Antenna Blue Cross Life & Health Insurance Company

Transcription

1 STUDENT HEALTH INSURANCE THE MASTER S COLLEGE & SEMINARY DOMESTIC & INTERNATIONAL You can view a standard Summary of Benefits & Coverage(SBC) which is required by Health Care Reform. It summarizes your coverage in a format that all insurance companies now use. Just go to: studentinsurance.wellsfargo.com to find your school s plan and corresponding SBC. Or call to request a paper copy free of charge. Underwritten by: Anthem Blue Cross Life and Health Insurance Company Policy # Brokered by: Wells Fargo Insurance Services USA, Inc. Student Insurance Division

2 HEALTH CARE REFORM NOTICE: This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Review Services, we may be required to make additional changes to this summary of benefits. WHY DO I NEED INSURANCE? Having health insurance is important because, while medical care is excellent, the costs may be very high. Health insurance coverage can help minimize the risk that could force you to interrupt your education because of a financially devastating Injury or Sickness. It may allow you to focus on your studies instead of worrying about what would happen if faced with overwhelming medical bills. For these reasons, The Master s College and Seminary has selected a Student Health Insurance plan underwritten by Anthem Blue Cross Life and Health Insurance Company. Please read this brochure thoroughly. It is a brief description of the benefits, provisions, exclusions and limitations of the Plan. WHO IS ELIGIBLE TO ENROLL? All registered traditional students for the fall and spring/summer terms at The Master s College and Seminary are required to participate in this insurance program, un less proof of comparable coverage is furnished within 45 days of the effective date for each term. If coverage is not waived, the student premium will be charged to the tuition fee bill. Students enrolled in the Center for Professional Studies and Summer Institute Programs are not eligible to participate in this insurance program. To be a Covered Person under the Policy, the student must have paid the required costs and his/her name, student number and date of birth must have been included in the declaration made by the School or the Administrative Agent to the Company. All students must actively attend classes for the first 45 consecutive days following their effective date for the term purchased and/or pursuant to their visa requirements for the period for which coverage is purchased, except in the case of medical withdrawal or during school authorized breaks. The Company maintains its right to investigate student status and attendance records to verify that the Policy Eligibility requirements have been and continue to be met. If and whenever the Company discovers that Policy eligibility requirements have not or are not being met, its only obligation is a refund of premium less any claims paid. Eligible students who have a change in status and involuntarily lose coverage under another group insurance plan are also eligible to purchase The Master s College and Seminary Student Health Insurance Plan. These students must provide Wells Fargo Insurance with proof that they have lost insurance through another group (certificate and letter of ineligibility) within 30 days of the qualifying event. The ef fective date would be the later of the date the student enrolls and pays the premium or the day after prior coverage ends. DEPENDENT COVERAGE - Covered Students may also purchase dependent coverage. Eligible dependents are the Covered Student s spouse who resides with the Covered Student, domestic partner under a legally registered and valid domestic partnership, and children under 26 years of age. Dependents of an Eligible International student or visiting faculty member must possess a valid passport and a proper visa (F-2, J-2, or M-2). A Newborn will automatically be covered for Injury or Sickness from birth until 31 days old, providing that the student is covered under this plan. Coverage may be continued for that child when the Company is notified in writing within 31 days from the date of birth and by payment of any additional costs. A dependent may become eligible for coverage under the Policy only when the student becomes eligible or within 31 days of the following qualifying events with the appropriate documentation: marriage, birth, or adoption. Dependent coverage expires concurrently and in conjunction with that of the Covered Student, and Dependents must be re-enrolled when coverage terminates to maintain coverage. THE HEALTH CENTER TMC Health Center is located in the CPS 2 building on Placerita Canyon Road. Our goal is to keep students healthy and to help them recover when they are sick so that they can enjoy campus life and accomplish their educational objectives. A registered nurse is available (Master s College Students Only) for consultation, treatment of minor ailments, minor injuries and to be to be the first response for emergencies. The Health Center is not equipped to handle serious Injuries or Sicknesses; students will be referred off-campus for these conditions to obtain appropriate treatment at their own expense. To find PPO (Prudent Buyer Network) local doctors or hospitals call (800) or If you are ill and want to speak to a nurse contact 24/7 Nurse Advice Line (800) For online Student Assistance program and resources for everyday problems, visit Misplaced your insurance I.D. card? Call Wells Fargo Insurance (800) TMC Health Center Hours: Monday-Friday 9:00 a.m.-4:00 p.m.(except holidays) WHEN COVERAGE BEGINS Insurance under the Policy will become effective at 12:01 a.m. on the latest of: The Policy effective date (8/1/2013); The Policy effective date; The beginning date of the term for which premium has been paid; The day after the date for which the first premium for the Covered Stu dent s coverage is received by the Company; Authorized Agent or College IMPORTANT NOTICE - Premiums will not be pro-rated if the Insured Person enrolls past the first date of coverage for which he or she is applying. Re-enrolling students will be allowed a 30 day grace period from the term start date to enroll whereby the effective date will be backdated a maximum of 30 days. No coverage shall ever start prior to the term start date. 2 The Master s College & Seminary

3 WHEN COVERAGE ENDS Insurance of all Covered Persons terminates at 11:59 p.m. on the earliest of: The date the policy terminates for all Covered Persons (7/31/2014); The end of the period of coverage for which premium has been paid; The date the Covered Person enters military service. COVERAGE IS NOT AUTOMATICALLY RENEWED. To maintain continuous coverage, eligible persons must re-enroll when coverage terminates. PLAN COSTS ANNUAL 8/1/13-7/31/14 REFUNDS SPRING/SUMMER * 1/10/14-7/31/14 STUDENT $1,320 $ 771 SPOUSE $4,084 $2,382 PER CHILD $2,531 $1,476 *Spring/Summer term is for new entering students in the Spring only REFUNDS - A refund of premium will be granted for the reasons below only. No other refunds will be granted. If the Covered Person withdraws from school within the first 45 days of the coverage period, he/she will receive a full refund of the insurance premium provided that he/ she did not file a medical claim during this period. Writ ten proof of withdrawal from the school must be provided. If the Covered Person withdraws after 45 days of the coverage period, his/her coverage will remain in effect until the end of the term for which he/she has paid the premium. If the Covered Person enters the armed forces of any country he/she will not be covered under the Policy as of the date of such entry. A pro-rata refund of premium will be made for such person, upon written request received by WFIS within 45 days of entry into service. Refund requests should be directed to Wells Fargo Insurance at (800) Approved refunds will be assessed a $25 processing fee. ONLINE STUDENT ASSISTANCE PROGRAM Everyone experiences challenges in life. Usually, we can find our own solutions. But when we can t, those problems can affect our daily lives. This plan includes the Anthem Blue Cross OnLine Student Assistance Program. With OnLine, helpful information and resources for the everyday problems of living are just a mouse click away. When you need solutions, Anthem Blue Cross OnLine can help. With the OnLine Student Assistance Program, you and your family can access an online library of valuable articles covering mental and physical health, relationships/family issues, stress and emotional concerns and substance abuse. Browse the legal and financial resource center for general information on these topics. OnLine also provides important links to some of the most valuable Web resources available, as well as pertinent reading lists and helpful self-assessment tools. How to access the Anthem Blue Cross OnLine Program You and your family members can take advantage of this online resource by going to Simply enter your Program Name: The Master s College & Seminary College for access to helpful information and resources to assist you with the normal challenges of living. Many of the OnLine resources are also available in Spanish. EXTENSION OF BENEFITS AFTER TERMINATION If a Covered Person is confined to a Hospital on the date his or her coverage terminates, charges incurred during the continuation of that Hospital Confinement shall also be included in the term Eligible Expense. Benefits will be payable for the Eligible Expenses incurred after the date coverage terminates until the earliest of the following: (1) the date the Hospital confinement ends; (2) the end of the 90 day period following the date coverage terminated; or (3) the date the applicable Maximum Amount is reached. The Extension of Benefits will apply only to the extent the Covered Person will not be covered under the Policy or any other health insurance policy in the ensuing term of coverage. The Master s College & Seminary 3

4 PPO PRUDENT BUYER NETWORK PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED. Covering all Cali fornia ZIP codes, the Prudent Buyer network is the most geographically extensive PPO network in the state. The suitcase icon on your Medical ID card indicates that this plan can be used outside of California. The PPO network allows Insured s easy access to a wide range of medical providers. Insured s have the option to receive care from a provider who is not participating in the PPO network. The trade-off is higher out-of-pocket expenses. Participating providers (PPO Providers) agree to provide services to covered persons at discounted rates as payment in full. This is the incentive for Insured s to use PPO providers and protects them from being balance-billed (except for coinsurance, co-payments and deductible amounts). Providers working within a PPO facility (ex. a hospital) may not always be PPO providers. You should request that all of your provider services be performed by a PPO Provider when you use a PPO facility. When Non-PPO providers are used, you may be subject to higher out-of-pocket expenses. Additionally, PPO physicians agree to admit their patients to network hospitals, guaranteeing that discounted charges and utilization management savings will occur. With no claim forms to file, Insured s can focus on their health, not paperwork. Insured s can find a PPO physician in their area by calling Anthem at (800) , or by accessing the Find a Doctor link on MANDATED BENEFITS The following benefits are mandated coverages in the state of California. They will be included in all School plans issued under the Policy. Unless specified otherwise, all such coverage will be subject to any deductible, co-payment and co-insurance conditions of the Plan, as well as all other terms and conditions applicable to any other Covered Sickness. Mandated benefits as required by the state in which the Policy is issued include: PKU Treatment Benefit; Hospital Dental Procedures; Mastectomy-Reconstructive Surgery and Rehabilitation; Laryngectomy-Prosthetic Devices; Osteoporosis Benefit; Experimental or Investigational Therapies Treatment; Diabetes Equipment, Supplies and Service; Severe Mental Illness Treatment Benefit, which is a separate benefit from Mental and Nervous Disorders; and Pervasive Developmental Disorder or Autism. See the policy on file with the school for further details on these benefits. Students should refer to the Prudent Buyer Plan website at or call (800) to find a doctor or provider. GUIDELINES FOR CANCER SCREENING TESTS Anthem Blue Cross Life and Health will pay the charges incurred for the following cancer screening tests, subject to any deductibles, co-payments or co-insurance: 1. Screening mammogram performed according to the following schedule: a) A baseline mammogram for women age 35 to 39 inclusive; b) A mammogram for women age 40 to 49, inclusive, every two years or more frequently based on a Physician s recommendation; or c) A mammogram every year for women age 50 and over. 2. PAP tests for women 18 years of age and older as recommended by a Physician; 3. Prostate cancer screening, including digital rectal examinations and prostatespecific antigen tests if recommended by a Physician, at least once a year for men 50 years of age and older until age 72. Other generally accepted cancer screening tests, subject to all terms and conditions that would otherwise apply. 4 The Master s College & Seminary

5 Contracting Hospital: is a Hospital that has a contract with Anthem Blue Cross Life and Health to provide care to covered persons; however, this does not necessarily make it a Participating Hospital. Verify participation with your Physician. Co-payment: is a part of the Maximum Allowed Amount you are responsible for paying. Co-payment does not include charges for services that are not Covered Services or charges in excess of the Maximum Allowed Amount. Covered Services: are services that are Medically Necessary services or supplies which are listed in the benefit section of this brochure and for which you are entitled to receive benefits. The Company: is Wells Fargo Insurance which administers the Plan. Deductible: is a part of the Maximum Allowed Amount you must pay for Covered Services before any benefits are available to you under this plan. Your Plan Year Deductible is stated on page 6. Emergency: is a sudden, serious and unexpected acute illness, injury, condition (including without limitation sudden and unexpected severe pain), or a psychiatric emergency medical condition, which the insured person reasonably perceives could permanently endanger health if medical treatment is not received immediately. Anthem Blue Cross Life and Health will have sole and final determination as to whether services were rendered in connection with an emergency. The Insurer: is Anthem Blue Cross Life and Health Insurance Company. Insured Person: is the student or dependent. Maximum Allowed Amount: is the maximum amount of reimbursement that is allowed for covered medical services and supplies under the plan. Medically Necessary: are procedures, supplies, equipment or services that are considered to be: Appropriate and necessary for the diagnosis or treatment of a medical condition, and Provided for the diagnosis or direct care and treatment of the medical condition, and Within the standards of good medical practice within the organized medical community, and Not primarily for the convenience of the patient s Physician or another provider, and The most appropriate procedure, supply, equipment or service which can be safely provided that must satisfy the following requirements: 1) there must be valid scientific evidence demonstrating that the expected health benefits from the procedure, supply, equipment or service are clinically significant and produce a greater likelihood of benefit, without a disproportionately greater risk of harm or complications, for the patient with the particular medical condition being treated than other possible alternatives; and 2) generally accepted forms of treatment that are less invasive have been tried and found to be ineffective or are otherwise unsuitable; and 3) for Hospital stays, acute care as an inpatient is necessary due to the kind of services the patient is receiving or the severity of the medical condition, and that safe and adequate care cannot be received as an outpatient or in a less intensified medical setting. DEFINITIONS Non-Contracting Hospital: is a Hospital that does not have a standard contract nor a Prudent Buyer Participating Agreement with Anthem Blue Cross Life and Health. Only a portion of the amount which a Non-Contracting Hospital charges for services will be considered covered. The Insured will be responsible for any billed charges over the Maximum Allowed Amount. Non-Prudent Buyer Provider (Non-PPO): is a provider who does NOT have a Prudent Buyer Plan Participating Provider Agreement with Anthem Blue Cross Life and Health in effect at the time services are rendered. Only a portion of the amount which a Non-Prudent Buyer Provider charges for services will be considered covered. The Insured will be responsible for any billed charges over the Maximum Allowed Amount. Physician means: 1) A doctor of medicine (M.D.) or a doctor of osteopathy (D.O.) who is licensed to practice where the care is provided, or 2) One of the following providers, but only when the provider is licensed to practice where the care is provided, is rendering a service within the scope of that license, and such license is required to render that service, and is providing a service for which benefits are specified in this brochure: A physician assistant A licensed educational psychologist for the provision of behavioral health treatment services for the treatment of pervasive developmental disorder or autism only A licensed professional clinical counselor (L.P.C.C)* A nurse practitioner A dentist (D.D.S. or D.M.D.); An optometrist (O.D.); A dispensing optician; A podiatrist or chiropodist (D.P.M., D.S.P. or D.S.C.); A licensed clinical psychologist; A chiropractor (D.C.); An acupuncturist (A.C.); A licensed clinical social worker (L.C.S.W.); A marriage and family therapist (M.F.T.); A physical therapist (P.T. or R.P.T.); A speech pathologist*; An audiologist*; An occupational therapist (O.T.R.)*; A respiratory care practitioner (R.C.P.)*; A psychiatric mental health nurse (R.N.); A nurse midwife; A registered dietician (R.D.)* for the provision of diabetic medical nutrition therapy only Note: The providers indicated by asterisks (*) are covered only by referral of a Physician (M.D. or D.O.) as defined in 1 above. Prudent Buyer Provider (PPO): is one of the following providers which has a Prudent Buyer Plan Participating Provider Agreement with Anthem Blue Cross Life and Health in effect at the time services are rendered. A Hospital A Physician An Ambulatory Surgical Center A durable medical equipment outlet A clinical laboratory A Skilled Nursing Facility A facility which provides diagnostic imaging services A home health agency A home infusion therapy provider The Master s College & Seminary 5

6 6 The Master s College & Seminary SCHEDULE OF BENEFITS In addition to dollar and percentage co-pays, insured persons are responsible for deductibles, as described below. Please review the deductible information to know if a deductible applies to a specific covered service. Insured persons are also responsible for all costs over the plan maximums. Plan maximums and other important information appear in italics. Benefits are subject to all terms, conditions, limitations, and exclusions of the Policy. Plan maximums and other important information appear in italics. Benefits are subject to all terms, conditions, limitations, and exclusions of the Policy. Explanation of Covered Charges Plan payments are based on the Maximum Allowed Amount: PPO Providers The rate the provider has agreed to accept as reimbursement for covered services. Insured Persons are not responsible for the difference between the provider s usual charges & the Maximum Allowed Amount. Non-PPO Providers & Other Health Care Providers (includes those not represented in the PPO provider network) Reimbursement amount is based on the Insurer s rate or fee schedule, a rate negotiated with the provider, information from a third party vendor, or billed charges. Insured Persons are responsible for the difference between the provider s usual charges & the Maximum Allowed Amount. When using Non-PPO and Other Health Care Providers, insured persons are responsible for any difference between the covered expense & actual charges, as well as any deductible & co-pay. Plan year deductible for all providers $100/insured person; $300/family Deductible for non-ppo hospital or residential treatment center $500/admission (waived for emergency admission) Deductible for non-ppo hospital, residential treatment center $500/admission (waived for emergency admission) or ambulatory surgical center if utilization review not obtained Deductible for emergency room services $100/visit (waived if admitted directly from ER) Annual Out-of-Pocket Maximums for all providers $5,000/insured person/year The following do not apply to out-of-pocket maximums: deductibles listed above; dollar co-pays; percentage co-pays for non-covered charges. After an insured person reaches the out-of-pocket maximum, the insured person no longer pays percentage co-pays for the remainder of the year. However, insured person remains responsible for dollar co-pays; percentage co-pays for and, for non-ppo providers & other health care providers, costs in excess of the Maximum Allowed Amount. Benefit Year Maximum Covered Services Unlimited Hospital Services (subject to utilization review for inpatient services; waived for emergency admissions) Semi-private room, meals & special diets, & ancillary services Intensive Care Unit Outpatient medical care, surgical services & supplies (hospital care other than emergency room care) PPO: Student/ Dependent Co-Pay Non-PPO: Student/ Dependent Co-Pay Ambulatory Surgical Centers Outpatient surgery, services & supplies 40% (benefit limited to $350/day) Related Outpatient Medical Services & Supplies Ground or air ambulance transportation, services & disposable supplies Blood transfusions, blood processing & the cost of unreplaced blood & blood products Autologous blood (self-donated blood collection, testing, processing & storage for planned surgery) Emergency Care Emergency room services & supplies ($100 deductible, waived if admitted) Inpatient hospital services & supplies Physician Services Physician Medical Services Office & home visits Hospital & skilled nursing facility visits Surgeon & surgical assistant; anesthesiologist or anesthetist Diagnostic X-ray & Lab (including STD testing) (pre-authorization required for CT scans, MRA scans, MRI scans, MRS scans, NC scans & PET scans) Mental or Nervous Disorders Inpatient care (preauthorization required; waived for emergency admissions) Outpatient physician visits for psychotherapy and psychological testing (pre-service review required after the 12th visit) $20/visit 3 (deductible waived) % 1 40% 1 40% 1 40% 40% 40% 40% $20/visit 3 (deductible waived) 40% 1 40% 2 Continued on Next Page

7 Covered Services Physical Therapy, Physical Medicine & Occupational Therapy including Chiropractic (limited to 24 visits/benefit year; additional visits may be authorized) Home delivery drugs and medications Generic or brand name (90-day supply) PPO: Student/ Dependent Co-Pay Non-PPO: Student/ Dependent Co-Pay 40% (benefit limited to $25/visit) Co-pays: $30/generic; $40/formulary; $80/non-formulary Acupuncture Services for the treatment of disease, illness or injury (limited to $30/visit & 12 visits/benefit year) 4 40% 4 Temporomandibular Joint Disorders Splint therapy & surgical treatment 40% Pregnancy & Maternity Care Physician office visits Normal delivery, cesarean section, complications of pregnancy Inpatient physician services Hospital & ancillary services 24/7 NurseLine A 24-hour service that connects insured persons to a nurse or audio library with a toll-free call. The number is (800) Diabetes Education Programs (requires physician supervision) Teach insured persons & their families about the disease process, the daily management of diabetic therapy & self-management training Prosthetic Devices Coverage for breast prostheses; prosthetic devices to restore a method of speaking; surgical implants; artificial limbs or eyes; the first pair of contact lenses or eyeglasses when required as a result of eye surgery; & therapeutic shoes & inserts for Insureds with diabetes Durable Medical Equipment (DME) Rental or purchase of DME including hearing aids, dialysis equipment & supplies. (hearing aids benefit is available for one hearing aid per ear every three years) Skilled Nursing Facility (subject to utilization review) Semi-private room, services & supplies (limited to 100 days/calendar year; includes residential treatment center services) Home Health Care (subject to utilization review for inpatient services; waived for emergency admissions) Service & supplies from home health agency Home Infusion Therapy (subject to utilization review) Includes medication, ancillary services & supplies; caregiver training & visits by provider to monitor therapy; durable medical equipment; lab services Preventive Care Services Routine physical exams, screening, tests, education and immunizations administered with the intent of preventing future disease, illness or injury, and additional preventive care for women provided for in the guidelines supported by the Health Resources and Service Administration Adult Preventive Services (mammograms, pap smears & prostate cancer screenings) $20/visit 3 (deductible waived) $20/visit (deductible waived) No co-pay 40% 40% 40% 1 40% 40% 40% 40% 40% 40% (benefit limited to $600/day) No co-pay (deductible waived) Not covered No co-pay (deductible waived) Medical Treatment of Natural Teeth, Injury to sound, natural teeth 40% Outpatient Drugs and Medications Co-pays: $15/generic; Drugs and medication, including oral contraceptives & insulin, when dispensed by a retail pharmacy $20/formulary; $40/ (Benefit is on a reimbursement basis in a 30 day supply only) non-formulary 40% (deductible waived) Co-pays: $15/generic; $20/formulary; $40/nonformulary; PLUS 50% of the remaining prescription drug maximum allowed amount& costs in excess of the prescription drug maximum allowed amount 1 For California facilities, a discount applies if the facility has a contract with us for fee-for-service business. For California facilities without a contract, covered expense for non-emergency hospital charges and supplies is reduced by 25%, resulting in higher out-of-pocket costs for insured persons. 2 These providers are not represented in the PPO network. 3 The dollar co-pay applies only to the visit itself. An additional co-pay applies for any services performed in office (i.e., X-ray, lab, surgery). 4 Acupuncture services can be performed by a certified acupuncturist (C.A.), a doctor of medicine (M.D.), a doctor of osteopathy (D.O.), a podiatrist This Summary of Benefits is a brief review of benefits. Once enrolled, insured persons will receive a Certificate of Insurance, which explains the exclusions and limitations, as well as the full range of covered services of the plan, in detail. The Master s College & Seminary 7

8 1. Not Medically Necessary. Services or supplies that are not medically necessary, as defined. 2. Experimental or Investigative. Any experimental or investigative procedure or medication. But, if you are denied benefits because it is determined that the requested treatment is experimental or investigative, you may request an in dependent medical review as described in the certificate. 3. Outside the United States. Services or supplies furnished and billed by a provider outside the United States, unless the services or supplies are furnished in connection with urgent care or an emergency. For international students, expenses incurred within the insured person s home country. 4. Crime or Nuclear Energy. Conditions that result from: (1) your commission of or attempt to commit a felony as long as any injuries are not a result of a medical condition or an act of domestic violence; or (2) any release of nuclear energy, whether or not the result of war, when government funds are available for treatment of illness or injury arising from such release of nuclear energy. 5. Uninsured. Services received before your effective date or after your coverage ends. 6. Excess Amounts. Any amounts in excess of the Maximum Allowed Amount or the Benefit Year Maximum. 7. Work-Related. Work-related conditions if benefits are recovered or can be recovered, either by adjudication, settlement or otherwise, under any workers compensation, employer s liability law or occupational disease law, even if you do not claim those benefits. If there is a dispute or substantial uncertainty as to whether benefits may be recovered for those conditions pursuant to workers compensation benefits will be provided subject to our right or recovery and reimbursement under California Labor Code Section 4903, as specified as covered in the certificate. 8. Government Treatment. Any services you received if you are not required to pay for them or they are given to you for free that were provided by a local, state, or federal government agency, or by a public school system or school district, except when payment under this plan is expressly required by federal or state law. 9. Services of Relatives. Professional services received from a person who lives in your home or who is related to you by blood or marriage. 10. Voluntary Payment. Services for which you are not legally obligated to pay. Services for which you are not charged. Services for which no charge is made in the absence of insurance coverage, except services received at a nongovernmental charitable research hospital. Such a hospital must meet the following guidelines: It must be internationally known as being devoted mainly to medical research; At least 10% of its yearly budget must be spent on research not directly related to patient care; At least one-third of its gross income must come from donations or grants other than gifts or payments for patient care; It must accept patients who are unable to pay; and Two-thirds of its patients must have conditions directly related to the hospital s research. 11. Not Specifically Listed. Services not specifically listed in this plan as covered services. 12. Private Contracts. Services or supplies provided pursuant to a private contract between the insured person and a provider, for which reimbursement under 8 The Master s College & Seminary EXCLUSIONS & LIMITATIONS the Medicare program is prohibited, as specified in Section 1802 (42 U.S.C. 1395a) of Title XVIII of the Social Security Act. 13. Inpatient Diagnostic Tests. Inpatient room and board charges in connection with a hospital stay primarily for diagnostic tests which could have been performed safely on an outpatient basis. 14. Mental or Nervous Disorders. Academic or educational testing, counseling, and remediation. Treatment of mental or nervous disorders including rehabilitative care in relation to these conditions, except as specifically stated in the certificate. 15. Substance Abuse. Treatment of substance abuse, including conditions caused by, contributed to, or a result of the insured person s use of alcohol, illegal drugs, or drugs or medicines not taken in the dosage or for the purpose prescribed by the insured person s physician. Injury resulting from the insured person being legally intoxicated or under the influence of alcohol as defined by the jurisdiction in which the accident occurred. 16. Nicotine Use. Smoking cessation programs or treatment of nicotine or tobacco use. Smoking cessation drugs. 17. Orthodontia. Braces and other orthodontic appliances or services. 18. Dental Services or Supplies. For dental treatment, regardless of origin or cause, except as specified below. Dental treatment includes but is not limited to preventative care and fluoride treatments; dental x rays, supplies, appliances, dental implants and all associated expenses; diagnosis and treatment related to the teeth, jawbones or gums, including but not limited to: Extraction, restoration, and replacement of teeth; Services to improve dental clinical outcomes. This exclusion does not apply to the following: Services which we are required by law to cover; Services specified as covered in this booklet; Dental services to prepare the mouth for radiation therapy to treat head and/or neck cancer. 19. Hearing Aids or Tests. Hearing aids, except as specifically stated in the certificate. Routine hearing tests,except as specifically provided in the certificate. 20. Optometric Services or Supplies. Optometric services, eye exercise including orthoptics. Routine eye exams and routine eye refractions. Eyeglasses or contact lenses. 21. Outpatient Occupational Therapy. Outpatient occupational therapy, except by a home health agency as specifically stated in the certificate, or as specifically stated in the Physical Therapy, Physical Medicine and Occupational Therapy provision of the certificate. 22. Speech Therapy. Outpatient speech therapy. 23. Cosmetic Surgery. Cosmetic surgery or other services performed solely for beautification or to alter or reshape Norman (including aged) structures or tissues of the body to improve appearance. This exclusion does not apply to reconstructive surgery (that is, surgery performed to correct deformities caused by congenital or developmental abnormalities, illness, or injury for the purpose of improving bodily function or symptomatology or to create a normal appearance), including surgery performed to restore symmetry following mastectomy. Cosmetic surgery does not become reconstructive surgery because of psychological or psychiatric reasons. 24. Scalp Hair Prostheses. Including wigs or any form of hair replacement 25. Commercial Weight Loss Programs. Weight loss programs, whether or not they are pursued under medical or physician supervision, unless specifically listed as covered under the Plan. This exclusion includes, but is not limited to,

9 commercial weight loss programs (Weight Watchers, Jenny Craig, LA Weight Loss) and fasting programs. This exclusion does not apply to medically necessary treatments for morbid obesity or dietary evaluations and counseling, and behavioral modification programs for the treatment of anorexia nervosa bulimia nervosa. Surgical treatment for morbid obesity will not be covered. 26. Sex Transformation. Procedures or treatment to change characteristics of the body to those of the opposite sex. 27. Sterilization Reversal. 28. Infertility Treatment. Services or supplies furnished in connections with the diagnosis and treatment of infertility, including, but not limited to, diagnostic tests, medication, surgery, artificial insemination, in vitro fertilization, sterilization reversal, and gamete intrafallopian transfer. 29. Orthopedic Supplies. Orthopedic shoes and shoe inserts, except for orthopedic footwear used as an integral part of a brace, shoe inserts that are custom molded to the patient, or therapeutic shoes and inserts designed to treat for complications due to diabetes, except as specified as covered in the Certificate. 30. Air Conditioners. Air purifiers, air conditioners, or humidifiers. 31. Custodial Care and Rest Cures. Inpatient room and board charges in connection with a hospital stay primarily for environmental change, physical therapy or treatment of chronic pain. Custodial care or rest cures. Services provided by a rest home, a home for the aged, a nursing home or any similar facility. Services provided by a skilled nursing facility. 32. Health Club Memberships. Health club memberships, exercise equipment, charges from a physical fitness instructor or personal trainer, or any other charges for activities, equipment or facilities used for developing or maintaining physical fitness, even if ordered by a physician. This exclusion also applies to health spas. 33. Personal Items. Any supplies for comfort, hygiene or beautification. 34. Education or Counseling. Educational services or nutritional counseling, or any services that are educational, vocational, or training in nature, except as specifically stated under the Diabetes provision of the certificate. 35. Food or dietary supplements, except as specifically stated under the Special Food Products provision of the certificate. 36. Telephone and Facsimile Machine Consultations. Consultations provided by telephone or facsimile machine. 37. Routine Exams or Tests. Routine physical exams or tests which do not directly treat an actual illness, injury or conditions including those required by employment or government authority, except as specifically stated in the certificate. 38. Acupuncture. Acupuncture treatment except as specifically stated in the Acupuncture provision of the certificate. Acupressure, or massage to control pain, treat illness or promote health by applying pressure to one or more specific areas of the body based on dermatomes or acupuncture points. 39. Eye Surgery for Refractive Defects. Any eye surgery solely or primarily for the purpose of correcting refractive defects of the eye such as nearsightedness (myopia) and/or astigmatism. Contact lenses and eyeglasses required as a result of this surgery. 40. Physical Therapy or Physical Medicine. Services of a physician for physical therapy or physical medicine, except when provided during a covered inpatient confinement, or as specifically stated in the certificate and in the Physical Therapy, Physical Medicine and Occupational Therapy provision of the certificate. EXCLUSIONS & LIMITATIONS (CONTINUED) 41. Outpatient Drugs and Medication. Outpatient prescription drugs or medications and insulin, except as specifically stated in the certificate section of this booklet. Non-prescription, over-the-counter patent or proprietary drugs or medicines. Cosmetics, health or beauty aids. 42. Contraceptive Devices. Contraceptive devices prescribed for birth control except as specifically stated in the certificate. 43. Diabetic Supplies. Prescription and non-prescription diabetic supplies, except as specifically stated in the certificate. 44. Private Duty Nursing. Private duty nursing services. 45. Lifestyle Programs. Programs to alter one s lifestyle which may include but are not limited to diet, exercise, imagery or nutrition. This exclusion will not apply to cardiac rehabilitation programs approved by us. 46. Clinical Trials. Services and supplies in connections with clinical trials, except as specifically stated in the certificate. 47. Abortion. Elective termination of pregnancy. 48. Acne. Any services or supplies furnished in connection with the diagnosis and treatment of acne. 49. Aircraft. Treatment arising from a condition that occurred while riding in any aircraft, except as a fare-paying passenger on a regularly scheduled airline or charter flight. 50. Congenital Conditions. Any services or supplies furnished in connection with the diagnosis or treatment of congenital conditions, except as specifically stated in the certificate. 51. Foot Treatment. Services or supplies for the care of corns, calluses, weak, strained or flat feet. 52. Motor Vehicle. Expenses incurred due to or arising from a motor vehicle accident if the insured person operated the vehicle without a proper license in the jurisdiction where the accident occurred. 53. Organ and Tissue Transplants. Expenses incurred in connection with an organ or tissue transplant. 54. Sports Related Conditions. Expenses incurred for treatment of sport-related accidental injury resulting from interscholastic, intercollegiate, club or professional sports. Treatment arising from a condition sustained while participation in scuba diving, parachuting, hang gliding, sail planning, glider flying, parasailing or bungee jumping. 55. Travel. Expenses incurred for treatment arising from traveling against the advice of your physician, while on a waiting list for specific treatment, or when traveling for the purpose of obtaining medical treatment. 56. Non-Licensed Providers. Treatment or services rendered by non-licensed health care providers and treatment or services for which the provider of services is not required to be licensed. This includes treatment or services from a non-licensed provider under the supervision of a licensed physician, except as specifically provided or arranged by us. 57. Surrogate Mother Services. For any services or supplies provided to a person not covered under the plan in connection with a surrogate pregnancy (including but not limited to, the bearing of a child by another woman for an infertile couple.) 58. Treatment of varicose veins or telangiectatic dermal veins (spider veins) by any method (including sclerotherapy or other surgeries) when services are rendered for cosmetic purposes. The Master s College & Seminary 9

10 PRE-EXISTING CONDITION EXCLUSION No payment will be made for services or supplies for the treatment of a pre-existing period of six months following either: (a) your effective date or (b) the first day of any waiting period required by the group, whichever is earlier. If you were covered under creditable coverage, the time spent under the creditable coverage will be used to satisfy, or partially satisfy, the six-month period. The pre-existing condition exclusion does not apply to pregnancy nor to an insured person who is under age 19. CERTIFICATE OF CREDITABLE COVERAGE Your coverage under this Insurance Plan is creditable coverage under Federal Law. When your coverage terminates, you can request a Certificate of Creditable Coverage, which is evidence of your coverage under this health insurance plan. You need such certificate if you become covered under a group health plan or other health plan within 62 days after your coverage under this health insurance plan terminates. If the subsequent health plan excludes or limits coverage for medical conditions you have before you enroll, this certificate may be used to reduce or eliminate those exclusions or limitations. A Certificate of Creditable Coverage may be requested in writing from Wells Fargo Insurance. CONTINUOUS COVERAGE This Plan may be replacing a Prior Plan with another insurer. Prior Plan means (a) the Student Health Insurance policy or policies issued to the California State University immediately before the current Policy; (b) other policies providing Creditable Coverage as defined in this Plan. Injury or Sickness shall include an Injury sustained, or a Sickness first manifesting itself, while the Insured Person is continuously insured under the Prior Plan and became insured under this Plan without a break in coverage. But no benefits shall be payable for such Injury or Sickness to the extent that such benefits are payable under the Prior Plan for the same expenses. This will apply even though the Prior Plan provided that it will not duplicate the benefits under another Policy. Also, the total amount of benefits payable for Injury or Sickness under this Plan and the Prior Plan cannot exceed the Per Condition Aggregate Maximum. EXCESS COVERAGE The Insurer will reduce the amount payable under the policy to the extent expenses are covered under any Other Plan. The Insurer will determine the amount of benefits provided by Other Plans without reference to any coordination of benefits, non duplication of benefits, or other similar provisions. The amount from Other Plans includes any amount to which the Covered Person is entitled, whether or not a claim is made for the benefits. The policy is secondary coverage to all other policies. BCR 102 ED CONTINUATION OF BENEFITS AFTER TERMINATION Anthem Blue Cross Life and Health will extend benefits under the Policy for 30 days after the Insured s coverage would otherwise end if on that date he or she is 1) Hospital Confined for an Injury or Sickness covered by the Policy, and 2) under a doctor s care. Any benefits payable under this provision will not exceed the benefit maximums shown in the Schedule of Benefits. The cost of the Continuation of Benefits is one month s premium. ID CARDS Medical ID cards may be shipped before or within 3 weeks of your policy effective date. New ID cards will not be sent if you are renewing coverage with Anthem Blue Cross Life and Health and there are no benefit changes between plan years. Providers need your Member ID # from your ID card to identify you, verify your coverage and bill Anthem Blue Cross Life and Health. If you need to seek medical treatment prior to receiving your ID card, please use the temporary card and write in your Member # or call Wells Fargo Insurance at (800) to obtain your Member #. Renewing students will maintain the same Member #. Without a Member ID you can still seek medical treatment and submit a claim form for reimbursement. HOW DO I FILE A CLAIM? Usually, all providers of healthcare will bill Anthem Blue Cross Life and Health directly for services to Insureds. This is the preferred procedure - you are not bothered with claim forms, and Anthem Blue Cross Life and Health often needs more details than are ordinarily provided on bills to patients. But sometimes a physician or an ambulance company may not bill Anthem Blue Cross Life and Health and may send the bill directly to you. Also, your Student Health Services and pharmacies will not bill Anthem Blue Cross Life and Health. In these instances, Anthem Blue Cross Life and Health has no way of knowing about your claim. So, you must mail the bills to Anthem Blue Cross Life and Health within 90 days of treatment and include a claim form. Claim forms are available at You are urged to send Anthem Blue Cross Life and Health each bill immediately upon receipt. Mail to: Anthem Blue Cross Life and Health Insurance Company P.O. Box Los Angeles, CA Complete instructions for use of the claim form are on the form. 10 The Master s College & Seminary

11 REIMBURSEMENT FOR ACTS OF THIRD PARTIES Under some circumstances, an insured person may need services under this plan for which a third party may be liable or legally responsible by reason of negligence, an intentional act or breach of any legal obligation. In that event, the insurer will provide the benefits of this plan subject to the following: 1. The Insurer will automatically have a lien, to the extent of benefits provided, upon any recovery, whether by settlement, judgment or otherwise, that you receive from the third party, the third party s insurer, or the third party s guarantor. The lien will be in the amount of benefits the Insurer has paid under this plan for the treatment of the illness, disease, injury or condition for which the third party is liable. 2. You must advise the Insurer in writing, within 60 days of filing a claim against the third party and take necessary action, furnish such information and assistance, and execute such papers as the Insurer may require to facilitate enforcement of their rights. You must not take action which may prejudice the insurer s rights or interests under your plan. Failure to give the Insurer such notice or to cooperate with the Insurer, or actions that prejudice the Insurer s rights or interests will be a material breach of this plan and will result in your being personally responsible for reimbursing the Insurer. 3. The Insurer will be entitled to collect on their lien even if the amount you or anyone recovered for you (or your estate, parent or legal guardian) from or for the account of such third party as compensation for the injury, illness or condition is less than the actual loss you suffered. ARBITRATION AGREEMENT Any dispute or claim, of whatever nature, arising out of, in connection with, or in relation to this plan or the policy or breach or rescission thereof, or in relation to care or delivery of care, including any claim based on contract, tort, or statute, must be resolved by arbitration if the amount sought exceeds the jurisdictional limit of the small claims court. Any dispute or claim within the jurisdictional limits of the small claims court will be resolved in such court. The Federal Arbitration Act will govern the interpretation and enforcement of all proceedings under this Binding Arbitration provision. The insured person and Anthem Blue Cross Life and Health agree to be bound by this Binding Arbitration provision and acknowledge that they are each giving up their right to a trial by court or jury. The insured person and Anthem Blue Cross Life and Health agree to give up the right to participate in class arbitration against each other. The arbitration findings will be final and binding except to the extent that California or Federal law provides for the judicial review of arbitration proceedings. The arbitration is begun by the insured person making written demand on Anthem Blue Cross Life and Health. The arbitration will be conducted by Judicial Arbitration and Mediation Services ( JAMS ) according to its applicable Rules and Procedures. If, for any reason, JAMS is unavailable to conduct the arbitration, the arbitration will be conducted by another neutral arbitration entity, by mutual agreement of the insured person and Anthem Blue Cross Life and Health, or by order of the court, if the insured person and Anthem Blue Cross Life and Health cannot agree. The arbitration shall be held in the State of California. COMPLAINT NOTICE Should you have any complaints or questions regarding your coverage, you should first contact Wells Fargo Insurance. You may also contact Anthem Blue Cross Life and Health at: Anthem Blue Cross Life and Health Insurance Company (Anthem Blue Cross Life and Health) Customer Service Oxnard Street Woodland Hills, CA (800) If the problem is not resolved, you may also contact the California Department of Insurance at: California Department of Insurance Claims Service Bureau, 11th Floor 300 South Spring Street Los Angeles, California (800) 927-HELP (4357) In California (213) Out of California (800) Telecommunication Device for the Deaf Inquiry: Consumer Services link at The Master s College & Seminary 11