Student Health Insurance

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1 Student Health Insurance Portland State University Domestic Brokered by: Wells Fargo Insurance Services USA, Inc. Student Insurance Division Underwritten by: Aetna Life Insurance Company Policy # A

2 HOW MUCH DOES THE BASIC INSURANCE PLAN COST? The Basic Plan premium is included in the mandatory $230 Student Health Fee for students taking five (5) or more non-self-support credit hours.* Summer insurance is optional if taking less than 5 credits as long as the student is enrolled in the Basic Insurance Plan in the Spring. Rates include premium payable to Aetna Life Insurance Company, as well as administrative fees payable to other third parties. Rates also include premiums and fees for Accidental Death and Dismemberment, Medical Evacuation and Repatriation, Natural Disaster and Political Evacuation, and Worldwide Emergency Travel Assistance benefits/services provided through On Call International and it s contracted underwriting companies. Travel assistance services are offered by vendors who are independent contractors and not employees or agents of Chickering Claims Administrators, Inc., Aetna Life Insurance or their affiliates. Chickering Claims Administrators Inc. (CCA) provides access to certain Accidental Death and Dismemberment (AD&D); Medical Evacuation/Repatriation (MER); Natural Disaster and Political Evacuation (NDPE); and Worldwide Emergency Travel Assistance (WETA) coverages and services through a contractual relationship with On Call International, LLC (OnCall). Unless provided by Aetna Life Insurance Company, AD&D coverage is underwritten by United States Fire Insurance Company (USFIC). MER coverage is underwritten by Virginia Surety Company (VSC). NDPE coverage and services are underwritten by an insurer contracted with On Call. These services, programs or benefits are offered by vendors who are independent contractors and not employees or agents of Aetna. Coverage Period Fall 9/20/11-1/9/12 BASIC INSURANCE PLAN COST Winter 1/9/12-4/2/12 Spring 4/2/12-6/25/12 Summer 6/25/12-9/20/12 Enrollment Deadline 10/9/11 1/22/12 4/15/12 7/8/12 Students $ 111 $ 111 $ 111 $ 111 HOW AND WHEN DO I ENROLL IN THE PLAN? All domestic students taking five (5) PSU non-self-support credit hours or more during Fall, Winter, Spring and Summer terms are AUTOMATICALLY assessed a health fee of $230 in their tuition, which includes the Basic Insurance Plan. This cannot be waived, however, it does coordinate if you have other insurance. This plan is designed to assist in reducing, but not eliminating some of the medical expense of most minor sicknesses and injuries. *NOTE: Most self-support, continuing education and course credits received from TV, Internet, Video or Satellite are not eligible for the Health Fee, and therefore not eligible for this insurance. If you have questions about the types of credits you are taking, visit: SUMMER: Students taking 5 or more credits will automatically be assessed the health fee which includes Basic Insurance. Students taking 0 through 4 credits in the summer may voluntarily purchase insurance directly through Wells Fargo Insurance Services, USA, at (800) , as long as they had the insurance during spring term. This includes spring graduating students. HOW CAN I LEARN ABOUT PURCHASING ADDITIONAL COVERAGE FOR MYSELF OR MY DEPENDENTS? To view rates and enrollment instructions for the voluntary Supplemental Plan, which gives an ADDITIONAL $45,000 of coverage per condition, visit:. Note: You must first have the Student Health Fee (includes the Basic Insurance Plan) in order to purchase this extra coverage. Currently, there is no dependent plan offered for domestic students dependents. HOW CAN I GET A PRESCRIPTION BENEFIT? The Basic Insurance Plan does NOT cover prescriptions. If you need prescription coverage, you need to purchase the voluntary Supplemental Insurance Plan. Instructions to learn more and enroll are above. Visit: https://wfis.wellsfargo. com/psu for more information and to enroll in the Supplemental Insurance Plan. 2 Portland State University - Domestic

3 WHY IS A STUDENT HEALTH INSURANCE PLAN IMPORTANT? Health care costs are at an all-time high. Do not let an unexpected trip to the doctor or hospital set you back financially. Here are some things to think about: If you are covered as a dependent under your parents plan, coverage may end at a certain age. Most health plans have age restrictions that limit coverage for dependents up to age 26, even students. However, under the Student Health Insurance Plan you will be covered as long as you are taking 5 or more non-self-support credit hours at Portland State University. Even if you already carry other insurance through work or your parents, the Basic Insurance Plan will coordinate with your other insurance plan so that your out of pocket expenses are lessened. Your plan may not have network coverage where you attend school. Some plans have network restrictions depending on the area that you are in which can prevent you from seeing a doctor or going to a hospital. With this student insurance plan, you will have coverage and be able to visit a doctor/hospital anywhere in the U.S. or abroad with no network restrictions. WHERE CAN I GO FOR SERVICE? First try to visit the Center for Student Health and Counseling (SHAC) on SW 6th Avenue and Hall Street, (www.pdx.edu/shac/). Eligible students can see a physician, nurse, or mental health clinician at no charge.* The Basic Insurance Plan will cover most labs and x-rays, (pre-existing condition limitations apply), however, there is no prescription coverage. SHAC s professional staff consists of: General and Family Medicine doctors, Psychiatrists, Registered Nurses, Medical Assistants, Dentists, Hygienists, an Oral Surgeon, a Registered Dietitian, Licensed Clinical Social Workers and Licensed Psychologists. In addition, SHAC trains MD, Social Work, Psychology and Nursing residents and interns. If you need care that SHAC cannot provide, they ll refer you to a doctor or other health care provider who belongs to Aetna s Preferred Provider** network (doctors, specialists and facilities). You may visit any licensed health care provider directly for covered services, except for specific Plan restrictions on certain services. However, when you visit a Preferred Provider, you will generally have less out of pocket expense for your care. To learn more about Preferred Providers visit: Please note: The Basic Insurance Plan Benefit Copay of $20 will be waived and payable at 100% of Actual Charge when services are performed at the PSU Center for Student Health and Counseling (SHAC). *Some charges may be applied during summer term and for other services rendered at time of visit. **Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Portland State University - Domestic 3

4 THIS IS ONLY A PARTIAL DESCRIPTION OF THE BASIC INSURANCE PLAN. The Portland State University Basic Insurance Plan may not cover all your health care expenses. The Basic Insurance Plan excludes coverage for certain services and contains limitations on the amounts it will pay. Please visit: to read the complete PSU Domestic Student Basic Health Insurance Plan brochure and/or policy. This Basic Insurance Plan will never pay more than the maximums listed below in a coverage year. Additional Plan maximums may also apply. Some illnesses may cost more to treat and health care providers may bill you for what the Basic Insurance Plan does not cover. Benefits are payable for eligible medical expenses resulting from a covered accidental Bodily Injury when the first treatment is received within 90 days after the Injury, or resulting from Covered Expenses for an Illness, and any eligible follow-up expense incurred during the term of the Policy. Covered Expenses must be for treatment by or under the written order of a licensed doctor and will not exceed any Benefit payable of $7,500 per Accident or Illness, per academic year. Please refer to the full list of Exclusions and Definitions listed in the brochure available online at and for more detailed information on covered benefits. If a student carries any other type of insurance that would otherwise make benefit payments, the first $500 under the Basic Insurance Plan will be paid as PRIMARY, everything thereafter will be paid as SECONDARY. Please note: The Basic Insurance Plan Benefit Copay of $20 will be waived and payable at 100% of Actual Charge when services are performed at the PSU Center for Student Health and Counseling (SHAC). To learn more about adding extra coverage to the Basic Insurance Plan, visit:. The voluntary Supplemental Insurance Plan gives you an additional $45,000 of coverage per Accident or Illness, per academic year, and offers Prescription Coverage, Durable Medical Equipment and Transgender Surgery Expenses. 4 Portland State University - Domestic YOUR BASIC INSURANCE PLAN BENEFITS AT A GLANCE Basic Insurance Plan Academic Year Maximum $7,500 per condition $0 policy year deductible INPATIENT HOSPITALIZATION EXPENSES PREFERRED CARE NON-PREFERRED CARE Room and Board Expense 75% of the Negotiated Charge $250 Per Admission Deductible Intensive Care Unit Expense 75% of the Negotiated Charge $250 Per Admission Deductible Miscellaneous Hospital Expense, such as the cost of the operating room, laboratory tests, x-ray examinations, anesthesia, drugs (excluding take-home drugs) or medicines, physical therapy, therapeutic services & supplies. Physician Hospital Visit Expenses, limited to one visit per day 75% of the Negotiated Charge 60% of the Reasonable Charge SURGICAL EXPENSES (INPATIENT AND OUTPATIENT) PREFERRED CARE NON-PREFERRED CARE Surgical Expense 75% of the Negotiated Charge 60% of the Reasonable Charge Anesthetist & Assistant Surgeon Expense 20% of Surgical Allowance 20% of Surgical Allowance Ambulatory Surgical Expense 75% of the Negotiated Charge 60% of the Reasonable Charge OUTPATIENT EXPENSES PREFERRED CARE NON-PREFERRED CARE Physician s Office Visits Expense, limited to one visit per day. Consultant or Specialist Expense Emergency Room Visit Expense, Copay/Deductible waived if admitted. Physical Therapy Chiropractic Care Expense, limited to combined 10 visits per policy year maximum with acupuncture 75% of the Negotiated Charge after $150 Copay per visit. $25 Deductible per visit $25 Deductible per visit 100% of the Reasonable Charge after $150 Deductible per visit Dental Injury Expense, injury to sound natural teeth, limited to $100 per tooth 75% of Actual Charge 75% of Actual Charge Impacted Wisdom Teeth Expense, limited to $500 per Policy Year 75% of Actual Charge 75% of Actual Charge

5 YOUR BASIC INSURANCE PLAN BENEFITS AT A GLANCE (CONT D) MENTAL HEALTH AND SUBSTANCE ABUSE BENEFITS PREFERRED CARE NON-PREFERRED CARE Inpatient Mental Health and Substance Abuse Expense Prior review and approval must be obtained from Aetna Student Health. Outpatient Mental Health and Substance Abuse Expense Testing and Treatment for Learning Disability/Attention Deficit Disorder Expense $20 copay per visit 100% of Negotiated Charge after 60% of the Reasonable Charge, after 60% of Reasonable Charge after ADDITIONAL EXPENSES PREFERRED CARE NON-PREFERRED CARE Diagnostic X-Ray Expense 100% of Actual Charge 100% of Negotiated Charge after 60% of Reasonable Charge after Diagnostic Laboratory Expense 100% of Negotiated Charge 60% of Reasonable Charge High Cost Procedure Expense, Covered Procedures in excess of $200, such as, but not limited to outpatient diagnostic C.A.T. scans, Magnetic Resonance Imaging and Laser Treatments. Diabetic Testing Supplies Expense; including needles/syringes, test strips, diabetic test agents, glucose tablets, lancets/lancing devices, and alcohol swabs; insulin and oral hypoglycemics as well as blood glucose monitors. 75% of Negotiated Charge 60% of Reasonable Charge 75% of Negotiated Charge 60% of Reasonable Charge Maternity Expenses 75% of Negotiated Charge 60% of Reasonable Charge Pap Smear Expense, includes a pap smear and a pelvic exam annually for women age Mammography Expense, includes one baseline mammogram for women aged 40 and older Elective Abortion Expense, benefits limited to $2,500 per Policy Year 75% of the Negotiated Charge 60% of the Reasonable Charge Prescription Coverage N/A N/A The Plan will pay benefits in accordance with any applicable Oregon insurance law. The Portland State University Domestic Student Health Insurance Plan may not cover all your health care expenses. The plan excludes coverage for certain services and contains limitations on the amounts it will pay. Please read the Portland State University Domestic brochure carefully before deciding whether this plan is right for you. While this document and the Portland State University Domestic brochure tell you about some of the important features of the plan, other features may be important to you and some further limit what the plan will pay. If you want to look at the full plan description, which is contained in the Master Policy issued to Portland State University, you may contact us at (877) Portland State University - Domestic 5

6 EXCLUSIONS AND LIMITATIONS This list is only a partial list. Please refer to the School s brochure available at for a complete list of exclusions. This Policy does not cover nor provide benefits for: 1. Expense incurred for eye refractions; vision therapy; radial keratotomy; eyeglasses; contact lenses (except when required after cataract surgery); or other vision or hearing aids; or prescriptions or examinations except as required for repair caused by a covered injury. 2. Expense incurred as a result of an injury or sickness due to working for wage or profit or for which benefits are payable under any Workers Compensation or Occupational Disease Law. 3. Expense incurred for elective treatment or elective surgery except as specifically provided elsewhere in this Policy and performed while this Policy is in effect. 4. Expense incurred for cosmetic surgery; reconstructive surgery; or other services and supplies which improve; alter; or enhance appearance; whether or not for psychological or emotional reasons; (For exceptions, please read the full brochure) 5. Expense incurred as a result of preventive medicines; serums; vaccines. 6. Expense incurred as a result of commission of a felony. 7. Expense incurred by a covered person not a United States Citizen for services performed within the covered person s home country. 8. Expense incurred for treatment of temporomandibular joint dysfunction and associated myofascial pain. 9. Expenses incurred for or in connection with: procedures; services; or supplies that are; as determined by Aetna; to be experimental or investigational. (Please read the full brochure for specific definitions.) 10. Expenses incurred for gastric bypass; and any restrictive procedures, for weight loss. 11. Expenses incurred for breast reduction/mammoplasty. 12. Expenses incurred for any sinus surgery; except for acute purulent sinusitis. 13. Expense for injuries sustained as the result of a motor vehicle accident; to the extent that benefits are payable under other valid and collectible insurance; whether or not claim is made for such benefits. The Policy will only pay for those losses; which are not payable under the automobile medical payment insurance Policy. 14. Expense for services or supplies provided for the treatment of obesity and/ or weight control. 15. Expense for treatment and supplies for programs involving cessation of tobacco use. 16. Expense incurred for injury resulting from the plan or practice of intercollegiate sports (participating in sports clubs; or intramural athletic activities; is not excluded). 17. Expenses for routine physical exams; including expenses in connection with well newborn care; routine vision exams; routine dental exams; routine hearing exams; immunizations; or other preventive services and supplies; except to the extent coverage of such exams; immunizations; services; or supplies is specifically provided in the Policy. 18. Expense incurred for a treatment; service; or supply; which is not medically necessary; as determined by Aetna; for the diagnosis care or treatment of the sickness or injury involved. This applies even if they are prescribed; recommended; or approved; by the person s attending physician; or dentist. (Please read the full brochure to learn guidelines of medical necessity.) 19. Expenses incurred for: care, treatment, services, or supplies; for or related to obstructive sleep apnea; and sleep disorders; including CPAP and UPP. Any exclusion above will not apply to the extent that coverage is specifically provided by name in this Policy; or coverage of the charges is required under any law that applies to the coverage. If any discrepancy exists between this brochure and the Master Policy, the Master Policy will govern and control the payment of benefits. YOUR HOME AETNA NAVIGATOR Once you are a member of the Plan, you have access to Aetna Navigator, your secure member website. It is packed with personalized benefits and health information. Just call Wells Fargo Insurance Services at (800) , to obtain your medical ID number. In order to register for the first time, you will need to add a zero to the end of your medical ID number, and pick a user name and password. When you register with Aetna Navigator, you will have your own personal home page to: View your most recent claims Print a temporary ID card See who is covered under your Plan Use cost of care tool View your health history report which provides your health data in a portable and easy to read format And much more! IMPORTANT This is just a brief description of your benefits. For a full summary of the plan including refund requests, how to file a claim, mandated benefits and other important information, please visit or to view the Student Health Insurance brochure specifically designed for your school. 6 Portland State University - Domestic

7 NOTES Portland State University - Domestic 7

8 WELLS FARGO INSURANCE SERVICES, INC. PRIVACY POLICY We know that your privacy is important to you and we strive to protect the confidentiality of your non-public personal information. We do not disclose any non-public personal information about our customers or former customers to anyone, except as permitted or required by law. We believe we maintain appropriate physical, electronic and procedural safeguards to ensure the security of your non-public personal information. You may obtain a detailed copy of our privacy policy through your school, or by calling us toll-free at (800) or by visiting us at studentinsurance.wellsfargo.com. CLAIMS ADMINISTERED BY: Claims and Coverage Questions EMERGENCY TRAVEL ASSISTANCE: (Provide this information to your Emergency Contact) PREFERRED PROVIDER: To Find a Doctor or Provider in the Aetna Preferred Provider Network Aetna Student Health P.O. Box El Paso, TX (877) (toll-free) On Call International 24/7 Emergency Travel Assistance Services (866) (within U.S.) If outside the U.S., call collect by dialing the U.S. access code plus (603) Aetna Preferred Provider Network (877) (toll-free) PSU SHAC AFTER HOURS: (800) PRESCRIPTIONS: THE PLAN ADMINISTERED BY: Eligibility, Enrollment and General Questions Aetna Pharmacy Management (800) Wells Fargo Insurance Services USA, Inc. Student Insurance Division OR License No Cobblerock Drive, Suite 100 Rancho Cordova, CA (800) or (916) Fax: (916) This material is for information only and is not an offer or invitation to contract. Health insurance plans contain exclusions and limitations. The plan will pay benefits in accordance with any applicable Oregon insurance law. If any discrepancy exists between this pamphlet and the Master Policy, the Master Policy will govern and control the payment of benefits. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Information is believed to be accurate as of the production date; however, it is subject to change. Policy forms issued in OK include: GR NOTICE: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. IMPORTANT NOTE The Portland State University Student Health Insurance Plan is underwritten by Aetna Life Insurance Company (Aetna) and administered by Chickering Claims Administrators, Inc. Aetna Student Health is the brand name for products and services provided by these companies and their applicable affiliated companies. 8 Portland State University - Domestic

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