Aetna Student Health Plan Design and Benefits Summary Columbia University Medical Center Policy Year: Policy Number:

Transcription

1 Aetna Student Health Plan Design and Benefits Summary Columbia University Medical Center Policy Year: Policy Number: (877)

2 This is a brief description of the Student Health Plan. The Plan is underwritten by Aetna Life Insurance Company (Aetna). The exact provisions governing this insurance are contained in the Master Policy issued to Columbia University Medical Center and may be viewed online at If any discrepancy exists between this Brochure and the Policy, the Master Policy will govern and control the payment of benefits. Columbia University Medical Center Student Health Service Columbia University Medical Center (CUMC) Student Health Service (SHS) is CUMC s on campus health facility. The SHS offers a wide array of services provided by Primary Care Medical Services, the Mental Health Service and the Center for Student Wellness. Detailed information including hours of operation, student insurance information, and department services can be found at For more information, call the SHS at (212) Coverage Periods (CUMC Campus) CUMC Campus Students: Coverage for all insured CUMC students enrolled in the Plan for the following Coverage Periods. Coverage will become effective at 12:01 AM on the Coverage Start Date indicated below, and will terminate at 11:59 PM on the Coverage End Date indicated. Coverage Period Coverage Start Date Coverage End Date Enrollment/Waiver Deadline Annual 08/17/ /14/ /19/2014 Fall 08/17/ /19/ /19/2014 Spring/Summer 01/20/ /14/ /30/2015 Eligible Dependents: Coverage for dependents eligible under the Plan for the following Coverage Periods. Coverage will, will become effective at 12:01 AM on the Coverage Start Date indicated below, and will terminate at 11:59 PM on the Coverage End Date indicated. Coverage for insured dependents terminates in accordance with the Termination Provisions described in the Master Policy. Coverage Period Coverage Start Date Coverage End Date Enrollment/Waiver Deadline Annual 08/17/ /14/ /19/2014 Fall 08/17/ /19/ /19/2014 Spring/Summer 01/20/ /14/ /30/2015 Columbia University Medical Center Page 2

3 CUMC Campus Rates The rates below include both premiums for the student medical insurance plan underwritten by Aetna Life Insurance Company, as well as Columbia University fees for dental services provided by Columbia University College of Dental Medicine. CUMC Campus Rates Fall Semester Spring/Summer Semester Student $1,544 $2,037 Spouse/Domestic Partner $3,557 $4,688 Child(ren) $1,884 $2,483 Student Coverage Eligibility Full Time Students All registered full time students are automatically enrolled in the Columbia University Medical Center Plan if no valid waiver request is submitted. Waivers must be repeated annually and must demonstrate coverage under another comparable policy. Enrollment in the Columbia University Medical Center Student Medical Insurance Plan, either by automatic enrollment or online selection, is effective only upon the student's registration for the term for which coverage will be active. Once the student s insurance coverage decision has been determined for the Fall term, either by automatic enrollment, or waiver request, that decision will automatically be continued in the following Spring term as long as the student remains registered at the University. For students who do not register for the Spring 2015 Term, their insurance coverage will terminate on January 19, Part Time Students During the open enrollment period part time students may choose to enroll in the Columbia University Medical Center Student Medical Insurance Plan. Enrolling in the plan will automatically initiate enrollment in the CUMC Student Health Service Program, which is required. Please visit for more information about on campus services and the CUMC Student Health Service Program Fee. Part time students who have been insured under the Plan in previous years and wish to enroll again must re enroll by September 19, 2014 in order to avoid a break in coverage for conditions that existed in the prior policy years. Funded Graduate Students Please contact your departmental administrator, Financial Aid Office, or Fellowship Office for information about whether your school provides funding to cover any portion of the Student Medical Insurance Plan premium. Columbia University Medical Center Page 3

4 Student Veterans Student veterans may be eligible for health care benefits through the Veterans Administration (VA) for illnesses and injuries related to their service. CUMC Student Health recommends that Columbia studentveterans confirm their status with the VA and, if necessary, complete the VA paperwork needed to receive benefits in the New York City area. Most students who receive Post 9/11 GI Bill (Ch. 33) benefits may have costs for the CUMC Student Health Service Program and the Columbia Plan covered by the fees portion of the GI Bill. All students will be automatically enrolled in this plan unless a waiver request is submitted and approved by the waiver request deadline. How to Enroll CUMC Campus Eligible students will be automatically enrolled in this Plan, unless the completed waiver application has been received by Columbia University by the specified enrollment deadline dates listed in the applicable section of this Plan Design and Benefits Summary. Dependent Coverage Eligibility Covered students may also enroll their lawful spouse, same sex or opposite sex domestic partner and dependent children up to the age of 26. Enrollment To enroll the dependent(s) of a covered student, please complete the Dependent Enrollment Form on the CUMC Student Health website. The form, along with supporting documentation, should be submitted to the CUMC Insurance Office at 60 Haven Avenue, Tower 1, Apt. 3E, New York, NY Please bring both the form and supporting documentation at the same time to ensure timely enrollment. Dependent enrollment applications will not be accepted after the enrollment deadline unless there is a significant life change that directly affects their insurance coverage. An example of a significant life change would be loss of health coverage under another health plan. Please contact the CUMC Insurance Office at shsinsurance@cumc.columbia.edu or (212) for more information or with any questions. Preferred Provider Network Aetna Student Health has arranged for you to access a Preferred Provider Network in your local community. 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. Columbia University Medical Center Page 4

5 Pre certification Program Your Plan requires pre certification for a hospital stay. Pre certification simply means calling Aetna Student Health prior to treatment to get approval for a medical procedure or service. Pre certification may be done by you, your doctor, the hospital, or one of your relatives. Requests for certification must be obtained by contacting Aetna Student Health at (877) If you do not secure pre certification for non emergency inpatient admissions, or provide notification for emergency admissions, your covered medical expenses will be subject to a $200 per admission Deductible. If you do not secure pre certification for partial hospitalizations, your covered medical expenses will be subject to a $200 per admission Deductible. You ll need pre certification for the following inpatient services: All inpatient admissions, including length of stay, to a hospital, 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 hours for a vaginal delivery or 96 hours for a cesarean section; 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 Master Policy. Also you can view eligibility, notification guidelines, and benefit coverage. Pre certification of non emergency inpatient admissions and partial hospitalization Non emergency admissions must be requested at least three (3) business days prior to the planned admission or prior to the date the services are scheduled to begin. Pre certification of emergency inpatient admissions Emergency admissions must be requested within one (1) business day after the admission. Columbia University Medical Center Page 5

6 Description of Benefits Students The Plan excludes coverage for certain services and contains limitations on the amounts it will pay. 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. To look at the full Plan description, which is contained in the Master Policy issued to Columbia University Medical Center, you may access it online at If any discrepancy exists between this Brochure and the Policy, the Master Policy will govern and control the payment of benefits. All coverage is based on Recognized Charges unless otherwise specified. Policy Year Maximum Unlimited DEDUCTIBLE Unless otherwise indicated, the Policy Year Deductible must be met prior to benefits being payable. In addition to state and federal requirements for waiver of the Policy Year Deductible, this Plan will waive the Deductible for Outpatient Mental Health, Emergency Care, Pediatric Preventive Vision Services, and Preferred Care Pediatric Dental Services. Per visit or admission Deductibles do not apply towards satisfying the Policy Year Deductible. Preferred Care Students: None Non Preferred Care Students: $500 Per Policy Year COINSURANCE Covered Medical s are payable at the coinsurance percentage specified below, after any applicable Deductible. OUT OF POCKET MAXIMUMS Once the Individual or Family Out of Pocket Limit has been satisfied, Covered Medical s will be payable at 100% for the remainder of the Policy Year. The following expenses do not apply toward meeting the Out of Pocket Limit: expenses that are not covered medical expenses penalties, and other expenses not covered by this Policy Preferred Care Individual Out of Pocket: $3,000 Family Out of Pocket: $12,700 Non Preferred Care Individual Out of Pocket: $3,000 Family Out of Pocket: unlimited Columbia University Medical Center Page 6

7 Referral Requirements If you are enrolled in the Student Health Insurance Plan, the Columbia University Medical Center Student Health Service (SHS) serves as your source of primary care. Seeking care there first will reduce your out of pocket expenses, since no copayment is required. Referrals are required for most care outside the SHS (see exceptions below), including follow up specialist visits recommended by an emergency room clinician. Failure to obtain a referral will result in nonpayment of benefits afforded through the Plan. Students that have graduated and remain on the insurance plan will continue to need a referral if they reside within 50 miles of the Columbia University Medical Center. You are required to obtain a referral at the beginning of each policy year. Failure to obtain a referral for all treatment including continuing treatment at the beginning of each policy year will result in the non payment of benefits. Note: students receiving continuing Mental Health services will not be required to obtain a new referral each policy year. A Student Health Service referral is not required for the following conditions only: Dependents under the age of 18. An Emergency Medical Condition as defined in the Definitions section of this Brochure; however, you must return to the SHS for any necessary follow up care, or for a referral to a specialist for follow up care Routine Gynecological care Maternity care Elective termination of pregnancy One annual routine Pap smear screening, including the office visit, for women age 18 and older Students receiving services outside the Metropolitan New York area as defined by 50 miles away from Columbia University Medical Center Care obtained out of the country Covered preventive care services received more than 50 miles from Columbia University Medical Center. If a student, spouse or domestic partner is within 50 miles of Columbia University Medical Center, a referral is not required for covered preventive care services which are not offered by CUMC Student Health including but not limited to screenings for pregnant women, colorectal screenings, and screenings for dependent children. Please see a complete list of preventive services offered by CUMC at Although not required, students, spouses and domestic partners are strongly encouraged to discuss all preventive care needs with their Student Health Service provider. Inpatient Hospitalization Benefits Preferred Care Non Preferred Care Room and Board After a $250 copay per admission, 100% of the Negotiated Charge for a semi private room Miscellaneous Hospital Includes, but not limited to: operating room, laboratory tests/x rays, oxygen tent, and drugs, medicines, dressings Non Surgical Physicians Non surgical services of the attending Physician, or a consulting Physician 100% of the Negotiated Charge 100% of the Negotiated Charge Columbia University Medical Center Page 7

8 Surgical s Preferred Care Non Preferred Care Surgical (Inpatient and Outpatient) After a $100 copay per surgery, 100% of the Negotiated Charge Anesthesia (Inpatient and Outpatient) Assistant Surgeon (Inpatient and Outpatient) 100% of the Negotiated Charge 100% of the Negotiated Charge Ambulatory Surgical 100% of the Negotiated Charge Outpatient Preferred Care Non Preferred Care Hospital Outpatient Department 100% of the Negotiated Charge Walk in Clinic Visit Emergency Room Important Note: Please note that Non Preferred Care Providers do not have a contract with Aetna. The provider may not accept payment of your cost share (your deductible and coinsurance) as payment in full. You may receive a bill for the difference between the amount billed by the provider and the amount paid by this Plan. If the provider bills you for an amount above your cost share, you are not responsible for paying that amount. Please send Aetna the bill at the address listed on the back of your member ID card and Aetna will resolve any payment dispute with the provider over that amount. Make sure your member ID number is on the bill. Urgent Care After a $20 copay per visit, 100% of the Negotiated Charge After a $100 copay per visit (waived if admitted), 100% of the Negotiated Charge* After a $20 copay per visit, 100% of the Negotiated Charge After a $100 per visit deductible (waived if admitted), 100% of the Recognized Charge* Ambulance After a $100 copay per trip, 100% of the Negotiated Charge After a $100 per trip deductible, 100% of the Recognized Charge Physician s Office Visit This benefit includes visits to specialists. After a $20 copay per visit, 100% of the Negotiated Charge Columbia University Medical Center Page 8

9 Laboratory and X ray 100% of the Negotiated Charge High Cost Procedures Includes CT scans, MRIs, PET scans and Nuclear Cardiac Imaging Tests Therapy Includes Physical, Speech, and Occupational Therapy After a $50 copay per visit, 100% of the Negotiated Charge After a $20 copay per visit, 100% of the Negotiated Charge Chiropractic Therapy After a $20 copay per visit, 100% of the Negotiated Charge Chemotherapy Includes oral chemotherapy and 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 Durable Medical and Surgical Equipment After a $20 copay per visit, 100% of the Negotiated Charge 90% of the Negotiated Charge Prosthetic Devices 90% of the Negotiated Charge Hearing Aids Benefit is limited to a single purchase (including repair/replacement) every three years. Bone Anchored Hearing Aids (if certain criteria are met) are limited to 1 per Lifetime. Dental Injury Allergy Testing and Treatment 90% of the Negotiated Charge After a $20 copay per visit, 100% of the Actual Charge Covered Medical s are payable on the same basis as any other Columbia University Medical Center Page 9

10 Diagnostic Testing For Learning Disabilities 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 s are payable on the same basis as any other Dental for Impacted Wisdom Teeth After a $20 copay per visit, 100% of the Actual Charge Preventive Care Preferred Care Non Preferred Care Pap Smear Screening 100% of the Negotiated Charge* Mammogram Includes one baseline mammogram for women between age 35 and 40. Coverage is also provided for one routine annual mammogram for women age 40 and older, as well as when medically indicated for women with risk factors who are under age 40. Risk factors for women under 40 are: prior personal history of breast cancer, positive genetic testings, family history of breast cancer, or other risk factors Also includes comprehensive ultrasound screening for the entire breast or breasts if a mammogram demonstrates heterogenous or dense breast tissue and when determined to be medically necessary by a licensed physician Immunizations Includes travel immunizations and flu shots Routine Physical Exam Includes routine tests and related lab fees Routine Screening for Sexually Transmitted Disease 100% of the Negotiated Charge* 100% of the Negotiated Charge* 100% of the Negotiated Charge* 100% of the Negotiated Charge* Routine Colorectal Cancer 100% of the Negotiated Charge* Columbia University Medical Center Page 10

11 Screening Includes charges for colorectal cancer examination and laboratory tests, for any nonsymptomatic person age 50 or more, or a symptomatic person under age 50, for the following: one fecal occult blood test every 12 months in a row, a Sigmoidoscopy at age 50 and every 3 years thereafter, one digital rectal exam every 12 months in a row, a double contrast barium enema, once every 5 years, a colonoscopy, once every 10 years,virtual colonoscopy, Stool DNA Routine Prostate Cancer Screening Includes charges incurred by a covered person for the screening of cancer as follows: For a male age 50 or over; one digital rectal exam and one prostate specific antigen test each Policy Year. For a male age 40 and over, with a family history of prostate cancer or other prostate cancer risk factors, one digital rectal exam and one prostate specific antigen test each Policy Year. For a male, at any age, with a prior history of prostate cancer, one digital rectal exam and one prostate specific antigen test each Policy Year Pediatric Vision Care Exam Supplies are limited to 1 pair of glasses (lenses and frames) per Policy Year. Contact lenses covered if medically necessary. 100% of the Negotiated Charge* 100% of the Negotiated Charge* * Covered Medical s include routine vision exam (including refraction & Glaucoma Testing), non cosmetic eyeglass frames, prescription lenses or prescription contact lenses (not both). Benefits are provided to covered persons through age 18. Columbia University Medical Center Page 11

12 Pediatric Routine Dental Exam Covered dental expenses include charges made by a dental provider for the dental services listed in the Pediatric Dental Care Schedule. To view the Pediatric Dental Care Schedule please refer to the Columbia University Medical Center page on the Aetna Student Health website, Benefits are provided to covered persons through age 18. Pediatric Basic Dental Care Covered dental expenses include charges made by a dental provider for the dental services listed in the Pediatric Dental Care Schedule. To view the Pediatric Dental Care Schedule please refer to the Columbia University Medical Center page on the Aetna Student Health website, Benefits are provided to covered persons through age 18. Pediatric Major Dental Care Covered dental expenses include charges made by a dental provider for the dental services listed in the Pediatric Dental Care Schedule. To view the Pediatric Dental Care Schedule please refer to the Columbia University Medical Center page on the Aetna Student Health website, Benefits are provided to covered persons through age % of the Negotiated Charge* 70% of the Negotiated Charge* 50% of the Recognized Charge 50% of the Negotiated Charge* 50% of the Recognized Charge Columbia University Medical Center Page 12

13 Pediatric Orthodontia Medically necessary comprehensive treatment. Replacement of retainer (limit one per lifetime). Benefits are provided to covered persons through age 18. Treatment of Mental and Nervous Disorders 50% of the Negotiated Charge* 50% of the Recognized Charge Preferred Care Non Preferred Care Biologically based Mental Illness and for Children with Serious Emotional Disturbances Inpatient After a $250 copay per admission, 100% of the Negotiated Charge Biologically based Mental Illness and for Children with Serious Emotional Disturbances Outpatient After a $20 copay per visit, 100% of the Negotiated Charge* * Other than Biologically based Mental Illness and Children with Serious Emotional Disturbances Inpatient After a $250 copay per admission, 100% of the Negotiated Charge Other than Biologically based Mental Illness and Children with Serious Emotional Disturbances Outpatient After a $20 copay per visit, 100% of the Negotiated Charge* * Alcoholism and Drug Addiction Treatment Inpatient Outpatient Preferred Care After a $250 copay per admission, 100% of the Negotiated Charge After a $20 copay per visit, 100% of the Negotiated Charge Non Preferred Care Columbia University Medical Center Page 13

14 Maternity Benefits Preferred Care Non Preferred Care Maternity Prenatal Care/Comprehensive Lactation Support and Counseling Services Breast Feeding Durable Medical Equipment Well Newborn Nursery Care Covered Medical s for pregnancy, childbirth, and complications of pregnancy are payable on the same basis as any other sickness, member cost sharing is based on the type of service performed and the place of service where it is rendered 100% of the Negotiated Charge* 100% of the Negotiated Charge* 100% of the Negotiated Charge Family Planning Unless specified below, not covered under this benefit are charges for: Services which are covered to any extent under any other part of this Plan; Services and supplies incurred for an abortion; Services provided as a result of complications resulting from a voluntary sterilization procedure and related followup care; Services which are for the treatment of an identified illness or injury; Services that are not given by a physician or under his or her direction; Psychiatric, psychological, personality or emotional testing or exams; Any contraceptive methods that are only "reviewed" by the FDA and not "approved" by the FDA; Male contraceptive methods, or devices; The reversal of voluntary sterilization procedures, including any related follow up care Voluntary Sterilization Coverage for tubal ligation for voluntary sterilization 100% of the Negotiated Charge* Voluntary Sterilization Coverage for vasectomy for voluntary sterilization After a $100 copay per surgery, 100% of the Negotiated Charge Contraceptives Important note: Brand Name Prescription Drug or Devices for a Preferred Provider will be covered at 100% of the Negotiated Charge, including waiver of per Policy Year Deductible, if a Generic Prescription Drug or Device is not available in the same therapeutic drug class or the prescriber specifies Dispense as Written 100% of the Negotiated Charge* Columbia University Medical Center Page 14

15 Prescription Drug Coverage Preferred Care Non Preferred Care Prescribed Medicines Prior Authorization may be required for certain Prescription Drugs and some medications may not be covered under this Plan. For assistance and a complete list of excluded medications, or drugs requiring prior authorization, please contact Aetna Pharmacy Management at (888) RX AETNA (available 24 hours). Aetna Specialty Pharmacy provides specialty medications and support to members living with chronic conditions. The medications offered may be injected, infused or taken by mouth. For additional information please go to 100% of the Negotiated Charge following a $10 Copay for each Generic Prescription Drug, a $35 Copay for each Preferred Brand Name Prescription Drug, or a $50 Copay for each Non Preferred Brand Name Prescription Drug. following a $10 Deductible for each Generic Prescription Drug, a $35 Deductible for each Preferred Brand Name Prescription Drug, or a $50 Deductible for each Non Preferred Brand Name Prescription Drug. You must pay out of pocket for Prescriptions at a Non Preferred Pharmacy and then submit the receipt with a Prescription Claim Form for reimbursement. Additional Benefits Preferred Care Non Preferred Care Diabetic Treatment and Supplies s Outpatient Diabetic Selfmanagement Education Program Temporomandibular Joint Dysfunction Includes charges incurred by a covered person for treatment of Temporomandibular Joint (TMJ) Dysfunction, when the TMJ disorder is medical in origin Elective Abortion Benefits are limited to $500 per Policy Year. Covered Medical s are payable on the same basis as any other Covered Medical s are payable on the same basis as any other Covered Medical s are payable on the same basis as any other 100% of the Negotiated Charge Acupuncture 100% of the Negotiated Charge Hospice After a $250 copay per visit, 100% of the Negotiated Charge Columbia University Medical Center Page 15

16 Bereavement Counseling Includes counseling services for members family either before or after death of the member Benefits are limited to a maximum of 5 sessions. Home Health Care After a $20 copay per visit, 100% of the Negotiated Charge After a $20 copay per visit, 100% of the Negotiated Charge Licensed Nurse 100% of the Negotiated Charge Skilled Nursing Facility Rehabilitation Facility Bariatric Surgery Includes services rendered as part of medically necessary bariatric surgery treatment for morbid obesity Human Organ Transplant Includes transplants for surgeries determined to be nonexperimental and noninvestigational Exercise Facility Reimbursement Benefits are limited to $200 for a member every 6 months. Basic and Comprehensive Infertility Benefits do not include: Advanced Reproductive Technology (ART) Benefits Advanced Reproductive Technology is defined as: In vitro fertilization (IVF); Zygote intrafallopian transfer (ZIFT); Gamete intra fallopian transfer (GIFT); Cryopreserved embryo transfers; and Intracytoplasmic sperm injection (ICSI); or ovum microsurgery After a $250 copay per admission, 100% of the Negotiated Charge for the semi private room rate After a $250 copay per admission, 100% of the Negotiated Charge for the rehabilitation facility s daily room and board maximum for semi private accommodations for the semi private room rate for the rehabilitation facility s daily room and board maximum for semi private accommodations Covered Medical s are payable on the same basis as any other Covered Medical s are payable on the same basis as any other 100% of the Actual Charge Covered Medical s are payable on the same basis as any other Columbia University Medical Center Page 16

17 Autism Spectrum Disorder Includes screening, diagnosis and treatment of autism spectrum disorder. "Autism spectrum disorder" means any pervasive developmental disorder as defined in the most recent edition of the diagnostic and statistical manual of mental disorders, including autistic disorder, Asperger's disorder, Rett's disorder, childhood disintegrative disorder, or pervasive developmental disorder not otherwise specified (PDD NOS). "Applied behavior analysis" means the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior Covered Medical s are payable on the same basis as any other Benefits are limited to a maximum of 680 hours of treatment per policy for applied behavior analysis. *Annual Deductible does not apply to these services Columbia University Medical Center Page 17

18 Description of Benefits Dependents The Plan excludes coverage for certain services and contains limitations on the amounts it will pay. 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. To look at the full Plan description, which is contained in the Master Policy issued to Columbia University Medical Center, you may access it online at If any discrepancy exists between this Brochure and the Policy, the Master Policy will govern and control the payment of benefits. All coverage is based on Recognized Charges unless otherwise specified. Policy Year Maximum Unlimited DEDUCTIBLE Unless otherwise indicated, the Policy Year Deductible must be met prior to benefits being payable. In addition to state and federal requirements for waiver of the Policy Year Deductible, this Plan will waive the Deductible for: In addition, annual deductible is also waived for Preferred Care Physician s Office Visit, Emergency Room, Preferred Care Therapy, Preferred Care Walk in Clinic Visit, Preferred Care Physical Therapy, Preferred Care Chemotherapy, Preferred Care Consultant, Preferred Care Elective Abortion, Preferred Care Musculoskeletal/Chiropractic Therapy, Preferred Care Acupuncture, Preferred Care Urgent Care, Preferred Care Mental and Nervous Disorders Outpatient, and Preferred Care Alcoholism and Drug Addiction Treatment Outpatient, Preferred Care Pediatric Dental Services, Pediatric Preventive Vision Services, and Outpatient Mental Health Treatment under Student Health Services referral. Per visit or admission Deductibles do not apply towards satisfying the Policy Year Deductible. Preferred Care Spouse: $150 per policy year Child: $150 per policy year Non Preferred Care Spouse: $500 per policy year Child: $500 per policy year Columbia University Medical Center Page 18

19 COINSURANCE Covered Medical s are payable at the coinsurance percentage specified below, after any applicable Deductible. OUT OF POCKET MAXIMUMS Once the Individual or Family Outof Pocket Limit has been satisfied, Covered Medical s will be payable at 100% for the remainder of the Policy Year. The following expenses do not apply toward meeting the Out of Pocket Limit: expenses that are not covered medical expenses penalties, and other expenses not covered by this Policy Referral Requirements Preferred Care Individual Out of Pocket: $3,000 Family Out of Pocket: $12,700 Non Preferred Care Individual Out of Pocket: $3,000 Family Out of Pocket: unlimited If you are enrolled in the Student Health Insurance Plan, the Columbia University Medical Center Student Health Service (SHS) serves as your source of primary care. Seeking care there first will reduce your out of pocket expenses, since no copayment is required. Referrals are required for most care outside the SHS (see exceptions below), including follow up specialist visits recommended by an emergency room clinician. Failure to obtain a referral will result in nonpayment of benefits afforded through the Plan. Students that have graduated and remain on the insurance plan will continue to need a referral if they reside within 50 miles of the Columbia University Medical Center. You are required to obtain a referral at the beginning of each policy year. Failure to obtain a referral for all treatment including continuing treatment at the beginning of each policy year will result in the non payment of benefits. Note: students receiving continuing Mental Health services will not be required to obtain a new referral each policy year. A Student Health Service referral is not required for the following conditions only: Dependents under the age of 18. An Emergency Medical Condition as defined in the Definitions section of this Brochure; however, you must return to the SHS for any necessary follow up care, or for a referral to a specialist for follow up care Routine Gynecological care Maternity care Elective termination of pregnancy One annual routine Pap smear screening, including the office visit, for women age 18 and older Students receiving services outside the Metropolitan New York area as defined by 50 miles away from Columbia University Medical Center Care obtained out of the country Covered preventive care services received more than 50 miles from Columbia University Medical Center. If a student, spouse or domestic partner is within 50 miles of Columbia University Medical Center, a referral is not required for covered preventive care services which are not offered by CUMC Student Health including but not limited to screenings for pregnant women, colorectal screenings, and screenings for dependent children. Please see a complete list of preventive services offered by CUMC at Although not required, students, spouses and domestic partners are strongly encouraged to discuss all preventive care needs with their Student Health Service provider. Columbia University Medical Center Page 19

20 Inpatient Hospitalization Benefits Preferred Care Non Preferred Care Room and Board 80% of the Negotiated Charge for a semi private room Miscellaneous Hospital Includes, but not limited to: operating room, laboratory tests/x rays, oxygen tent, and drugs, medicines, dressings Non Surgical Physicians Non surgical services of the attending Physician, or a consulting Physician 80% of the Negotiated Charge 80% of the Negotiated Charge Surgical s Preferred Care Non Preferred Care Surgical (Inpatient and Outpatient) Anesthesia (Inpatient and Outpatient) Assistant Surgeon (Inpatient and Outpatient) 80% of the Negotiated Charge 80% of the Negotiated Charge 80% of the Negotiated Charge Ambulatory Surgical 80% of the Negotiated Charge Outpatient Preferred Care Non Preferred Care Hospital Outpatient Department 80% of the Negotiated Charge Walk in Clinic Visit Emergency Room Important Note: Please note that Non Preferred Care Providers do not have a contract with Aetna. The provider may not accept payment of your cost share (your deductible and coinsurance) as payment in full. You may receive a bill for the difference between the amount billed by the provider and the amount paid by this Plan. If the provider bills you for an amount above your cost share, you are not responsible for paying that amount. Please send Aetna the bill at the address listed on the back of your member ID card and Aetna will resolve any payment dispute with the provider over that amount. Make sure your member ID number is on the bill. After a $40 Copay per visit, 100% of the Negotiated Charge* After a $100 copay per visit (waived if admitted), 100% of the Negotiated Charge* After a $100 per visit deductible (waived if admitted), 100% of the Recognized Charge* Columbia University Medical Center Page 20

21 Urgent Care After a $40 copay per visit, 100% of the Negotiated Charge* Ambulance 80% of the Negotiated Charge 80% of the Recognized Charge Physician s Office Visit This benefit includes visits to specialists. After a $40 copay per visit, 100% of the Negotiated Charge* Laboratory and X ray 80% of the Negotiated Charge High Cost Procedures Includes CT scans, MRIs, PET scans and Nuclear Cardiac Imaging Tests 80% of the Negotiated Charge Therapy Includes Physical, Speech, and Occupational Therapy After a $40 copay per visit, 100% of the Negotiated Charge* Chiropractic Therapy After a $40 copay per visit, 100% of the Negotiated Charge* Chemotherapy Includes oral chemotherapy and 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 Durable Medical and Surgical Equipment After a $40 copay per visit, 100% of the Negotiated Charge* 80% of the Negotiated Charge Prosthetic Devices 80% of the Negotiated Charge Hearing Aids Benefit is limited to a single purchase (including repair/replacement) every three years. Bone Anchored Hearing Aids (if certain criteria are met) are limited to 1 per Lifetime. Dental Injury 80% of the Negotiated Charge 80% of the Actual Charge Columbia University Medical Center Page 21

22 Allergy Testing and Treatment Diagnostic Testing For Learning Disabilities 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 Dental for Impacted Wisdom Teeth Covered Medical s are payable on the same basis as any other Covered Medical s are payable on the same basis as any other 80% of the Actual Charge Preventive Care Preferred Care Non Preferred Care Pap Smear Screening 100% of the Negotiated Charge* Mammogram Includes one baseline mammogram for women between age 35 and 40. Coverage is also provided for one routine annual mammogram for women age 40 and older, as well as when medically indicated for women with risk factors who are under age 40. Risk factors for women under 40 are: prior personal history of breast cancer, positive genetic testings, family history of breast cancer, or other risk factors Also includes comprehensive ultrasound screening for the entire breast or breasts if a mammogram demonstrates heterogenous or dense breast tissue and when determined to be medically necessary by a licensed physician Immunizations Includes travel immunizations and flu shots 100% of the Negotiated Charge* 100% of the Negotiated Charge* Columbia University Medical Center Page 22

23 Routine Physical Exam Includes routine tests and related lab fees Routine Screening for Sexually Transmitted Disease Routine Colorectal Cancer Screening Includes charges for colorectal cancer examination and laboratory tests, for any nonsymptomatic person age 50 or more, or a symptomatic person under age 50, for the following: one fecal occult blood test every 12 months in a row, a Sigmoidoscopy at age 50 and every 3 years thereafter, one digital rectal exam every 12 months in a row, a double contrast barium enema, once every 5 years, a colonoscopy, once every 10 years,virtual colonoscopy, Stool DNA Routine Prostate Cancer Screening Includes charges incurred by a covered person for the screening of cancer as follows: For a male age 50 or over; one digital rectal exam and one prostate specific antigen test each Policy Year. For a male age 40 and over, with a family history of prostate cancer or other prostate cancer risk factors, one digital rectal exam and one prostate specific antigen test each Policy Year. For a male, at any age, with a prior history of prostate cancer, one digital rectal exam and one prostate specific antigen test each Policy Year 100% of the Negotiated Charge* 100% of the Negotiated Charge* 100% of the Negotiated Charge* 100% of the Negotiated Charge* Columbia University Medical Center Page 23

24 Pediatric Vision Care Exam Supplies are limited to 1 pair of glasses (lenses and frames) per Policy Year. Contact lenses covered if medically necessary. 100% of the Negotiated Charge* * Covered Medical s include routine vision exam (including refraction & Glaucoma Testing), non cosmetic eyeglass frames, prescription lenses or prescription contact lenses (not both). Benefits are provided to covered persons through age 18. Pediatric Routine Dental Exam Covered dental expenses include charges made by a dental provider for the dental services listed in the Pediatric Dental Care Schedule. To view the Pediatric Dental Care Schedule please refer to the Columbia University Medical Center page on the Aetna Student Health website, Benefits are provided to covered persons through age 18. Pediatric Basic Dental Care Covered dental expenses include charges made by a dental provider for the dental services listed in the Pediatric Dental Care Schedule. To view the Pediatric Dental Care Schedule please refer to the Columbia University Medical Center page on the Aetna Student Health website, Benefits are provided to covered persons through age % of the Negotiated Charge* 70% of the Negotiated Charge* 50% of the Recognized Charge Columbia University Medical Center Page 24

25 Pediatric Major Dental Care Covered dental expenses include charges made by a dental provider for the dental services listed in the Pediatric Dental Care Schedule. To view the Pediatric Dental Care Schedule please refer to the Columbia University Medical Center page on the Aetna Student Health website, Benefits are provided to covered persons through age 18. Pediatric Orthodontia Medically necessary comprehensive treatment. Replacement of retainer (limit one per lifetime). Benefits are provided to covered persons through age 18. Treatment of Mental and Nervous Disorders Biologically based Mental Illness and for Children with Serious Emotional Disturbances 50% of the Negotiated Charge* 50% of the Recognized Charge 50% of the Negotiated Charge* 50% of the Recognized Charge Preferred Care Non Preferred Care 80% of the Negotiated Charge Inpatient Biologically based Mental Illness and for Children with Serious Emotional Disturbances After $20 copay per visit, 100% of the Negotiated Charge* Outpatient Other than Biologically based Mental Illness and Children with Serious Emotional Disturbances 80% of the Negotiated Charge Inpatient Other than Biologically based Mental Illness and Children with Serious Emotional Disturbances Outpatient After $20 copay per visit, 100% of the Negotiated Charge* Columbia University Medical Center Page 25

26 Alcoholism and Drug Addiction Treatment Preferred Care Non Preferred Care Inpatient 80% of the Negotiated Charge Outpatient After $20 copay per visit, 100% of the Negotiated Charge* Maternity Benefits Preferred Care Non Preferred Care Maternity Prenatal Care/Comprehensive Lactation Support and Counseling Services Breast Feeding Durable Medical Equipment Well Newborn Nursery Care Covered Medical s for pregnancy, childbirth, and complications of pregnancy are payable on the same basis as any other sickness, member cost sharing is based on the type of service performed and the place of service where it is rendered 100% of the Negotiated Charge* 100% of the Negotiated Charge* 80% of the Negotiated Charge Family Planning Unless specified below, not covered under this benefit are charges for: Services which are covered to any extent under any other part of this Plan; Services and supplies incurred for an abortion; Services provided as a result of complications resulting from a voluntary sterilization procedure and related followup care; Services which are for the treatment of an identified illness or injury; Services that are not given by a physician or under his or her direction; Psychiatric, psychological, personality or emotional testing or exams; Any contraceptive methods that are only "reviewed" by the FDA and not "approved" by the FDA; Male contraceptive methods, or devices; The reversal of voluntary sterilization procedures, including any related follow up care Voluntary Sterilization Coverage for tubal ligation for voluntary sterilization 100% of the Negotiated Charge* Voluntary Sterilization Coverage for vasectomy for voluntary sterilization 80% of the Negotiated Charge Columbia University Medical Center Page 26

27 Contraceptives Important note: Brand Name Prescription Drug or Devices for a Preferred Provider will be covered at 100% of the Negotiated Charge, including waiver of per Policy Year Deductible, if a Generic Prescription Drug or Device is not available in the same therapeutic drug class or the prescriber specifies Dispense as Written 100% of the Negotiated Charge* Prescription Drug Coverage Preferred Care Non Preferred Care Prescribed Medicines Prior Authorization may be required for certain Prescription Drugs and some medications may not be covered under this Plan. For assistance and a complete list of excluded medications, or drugs requiring prior authorization, please contact Aetna Pharmacy Management at 888 RX AETNA (available 24 hours). Aetna Specialty Pharmacy provides specialty medications and support to members living with chronic conditions. The medications offered may be injected, infused or taken by mouth. For additional information please go to 100% of the Negotiated Charge following a $10 Copay for each Generic Prescription Drug, a $35 Copay for each Preferred Brand Name Prescription Drug, or a $50 Copay for each Non Preferred Brand Name Prescription Drug. following a $10 Deductible for each Generic Prescription Drug, a $35 Deductible for each Preferred Brand Name Prescription Drug, or a $50 Deductible for each Non Preferred Brand Name Prescription Drug. You must pay out of pocket for Prescriptions at a Non Preferred Pharmacy and then submit the receipt with a Prescription Claim Form for reimbursement. Additional Benefits Preferred Care Non Preferred Care Diabetic Treatment and Supplies s Covered Medical s are payable on the same basis as any other Outpatient Diabetic Selfmanagement Education Program Covered Medical s are payable on the same basis as any other Columbia University Medical Center Page 27

28 Temporomandibular Joint Dysfunction Includes charges incurred by a covered person for treatment of Temporomandibular Joint (TMJ) Dysfunction, when the TMJ disorder is medical in origin Covered Medical s are payable on the same basis as any other Elective Abortion 80% of the Negotiated Charge Acupuncture After $40 copay per visit, 100% of the Negotiated Charge* Hospice 80% of the Negotiated Charge Bereavement Counseling Includes counseling services for members family either before or after death of the member 80% of the Negotiated Charge Benefits are limited to a maximum of 5 sessions. Home Health Care 80% of the Negotiated Charge Licensed Nurse 80% of the Negotiated Charge Skilled Nursing Facility Rehabilitation Facility Bariatric Surgery Includes services rendered as part of medically necessary bariatric surgery treatment for morbid obesity Human Organ Transplant Includes transplants for surgeries determined to be nonexperimental and noninvestigational Exercise Facility Reimbursement Benefits are limited to $100 for a spouse every 6 months. 80% of the Negotiated Charge for the semi private room rate 80% of the Negotiated Charge for the rehabilitation facility s daily room and board maximum for semi private accommodations for the semi private room rate for the rehabilitation facility s daily room and board maximum for semi private accommodations Covered Medical s are payable on the same basis as any other Covered Medical s are payable on the same basis as any other 100% of the Actual Charge Columbia University Medical Center Page 28

29 Basic and Comprehensive Infertility Benefits do not include: Advanced Reproductive Technology (ART) Benefits Advanced Reproductive Technology is defined as: In vitro fertilization (IVF); Zygote intrafallopian transfer (ZIFT); Gamete intra fallopian transfer (GIFT); Cryopreserved embryo transfers; and Intracytoplasmic sperm injection (ICSI); or ovum microsurgery Autism Spectrum Disorder Includes screening, diagnosis and treatment of autism spectrum disorder. "Autism spectrum disorder" means any pervasive developmental disorder as defined in the most recent edition of the diagnostic and statistical manual of mental disorders, including autistic disorder, Asperger's disorder, Rett's disorder, childhood disintegrative disorder, or pervasive developmental disorder not otherwise specified (PDD NOS). "Applied behavior analysis" means the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior Covered Medical s are payable on the same basis as any other Covered Medical s are payable on the same basis as any other Benefits are limited to a maximum of 680 hours of treatment per policy for applied behavior analysis. *Annual Deductible does not apply to these services Columbia University Medical Center Page 29

30 Exclusions This Plan does not cover nor provide benefits for: 1. incurred as a result of dental treatment, except for treatment resulting from injury to sound natural teeth within 12 months of the accident and except for dental care necessary due to a congenital disease or anomaly, or for extraction of impacted wisdom teeth as provided elsewhere in this Policy. 2. incurred for services normally provided without charge by the Policyholder's Health Service, Infirmary or Hospital, or by health care providers employed by the Policyholder. 3. incurred for eye refractions, vision therapy, radial keratotomy, eyeglasses, contact lenses (except when required after cataract surgery), or other vision or hearing aids, or prescriptions or examinations except as required for repair caused by a covered injury or as provided elsewhere in this plan. 4. incurred as a result of injury due to participation in a riot. "Participation in a riot" means taking part in a riot in any way; including inciting the riot or conspiring to incite it. It does not include actions taken in self defense so long as they are not taken against persons who are trying to restore law and order. 5. Aviation. This does not apply if a person is a fare paying passenger or a scheduled charter flight operated by a scheduled airline. 6. incurred as a result of an injury or sickness due to working for wage or profit or for which benefits are provided under any Workers' Compensation or Occupational Disease Law. 7. incurred as a result of an injury sustained or sickness contracted while in the service of the Armed Forces of any country. Upon the covered person entering the Armed Forces of any country, the unearned pro rata premium will be refunded to the Policyholder. 8. incurred for treatment provided in a governmental hospital unless there is a legal obligation to pay such charges in the absence of insurance. 9. incurred for elective treatment or elective surgery except as specifically provided elsewhere in this Policy and performed while this Policy is in effect. 10. incurred for cosmetic surgery, reconstructive surgery, or other services and supplies which improve, alter, or enhance appearance, whether or not for psychological or emotional reasons, except to the extent needed to (a) improve the function of a part of the body that is not a tooth or structure that supports the teeth and (b) is malformed as a result of a severe birth defect, including harelip, webbed fingers or toes; or (c) as direct result of disease or surgery performed to treat a disease or injury. This exclusion does not apply to reconstructive surgery when such service is incidental to or follows surgery resulting from trauma, infection, or other diseases of the involved part and reconstructive surgery because of congenital disease or anomaly of a covered dependent child which has resulted in a functional defect. (d) Repair of an injury (including reconstructive surgery for prosthetic device for a covered person who has undergone a mastectomy) which occurs while the covered person is covered under this Policy. Surgery must be performed in the next calendar year. Columbia University Medical Center Page 30