-Preferred Care: After a $25 per visit Deductible, 60% of the Recognized Benefits are limited to 1 visit per day. Emergency Room Covered Medical include medically necessary services provided for the sudden onset of a medical condition that manifests itself by signs and symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in: serious jeopardy to the individual's health or to a pregnancy in the case of a pregnant woman, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. Benefits for Emergency Medical Services up to the point of stabilization are payable as Sindecuse Health Center: Follow-up care, after a $10 per visit Copay, 100% of the Negotiated Preferred Care: After a $150 per visit Copay (waived if admitted), 80% of the Negotiated Charge up to $25,000, then 100% thereafter. Covered Medical include medically necessary services provided for the sudden onset of a medical condition that manifests itself by signs and symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in: serious jeopardy to the individual's health or to a pregnancy in the case of a pregnant woman, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. Benefits for Emergency Medical Services up to the point of stabilization are payable as Sindecuse Health Center: Follow-up care, after a $10 per visit Copay, 100% of the Negotiated Preferred Care: After a. $150 per visit Copay (waived if admitted), 80% of the Negotiated Charge up to $25,000, then 100% thereafter. 13

14 Emergency Room (Continued) Laboratory Non-Preferred Care: After a $150 per visit Deductible (waived if admitted), 80% of the Recognized Charge up to $25,000, then 100% thereafter. Covered Medical are payable as Sindecuse Health Center: 100% of the Negotiated Preferred Care: After a $25 per visit Copay, 80% of the Negotiated Charge to $25,000, then 100% thereafter. Non-Preferred Care: After a $25 per visit Deductible, 60% of the Recognized Non-Preferred Care: After a $150 per visit Deductible (waived if admitted), 80% of the Recognized Charge up to $25,000, then 100% thereafter. Covered Medical are payable as Sindecuse Health Center: 100% of the Negotiated Preferred Care: After a $25 per visit Copay, 80% of the Negotiated Charge to $25,000, then 100% thereafter. Non-Preferred Care: After a $25 per visit Deductible, 60% of the Recognized X-Ray Covered Medical are payable as Sindecuse Health Center: 100% of the Negotiated Preferred Care: 80% of the Negotiated Charge to $25,000, then 100% thereafter. Covered Medical are payable as Sindecuse Health Center: 100% of the Negotiated Preferred Care: 80% of the Negotiated Charge to $25,000, then 100% thereafter. Hospital Outpatient Department Expense Covered Medical includes treatment rendered in a Hospital Outpatient Department. Covered Medical do not include Emergency Room/Urgent Care Treatment, Walkin Clinic, Therapy, Chemotherapy and Radiation, and outpatient surgical services, including physician, anesthesia and facility charges, which are covered as outlined under the individual benefit types listed in this schedule of benefits. Preferred Care: After a $25 per visit Copay, 80% of the Negotiated Charge to $25,000, then 100% thereafter. Non-Preferred Care: After a $25 per visit Deductible, 60% of the Recognized Covered Medical includes treatment rendered in a Hospital Outpatient Department. Covered Medical do not include Emergency Room/Urgent Care Treatment, Walkin Clinic, Therapy, Chemotherapy and Radiation, and outpatient surgical services, including physician, anesthesia and facility charges, which are covered as outlined under the individual benefit types listed in this schedule of benefits. Preferred Care: After a $25 per visit Copay, 80% of the Negotiated Charge to $25,000, then 100% thereafter. Non-Preferred Care: After a $25 per visit Deductible, 60% of the Recognized Walk-In Clinic Covered Medical include services rendered in a walk-in clinic. Covered Medical are payable as Preferred Care: After a $25 per visit Copay, 80% of the Negotiated Charge to $25,000, then 100% thereafter. Non-Preferred Care: After a $25 per visit Deductible, 60% of the Recognized Covered Medical include services rendered in a walk-in clinic. Covered Medical are payable as Preferred Care: After a $25 per visit Copay, 80% of the Negotiated Charge to $25,000, then 100% thereafter. Non-Preferred Care: After a $25 per visit Deductible, 60% of the Recognized 14

15 Urgent Care Benefits include charges for treatment by an urgent care provider. Please note: A Covered Person should not seek medical care or treatment from an urgent care provider if their illness, injury, or condition, is an emergency condition. The Covered Person should go directly to the emergency room of a hospital or call 911 (or the local equivalent) for ambulance and medical assistance. Urgent Care Benefits include charges for an urgent care provider to evaluate and treat an urgent condition. Covered Medical for urgent care treatment are payable as Preferred Care: After a $25 per visit Copay, 80% of the Negotiated Charge up to $25,000, then 100% thereafter. Non-Preferred Care: After a $25 per visit Deductible, 60% of the Recognized The Covered Person should contact their primary care Physician after medical care is provided to treat an urgent condition. Benefits include charges for treatment by an urgent care provider. Please note: A Covered Person should not seek medical care or treatment from an urgent care provider if their illness, injury, or condition, is an emergency condition. The Covered Person should go directly to the emergency room of a hospital or call 911 (or the local equivalent) for ambulance and medical assistance. Urgent Care Benefits include charges for an urgent care provider to evaluate and treat an urgent condition. Covered Medical for urgent care treatment are payable as Preferred Care: After a $25 per visit Copay, 80% of the Negotiated Charge up to $25,000, then 100% thereafter. Non-Preferred Care: After a $25 per visit Deductible, 60% of the Recognized The Covered Person should contact their primary care Physician after medical care is provided to treat an urgent condition. Ambulance Covered Medical are payable as 80% of the Actual Charge up to $25,000, then 100% thereafter for the services of a professional ambulance to or from a hospital, when required due to the emergency nature of a covered Accident or Sickness. Emergency medical health services include, but are not limited to, the use of emergency vehicles and emergency air transport to ensure the ability to stabilize the patient. Benefit for an Air Ambulance is payable to a $300 maximum per trip. Covered Medical are payable as 80% of the Actual Charge up to $25,000, then 100% thereafter for the services of a professional ambulance to or from a hospital, when required due to the emergency nature of a covered Accident or Sickness. Emergency medical health services include, but are not limited to, the use of emergency vehicles and emergency air transport to ensure the ability to stabilize the patient. Benefit for an Air Ambulance is payable to a $300 maximum per trip. Pre-Admission Testing Covered Medical for Pre-Admission testing charges while an outpatient before scheduled surgery are payable as any other condition. Covered Medical for Pre-Admission testing charges while an outpatient before scheduled surgery are payable as any other condition. 15

16 High Cost Procedure Covered Medical include charges incurred by a Covered Person are payable as Preferred Care: 80% of the Negotiated Charge to $25,000, then 100% thereafter. For purposes of this benefit, High Cost Procedure means any outpatient procedure costing over $200. Covered Medical include charges incurred by a Covered Person are payable as Preferred Care: 80% of the Negotiated Charge to $25,000, then 100% thereafter. For purposes of this benefit, High Cost Procedure means any outpatient procedure costing over $200. Dental Injury Expense Covered Medical include dental work, surgery, and orthodontic treatment needed to remove, repair, replace, restore, or reposition: Natural teeth damaged, lost, or removed, or Other body tissues of the mouth fractured or cut due to injury. The accident causing the injury must occur while the person is covered under this Plan. Any such teeth must have been: Free from decay, or In good repair, and Firmly attached to the jawbone at the time of the injury. If: Crowns (caps), or Dentures (false teeth), or Bridgework, or In-mouth appliances, are installed due to such injury, Covered Medical include only charges for: The first denture or fixed bridgework to replace lost teeth, The first crown needed to repair each damaged tooth, and An in-mouth appliance used in the first course of orthodontic treatment after the injury. Surgery needed to: Treat a fracture, dislocation, or wound. Cut out cysts, tumors, or other diseased tissues. Alter the jaw, jaw joints, or bite relationships by a cutting procedure when appliance therapy alone cannot result in functional improvement. Non-surgical treatment of infections or diseases. This does not include those of, or Covered Medical include dental work, surgery, and orthodontic treatment needed to remove, repair, replace, restore, or reposition: Natural teeth damaged, lost, or removed, or Other body tissues of the mouth fractured or cut due to injury. The accident causing the injury must occur while the person is covered under this Plan. Any such teeth must have been: Free from decay, or In good repair, and Firmly attached to the jawbone at the time of the injury. If: Crowns (caps), or Dentures (false teeth), or Bridgework, or In-mouth appliances, are installed due to such injury, Covered Medical include only charges for: The first denture or fixed bridgework to replace lost teeth, The first crown needed to repair each damaged tooth, and An in-mouth appliance used in the first course of orthodontic treatment after the injury. Surgery needed to: Treat a fracture, dislocation, or wound. Cut out cysts, tumors, or other diseased tissues. Alter the jaw, jaw joints, or bite relationships by a cutting procedure when appliance therapy alone cannot result in functional improvement. Non-surgical treatment of infections or diseases. This does not include those of, or 16

17 related to, the teeth. Covered Medical are payable as Preferred Care: 80% of the Actual Charge to $25,000, then 100% thereafter. Non-Preferred Care: 80% of the Actual Charge to $25,000, then 100% thereafter. related to, the teeth. Covered Medical are payable as Preferred Care: 80% of the Actual Charge to $25,000, then 100% thereafter. Non-Preferred Care: 80% of the Actual Charge to $25,000, then 100% thereafter. Allergy Testing Expense Benefits include charges incurred for diagnostic testing of allergies. Covered Medical include, but are not limited to, charges for the following: laboratory tests, Physician office visits, prescribed medications for testing of the allergy, including any equipment used in the administration of prescribed medication, and other medically necessary supplies and services. Covered Medical are payable as any other condition. Benefits include charges incurred for diagnostic testing of allergies. Covered Medical include, but are not limited to, charges for the following: laboratory tests, Physician office visits, prescribed medications for testing of the allergy, including any equipment used in the administration of prescribed medication, and other medically necessary supplies and services. Covered Medical are payable as any other condition. Diagnostic Testing for Attention Disorders and Learning Disabilities Expense Covered Medical for diagnostic testing for; attention deficit disorder, or attention deficit hyperactive disorder, are payable as Preferred Care: After a $25 per visit Copay, 80% of the Negotiated Charge to $25,000, then 100% thereafter. Non-Preferred Care: After a $25 per visit Deductible, 60% of the Recognized Once a Covered Person has been diagnosed with one of these conditions, medical treatment will be payable as detailed under the outpatient Treatment of Mental and Nervous Disorders portion of this Plan. Covered Medical for diagnostic testing for; attention deficit disorder, or attention deficit hyperactive disorder, are payable as Preferred Care: After a $25 per visit Copay, 80% of the Negotiated Charge to $25,000, then 100% thereafter. Non-Preferred Care: After a $25 per visit Deductible, 60% of the Recognized Once a Covered Person has been diagnosed with one of these conditions, medical treatment will be payable as detailed under the outpatient Treatment of Mental and Nervous Disorders portion of this Plan. 17

18 Physical Therapy and Occupational Therapy Covered Medical include charges incurred by a Covered Person for the following types of therapy provided on an outpatient basis: Physical Therapy, Occupational Therapy. Covered Medical are payable as Sindecuse Health Center: 100% of the Negotiated Preferred Care: After a $25 per visit Copay, 50% of the Negotiated. Non-Preferred Care: After a $25 per visit Deductible, 50% of the Recognized Benefits are limited to $1,000 per Policy Year. Physician prescribed massage therapy is limited to 1 visit per month to a $70 maximum per visit. Covered Medical include charges incurred by a Covered Person for the following types of therapy provided on an outpatient basis: Physical Therapy, Occupational Therapy. Covered Medical are payable as Sindecuse Health Center: 100% of the Negotiated Preferred Care: After a $25 per visit Copay, 50% of the Negotiated. Non-Preferred Care: After a $25 per visit Deductible, 50% of the Recognized Benefits are limited to $1,000 per Policy Year. Physician prescribed massage therapy is limited to 1 visit per month to a $70 maximum per visit. Speech and Hearing Therapy Covered Medical include charges incurred by a Covered Person for the following types of therapy provided on an outpatient basis: Speech Therapy, Hearing Therapy. Outpatient Care Covered Medical are payable as Preferred Care: After a $25 per visit Copay, 80% of the Negotiated Charge to $25,000, then 100% thereafter. Non-Preferred Care: After a $25 per visit Deductible, 60% of the Recognized Inpatient Care Covered Medical are payable as Preferred Care: 80% of the Negotiated Charge to $25,000, then 100% thereafter. Covered Medical include charges incurred by a Covered Person for the following types of therapy provided on an outpatient basis: Speech Therapy, Hearing Therapy. Outpatient Care Covered Medical are payable as Preferred Care: After a $25 per visit Copay, 80% of the Negotiated Charge to $25,000, then 100% thereafter. Non-Preferred Care: After a $25 per visit Deductible, 60% of the Recognized Inpatient Care Covered Medical are payable as Preferred Care: 80% of the Negotiated Charge to $25,000, then 100% thereafter. 18

19 Chemotherapy Radiation Therapy Covered Medical for chemotherapy, including anti-nausea drugs used in conjunction with the chemotherapy, radiation therapy, tests and procedures, physiotherapy (for rehabilitation only after a surgery), and expenses incurred at a radiological facility. Covered Medical also include expenses for the administration of chemotherapy and visits by a health care professional to administer the chemotherapy. Such expenses are payable as Preferred Care: 80% of the Negotiated Charge to $25,000, then 100% thereafter. Covered Medical for chemotherapy, including anti-nausea drugs used in conjunction with the chemotherapy, radiation therapy, tests and procedures, physiotherapy (for rehabilitation only after a surgery), and expenses incurred at a radiological facility. Covered Medical also include expenses for the administration of chemotherapy and visits by a health care professional to administer the chemotherapy. Such expenses are payable as Preferred Care: 80% of the Negotiated Charge to $25,000, then 100% thereafter. Chiropractic Therapy Covered Medical include charges incurred by a Covered Person for the following types of therapy provided on an outpatient basis: Chiropractic Care. for Chiropractic Care are Covered Medical, if such care is related to neuromusculoskeletal conditions and conditions arising from: the lack of normal nerve, muscle, and/or joint function. Covered Medical are payable as Preferred Care: After a $25 per visit Copay, 80% of the Negotiated Charge to $25,000, then 100% thereafter. Non-Preferred Care: After a $25 per visit Deductible, 60% of the Recognized Charge. Covered Medical include charges incurred by a Covered Person for the following types of therapy provided on an outpatient basis: Chiropractic Care. for Chiropractic Care are Covered Medical, if such care is related to neuromusculoskeletal conditions and conditions arising from: the lack of normal nerve, muscle, and/or joint function. Covered Medical are payable as Preferred Care: After a $25 per visit Copay, 80% of the Negotiated Charge to $25,000, then 100% thereafter. Non-Preferred Care: After a $25 per visit Deductible, 60% of the Recognized Durable Medical Equipment Covered Medical are payable as Sindecuse Health Center: 100% of the Negotiated Preferred Care: 80% of the Negotiated Charge to $25,000, then 100% thereafter. Non-Preferred Care: 80% of the Recognized Charge to $25,000, then 100% thereafter. Benefits are payable to a maximum of $200 per condition per Policy Year. Covered Medical are payable as Sindecuse Health Center: 100% of the Negotiated Preferred Care: 80% of the Negotiated Charge to $25,000, then 100% thereafter. Non-Preferred Care: 80% of the Recognized Charge to $25,000, then 100% thereafter. Benefits are payable to a maximum of $200 per condition per Policy Year. 19

20 Prosthetic Devices Expense Benefits include charges for: artificial limbs, or eyes, and other non-dental prosthetic devices, as a result of an accident or Sickness. Covered Medical do not include: eye exams, eyeglasses, vision aids, hearing aids, communication aids, and orthopedic shoes, foot orthotics, or other devices to support the feet. Covered Medical are payable as Sindecuse Health Center: 100% of the Negotiated Preferred Care: 80% of the Negotiated Charge to $25,000, then 100% thereafter. Non-Preferred Care: 80% of the Recognized Charge to $25,000, then 100% thereafter. Benefits are payable to a maximum of $200 per condition per Policy Year. Benefits include charges for: artificial limbs, or eyes, and other non-dental prosthetic devices, as a result of an accident or Sickness. Covered Medical do not include: eye exams, eyeglasses, vision aids, hearing aids, communication aids, and orthopedic shoes, foot orthotics, or other devices to support the feet. Covered Medical are payable as Sindecuse Health Center: 100% of the Negotiated Preferred Care: 80% of the Negotiated Charge to $25,000, then 100% thereafter. Non-Preferred Care: 80% of the Recognized Charge to $25,000, then 100% thereafter. Benefits are payable to a maximum of $200 per condition per Policy Year. Consultant or Specialist Covered Medical include the expenses for the services of a consultant or specialist, when referred by the School Health Services. The services must be requested by the attending physician for the purpose of confirming or determining to confirm or determine a diagnosis. Covered Medical are covered as Preferred Care: After a $25 per visit Copay, 80% of the Negotiated Charge to $25,000, then 100% thereafter. Non-Preferred Care: After a $25 per visit Deductible, 60% of the Recognized 1 visit per day maximum. Covered Medical include the expenses for the services of a consultant or specialist, when referred by the School Health Services. The services must be requested by the attending physician for the purpose of confirming or determining to confirm or determine a diagnosis. Covered Medical are covered as Preferred Care: After a $25 per visit Copay, 80% of the Negotiated Charge to $25,000, then 100% thereafter. Non-Preferred Care: After a $25 per visit Deductible, 60% of the Recognized 1 visit per day maximum. 20

21 Mental Health Benefits Mental and Nervous Disorders Inpatient Covered Medical for the treatment of a mental and nervous disorders while confined as a inpatient in a hospital or facility licensed for such treatment are payable as Preferred Care: 80% of the Negotiated Charge to $25,000, then 100% thereafter. Partial hospitalization, inpatient, and outpatient benefits for Treatment Of Mental And Nervous Disorders require pre certification. Covered Medical also include the charges made for treatment received during partial hospitalization in a hospital or treatment facility. Prior review and approval must be obtained on a case-by-case basis by contacting Aetna Student Health. When approved, benefits will be payable in place of an inpatient admission, whereby 2 days of partial hospitalization may be exchanged for 1 day of full hospitalization. Covered Medical for the treatment of a mental and nervous disorders while confined as a inpatient in a hospital or facility licensed for such treatment are payable as Preferred Care: 80% of the Negotiated Charge to $25,000, then 100% thereafter. Partial hospitalization, inpatient, and outpatient benefits for Treatment Of Mental And Nervous Disorders require pre certification. Covered Medical also include the charges made for treatment received during partial hospitalization in a hospital or treatment facility. Prior review and approval must be obtained on a case-by-case basis by contacting Aetna Student Health. When approved, benefits will be payable in place of an inpatient admission, whereby 2 days of partial hospitalization may be exchanged for 1 day of full hospitalization. Mental and Nervous Disorders Outpatient Covered Medical for outpatient treatment of a mental and nervous disorders are payable as Sindecuse Health Center: 100% of the Negotiated Preferred Care: 80% of the Negotiated Non-Preferred Care: 50% of the Recognized Charge to a maximum of $50 per day. Benefits are limited to $500 per Policy Year. Covered Medical for outpatient treatment of a mental and nervous disorders are payable as Sindecuse Health Center: 100% of the Negotiated Preferred Care: 80% of the Negotiated Non-Preferred Care: 50% of the Recognized Charge to a maximum of $50 per day. Benefits are limited to $500 per Policy Year. 21

22 Substance Abuse Benefits Inpatient Covered Medical for the treatment of a substance abuse condition while confined as a inpatient in a hospital or facility licensed for such treatment are payable on the same basis as any other Sickness. Covered Medical are covered as Preferred Care: 80% of the Negotiated Charge to $25,000, then 100% thereafter. Partial hospitalization, inpatient, and outpatient benefits for Treatment Of Alcohol and Drug Addiction require pre certification. Covered Medical also include the charges made for treatment received during partial hospitalization in a hospital or treatment facility. Prior review and approval must be obtained on a case-by-case basis by contacting Aetna Student Health. When approved, benefits will be payable in place of an inpatient admission, whereby 2 days of partial hospitalization may be exchanged for 1 day of full hospitalization. Benefits are limited to 60 days per condition per Policy Year. Covered Medical for the treatment of a substance abuse condition while confined as a inpatient in a hospital or facility licensed for such treatment are payable on the same basis as any other Sickness. Covered Medical are covered as Preferred Care: 80% of the Negotiated Charge to $25,000, then 100% thereafter. Partial hospitalization, inpatient, and outpatient benefits for Treatment Of Alcohol and Drug Addiction require pre certification. Covered Medical also include the charges made for treatment received during partial hospitalization in a hospital or treatment facility. Prior review and approval must be obtained on a case-by-case basis by contacting Aetna Student Health. When approved, benefits will be payable in place of an inpatient admission, whereby 2 days of partial hospitalization may be exchanged for 1 day of full hospitalization. Benefits are limited to 60 days per condition per Policy Year. Outpatient Covered Medical for outpatient treatment of a substance abuse condition are payable as any other condition. Benefits are limited to $3,969 per Policy Year. Covered Medical for outpatient treatment of a substance abuse condition are payable as any other condition. Benefits are limited to $3,969 per Policy Year. 22

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