SHIP. Point Loma Nazarene University Plan Brochure. Student Health Insurance Plan

Transcription

1 SHIP Plan Brochure Student Health Insurance Plan Please Note: This document has changed. See back page for details. Point Loma Nazarene University Inside you will find: Costs of coverage Information on the PPO network Schedule of benefits Exclusions Definitions of insurance terms Claim filing instructions Underwritten by: United States Fire Insurance Company Policy Number: US NOTICE REGARDING HEALTH CARE REFORM Your student health insurance coverage, offered by United States Fire Insurance Company, may not meet the minimum standards required by the Health Care Reform Law for restrictions on annual dollar limits. The annual dollar limits ensure that consumers have sufficient access to medical benefits throughout the annual term of the policy. The restriction for annual dollar limits for group and individual health insurance coverage is $2 million for policy years beginning on or after September 23, 2012, but before January 1, The restriction for annual dollar limits for student health insurance coverage is $500,000 for policy years beginning on or after September 23, 2012, but before January 1, Your student health insurance coverage includes a policy year limit of $500,000 that applies to the Essential Health Benefits provided in the Schedule of Benefits, unless otherwise specified. Be advised that you may be eligible for coverage under a group health plan of a parent s employer or under a parent s individual health insurance policy if you are under 26 years of age. Contact the plan administrator of the parent s employer plan or the parent s individual health insurance company for more information. For more information on how Health Care Reform affects the Student Health Insurance Plan at your school, visit If you have any questions or concerns about this notice, contact customer service at PLNUCA-B13

2 TABLE OF CONTENTS Eligibility...4 Enrollment...4 Refund Policy...4 Terms of Coverage...5 Important Dates and Costs of Coverage...5 Preferred Provider Organization...5 Wellness Center...6 Schedule of Benefits...6 Preventive Services...7 State Mandated Benefits...8 Extension of Benefits...8 Excess Coverage...8 General Exclusions...8 Pre-Existing Condition Limitation...9 Definitions...9 Claim Procedure...11 Certification of Qualifying Health Plan Coverage...12 Authorized Representation...12 Summary of Privacy Policy...12 ID CARD Download your insurance ID card at If you go to a Doctor s office, urgent care center, or hospital, you will be asked for your ID card. Carry your insurance identification card with you at all times. NO-COST LANGUAGE ASSISTANCE SERVICES You can get an interpreter and get documents read to you in your language. For help, call the number listed on your insurance ID card or For more help, call the CA Department of Insurance at NOTICE For further information on this plan, visit This brochure is a brief summary of the coverage. Full details are in the policy (AH-27261) issued to Point Loma Nazarene University. A copy of the policy may be reviewed at the Wellness Center. Any discrepancy between this brochure and the policy will be governed by the policy. Fairmont Specialty Privacy Statement We know that your privacy is important to you and we strive to protect the confidentiality of your non-public personal information. We do not disclose any non-public personal information about our insureds or former insureds to anyone, except as permitted or required by law. We maintain appropriate physical, electronic and procedural safeguards to ensure the security of your non-public personal information. You may obtain a detailed copy of our privacy policy through your school, or by contacting Personal Insurance Administrators, Inc. (PIA) at

3 IMPORTANT CONTACT INFORMATION AND RESOURCES FOR YOUR STUDENT HEALTH INSURANCE PLAN (SHIP) Insurance Company United States Fire Insurance Company Policy Number US Claims Submission For submitting claims by mail, complete a claim form and send, along with the bill(s), to: Personal Insurance Administrators, Inc. P.O. Box 6040 Agoura Hills, CA Providers may submit claims electronically: PAYER ID Monday Friday 8:00 a.m. to 5:00 p.m. (4:00 p.m. on Fridays) PT PPO Network To locate PPO Doctors and facilities, contact: California Foundation for Medical Care To download a plan summary, FAQ, or ID card or for further information on this plan, visit: WELLNESS CENTER The campus Wellness Center offers free medical and counseling services to undergraduate students during the academic year. There are charges for medications, lab tests, injections and physicals. Charges will be applied to the student s account. The staff can also assist you in finding local Doctors, Hospitals, and Urgent Care centers. Hours of Operation: 8:00 a.m. to 4:00 p.m. (closed for University holidays) Phone: SDWellnessCenter@pointloma.edu Location: 1st Floor, Nicholson Commons Page 3

4 ELIGIBILITY Students Any student who is registered at Point Loma Nazarene University is eligible to be insured. Insured students must actively attend classes for at least the first 31 days from their effective date of coverage, or the entire period for which coverage is purchased, whichever is the lesser, except in the case of medical withdrawal (as verified and approved by the school). Dependents Students may also insure their eligible Dependents, including their legally married spouse, domestic partner, or child under the age of 26. For a newly acquired Dependent child, that child will be covered under the plan for the first 31 days after: 1) the birth date of the newly born child; 2) the effective date of adoption of the child by the student; or 3) the date of placement of the child for adoption with the student. Coverage for such child will be for Sickness and Injury, including medically diagnosed congenital defects, birth abnormalities, prematurity, and nursery care. Should the student s coverage terminate before the end of the 31-day period, newborn coverage will not extend beyond the student s termination date. The insured student will have the right to continue coverage for the child beyond 31 days. To continue the coverage the insured student must, within 31 days after the birth, adoption, or placement for adoption: 1) submit a completed enrollment form; and 2) pay the required additional premium (if any) for the continued coverage. If the insured student does not use this right as stated here, all coverage as to that child will terminate at the end of the first 31 days after the child s birth, adoption, or placement for adoption. The Company maintains its right to investigate student (and Dependent) status and attendance records to verify that the Plan eligibility requirements have been met. If and whenever the Company discovers that the Plan eligibility requirements have not been met, its only obligation is refund of premium less any claims paid. ENROLLMENT Undergraduate Students Undergraduate students are automatically enrolled in the Student Health Insurance Plan but may waive coverage by presenting satisfactory evidence of comparable health insurance coverage to the University by the Waiver Deadline Date. Please contact your school for information on how to waive SHIP. If an eligible undergraduate student has waived out of the plan and later experiences an Involuntary Loss of Coverage, he or she may submit to the University notification of interest to enroll in the Plan for the remainder of the current term, provided it is done within 63 days of termination of prior coverage. Please note premium payments cannot be prorated. Students must pay the entire premium for the term in which they are electing to enroll. Graduate Students Graduate students may enroll on a voluntary basis by completing and submitting the enrollment form, available online at along with proper premium payment by the Enrollment Deadline Date. Dependents Students who wish to enroll their eligible Dependents must submit the enrollment form, available online at along with proper payment, by the Enrollment Deadline Date. Eligible Dependents must be enrolled by the Enrollment Deadline Date or within 31 days of birth, adoption, or marriage (proof of date may be requested). Failure of the student to enroll for Dependent coverage within the 31-day enrollment period shall be construed as rejection of coverage. Dependents must be enrolled in the same term in which the student is enrolled. For questions regarding student or Dependent enrollment, please contact Ascension at REFUND POLICY There are no premium refunds, except when an insured student enters full-time active military service, at which time a pro rata refund of premium paid (for number of full months remaining) will be made upon written request. In the event a claim has been filed, premium is fully earned and a refund is not available under any circumstances. Page 4

5 TERMS OF COVERAGE Effective Dates The Plan is effective at 12:01 a.m. on August 1, Coverage will become effective at 12:01 a.m. on the first date of the applicable term in which the student is enrolled. Students who register late have up until the Deadline Date listed to apply for coverage. Coverage for students who have previously waived out of the insurance and are enrolling due to an Involuntary Loss of Coverage and covered Dependents will become effective at 12:01 a.m. on the latest of: 1) the effective date of the term for which premium has been paid; or 2) the day immediately following the date on which the student or Dependent is enrolled and premium is paid. Termination Dates The Plan terminates at 12:01 a.m. on August 1, Coverage terminates at 12:01 a.m. on the earliest of the following dates: 1. The date the Policy is terminated by the Policyholder; 2. The last day of the Term of Coverage for which premium is paid; 3. The date a Covered Person enters full-time active military service; 4. The last day of the period through which premium has been paid, following the date a Dependent ceases to be a Dependent as described in this brochure. In no event will Dependent coverage extend beyond that of the insured student, except as specifically provided under the Extension of Benefits provision. There is no continuation coverage for this plan for students and/or Dependents who are no longer eligible. We do not send termination or renewal notices. It is the Covered Person s responsibility to renew coverage in a timely manner, subject to continuing eligibility. Eligibility requirements must be met each time premium is paid to renew coverage. IMPORTANT DATES AND COSTS OF COVERAGE Annual Fall Spring/Summer Dates of Coverage 08/01/13 to 08/01/14 08/01/13 to 01/13/14 01/13/14 to 08/01/14 Enrollment Deadline Date 09/01/13 09/01/13 02/13/14 Dependent Enrollment Deadline Date 09/01/13 09/01/13 02/13/14 Waiver Deadline Date 09/27/13 09/27/13 02/07/14 Student $1, $ $ Spouse/Domestic Partner $1, $ $ Child(ren) $2, $1, $1, Spouse + Child(ren) $4, $2, $2, Domestic Partner + Child(ren) $4, $2, $2, Please note that continuing students must renew their coverage within 31 days of their previous termination date in order to maintain Continuous Coverage, regardless of the Enrollment Deadline Date. PREFERRED PROVIDER ORGANIZATION Please read the following information so you will know from whom or what group of providers health care may be obtained. Please note that utilization of a PPO network provider may significantly reduce your out-of-pocket costs. This plan has incorporated into the coverage access to the California Foundation for Medical Care network of Hospitals and Doctors (PPO). If PPO providers are utilized, the out-of-pocket expense incurred will be considerably less than the out-of-pocket expense incurred when utilizing a non-network provider. For a complete listing of the PPO Hospital and Doctor facilities, please consult the Provider Directory available at the Wellness Center, contact the California Foundation for Medical Care at , or visit Please be aware that if you are treated at a PPO Hospital, it does not mean that all providers at that Hospital are PPO providers. In addition, if you are referred by a PPO provider to another provider or facility, it does not mean that the provider or facility to which you are referred is also a PPO provider. Page 5

6 WELLNESS CENTER The campus Wellness Center offers free medical and counseling services to undergraduate students during the academic year. There are charges for medications, lab tests, injections and physicals. Charges will be applied to the student s account. The staff can also assist you in finding local Doctors, Hospitals, and Urgent Care centers. Hours of Operation: Phone: Location: 8:00 a.m. to 4:00 p.m. (closed for University holidays) SDWellnessCenter@pointloma.edu 1st Floor, Nicholson Commons SCHEDULE OF BENEFITS The Company will pay for the Eligible Expenses listed below, up to the following limits. Maximum Benefit: Deductible: Office Visit Copay: ER Copay: $500,000 per plan year for all conditions combined, including prescription drugs $50 per Injury or Sickness (if an Injury is treated within 48 hours after the Injury is sustained, the deductible will be waived) $15 per visit for doctor s office and urgent care $50 per visit for hospital emergency room (waived if admitted) Covered Expenses include the following, subject to the limitations indicated above or below: PREVENTIVE/WELLNESS SERVICES PPO NON-PPO Adult Wellness Visit includes screening for certain conditions such as: cancer, high cholesterol, depression, diabetes, obesity, and sexually transmitted diseases, as recommended by the U.S. Department of Health and Human Services Immunizations includes but not limited to: flu shot, tetanus, diphtheria, pertussis, Tdap, hepatitis A, hepatitis B, HPV, measles-mumps-rubella, pneumonia, varicella, meningococcal; only as recommended by the U.S. Centers for Disease Control and Prevention Page 6 100% of Preferred Allowance DEDUCTIBLE & COPAY WAIVED 100% of Preferred Allowance DEDUCTIBLE & COPAY WAIVED 60% of URC 60% of URC OUTPATIENT PPO NON-PPO Doctor Visits limited to a maximum of 20 visits per plan year Emergency Medical Condition Expense use of emergency room and supplies Urgent Care 80% of Preferred Allowance after $15 copay per visit 80% of Preferred Allowance after $50 copay per visit 80% of Preferred Allowance after $15 copay per visit 60% of URC after $15 copay per visit 80% of URC after $50 copay per visit 60% of URC after $15 copay per visit Surgeon s Fees Assistant Surgeon Anesthetist professional services in connection with out-patient surgery Day Surgery Miscellaneous Physiotherapy limited to a maximum of 20 visits per plan year Treatment of Mental or Nervous Disorders limited to a maximum of 20 visits per plan year; only when referred by the Student Health Center, the Director of the Counseling Center, or the attending Doctor Treatment of Substance Abuse limited to a maximum of 20 visits per plan year; only when referred by the Director of the Counseling Center or the licensed Medical Director of the Health Center 50% of Preferred Allowance after $15 copay per visit 50% of URC after $15 copay per visit Diagnostic X-Ray and Laboratory Services Radiation Therapy and Chemotherapy Tests and Procedures diagnostic services and medical procedures performed by a Doctor other than Doctor s visits, physical therapy, X-rays, lab procedures (continued on page 7)

7 SCHEDULE OF BENEFITS (continued) INPATIENT PPO NON-PPO Hospital Confinement/Room and Board and Hospital Miscellaneous daily average semi-private room rate and general nursing care provided by a Hospital; Hospital Miscellaneous Expenses, such as the cost of the operating room, laboratory tests, X-ray examinations including professional fees, anesthesia, physical therapy, drugs (excluding take-home drugs) or medicines, therapeutic services and supplies; includes intensive care Maternity and Newborn Care while Hospital Confined, and routine nursery care provided immediately after birth, up to 48 hours after birth (96 hours for cesarean delivery) Licensed Nurse Expense private-duty nursing care Surgeon s Fees Assistant Surgeon Anesthetist professional services in connection with inpatient surgery Pre-Admission Testing if testing occurs within three (3) days prior to admission Doctor Visits limited to a maximum of 20 visits per plan year Treatment of Mental or Nervous Disorders Treatment of Substance Abuse OTHER PPO NON-PPO Ambulance Services 80% of Preferred Allowance 80% of URC Durable Medical Equipment/Braces and Appliances/Prosthetic Devices 80% of Preferred Allowance 80% of URC Consultant Doctor Fees Dental Treatment for Injury to natural teeth only; up to a maximum of $400 per plan year Severe Mental Illness Pregnancy including complications of pregnancy 80% of Preferred Allowance 80% of URC paid as any other Sickness paid as any other Sickness OUTPATIENT PRESCRIPTION DRUGS PPO NON-PPO includes medication for the management and treatment of diabetes $10 copay for generic; $20 copay for brand name (per 30-day supply) PREVENTIVE SERVICES In addition to the Covered Services listed, the following services shall be covered without regard to any deductible, copayment, or coinsurance requirement that would otherwise apply: 1. Evidence-based items or services that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force; 2. Immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the Covered Person involved; 3. With respect to Covered Persons who are infants, children and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; 4. With respect to Covered Persons who are women, such additional preventive care and screenings not described in paragraph (1) as provided for in comprehensive guidelines supported by the Health Resources and Services Administration. For purposes of this section, recommendations of the United States Preventive Service Task Force regarding breast cancer screening, mammography, and prevention issued in or around November 2009 are not considered to be current. No recommendation of the United States Preventive Service Task Force shall serve to reduce the mammogram benefits. Please visit for more details on what is included under the federal Preventive Services requirement. Page 7

8 STATE MANDATED BENEFITS The State of California mandates coverage for the following: 1) equipment, supplies and outpatient self-management training for diabetes; 2) phenylketonuria(pku), including enteral formulas and special food products that are part of a diet prescribed by a Doctor; 3) treatment of Severe Mental Illness; 4) anesthesia and facility charges for dental procedures under certain circumstances; 5) mammograms; 6) prostate, colorectal and cervical cancer screening and generally medically accepted cancer screening tests; 7) breast cancer screening, diagnosis, and treatment; 8) a second opinion requested by a Covered Person or Doctor; 9) participation in the Expanded Alpha Feto Protein (AFP) Program; 10) prosthetic devices to restore a method of speaking incidental to laryngectomy; 11) diagnosis, treatment and management of osteoporosis; 12) clinical trials for cancer; 13) HIV testing (up to a maximum of two tests per plan year); 14) AIDS vaccine; 15) reconstructive surgery under certain circumstances; 16) telemedicine medical services; 17) prescription contraceptive drugs or devices (if there is a prescription drug benefit); and 18) treatment of conditions relating to diethylstilbestrol exposure; 19) Medically Necessary surgical treatment for jawbone conditions (TMJ); and 20) maternity services as provided by CA Insurance Code section (a). Please see the Policy on file with the University for further details. EXTENSION OF BENEFITS If the Covered Person is under a Doctor s care for a condition covered by the Plan, the benefit period will be extended for up to three (3) months from the termination date while such care continues, up to the plan maximum. If the Covered Person is totally disabled due to a condition covered by the Plan, the benefit period will be extended for up to six (6) months from the termination date for such condition, up to the plan maximum. Totally disabled means the inability to perform those activities that are normal for a person in good health of the same age and sex. Dependents who are newly acquired during the insured student s Extension of Benefits period are not eligible for benefits under this provision. EXCESS COVERAGE This plan of insurance is secondary and provides benefits in accordance with all of its provisions only to the extent that benefits are not provided by any other valid and collectible insurance. If the insured is covered by other valid and collectible insurance, all benefits payable by such insurance will be determined before benefits will be paid by this plan. This plan is the second payor to any other insurance having primary status or no coordination or non-duplication of benefits provision. Benefits paid by this plan will not exceed: 1) any applicable plan maximums; and 2) 100% of the compensable expenses incurred when combined with benefits paid by any other valid and collectible insurance. Other valid and collectible insurance means: 1. Coverage provided by an organization subject to the regulations of insurance law or insurance authorities or any State of the United States or any province of Canada; 2. Any hospital or medical service organization, group insurance or coverage provided by a union welfare plan, or employer or any employee benefit organization, except Student Health Center generated expense for laboratory and prescription drug expense; or 3. Compulsory benefit statutes (including any Workers Compensation or Employer s Liability statute) whether provided by a governmental agency or otherwise. Benefits payable under another plan include the benefits that would have been payable had the claim been duly submitted. GENERAL EXCLUSIONS The Plan won t pay benefits for: 1. Treatment, services, or supplies that: a) Are not Medically Necessary; b) Are not prescribed by a Doctor as necessary to treat a Sickness or Injury; c) Are determined to be experimental/investigational in nature by the Company; d) Are received without charge or legal obligation to pay; e) Would not routinely be paid in the absence of insurance; f) Are received from any family member; 2. Any accident where the Covered Person is the operator of a motor vehicle and does not possess a current and valid motor vehicle operator s license; 3. Any loss covered by state or federal worker s compensation law, employers liability law, occupational disease law, or similar laws or act; Page 8 (continued on page 8)

9 EXCLUSIONS (continued) 4. Cosmetic procedures, except cosmetic surgery required to correct an Injury for which benefits are otherwise payable under this Plan or for nonmalignant warts, moles, and lesions; congenital conditions, except expenses for cosmetic treatment or cosmetic surgery when required to correct congenital disease or anomaly of a covered newborn Dependent; 5. Dental treatment, except as specifically provided for in the Schedule; 6. Elective surgery and elective treatment, except as required to correct an Injury for which benefits are otherwise payable under the Plan; Elective treatment includes but is not limited to breast implants, breast reduction, circumcision, deviated nasal septum other than for Medically Necessary treatment of covered acute purulent sinusitis, sexual reassignment surgery; 7. Eye examinations, prescriptions, or fitting of eyeglasses and contact lenses, or other treatment for visual defects and problems, unless payable as a covered expense associated with a Sickness or Injury covered by the Plan; and hearing aids; 8. Participation in a riot or civil disorder, commission of or attempt to commit a felony, or fighting, except in self-defense; 9. 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 with the intent of inducing conception (examples of fertilization procedures are: ovulation induction procedures, in vitro fertilization, embryo transfer or similar procedures that augment or enhance your reproductive ability; premarital examinations; impotence, organic or otherwise; sterilization operations; tubal ligation; vasectomy; 10. Services and supplies furnished normally without charge by the participating institution s infirmary, its employees, or Doctors who work for the participating institution; 11. Flight in any kind of aircraft, except while riding as a passenger on a regularly scheduled flight of a commercial airline; 12. War or any act of war, declared or undeclared, or while in the armed forces of any country; 13. Treatment services or supplies which are determined to be experimental/investigational in nature by the Company. PRE-EXISTING CONDITION LIMITATION Pre-Existing Conditions are not covered for a period of six (6) months after the effective date of coverage. Pre-Existing Condition means a condition for which medical advice, diagnosis, care, or treatment, including use of prescription drugs, was recommended or received from a licensed health practitioner during the six (6) months immediately preceding the effective date of coverage. This limitation will be waived if, during the period immediately preceding the insured s effective date of coverage under the Plan, the insured was covered under prior creditable coverage for six (6) consecutive months. Credit will be given for the time the insured is covered under prior creditable coverage if the coverage was in force within 63 days prior to the effective date of this coverage. Prior creditable coverage means any individual or group policy, contract, or program that is underwritten or administered by an insurer, nonprofit hospital service plan, health care service plan, fraternal society, self-insured employer plan, or other type entity that provides or arranges medical, hospital, and surgical coverage that does not supplement other private or governmental plans. This includes continuation or conversion coverage but does not include accident-only, credit, disability income, Medicare Supplement, long-term care, dental, vision, workers compensation or similar law, or any other publicly sponsored health program. The Pre-Existing Condition Limitation does not apply to Covered Persons under the age of 19, or to pregnancy and complications of pregnancy. DEFINITIONS The following important definitions apply to this plan: Coinsurance means the percentage amount of covered expenses for which you are responsible for any medical service or supply. The coinsurance is shown in the Schedule. We will pay the remaining amount of covered expenses, subject to the maximum amount for specific services and the maximum benefit for all services. The Company means United States Fire Insurance Company. Fairmont Specialty and Crum & Forster are registered trademarks of United States Fire Insurance Company. Covered Expenses means charges that are: 1. Not in excess of Usual, Reasonable, and Customary charges; 2. Not in excess of the maximum benefit amount payable per service as shown in the Schedule; 3. Made for medical services and supplies not excluded under the Plan; 4. Made for services and supplies that are Medically Necessary; and 5. Made for medical services specifically included in the Schedule. Page 9 (continued on page 10)

10 DEFINITIONS (continued) Covered Person means a student and their eligible Dependents covered under the plan. The proper premium payment must be made to be covered under the plan. Deductible means the amount of expenses for covered services and supplies which must be incurred by the Covered Person before specified benefits become payable. Dependent means the insured student s lawful spouse or Domestic Partner under 70 years of age or child who is: 1. Under 26 years of age; and 2. Not provided coverage as a named subscriber, insured, enrollee, or Covered Person under any other group or individual health benefits plan, group health plan, church plan, or health benefits plan, or entitled to benefits under Title XVIII of the Social Security Act, Public Law 89-97, 42 U.S.C. section 1395 et seq; or 3. Of any age and is medically certified by a physician as having an intellectual disability or a physical disability and is dependent upon the insured student. Child can include stepchild, foster child, legally adopted child, a child of adoptive parents pending adoption proceedings, and natural child. Doctor means a practitioner of the healing arts who: 1) is properly licensed or certified to provide medical care under the laws of the state of practice; 2) provides medical services within the scope of his or her license or certificate; and 3) is not the Covered Person s Family Member. Doctor does not include: 1) the Covered Person; 2) the Covered Person s spouse, Dependent, parent, brother, or sister; or 3) a person who ordinarily resides with the Covered Person. Emergency Medical Condition means a medical condition that manifests itself by symptoms of sufficient severity that a prudent layperson possessing an average knowledge of health and medicine would reasonably expect that failure to receive immediate medical attention would place the health of a person (or fetus in the case of a pregnant woman) in serious jeopardy. Expenses incurred for a Hospital emergency room will be paid only for a Sickness or Injury fulfilling the above conditions. These expenses will not be paid for minor Sickness or minor Injuries. Essential Health Benefits means benefits covered under the Plan, in at least the following categories: ambulatory patient services, emergency services, Hospitalization, maternity and newborn care, mental health and substance use disorder services, including behavioral health treatment, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services, including oral and vision care. Such benefits shall be consistent with those set forth under the Patient Protection and Affordable Care Act of 2010 and any regulations issued pursuant thereto. Hospital means an institution: 1) operated pursuant to law; 2) primarily and continuously engaged in providing medical care and treatment to sick and injured persons on an inpatient basis; 3) under the supervision of a staff of doctors; 4) providing 24 hour nursing service by or under the supervision of a graduate registered nurse, (R.N.); 5) with medical, diagnostic and treatment facilities, and with major surgical facilities: a) on its premises; or b) available on a prearranged basis; and 6) charging for its services. Hospital does not include a clinic or facility for convalescent, custodial, educational or nursing care; the aged, drug addicts or alcoholics (except as stated below); or rehabilitation. For treatment of chemical dependency the definition of Hospital includes a treatment center which provides a program for treatment of chemical dependency according to a written treatment plan approved and monitored by a doctor. Such facility must be: 1) affiliated with a Hospital under a contract agreement with an established system of outpatient referrals; or 2) accredited as such by the Joint Commission on Accreditation of Hospitals; or 3) licensed as a chemical dependency treatment program; or 4) licensed, certified or approved as an chemical dependency treatment program or center by any state agency having legal authority to so license, certify or approve. Injury means bodily harm resulting, directly and independently of disease or bodily infirmary, from an accident. All Injuries to the same person sustained in one accident, including all related conditions and recurring symptoms for Injuries, will be considered one Injury. Medically Necessary means those services or supplies provided or prescribed by a Hospital or Doctor that are: 1) essential for the symptoms and diagnosis or treatment of the Sickness or Injury; 2) provided for the diagnosis, or the direct care and treatment, of the Sickness or Injury; 3) in accordance with the standards of good medical practice; 4) not primarily for the insured s convenience or that of insured s Doctor; and 5) the most appropriate supply or level of service that can safely be provided. Mental or Nervous Disorder means a Sickness that is a mental, emotional or behavioral disorder. All diagnoses classified as a Mental Disorder according to the ICD-9 (International Classification of Diseases, 9th Revision, codes 290 through 319 inclusive) are considered one Sickness. Physiotherapy means any form of the following: physical or mechanical therapy; diathermy; ultra-sonic therapy; heat treatment in any form; manipulation or massage administered by a Doctor. Page 10 (continued on page 11)

11 DEFINITIONS (continued) Pre-Existing Condition means a Sickness or Injury for which medical care, treatment, diagnosis, or advice was received or recommended within the six (6) months prior to the insured s effective date of coverage under the Plan. Pregnancy, including complications of pregnancy, will not be considered a Pre-Existing Condition. Severe Mental Illness means 1) schizophrenia; 2) schizo-affective disorder; 3) bipolar disorder (manic-depressive illness); 4) major depressive disorders; 5) panic disorder; 6) obsessive-compulsive disorder; 7) pervasive developmental disorder or autism; 8) anorexia nervosa; and 9) bulimia nervosa. Sickness means illness or disease, and includes pregnancy and complications of pregnancy. All related conditions and recurring symptoms of Sickness will be considered one Sickness. Substance Abuse means the abuse of, psychological or physical dependence on, or addiction to alcohol or a controlled substance. A controlled substance is a toxic inhalant (volatile chemical/abusable glue or paint) or a substance designated as a controlled substance. Total Disability means the inability to perform those activities that are normal for a person in good health of the same age and sex. Usual, Reasonable, and Customary (URC) means: 1. Charges and fees for medical services or supplies that are the lesser of: a) the usual charge by the provider for the service or supply given; or b) the average amount charged for the service or supply in the area where service or supply is received; and 2. Treatment and medical service that is reasonable in relationship to the service or supply given and the severity of the condition. Usual, Reasonable and Customary charges are calculated using the national database of Ingenix, Inc, at the 90th percentile CLAIM PROCEDURE In the event of Injury or Sickness: 1. Seek treatment from the nearest Doctor, urgent care or Hospital. You may choose any Doctor or Hospital, but using the Doctors and Hospitals available through the California Foundation for Medical Care (PPO) may significantly decrease your costs. For a complete listing of these PPO Doctor and Hospital facilities, call or visit 2. If you go to a Doctor s office or to the Hospital, be sure to show your identification card (attached to this brochure). Dependents covered under the plan do not receive separate ID cards and may use the insured student s ID card to obtain treatment. If the Doctor or Hospital needs to verify coverage for you or your Dependents, have them call Personal Insurance Administrators, Inc., at You should carry your insurance ID card with you at all times. 3. Obtain claim form in person from the Wellness Center, or by visiting 4. Follow the instructions for completing and filing claims which are listed on the claim form. 5. Send claim form along with itemized Hospital and medical bills to: Personal Insurance Administrators, Inc. P.O. Box 6040 Agoura Hills, CA Providers may submit claims electronically: PAYER ID If you have questions about the status of your claim after it has been submitted, please call Personal Insurance Administrators, Inc., at The completed claim form and all Hospital and medical bills must be submitted for payment within 90 days after the date loss occurs. Failure to furnish this information within the 90-day period shall not invalidate nor reduce your claim if it was not reasonably possible to file the claim within this time, provided that the claim form is submitted as soon as is reasonably possible. In no event, except in the absence of legal capacity, will a claim be honored later than one (1) year from the date of first medical treatment. You have the right to request an independent medical review if health care services have been improperly denied, modified, or delayed based on medical necessity. Always keep a copy of all documents submitted for claims. Page 11

12 CERTIFICATION OF QUALIFYING HEALTH PLAN COVERAGE If you are no longer eligible to be insured under the plan and need to obtain proof of insurance, you may request a Certification of Qualifying Health Plan Coverage from the plan administrator (Ascension Benefits & Insurance Solutions). This request can be made by phone or in writing, and it must include the name of the school and the name of each person who is no longer eligible to be insured under the plan. AUTHORIZED REPRESENTATION In accordance with state and federal rules and regulations, we will not disclose individual information without authorization. This includes disclosures to family members for insured individuals who have reached the age of majority. If you would like to authorize an additional party to act as a personal representative for matters pertaining to this insurance plan, we must have an Authorization Form on file. To request a form, please contact Ascension at the address below or download a form at PrivacyAuthorizationForm.pdf and mail it to the address below. SUMMARY OF PRIVACY POLICY If you are covered under one of our insurance plans, we are committed to protecting your privacy. We strongly believe in maintaining the confidentiality of the personal information we obtain and/or receive about you. We do not disclose any nonpublic information about you to anyone, except as permitted or required by law. We do not sell or otherwise disclose your personal information to anyone for purposes unrelated to our products and services. We maintain physical, electronic, and procedural safeguards that comply with federal and state regulations to protect information about you from unauthorized disclosure. We may disclose any information we believe necessary to conduct our business as is legally required. You have the right to access, review, and correct all personal information collected. You may review this Privacy Policy in its entirety, or the Privacy Policies of other entities servicing the Policy, by writing to the address or visiting the website below. You may also submit a request to review your information, in writing, to the address below. Attention: Privacy Manager Ascension Benefits & Insurance Solutions P.O. Box Los Angeles, CA Phone: Facsimile: Website: CA License No. 0G55426 To download a plan summary, FAQ, or ID card or for further information on this plan, visit: Plan Administrator:

13 BROCHURE ADDENDUM POLICY NUMBER: US DATE: 12/17/2013 NOTICE: The benefits contained within have been revised since original publication. The revisions are included within the body of the document and are summarized here for reference. 1. Pg. 6 Changed Outpatient Doctor Visits to Limited to a maximum of 20 visits per plan year. 2. Pg. 7 Changed Inpatient Doctor Visits to Limited to a maximum of 20 visits per plan year. 3. Pg. 7 Removed Up to a maximum of 3 days per plan year from Inpatient Treatment of Substance Abuse. 4. Pg. 9 Removed Intentionally self-inflicted Injury, suicide, or any attempt thereat exclusion. The corrected benefits are listed below: Outpatient Doctor Visits Inpatient Doctor Visits Inpatient Treatment of Substance Abuse Limited to a maximum of 20 visits per plan year Limited to a maximum of 20 visits per plan year Up to Maximum Benefit Please contact the Plan Administrator if you have any questions about this notice. Plan Administrator: