Plan Design & Benefits Summary: Cornell University Student Health Insurance Plan (SHIP) Policy Year: Policy Number:

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1 Plan Design & Benefits Summary: Cornell University Student Health Insurance Plan (SHIP) Policy Year: Policy Number:

2 Table of Contents Summary of the Cornell University Student Health Insurance Plan (SHIP)... 3 Where to Find Help... 3 Frequently Asked Questions... 4 Coverage periods... 6 Rates... 6 Premium Refund Policy... 6 Student coverage... 6 Dependent coverage... 7 Participating Network... 7 Gannett Health Services Description of Benefits

3 Summary of the Cornell University Student Health Insurance Plan (SHIP) 1 SHIP has been developed especially for Cornell students (and their dependents) to provide access to comprehensive health services both on campus and around the world. An overview of benefits and cost-sharing information is included in this document. For additional information about SHIP coverage at Cornell, in the Ithaca area, and beyond, how to make the most of your benefits, and other aspects of this plan, please contact the Office of Student Health Insurance or visit Services for SHIP are administered by Aetna Student Health. To learn more about Aetna Student Health or to review the SHIP Certificate of Coverage and the exact provisions governing this insurance, go to or call Cornell s SHIP is a policy that: Provides extensive coverage at a reasonable cost for most on- or off-campus health care from August 17 through August 16, of the following year. Provides coverage 24 hours a day, 365 days a year, anywhere in the world. For students in Ithaca, provides coordination of services by Gannett Health Services staff and a preferred provider network that includes the local hospital. Covers pre-existing health conditions. Guards against catastrophic expenses. Continues coverage for students taking a leave of absence. Meets or exceeds all F-1 and J-1 Visa Requirements. Meets or exceeds all Federal, State, and American College Health Association standards for health insurance. Includes access to worldwide travel assistance and emergency air transportation services through On Call International (for more information visit [search Worldwide Medical Assistance. ]). Provides convenient assistance with enrollment and claims submission through the Cornell University Office of Student Health Insurance. 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 non-emergency situations please visit or call Gannett Health Services at (607) Got Questions? Get Answers with Aetna s Navigator As a part of SHIP, you have access to Aetna Navigator, your secure member website, packed with personalized claims and health information. You can take full advantage of our interactive website to complete a variety of self-service transactions online. By logging into Aetna Navigator, you can: 1 This document only summarizes the Cornell University Student Health Insurance Plan (SHIP) and does not pertain to any other insurance plans at Cornell University. 3

4 Review who is covered under your plan. Request member ID cards. View Claim Explanation of Benefits (EOB) statements. Estimate the cost of common health care services and procedures to better plan your expenses. Research the price of a drug and learn if there are alternatives. Find health care professionals and facilities that participate in your plan. Send an to Aetna Student Health Customer Service at your convenience. View the latest health information and news, and more! How Do I Register? Go to Need help with registering onto Aetna Navigator? Registration assistance is available toll free, Monday through Friday, from 7 a.m. to 9 p.m. Eastern Time at (800) Frequently Asked Questions For Questions About: Enrollment Claim Questions Pre-Certification Participating s Appeal Process General Insurance Matters ID Cards Please Contact: Aetna Student Health P.O. Box El Paso, TX (800) (781) (Outside the United States Collect Calls are accepted) Your official ID card will be issued as soon as possible. In the meantime, you may print a copy directly from the Aetna Student Health website: [If you need assistance, please contact the Office of Student Health Insurance.] Present your ID card any time you access a health care provider to facilitate prompt payment of your claims. Note: You do not need an ID card to be eligible to receive care, as your benefits are still payable according to the Policy, but having one on hand makes speeds up billing & payment. FOR LOST ID CARDS, CONTACT: Aetna Student Health (800) , or (781) (Outside the United States Collect Calls are accepted) or you may visit the Aetna Student Health website at 4

5 Enrollment Forms Bursar Bill Charges Premium Fees General Questions Waiver Process Gannett Health Services hours, appointments, departments, staff. Medical, counseling, physical therapy, and pharmacy services on campus. Cornell University Office of Student Health Insurance 409 College Avenue, Suite 211 Ithaca, NY (607) Website: Gannett Health Services 110 Ho Plaza Ithaca, NY (607) Website: Managing referrals to and from outside providers Personal and campus health issues and concerns Specialty pharmaceuticals. Status of Pharmacy Claim Pharmacy Claim Forms Excluded Drugs and Pre-Authorization On Call International 24/7 Emergency Travel Assistance Services Aetna Pharmacy Management (888) RX-AETNA or (888) (Available 24 hours) On Call International at (866) (within U.S.). If outside the U.S., call collect by dialing the U.S. access code plus (603) Please also visit 5

6 and visit your school-specific site for further information. Coverage periods For students and eligible dependents enrolled in the Plan, Coverage will become effective at 12:00 AM on the Coverage Start Date indicated below, and will terminate at 11:59 PM on the Coverage End Date indicated. Dates for summer coverage vary by program. Please consult the Cornell University Office of Student Health Insurance for more information. Coverage Period Coverage Start Date Coverage End Date Annual 08/17/ /16/2015 Fall* 08/17/ /31/2014 Spring 01/16/ /16/2015 *There is no fall-only enrollment option. Plan members are enrolled for the year or the spring only. Rates Rates Undergraduates and Graduate Students Student $2,352 Spouse/Domestic Partner $4,709 Child(ren) $3,385 Premium Refund Policy There are limited circumstances under where SHIP may be canceled and the premium refunded, and no refund is available if claims have been made. Please click here for more information. Student coverage Eligibility The following individuals are eligible for coverage under SHIP: All full-time registered students (as defined and reported by the Cornell University Registrar). Students registered in absentia. 6

7 Students on a University-approved leave of absence are also eligible to enroll prior to September 30, 2014, provided that they were enrolled during the previous year. Students on a University-approved leave of absence may purchase the Student Health Insurance Plan for only one year. Please Note: Students on leave and in absentia are not automatically enrolled and must reenroll in SHIP each year. Enrollment Every full time student (including non-degree students) will be enrolled in and billed for the Student Health Insurance Plan. The premium will be charged to the student s August 2014 bursar bill. A pro-rated charge is applied in January for spring entrants. If a waiver application is received by the deadline and is approved, a full credit will be issued on the next bursar bill. Dependent coverage Eligibility Covered students may also enroll their lawful spouse or domestic partner and dependent children up to the age of 29. Enrollment Dependents are not automatically enrolled. Covered students who wish to enroll their eligible dependents in the Student Health Insurance Plan must contact the Cornell University Office of Student Health Insurance to fill out the necessary forms and to make appropriate premium payments. An application for family coverage must be made each year. The enrollment deadline for the annual policy is September 30, The enrollment deadline for Spring coverage is February 28, If the dependent experiences a significant life change that directly affects his or her insurance coverage, the deadline to enroll is 31 days after the significant life changing event. A life changing event may include a loss of coverage from a prior plan, marriage, divorce, and other reasons beyond a person s control. Coverage for dependents will begin on August 17, 2014, if they are enrolled prior to the September 30, 2014 deadline. Participating Network Aetna Student Health provides access to a Participating Network in your local community and across the country. To maximize your savings and reduce your out-of-pocket expenses, select a Participating. It is to your advantage to use a Participating because savings may be achieved from the Negotiated Charges these providers have agreed to accept as payment for their services. You may obtain information regarding Participating s by contacting Aetna Student Health at (800) , or through the Internet by accessing DocFind at 7

8 Gannett Health Services Gannett Health Services, located on central campus, offers responsive, confidential, high-quality medical services; pharmacy services; counseling and psychological services; physical therapy; and health education services to all full-time registered Cornell students. Gannett also facilitates access to urgent and emergency services and provides referrals to area specialty health care. Its high standard of service has been recognized by the Accreditation Association for Ambulatory Health Care, Inc. SHIP members residing in the Ithaca area: Gannett is your primary care provider. Except in an emergency or for ob/gyn services, whenever you need health care, you should begin at Gannett to receive the maximum benefit for services. Accessing care Appointments are recommended to address most of your health care needs. However, urgent care and nurse visits are available during building hours and students can consult with a Gannett health care provider by phone 24 hours a day, 365 days a year. Emergency services in Ithaca are available from Cayuga Medical Center (CMC). If you need emergency medical care, consult by phone with a Gannett health care provider who can offer advice and, if needed, help arrange transportation to the hospital emergency room. In the event of your treatment or hospitalization at CMC Gannett and CMC will share relevant medical information as needed for the continuity of your care. Fees at Gannett All full-time registered Cornell students (whether on SHIP or not) can meet with a health care provider or counselor at Gannett, usually for a $10 student visit charge. Fees may be paid at the time of service or charged to your bursar bill during the academic year. If you have private health insurance, fees are charged for most other services. Carefully review your health insurance policy to make sure it will provide adequate coverage for expenses. Gannett does not bill private health insurance companies directly but can provide a receipt for services that you submit to your insurance company for reimbursement. The Student Health Insurance Plan covers most services at Gannett (including most X-rays, lab tests, and special procedures), but the student visit charges are not covered and are the responsibility of the SHIP member. Please check the Gannett website for more information about paying for health services. Contact Gannett 110 Ho Plaza Ithaca, NY Phone: Web: 8

9 SHIP requires preauthorization before you receive certain services. means calling Aetna Student Health prior to treatment to get approval for a procedure or service. may be done by you, your health care provider, the hospital, or one of your relatives. Call the phone number on your SHIP ID card to get additional details regarding preauthorization. Please consult the Certificate of Coverage for a full list of services requiring preauthorization. DOES NOT guarantee the payment of benefits for your inpatient Each claim is subject to medical policy review, in accordance with the exclusions and limitations contained in the Certificate of Coverage. Also you can view eligibility, notification guidelines, and benefit coverage. of non-emergency inpatient s and partial hospitalization Non-emergency s and partial hospitalization must be requested at least three business days prior to the planned or prior to the date the services are scheduled to begin. of emergency inpatient s Emergency s must be requested within 48 hours after the. 9

10 Description of Benefits The chart below illustrates some of the services covered and benefits offered under this plan. The plan excludes coverage for certain services and contains limitations on the amounts it will pay. 2 While this Plan Design and Benefits Summary document will tell you about some of the important features of the plan, other features may be important to you and some may further limit what the plan will pay. If you wish to review the full plan description, contained in the Certificate of Coverage issued by Cornell University, you may access it online at Cost-Sharing 3 In-Area Participating Out-of-Area Participating Non-Participating None None $150 per plan year Individual Out-of-Pocket Limit Individual $3,000 See In-Area $4,000 Family $4,000 See In-Area $5,000 There is one combined limit for both In-Area and Out-of-Area Participating Cost-Sharing. Service In-Area Participating Out-of-Area Participating Non-Participating Primary Care Office Visits $25 Copayment and 0% $25 Copayment and 20% $25 Copayment per visit Specialist Office Visits $25 Copayment and 0% Preventive Care (e.g. physical exams, well $25 Copayment and 20% $25 Copayment per visit Referral Covered in full Covered in full 30% after 2 Please consult the Certificate of Coverage for a full list of services for which this plan does not provide benefits. This plan does not cover services not listed in the Certificate of Coverage including holistic medicine, massage therapy, mental health care training treatment, personal hygiene and convenience items, and virtual consultations. 3 Coverage is based on the Allowed Amount. Please see the Certificate of Coverage for more information. 10

11 Service In-Area Participating Out-of-Area Participating Non-Participating woman visits, and well child visits). $150 plan year deductible. Ambulance Services Covered in full Covered in full Covered in full Emergency Department $75 Copayment and 0% $75 Copayment and 0% $75 Copayment and 0% Visit Copayment waived if Hospital. Inpatient Medical Visits 0% 20% $250 30% based off of the semi-private room rate Laboratory Procedures Performed in a PCP Office 0% 20% 30% after $150 plan year Performed as Outpatient Hospital Services Maternity & Newborn Care $75 Copayment and 0% $75 Copayment and 20% $75 Copayment Prenatal Care Covered in full Covered in full $25 Copay Inpatient Hospital Services and Birthing Center Birthing Center: $100 Copayment, and 0% per Birthing Center: $100 Copayment, and 20% per ; Birthing Center: $100 Copayment, and 30% per ; after $150 is required, after the 48 hours for vaginal delivery, or after 96 hours for cesarean Inpatient: and 0% per Inpatient: and 20% per Inpatient: per ; after $150 Rehabilitation Services (Physical Therapy, Occupational Therapy or $25 Copayment and 0% $25 Copayment and 20% $25 Copayment 11

12 Service In-Area Participating Out-of-Area Participating Non-Participating Speech Therapy Surgical Services Inpatient Hospital Surgery Outpatient Hospital Surgery Inpatient Mental Health Care (for a continuous confinement when in a Hospital) ; Referral. However, is Not for Emergency Admissions Outpatient Mental Health Care (Including Partial Hospitalization & Intensive Outpatient Program Services) $150 Copayment and 0% $150 Copayment and 0% and 0% per ; Referral $10 Copayment and 0% Referral $150 Copayment and 20% $150 Copayment and 20% and 20% per $10 Copayment and 20% $150 $150 per ; after $150 $10 Copayment per after $150 plan year Inpatient Substance Use Services (for a continuous confinement when in a Hospital) ; Referral. However, is Not for Emergency Admissions Outpatient Substance Use Services Pharmacy 30 day Supply per Prescription: and 0% per 0% Referral and 20% per per ; after $150 20% 30% after $150 Generic $12 Copayment $12 Copayment $12 Copayment 12

13 Service In-Area Participating Out-of-Area Participating Non-Participating Preferred Brand Name $30 Copayment $30 Copayment $30 Copayment Non-Preferred Brand Name $40 Copayment $40 Copayment $40 Copayment This self insured plan is funded by Cornell University, with claims administration services provided by Chickering Claims Administrators, Inc. (CCA). Aetna Student Health is the brand name for products and services provided by Aetna and CCA and their applicable affiliated companies. Cornell University has sole responsibility for the accuracy of the information contained in this Plan Document. 13

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