Marymount Manhattan College. Student Health Insurance Plan Underwritten by Tufts Insurance Company. Policy Number: SP100103

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1 Marymount Manhattan College Student Health Insurance Plan Underwritten by Tufts Insurance Company. Policy Number: SP

2 Dow Zanghi Student Health Center The Dow Zanghi Student Health Center provides primary medical care to Marymount Manhattan College (MMC) students. It is operated by Mount Sinai Beth Israel / Student Health Services Network in partnership with the College. All students, including commuters and those living at the other MMC residence halls, may use the Health Center free of charge with a current MMC identification card. Free services include diagnosis and treatment, follow-up and evaluation, blood-drawing, health education, writing prescriptions and referrals. Lab work, prescriptions and some immunizations, such as the MMR Vaccines, have fees associated. These fees may be charged back to the student s health insurance company. The Center is staffed by a physician assistant and a medical assistant. Students may call the Health Center at (212) to make an appointment, or walk in during hours of operation. Location: 231 East 55th St at the 55th St. Residence Hall Telephone: (212) Web Page: https://www.mmm.edu/offices/dow-zanghi-health-center/ Office Hours: Monday, Thursday, Friday: 9:00 a.m - 5:00 p.m., closed 12:30 p.m. - 1:00 p.m. Tuesday & Wednesday: 11:00 a.m. - 7:00 p.m., closed 2:30 p.m. - 3:00 p.m. After hours, for urgent medical issues, students can call the Mount Sinai Beth Israel physicians triage on-call number: (212) Did you know? The cost of the Marymount Manhattan College Student Health Insurance Plan may be less expensive than coverage as a dependent under your parent s Plan. Useful contact info: Christie Student Health Customer Care: (844) CVS Health (Prescription Drug Information): (866) Hour Nurse Line: (866) Europ Assistance: (866) Mail claims to: Cigna PO Box Chattanooga, TN Search for a provider: *This plan is underwritten by Tufts Insurance Company (TIC), and administered by Christie Student Health Plans LLC (CSHP). Christie Student Health is the brand name for products and services provided by TIC and CSHP and their applicable affiliated companies. 1

3 Top 5 Things You Need To Know #1 The Student Health PPO Plan provides coverage for basic care and prescription drugs which includes, but is not limited to the following: Primary Care Care for many specialists Urgent Care Mental and behavioral health care/counseling Lab testing and screenings #2 The Student Health PPO Plan provides nationwide coverage with access to over 840,000 providers and 6,000 hospitals. #3 Your Student Health PPO Plan also includes worldwide travel assistance. For more details, visit #4 All full-time students will be automatically enrolled and billed for the Student Health PPO Plan. International students will be automatically enrolled in the Plan and are required to maintain this coverage. To determine your eligibility and view waiver details, go to page 3 of this brochure. #5 Once registered, you can access all of the tools the Student Portal has to offer, including accessing a copy of your ID card. Online Tools Our Student Portal provides students with one central location for all of your student health insurance needs, including getting a copy of your ID card, viewing claims, searching for a provider or hospital and viewing eligibility details and benefit documents. 2

4 Are you eligible? To be eligible for this Insurance Program, you must be a full time student, enrolled in 12 or more credit hours. All eligible students will be automatically enrolled and the insurance charge will be applied to your tuition bill unless proof of comparable coverage is submitted by the waiver deadline date. Coverage is required for International students. As such, International students are automatically enrolled and do not have the opportunity to waive this coverage. A student must actively attend classes for at least the first 31 days after the date for which coverage is purchased unless he or she withdraws from classes due to an Injury or Sickness and the absence is an approved medical leave. Home study, correspondence, Internet classes and television (TV) courses do not fulfill the eligibility requirements that the student must actively attend classes. We maintain the right to investigate student status and attendance records to verify that the eligibility requirements have been met. If we discover the eligibility requirements have not been met, we reserve the right to terminate coverage and our only obligation is refund of premium. Dependent Coverage Insured students who are enrolled in the Student Health PPO Plan may also enroll their eligible dependents. Eligible dependents under the plan include the person s spouse or domestic partner and dependent children under age twenty-six (26). Dependent eligibility expires concurrently with that of the insured student. Students may also enroll their dependents within thirty-one (31) days of an eligible qualifying life event. Eligible qualifying events for a dependent are defined in the Certificate of Coverage. Enrollment requests (including payments) received after the thirty-one (31) days following the qualifying event will not be accepted. Coverage will be effective as of the date of the qualifying life event. Did you know? You can save money by visiting a participating provider through the Cigna PPO network. Enrollment and Waiver Details The premium for insurance coverage for all eligible students is automatically added to your tuition bill unless proof of comparable coverage is submitted by the waiver deadline date. If you are already covered by another insurance plan, you will be able to complete an online Opt-Out waiver at The insurance charge will be removed from your tuition bill once you have successfully completed the online waiver. Please contact Christie Student Health at (844) for more information on how to waive the plan. All international students attending MMC on a student visa will remain enrolled and are not eligible to waive the Student Health PPO Plan. Waiver Deadline The deadline for students to complete the waiver form for annual coverage is September, Students who do not submit an online waiver form by the deadline will be enrolled in and billed for the Student Health PPO Plan. The deadline for new incoming spring students to complete the waiver form for spring coverage is February 15, Students who do not submit an online waiver form by the deadline will be enrolled in and billed for the Student Health PPO Plan. 3

5 Marymount Manhattan College Student Health Insurance The Marymount Manhattan College Student Health PPO Plan is a fully insured student health insurance plan underwritten by Tufts Insurance Company ( TIC ), and administered by Christie Student Health. Your Plan is a Preferred Provider Organization or PPO Plan. It provides you with a higher level of coverage when you receive covered medical expenses from providers who are part of the Plan s network referred to as Participating Providers. The participating providers participate in the Cigna network outside of MA and RI, and in the Tufts Health Plan network in MA and RI. The Plan also provides coverage when you obtain Covered Medical Expenses from providers who are not part of the Plan s network, referred to as Non-Participating Providers. The premium rates and the list of Covered Services are illustrated in the tables below. Please contact Christie Student Health Customer Care at (844) with any questions you may have about the Plan. Did you know? The Student Health PPO Plan includes discount vision services. Effective and Termination Dates Below are the effective and termination dates for the Policy Year: All Students Effective Date Termination Date Annual 08/15/15 08/14/16 Spring 01/01/16 08/14/16 Member Rates Annual 08/15/15 08/14/16 Spring 01/1/16 08/14/16 Student $1,745 $1,082 Spouse/ Domestic Partner $4,580 $2,841 Per Child $2,878 $1,785 Rates above include both premium and administrative fees. 4

6 Covered Services The covered services below are for students and their dependents. For a full description of covered benefits, please view the Marymount Manhattan College PPO Certificate by visiting Annual Deductible Out of Pocket Maximum Plan Maximum Benefit type Inpatient Hospital for a Continuous Confinement Participating Provider: $250 per member Non-Participating Provider: $500 per member Participating Provider: $4,500 per member; $12,700 per family Non-Participating Provider: $7,000 per member Unlimited Participating Provider Member Responsibility Non-Participating Provider Member Responsibility 20% of allowed amount 40% of reasonable charges Inpatient Miscellaneous Expense 20% of allowed amount 40% of reasonable charges Inpatient Medical Visits 20% of allowed amount 40% of reasonable charges Surgical Services 20% of allowed amount 40% of reasonable charges Anesthesia Services (all settings) 20% of allowed amount 40% of reasonable charges Ambulatory Surgical Center Facility Fee 20% of allowed amount 40% of reasonable charges Emergency Department 20% of allowed amount, following a $100 copay per visit (copay waived if admitted) 20% of reasonable charges, following a $100 copay per visit (copay waived if admitted) Urgent Care Center 20% of allowed amount 20% of reasonable charges Pre-Hospital Emergency Medical Services (Ambulance Services) 20% of allowed amount 20% of reasonable charges Primary Care Office Visits (or Home Visits) 20% of allowed amount 40% of reasonable charges Diagnostic Testing 20% of allowed amount 40% of reasonable charges Diagnostic Radiology Services 20% of allowed amount 40% of reasonable charges Advanced Imaging Services 20% of allowed amount 40% of reasonable charges Habilitation Services (Physical Therapy, Occupational Therapy or Speech Therapy) 20% of allowed amount 40% of reasonable charges Chiropractic Services 20% of allowed amount 40% of reasonable charges Acupuncture 20% of allowed amount 40% of reasonable charges Chemotherapy 20% of allowed amount 40% of reasonable charges Durable Medical Equipment & Braces 20% of allowed amount 40% of reasonable charges Prosthetic Devices 20% of allowed amount 40% of reasonable charges External Hearing Aids 20% of allowed amount 40% of reasonable charges Allergy Testing and Treatment 20% of allowed amount 30% of reasonable charges Routine Gynecological Services/Well Woman Exams* Covered in full 30% of reasonable charges Mammography Screenings* Covered in full 30% of reasonable charges Adult Immunizations* Covered in full 30% of reasonable charges Continued on next page. Adult Annual Physical Examinations* Covered in full 30% of reasonable charges 5

7 Annual Deductible Participating Provider: $250 per member Non-Participating Provider: $500 per member Out of Pocket Maximum Covered Services, cont. Plan Maximum Benefit type Participating Provider: $4,500 per member; $12,700 per family Non-Participating Provider: $7,000 per member Unlimited Participating Provider Member Responsibility Non-Participating Provider Member Responsibility Adult Immunizations* Covered in full 30% of reasonable charges Adult Annual Physical Examinations* Covered in full 30% of reasonable charges Screening for Prostate Cancer* Covered in full 30% of reasonable charges Inpatient Mental Health Care, including residential treatment (for a continuous confinement when in a Hospital) Outpatient Mental Health Care (Including Partial Hospitalization & Intensive Outpatient Program Services) 20% of allowed amount 40% of reasonable charges 20% of allowed amount 40% of reasonable charges Prescription Drugs* Covered in full following: $15 copay for Generic $35 copay for Preffered Brand name drugs $70 copay for Non-Preferred Brand Covered in full following: $15 copay for Generic $35 copay for Preffered Brand name drugs $70 copay for Non-Preferred Brand *The annual deductible is waived for these services. Some benefits above may require prior authorization. Please refer to your Certificate of Insurance for additional details. For a full description of covered benefits and exclusions, please visit to learn more. If there is a conflict between this overview and the PPO Certificate, the PPO Certificate is the governing document. Exclusions Certain services are not covered under this plan including: Aviation. We do not cover services arising out of aviation, other than as a fare-paying passenger on a scheduled or charter flight operated by a scheduled airline. Convalescent and Custodial Care. We do not cover services related to rest cures, custodial care and transportation. Custodial care means help in transferring, eating, dressing, bathing, toileting and other such related activities. Custodial care does not include Covered services determined to be Medically Necessary. Cosmetic Services. We do not Cover cosmetic services, Prescription Drugs, or surgery except that cosmetic surgery shall not include reconstructive surgery when such service is incidental to or follows surgery resulting from trauma, infection or diseases of the involved part, and reconstructive surgery because of congenital disease or anomaly of a covered Child which has resulted in a functional defect. We also cover services in connection with reconstructive surgery following a mastectomy, as provided elsewhere in your Certificate. Cosmetic surgery does not include surgery determined to be Medically Necessary. If a claim for a procedure listed in 11 NYCRR 56 (for example, certain plastic surgery and dermatology procedures) is submitted retrospectively and without medical information, any denial will not be subject to the Utilization Review process of your Certificate. Continued on next page. 6

8 Dental Services. We do not cover dental services except for: care or treatment due to accidental injury to sound natural teeth within 12 months of the accident; dental care or treatment necessary due to congenital disease or anomaly; or except as specifically stated in the oral surgery or pediatric dental care section of your Certificate. Experimental or Investigational Treatment. We do not cover any health care service, procedure, treatment, device, or Prescription Drug that is experimental or investigational. However, we will Cover experimental or investigational treatments, including treatment for Your rare disease or patient costs for Your participation in a clinical trial, when Our denial of services is overturned by an External Appeal Agent certified by the State. However, for clinical trials we will not cover the costs of any investigational drugs or devices, non-health services required for You to receive the treatment, the costs of managing the research, or costs that would not be Covered under your Certificate for non-investigational treatments. See your Certificate for a further explanation of Your Appeal rights. Foot Care. We do not cover foot care, in connection with corns, calluses, flat feet, fallen arches, weak feet, chronic foot strain or symptomatic complaints of the feet, except as specifically listed in your Certificate. For foot care related to diabetes, see your Certificate. Government Facility. We do not Cover care or treatment provided in a Hospital that is owned or operated by any federal, state or other governmental entity, except as otherwise required by law. Medically Necessary. In general, we will not Cover any health care service, procedure, treatment, device or Prescription Drug that We determine is not Medically Necessary. If an External Appeal Agent certified by the State overturns our denial, however, We will Cover the procedure, treatment, service, or Prescription Drug for which Coverage has been denied, to the extent that such procedure, treatment, service, or Prescription Drug is otherwise Covered under the terms of your Certificate. Medicare or Other Governmental Program. We do not cover services if benefits are provided for such services under the federal Medicare program or other governmental program (except Medicaid). Military Service. We do not cover an illness, treatment or medical condition due to service in the Armed Forces or auxiliary units. No-Fault Automobile Insurance. We do not cover any benefits to the extent provided for any loss or portion thereof for which mandatory automobile no-fault benefits are recovered or recoverable. This exclusion applies even if you do not make a proper or timely claim for the benefits available to you under a mandatory no-fault policy. Services Provided by a Family Member. We do not cover services performed by a member of the Covered person s immediate family. Immediate family shall mean a child, spouse, mother, father, sister, or brother of you or your spouse. Services With No Charge. We do not cover services for which no charge is normally made. Services not Listed. We do not cover services that are not listed in your Certificate as being covered. Vision Services. We do not cover the examination or fitting of eyeglasses or contact lenses, except as specifically stated in your Certificate. Workers Compensation. We do not cover services if benefits for such services are provided under any state or federal Workers Compensation, employers liability or occupational disease law. If there is a conflict between this overview and the PPO Certificate, the PPO Certificate is the governing document. If you have questions, please contact Christie Student Health Customer Care: (844)

9 Your plan also includes Worldwide Assistance Your Plan includes worldwide travel assistance through Europ Assistance (including medical evacuation and repatriation coverage). Whether you are studying abroad or traveling on vacation, you can have the comfort of knowing that help is only a phone call away. 24 Hour Nurse Help Line Nurse24 will provide participants with immediate and reliable health advice and information. Registered nurses are available 24 hours a day, 7 days a week to answer any health questions. Member Perks Discounts at Jenny Craig You can choose a FREE 30-day program or 25% off any premium program. In addition reimbursements are offered for up to three months of certain Jenny Craig programs. *Programs do not include the cost of food, or shipping, if applicable. At participating locations only. Additional restrictions apply. Careington Dental Discounts Program Discount on Glasses & Eye Care You are eligible for discounts on vision correction services and eyewear from participating EyeMed providers. Dietary & Nutritional Supplement Discounts You can save 15% or more off of the manufacturers suggested retail price on a wide variety of vitamins, supplements and popular energy and protein bars through ChooseHealthy.com. The Careington dental discounts program is available to you and your eligible dependents on a voluntary basis to provide access to quality dental care at reduced rates. Save 20% to 50% on most dental procedures including routine oral exams, unlimited cleanings and major work such as dentures, root canals and crowns at over 200,000 dental access points through Careington and DenteMax. Annual Rates 8/15/15-8/14/16 Individual and family rate: $15 per year To enroll in the Careington Dental Discounts Program, please visit christiestudenthealth.com/mmc. If you have questions regarding the program, please call Careington Dental Customer Service at (800)

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