Student Health Insurance Designed for the Students of

Transcription

1 Student Health Insurance Designed for the Students of Underwritten by: Companion Life Insurance Company Columbia, SC As Policy form #BSHP-POL Policy Number: 2015I5A83 Group Number: S Effective: August 15, 2015 to August 15, 2016 IMPORTANT NOTICE This brochure provides a brief description of the important features of the Policy. It is not a Policy. Terms and conditions of the coverage are set forth in the Policy. Please keep this material with your important papers. TABLE OF CONTENTS Where to find help?... 3 Am I eligible?... 3 Coverage for dependents... 3 How do I waive/enroll?... 4 Late waiver/waiver appeal process... 4 Effective dates and cost... 4 Termination of benefits... 5 Premium refund policy... 5 Extension of benefits... 5 Definitions Preferred provider information... 9 Pre-certification policy... 9 Basic Accident and Sickness Benefits Mandated Benefits Medical Evacuation Benefit Repatriation of Remains Benefit Right of Reimbursement Exclusions Claim Procedures Claim Appeal Process Value Added Services NONDISCRIMINATORY Health care services and any other benefits to which a Covered Person is entitled are provided on a nondiscriminatory basis, including benefits mandated by state and federal law. 15-I5A83 (Bro.) 2

2 WHERE TO FIND HELP For questions about claims status, eligibility, enrollment and benefits please contact: CONSOLIDATED HEALTH PLANS 2077 Roosevelt Avenue Springfield, MA (413) Toll Free (800) AM I ELIGIBLE? Northampton Community College (NCC) requires students accepted into certain programs of study or residing in on-campus housing to carry health insurance while enrolled at NCC. International students studying on an F-1 Student Visa are also required to carry health insurance. Students enrolled in the following programs are enrolled in the college student group health insurance plan unless they have their own insurance and WAIVE the college insurance plan: Allied Health Majors Residents in On-Campus Housing International Students F1 Visa Only Students must actively attend class for at least the first 31 days after the date for which coverage is purchased. Home study, correspondence, on-line classes, and television (TV) courses, do not fulfill the eligibility requirement that the student actively attend classes. If it is discovered the eligibility requirements have not been met, our only obligation is to refund premium, less any claims paid. This plan provides worldwide protection 24 hours per day during the term of the policy for each student insured. This includes coverage on and off campus, at home or while traveling between home and school during interim vacation periods. COVERAGE FOR DEPENDENTS Insured Students who are enrolled in the Student Health Insurance Plan may also enroll their eligible Dependents. An eligible Dependent is a spouse or a child up to age 26. Dependent eligibility expires concurrently with that of the Insured Student. Students may also enroll their Dependents within sixty (60) days of an eligible qualifying event. Eligible qualifying events for a Dependent are defined as birth or marriage (to the Insured Student). Students interested in enrolling their Dependents because of a qualifying event should contact Consolidated Health Plans for an enrollment form and premium information. Coverage will be effective as of the date of the qualifying event. Enrollment requests (including payments) received after the sixty (60) days following the qualifying event will not be accepted. HOW DO I WAIVE/ENROLL? If You are eligible to be covered under this Program, You are automatically enrolled, unless You waive coverage. To document proof of comparable coverage, students need to complete the online Waiver Form and submit it prior to the start of the school year. To submit the online Waiver Form: 1. Go to 2. Click on the Waiver link; and 3. Complete all of the required information as directed. WAIVER DEADLINES Fall: August, 31, 2015; Spring: January 31, 2016 ENROLLMENT DEADLINES Fall: September 5, 2015; Spring: January 31, 2016 If You are eligible for coverage and wish to enroll in the Plan outside of these enrollment opportunities, You must present documentation from Your former insurance company that it is no longer providing You with personal Accident and Sickness insurance coverage. Your Effective Date of coverage under this Insurance Program will be the date that Your former insurance expired, but only if You make the request for coverage within sixty (60) days from the date that Your previous plan expired. Otherwise, the Effective Date of coverage under this Insurance Program will be the first (1 st ) of the month following Our receipt of Your written request for coverage. The appropriate premium must accompany Your enrollment form for coverage. LATE WAIVER/WAIVER APPEAL PROCESS After the deadline, the Student Health Insurance Plan may not be waived/cancelled, except as provided by policy guidelines. EFFECTIVE DATES AND COSTS The Northampton Community College Student Health Insurance Plan provides coverage to students for a twelve (12) month period from 12:01 a.m. August 15, 2015, through 12:01 a.m. August 15, Annual 8/15/2015-8/15/2016 Fall 8/15/15-12/31/15 Returning Spring 1/1/16-8/15/16 New Spring 1/1/16-8/15/16 Student* $2,500 $1,097 $1,403 $1,493 Spouse $4,555 $1,904 $2,651 $2,651 Each $1,431 $1,992 $1,992 $3,423 Child *The above student rates include an administrative fee. 3 4

3 TERMINATION OF BENEFITS An Insured's coverage will end on the earliest of the date: 1. The Policy terminates; 2. The Insured is no longer eligible; or 3. The period ends for which premium is paid. A Dependent's coverage will end on the earliest of the date: 1. He or she is no longer a Dependent; 2. The Insured's coverage ends; or 3. The period ends for which premium is paid; or 4. the Policy terminates PREMIUM REFUND POLICY If you withdraw from school within the first 31 days of a coverage period, you will not be covered under the Policy and the full premium will be refunded, less any claims paid. After 31 days, you will be covered for the full period that you have paid the premium for, and no refund will be allowed. (This refund policy will not apply if you withdraw due to a covered Accident or Sickness.) Exception: A Covered Person entering the armed forces of any country will not be covered under the Policy as of the date of such entry. In this case, a pro-rata refund of premium will be made for any such person and any covered dependents upon written request received by Consolidated Health Plans within 90 days of withdrawal from school. EXTENSION OF BENEFITS If a Covered Person is confined in a Hospital for a medical condition on the date his insurance ends, expenses Incurred during the continuation of that Hospital stay will be considered a Covered Expense, but only while such expenses are incurred during the 90 day period following the termination of insurance. We will not continue to pay these Covered Expenses if: 1. The Covered Person's medical condition no longer continues; 2. The Covered Person reaches the Lifetime Aggregate Maximum per covered Accident or covered Sickness; 3. The Covered Person obtains other coverage; or 4. The Covered Expenses are incurred more than 3 months following termination of insurance. DEFINITIONS Accident means an unexpected and unintended event which is the direct cause of an Injury. The Accident must occur while the Covered Person is insured under the Policy. Copayment means a fixed dollar amount that the Covered Person must pay before benefits are payable under the Policy. Covered Accident means an Accident that occurs while coverage is in force for a Covered Person and results in a loss or Injury covered by the Policy for which benefits are payable. Covered Expenses means expenses actually incurred by or on behalf of a Covered Person for treatment, services and supplies not excluded or limited by the Policy. Coverage under the Policy must remain continuously in force from the date the Accident or Sickness occurs until the date treatment, services or supplies are received for them to be a Covered Expense. A Covered Expense is deemed to be incurred on the date such treatment, service or supply, that gave rise to the expense or the charge, was rendered or obtained. Covered Sickness means Sickness, disease or trauma related disorder due to Injury which: 1.) Causes a loss while the Policy is in force; and 2.) which results in Covered Medical Expenses. Covered Sickness includes Mental Health Disorders and Substance Abuse Disorders. Deductible means the dollar amount of Covered Expenses that must be incurred as an out-of-pocket expense by each Covered Person on a Policy Term basis before benefits are payable under the Policy. Dependent means: 1) an Insured's lawful spouse; or 2) an Insured's natural, adopted or foster child or child for whom the Member has legal custody or legal guardianship who is under the age of 26. Coverage will continue for a child who is 26 or more years old, chiefly supported by his or her parent or dependent on other care providers and incapable of self-sustaining employment by reason of a handicapped condition that occurred before the attainment of the limiting age. Proof of the child's condition and dependence will be requested by Us within 2 months prior to the date the child will cease to qualify as a child as defined above. Such proof must be submitted to Us within 31 days from the date of the request. We may, at reasonable intervals thereafter, require proof of the continuation of such condition and dependence. If proof is not submitted within the 31 days following any such request, coverage for the Dependent will terminate. With respect to a handicapped child, dependent on other care providers means such child requires a Community Integrated Living Arrangement, group home, supervised apartment, or other residential services licensed or certified by the Department of Human Services, the Department of Public Health, or the Department of Public Aid. 5 6

4 The term spouse also includes your domestic partner. You and your domestic partner must submit a complete domestic partner affidavit and meet the following criteria to qualify your domestic partner for insurance under this group policy. For at least six consecutive months prior to the effective date of your domestic partner insurance, you and your domestic partner: 1. are and have been each other's sole domestic partner, and have maintained the same principal place of residence and intend to do so indefinitely; 2. are both at least 18 years of age; 3. are not married or related by blood; and 4. are jointly responsible for each other's welfare and financial obligations. The term also includes the child of your domestic partner. Doctor means a Doctor licensed to practice medicine. It also means any other practitioner of the healing arts who is licensed or certified by the state in which his or her services are rendered and acting within the scope of that license or certificate. It will not include a Covered Person or member of the Covered Person s Immediate Family or household. Elective Surgery or Elective Treatment means those health care services or supplies that do not meet the health care need for a Sickness or Injury. Elective surgery or elective treatment includes any service, treatment or supplies that: 1. Are deemed by the Insurer to be researched, investigative, or experimental; 2. Are not generally recognized and accepted medical practices in the United States. Essential Health Benefits mean benefits that are defined as such by the Secretary of Labor in the following general categories, and the items and service covered within the categories: 1. Ambulatory patient services; 2. Emergency services; 3. Hospitalization; 4. Maternity and newborn care; 5. Mental health and substance use disorder services, including behavioral health treatment; 6. Prescription drugs; 7. Rehabilitative and habilitative services and devices; 8. Laboratory services; 9. Preventative and wellness services and chronic disease management; and 10. Pediatric services, including oral and vision care. Experimental or Investigational means any procedure, treatment, facility, supply, device, or drug that: 1. Is not generally accepted by the United States medical community as effective for diagnosis, care or treatment; or 2. Is subject to research protocols indicating that the procedure, treatment, facility, supply, device or drug is experimental or investigational ; or 3. Requires the patient to sign a consent form which indicates that the procedure, treatment, supply, device or drug is experimental or investigational or is part of a research or study program; or Requires the provider s institutional review board to acknowledge that the procedure, treatment, facility, supply, device or drug is experimental or investigational, and subject to the board s approval. Injury means accidental bodily harm sustained by a Covered Person that results directly and independently of disease and any bodily infirmity from a Covered Accident. All injuries sustained by one person in any one Accident, including all related conditions and recurrent symptoms of these injuries, are considered a single Injury. Insured means a person in a Class of Eligible Persons who enrolls for coverage and for whom the required premium is paid making insurance in effect for that person. An Insured is not a Dependent covered under the Policy. Medically Necessary means a service, drug or supply which is necessary and appropriate for the diagnosis and treatment of a Covered Injury and Covered Sickness in accordance with generally accepted standards of medical practice in the United States at the time the service, drug or supply is provided. A service, drug or supply will not be considered as Medically Necessary if, it: 1. Is investigational, experimental or for research purposes; 2. Is provided solely for the convenience of the patient, the patient s family Doctor, Hospital or any other provider; 3. Exceeds in scope, duration or intensity the level of care that is needed to provide safe, adequate and appropriate diagnosis or treatment; 4. Could have been omitted without adversely affecting the person s condition or the quality of medical care; or 5. Involves the use of a medical device, drug or substance not formally approved by the United States Food and Drug Administration. Out-of-Network means a provider who has not agreed to any prearranged fee schedules. We will not pay charges in excess of the Usual and Customary Charges. Preferred Allowance means the amount a Preferred Provider will accept as payment in full for covered medical expenses. Preferred Provider means the Doctors, Hospitals and other health care providers who have contracted to provide specific medical care at negotiated prices. Substance Abuse means abuse of or addiction to drugs or alcohol. Usual and Customary Charge means the average amount charged by most providers for treatment, service or supplies in the geographic area where the treatment, service or supply is provided. We, Our, Us means Companion Life Insurance Company, Inc., or its authorized agent. 7 8

5 PPO PLAN - PREFERRED PROVIDER INFORMATION The Northampton Community College health insurance plan for the Policy Year has a Preferred Provider Organization Network through Cigna. To maximize Your savings and reduce Your out-of-pocket expense, select a Preferred Provider. Preferred Providers are independent contractors and are neither employees nor agents of Northampton Community College, Consolidated Health Plans, or Companion Life Insurance Company. You can obtain information regarding Preferred Providers through the Internet at: Choose PPO option. PRE-CERTIFICATION POLICY This plan does not require pre-certification of benefits. Please refer to the schedule of benefits section of the policy for covered benefits. ACCIDENT AND SICKNESS EXPENSE BENEFITS This plan waives the In- and Out-of-Network Annual Deductible for Covered Medical Expenses for the following services: Physician Office Visit Expense, Outpatient Mental Health & Substance Abuse Office Visit Expenses, Consultant Expense, Walk-In Clinic Expense, Urgent Care Expense, Emergency Room Expense, Pediatric Preventative Care Expense, Pap Smear Screening Expense, and Mammogram Expense. Covered Expenses are considered incurred on the date the treatment or service is rendered or the supply is furnished. Covered Medical Expenses are: Aggregate Maximum Benefit Unlimited Deductible, per Insured or Dependent Coinsurance Out-of-Pocket Maximum per Policy Year Out of Country Coverage INPATIENT EXPENSE BENEFIT Hospital Room and Board, limited to the Daily semi-private room rate including general nursing care provided and charged for by the Hospital. Intensive Care We will make this payment in lieu of the semi-private room expenses. PPO Provider Out-of-Network Provider $600 per Policy $1,200 per Policy Year Year 70% of Preferred 50% of Usual and Allowance (PA) Customary (U&C) $6,350 Individual $12,700 Family None 50% of Billed Charges PPO Provider Out-of-Network Provider 70% of PA after a $300 copay per admission 70% of PA after a $300 per admission copay 50% of (U&C) after a $300 copay per admission 50% of U&C after a $300 per admission copay Hospital Miscellaneous Expense, incurred while Hospital Confined or as a precondition for being Hospital Confined, for services and supplies such as the cost of operating room, laboratory tests, X-ray examinations, anesthesia, drugs (excluding take home drugs) or medicines, physical 70% of PA 50% of U&C therapy, therapeutic services and supplies. In computing the number of days payable under this benefit, the date of admission will be counted but not the date of discharge. Surgery 70% of PA 50% of U&C Assistant Surgeon 70% of PA 50% of U&C Anesthetist 70% of PA 50% of U&C Doctor s Visits, Limited to 1 visit per day. Does not apply when related to surgery. 70% of PA 50% of U&C Skilled Nursing Facility up to a maximum of 120 days per Policy Year Mental Health Disorders and Substance Abuse % of PA after a $300 per admission copay Same as any other covered sickness 50% of U&C after a $300 per admission copay Same as any other covered sickness OUTPATIENT EXPENSE BENEFIT Surgery 70% of PA 50% of U&C Day Surgery Miscellaneous 70% of PA 50% of U&C Assistant Surgeon 70% of PA 50% of U&C Anesthetist 70% of PA 50% of U&C Primary Care Visit to treat an Injury or Sickness (includes syringes and needles dispensed during a visit), Specialist Visit, Other Practitioner Office Visit, Consultant Physician Services when requested by the attending physician. Preventive Care and Wellness Services (no deductible, copay, or coinsurance will apply to in-network services) $25 copay per visit, then 100% of PA $40 copay per visit, then 100% of U&C 100% of PA 100% of U&C

6 Medical Emergency Expense Inpatient deductible applies to out-ofnetwork $100 copay (waived if admitted), then 80% of PA $100 copay (waived if admitted), then 80% of U&C Diagnostic X-ray Services 70% of PA 50% of U&C Laboratory Procedures 70% of PA 50% of U&C Rehabilitative/Habilitative therapies including Physical, Occupational, 70% of PA 50% of U&C Speech, and Chiropractic Care Radiation and Chemotherapy 70% of PA 50% of U&C Hospice 70% of PA 50% of U&C Home Health Care 70% of PA 50% of U&C Urgent Care $50 copay per visit, then 70% of PA $75 copay per visit, then 50% of U&C Routine Eye Exam (Adult) Mental Health Disorders and Substance Abuse Ambulance Service Additional Benefits $25 copay per visit, then 70% of PA Same as any other covered sickness 100% of PA after a $100 copay per trip $40 copay per visit, then 50% of U&C Same as any other covered sickness 100% of U&C after a $100 copay per trip Prescription Drugs - must be filled at participating Cigna pharmacy. Go to Medical Evacuation Repatriation $30 copay for a 30-day supply of a generic drug ($0 copay for a 30-day supply of a generic contraceptive) or $60 copay for a 30-day supply of a preferred brand name drug; $75 copay for a 30-day supply of a brand name drug 100% of U&C 100% of U&C MANDATED BENEFITS This plan will also pay any applicable benefits mandated by Pennsylvania State Insurance Law, the same as for any other covered sickness unless stated otherwise. All mandated benefits are subject to the terms and conditions generally applicable to other benefits provided under the policy. If any Preventive Services Benefit is subject to the mandated benefits required by state law, they will be administered under the federal or state guideline, whichever is more favorable to the student. Mastectomy and Reconstructive Surgery Benefit: We will pay the Usual and Reasonable expenses incurred for inpatient care following a Mastectomy for the length of stay that the treating Physician determines is necessary to meet generally accepted criteria for safe discharge. We will also provide coverage for a home health care visit that the treating Physician determines is necessary within forty-eight (48) hours after discharge when the discharge occurs within forty-eight (48) hours following admission for the Mastectomy. We will also provide coverage for Prosthetic Devices; physical complications including lymphedemas; and Reconstructive Surgery incident to any Mastectomy in a manner determined in consultation with the attending Physician and the Insured Person. Mastectomy means the removal of all or part of the breast for Medically Necessary reasons, as determined by a Physician. Prosthetic Devices means the use of initial and subsequent artificial devices to replace the removed breast or portions thereof, pursuant to an order of the Insured Person s Physician. Reconstructive Surgery means a surgical procedure performed on one breast or both breasts following a mastectomy, as determined by the treating Physician, to reestablish Symmetry Between Breasts or alleviate functional impairment caused by the mastectomy. The term Reconstructive Surgery shall include, but is not limited to, augmentation mammoplasty, reduction mammoplasty and mastopexy. Accidental Dental Expense, injury to sound, natural teeth 70% of PA 70% of U&C Maternity 100% of PA 100% of U&C Durable Medical Equipment 70% of PA 50% of U&C Acupuncture in lieu of Anesthesia Expense 70% of PA 50% of U&C Pediatric Dental 1 check-up every 6 months 100% 50% Pediatric Vision 1 exam per Policy Year including one set of frames and 100% 50% Symmetry Between Breasts means approximate equality in size and shape of lenses the non-diseased breast with the diseased breast after definitive Intercollegiate, Club and Intramural No Benefit Reconstructive Surgery on the diseased or non-diseased breast has been Sports Injuries performed. Abortion Expense (elective) No Benefit 11 12

7 Treatment and Self-Management of Diabetes Benefit: We will pay the Usual and Reasonable expenses incurred the equipment, supplies and outpatient selfmanagement training and education, including medical nutrition therapy for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes and non-insulin-using diabetes if prescribed by a Physician. Equipment and supplies shall include the following: blood glucose monitors, monitor supplies, insulin, injection aids, syringes, insulin infusion devices, pharmacological agents for controlling blood sugar and orthotics. Diabetes outpatient self-management training and education shall be provided under the supervision of a Physician with expertise in diabetes to ensure that persons with diabetes are educated as to the proper self-management and treatment of their diabetes, including information on proper diets. Coverage for self-management education and education relating to diet and prescribed by a Physician shall include: 1. visits medically necessary upon the diagnosis of diabetes; 2. visits under circumstances whereby a Physician identifies or diagnoses a significant change in the patient's symptoms or conditions that necessitates changes in a patient's self-management; and 3. where a new medication or therapeutic process relating to the person's treatment and/or management of diabetes has been identified as medically necessary by a licensed Physician. Cancer Benefits: We will pay the Usual and Reasonable expenses incurred for cancer chemotherapy and cancer hormone treatments, whether performed in a Physician's office, in an outpatient department of a Hospital, in a Hospital as a Hospital inpatient or in any other medically appropriate treatment setting on the same basis as benefits for cancer chemotherapy and cancer hormone treatments and services which have been approved by the United States Food and Drug Administration for general use in treatment of cancer. Coverage for Cost of Nutritional Supplements Benefits: We will pay the Usual and Reasonable expenses incurred for the cost of nutritional supplements (formulas) as Medically Necessary for the therapeutic treatment of phenylketonuria, branched-chain ketonuria, galactosemia and homocystinuria as administered under the direction of a Physician. There is no Deductible imposed for this Benefit. Dental Anesthesia for Children and Developmentally Disabled Insured Persons: We will pay the Usual and Reasonable expenses incurred for General Anesthesia and Associated Medical Costs provided to an Eligible Dental Patient for Dental Care. This Benefit does not cover Dental Care for which general anesthesia is provided nor does it cover general anesthesia for Dental Care rendered for temporal mandibular joint disorders. For purposes of this Benefit: Associated Medical Costs means hospitalization and all related medical expenses normally incurred as a result of the administration of General Anesthesia. Dental Care means the diagnosis, treatment planning and implementation of services directed at the prevention and treatment of diseases, conditions and dysfunctions relating to the oral cavity and its associated structures and their impact upon the human body or the implementation of professional dental care provided to dental patients by a legally qualified dentist or Physician operating within the scope of the dentist's or Physician's training and licensure. Eligible Dental Patient means an Insured Person who is seven (7) years of age or younger or developmentally disabled for whom a successful result cannot be expected for treatment under local anesthesia and for whom a superior result can be expected for treatment under General Anesthesia. General Anesthesia means a controlled state of unconsciousness, including deep sedation, that is produced by a pharmacologic method, a nonpharmacologic method or a combination of both and that is accompanied by a complete or partial loss of protective reflexes that include the Insured Person's inability to maintain an airway independently and to respond purposefully to physical stimulation or verbal command. Autism Spectrum Disorders Benefit: We will pay the Usual and Reasonable expenses incurred for the diagnostic assessment and treatment of Autism Spectrum Disorder and services for Insured children under the age of 21, up to $36,000 per year. Treatment must be: 1. for an Autism Spectrum Disorder; 2. Medically necessary; 3. Identified in a treatment plan; 4. Be prescribed, ordered or provided by a licensed physician, licensed physician assistant, licensed psychologist, licensed clinical social worker or certified registered nurse practitioner; and 5. Be provided by an autism service provider or a person, entity or group that works under the direction of an autism service provider. Diagnostic assessment and treatment of Autism Spectrum Disorders include: 1. Prescription drugs and blood level tests; 2. Services of a psychiatrist and/or psychologist (direct or consultation); 3. Applied behavioral analysis; and 4. Other rehabilitative care and therapies, such as speech and language pathologists, occupational and physical therapists. Child Immunizations Benefit: When Dependent coverage is a part of this policy, We will pay the expenses incurred for childhood immunizations and for medically necessary booster doses of all immunizing agents used in child immunizations. As used in this benefit, child immunizations, including the immunizing agent, reimbursement for which will not exceed 150% of the average wholesale price, 13 14

8 which, as determined by the Pennsylvania Department of Health, conform with the standards of the Advisory Committee on Immunization Practices of the Center For Disease Control, the United States Department of Health and Human Services. Benefits for such immunizations will be exempt from any deductible requirements or specific benefit limitations, subject to any Aggregate Lifetime Maximum Benefit or Policy Maximums. Benefits for such immunizations will be exempt from any deductible requirements or specific benefit limitations. Medical Foods (Enteral Formulas) Benefit: We will pay the Usual and Reasonable expenses incurred for the treatment of inherited metabolic diseases on the same basis as any other Covered Sickness, except that any deductible provisions will not apply to the enteral formulas portion of this benefit. Inherited metabolic diseases include those characterized by deficient metabolism or malabsorption originating from congenital defects or defects arising shortly after birth, of amino acid, organic acid, carbohydrate or fat, including phenylketonuria, branched-chain ketonuria, galactosemia and homocystinuria. Such treatment will include the enteral formulas and special food products that are part of a diet prescribed by a licensed Physician and managed by a health care professional in consultation with a Physician who specializes in the treatment of metabolic disease. Such diet must be deemed Medically Necessary to avert the development of serious physical and mental disabilities or to promote normal development or function as a consequence of an inherited metabolic disease. We will provide coverage for this benefit only to the extent that the cost of Medically Necessary formulas and special food products exceeds the cost of a normal diet. For the purposes of this benefit, the following definitions will apply: Enteral formula means an enteral product or enteral products for use at home that are prescribed by a Physician or nurse practitioner, or ordered by a registered dietician upon referral by a health care provider authorized to prescribe dietary treatments as being Medically Necessary for the treatment of an inherited metabolic disease. Special Food Product means a food product that is: a. Prescribed by a Physician or nurse practitioner for the treatment of an inherited metabolic disease and is consistent with the recommendations and best practices of qualified health professionals with expertise germane to, and experience in the treatment and care of such condition. It does not include a food that is naturally low in protein, but may include a food product that is specially formulated to have less than one gram of protein per serving; and b. Used in place of normal food products, such as grocery store foods used by the general population. MEDICAL EVACUATION When as a result of a Covered Accident or Sickness, You or Your covered Dependent is hospitalized for five (5) days or more, The Company will pay, upon the recommendation and approval of the attending Physician, for the evacuation of You or Your covered Dependent to Your natural country, or to a facility operated pursuant to the law for the care and treatment of injured or ill persons, the actual U&C expense incurred not to exceed the unlimited aggregate plan maximum. This benefit is payable in addition to any other benefit of the Policy. Emergency Medical Evacuation must be approved in advance by the Company. See Policy for full benefit description. REPATRIATION OF REMAINS COVERAGE If You or Your covered Dependent dies while insured under this policy, The Company will pay the actual U&C expenses incurred for preparation, including cremation and transportation to Your home country (in accordance with the applicable international requirements) the remains of the deceased s body, but not to exceed the unlimited plan aggregate maximum. This benefit is payable in addition to any other benefit of the Policy. Repatriation of Remains must be approved in advance by the Company. RIGHT OF REIMBURSEMENT If a Covered Person incurs expenses for Sickness or Injury that occurred due to the negligence of a third party: (a) We have the right to reimbursement for all benefits We have paid from any and all damages collected from the third party for those same expenses whether by action at law, settlement or compromise by the Covered person, Covered Person's parents, if the Covered Person is a minor, or Covered Person's legal representative as a result of that Sickness or Injury, and (b) We are assigned the right to recover from the third party, or his or her insurer, to the extent of the benefits paid for that Sickness or Injury. EXCLUSIONS Any exclusion in conflict with the Patient Protection and Affordable Care Act will be administered to comply with the requirements of the Act. The plan does not cover nor provide benefits for any of the following, except as otherwise provided by the benefits of this Policy and as shown in the Schedule of Benefits. The Policy does not provide coverage for loss caused by or resulting from: 1. Charges that are not Medically Necessary or in excess of the Usual and Customary charge; 2. Expenses in connection with services and prescriptions for eye examinations, eye refractions, eye glasses or contact lenses, or the fitting of eyeglasses or contact lenses, radial keratotomy or laser surgery for vision correction or the treatment of visual defects or problems, except as specifically provided; 15 16

9 3. Expenses in connection with cosmetic treatment or cosmetic surgery, except as a result of: a. a covered Injury that occurred while the Covered Person was insured; b. a covered child's congenital defect or anomaly; or c. as specifically provided for in the Policy. 4. Injuries arising out of: a. playing or participating in an interscholastic, intercollegiate, or professional sport, contest or competition; b. traveling to or from such sport, contest or competition as a participant; or c. participation in any practice or conditioning program for such sport, contest, or competition. 5. Drugs and medications for the treatment of impotence and/or sexual dysfunction; 6. Reproductive/Infertility procedures and fertility tests, including but not limited to: family planning, fertility tests, infertility (male or female), including any supplies rendered for the purpose or with the intention of achieving conception; premarital examinations. Examples of fertilization procedures are: ovulation induction; in vitro fertilization; embryo transplant; or similar procedures that augment or enhance the Covered Person's reproductive ability; impotence organic or otherwise. 7. Expenses incurred in connection with voluntary sterilization or sterilization reversal, vasectomy or vasectomy reversal and sexual reassignment; 8. War, or any act of war, whether declared or undeclared; service in the Armed Forces of any country. Loss which occurs during or as a result of committing or attempting to commit an assault, felony, or participation in a riot or insurrection, engaging in an illegal occupation; 9. Expenses incurred for Injury or Sickness for which benefits are paid or payable under any Worker's Compensation or Occupational Disease Law or Act, or similar legislation. 10. Treatment, services, supplies, in a Veteran's Administration or Hospital owned or operated by a national government or its agencies unless there is a legal obligation for the Covered Person to pay for the treatment. 11. Expenses incurred for dental care or treatment of the teeth, gums or structures directly supporting the teeth, including surgical extractions of teeth. This exclusion does not apply to the repair of Injuries to sound natural caused by a covered Injury, and except as specifically provided in the Hospitalization and Anesthesia for Dental Procedures expense benefit; or Pediatric Dental Care. 12. Autistic disease of childhood, hyperkinetic syndromes, milieu therapy, conceptual handicap, developmental delay or disorder, or mental retardation; 13. Elective Surgery or Elective Treatment as defined by the Policy; 14. Foot care including: flat foot conditions, supportive devices for the foot, subluxations, care of corns, bunions (except capsular or bone surgery), calluses, toenails, fallen arches, week feet, foot strain, and symptomatic complaints of the feet, except those related to diabetic care; 15. Hearing examinations or hearing aids; or other treatment for hearing defects or problems. "Hearing defects" means any physical defect of the ear which does or can impair normal hearing, apart from the disease process; 16. Immunizations, except as specifically provided in the Policy; preventive medicines or vaccines, except when required for treatment of a covered Injury or as specifically provided in the Policy; 17. Hirsutism, alopecia; 18. Weight management, weight reduction, treatment for obesity, surgery for the removal of excess skin or fat, or nutrition programs, except as related to treatment for diabetes

10 CLAIM PROCEDURES 1. Itemized medical bills should be mailed promptly to Cigna at the address listed. SUBMIT ALL CLAIMS TO: Cigna PO Box Chattanooga, TN Electronic Payor ID: Direct all questions regarding benefits available under the Plan, claim procedures, status of a submitted claim or payment of a claim to Consolidated Health Plans. CLAIMS ADMINISTRATOR: Consolidated Health Plans 2077 Roosevelt Ave Springfield, MA Local: (413) or Out of area: (800) Group: S Medical bills must be submitted within ninety (90) days from the date of treatment. We will pay benefits to You or a parent when a receipted bill is submitted for a covered claim. When benefits are assigned, they will be paid directly to the provider of hospital-medical care. Claim forms may be obtained from the college, if at college, or from the above when away from college. CLAIMS APPEAL PROCESS Once a claim is processed and upon receipt of an Explanation of Benefits (EOB), an Insured Person who disagrees with how a claim was processed may appeal that decision. The Insured Person must request an appeal in writing within 180 days of the date appearing on the EOB. The appeal request must include any additional information to support the request for appeal, e.g. medical records, physician records, etc. Please submit all requests to the Claims Administrator. Claims Administrator: CONSOLIDATED HEALTH PLANS 2077 Roosevelt Avenue Springfield, MA (413) Toll Free (800) This plan is underwritten by: COMPANION LIFE INSURANCE COMPANY COLUMBIA, SC As Policy Form No.: BSHP-POL For a copy of the Company s privacy notice you may go to: or Request one from the Health Office at your School or Request one from: Companion Life Insurance Company C/O Privacy Officer 70 Genesee Street Utica, NY (Please indicate the school you attend with your written request) Representations of the Plan must be approved by the Company

11 VALUE ADDED SERVICES VISION DISCOUNT PROGRAM For Vision Discount Benefits please go to: EMERGENCY MEDICAL AND TRAVEL ASSISTANCE FrontierMEDEX ACCESS services is a comprehensive program providing You with 24/7 emergency medical and travel assistance services including emergency security or political evacuation, repatriation services and other travel assistance services when you are outside Your home country or 100 or more miles away from your permanent residence. FrontierMEDEX is your key to travel security. For general inquiries regarding the travel access assistance services coverage, please call Consolidated Health Plans at If you have a medical, security, or travel problem, simply call FrontierMEDEX for assistance and provide your name, school name, the group number shown on your ID card, and a description of your situation. If you are in North America, call the Assistance Center toll-free at: or if you are in a foreign country, call collect at: If the condition is an emergency, you should go immediately to the nearest physician or hospital without delay and then contact the 24-hour Assistance Center. FrontierMEDEX will then take the appropriate action to assist You and monitor Your care until the situation is resolved. Your out-of-pocket costs may be lower when you utilize Cigna PPO Providers. For a listing of Cigna PPO Providers, go to or contact Consolidated Health Plans at (413) , toll-free at (800) , or for assistance. THE SINGLE SOURCE FOR ALL OF YOUR INQUIRIES GENERAL INSURANCE QUESTIONS 3070 Riverside Drive, Columbus, OH Website: 21