Student Health Insurance Storrs Campus Regional Campus. Designed for the Graduate Assistants and Fellows of

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1 Student Health Insurance Designed for the Graduate Assistants and Fellows of Storrs Campus Regional Campus Underwritten by: Nationwide Life Insurance Company Columbus, OH Policy Number: Effective: August 15, 2014 to August 14, 2015 Group Number: S 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. We will notify Covered Persons of all material changes to the Policy. Please keep this material with your important papers. 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.

2 TABLE OF CONTENTS Where to find help?... 4 The University of Connecticut Student Injury and Sickness Insurance Plan... 4 UConn Student Health Services... 5 Am I eligible?... 5 Coverage for dependents... 6 Newborn Infant Coverage... 6 How do I waive/enroll? Involuntary Loss of Coverage... 7 Effective dates and cost Termination of Benefits Extension of Benefits... 9 Premium Refund Policy... 9 Definitions Preferred provider information Pre-certification policy Student Health Insurance Plan General Provisions / State Mandated Benefits Accidental Death & Dismemberment Medical Evacuation Benefit Repatriation Benefit Exclusions Subrogation and Recovery Rights Primary Provision Claim Procedures Claim Appeal Process Value Added Services WHERE TO FIND HELP? The University of Connecticut GA Student Health Insurance Plan has been developed especially for The University of Connecticut Graduate Assistants/Fellows for the Regional, Storrs and UCHC campus. The Plan provides coverage for Sicknesses and Injuries that occur on and off campus and includes special cost-saving features to keep the coverage as affordable as possible. The University of Connecticut is pleased to offer the Plan as described in this brochure. For Questions About: Please Contact: Health Services The University of Connecticut Student Health Services 234 Glenbrook Road, Unit 2011 Storrs, CT (860) GA Waiver Process To waive the GA Health Insurance Plan go to: Dependent Enrollment Bailey Agencies, Inc. 15 Thames Street, Suite 100 Groton, CT Phone : or Fax : (860) Insurance Benefits Preferred Provider Listings Claims Processing Id card Request Preferred Provider Listings Prescription Drug Benefit Consolidated Health Plans 2077 Roosevelt Avenue Springfield, Massachusetts (800) Consolidated Health Plans or Express Scripts (800) THE UNIVERSITY OF CONNECTICUT STUDENT HEALTH INSURANCE PLAN This is a brief description of the Injury and Sickness Medical Expense benefits available to The University of Connecticut Graduate Assistants/Fellows. The Plan is underwritten by Nationwide Life Insurance Company. If you are covered by this plan, you will be covered 24 hours a day, on or off campus, throughout the United States and around the world. The exact provisions governing this insurance are contained in the Master Policy. See the University for Additional Information. The Plan is administered by Consolidated Health Plans, 2077 Roosevelt Avenue, Springfield, Massachusetts,

3 UCONN STUDENT HEALTH SERVICES (SHS) STORRS CAMPUS ONLY 234 Glenbrook Road, Storrs, CT Phone (860) Emergencies call 911 Or Campus Police (860) HOURS OF OPERATION When Classes are in Session Monday Friday 8:00 a.m. 10:30 p.m. When Classes are in Session Saturday & Sunday 8:00 a.m. 3:30 p.m. Summer & School Breaks Monday Friday 8:30 a.m. 4:30 p.m. Advice Nurse When Classes are in Session Monday - Sunday 24 Hours Summer & School Breaks Saturday & Sunday CLOSED The UConn SHS is the University s on-campus health facility. Student Health Services is staffed by physicians, nurse practitioners and registered nurses. Any Storrs campus student who has paid the General University Fee is eligible to use Health Services. GA/GF from other campuses do not have access to SHS. The SHS provides a wide variety of services. This includes primary care visits with doctors, nurse practitioners, nurses and nutritionist. Additional charges may be incurred for laboratory testing, pharmacy items, X-rays, special medical procedures and visits with specialists. The Women s Clinic also charges for annual GYN exams. Many of the charges are reimbursable by this Plan or other private health insurance. AM I ELIGIBLE? Graduate Students & Graduate Fellows that have been offered and accepted an assistantship or fellowship with the University of Connecticut will be required to be covered under the UConn GA SHIP, unless they have demonstrated through completion of the Waiver, that they are covered under a Health Insurance policy of their own. If no waiver is completed enrollment will be automatic. The GA SHIP is heavily subsidized by UConn. All GA insurance premium costs and UConn provided subsidies will be posted to the GA s Tuition Fee bill in fall and spring installments. Enrollment in the health plan taking place in the fall will be processed for the full annual period. However, if your assistantship ends during Fall, and if it is determined that your assistantship terminated during the fall on or after 9/23 then your enrollment will remain in effect until 12/31. If it ends on or before 9/22 you will not be considered an active fall GA and coverage will be cancelled back to 8/15. Assistantships ending in Spring, if your assistantship ends on or after 02/15 then your enrollment will remain in effect until 8/14. If it ends after 1/1/ but before 2/15 you will not be considered an active GA for the spring and coverage will be cancelled back to 12/31. Graduate Fellows should contact Bailey Agencies, Inc. for enrollment COVERAGE FOR DEPENDENTS Eligible GA s who do enroll may also insure their Dependents on a voluntary basis. Eligible Dependents are the spouse (including a party to a civil union residing with the Insured) and children under 26 years of age. Dependent Eligibility expires concurrently with that of the Insured student. To enroll the dependent(s) of an eligible GA, please contact Bailey Agencies, Inc. directly at (860) or toll free at (800) or go to online at: The premium cost and subsidy for dependent additions will be posted to the GA s tuition fee bill. Please contact Bailey Agencies, Inc. for details. The fall enrollment deadline is September 23, 2014 and February 15, 2015 for the spring enrollment. The dependent enrollment application will not be accepted after the fall or spring enrollment deadlines, unless there is a significant life change that directly affects their insurance coverage, such as loss of health coverage under another health plan. NEWBORN INFANT COVERAGE An Insured s newborn child is automatically covered from the moment of birth until such child is sixty-one (61) days old. Coverage for such child will be for Sickness and Injury, including medically diagnosed congenital defects, birth abnormalities, prematurity and nursery care. The Insured must notify Us in writing within sixty-one (61) days of such birth and pay the required additional premium in order to have coverage for the newborn child continue beyond such sixty-one (61) day period. Coverage for an adopted child is effective upon the earlier of the date of placement for the purpose of adoption or the date of the entry of an order granting the adoptive parent custody of the child for purposes of adoption. Coverage for such child will be for Sickness and Injury, including medically diagnosed congenital defects, birth abnormalities, prematurity and nursery care. Coverage will continue unless the placement is disrupted prior to legal adoption and the child is removed from placement. The Insured must notify Us in writing within sixty-one (61) days of such adoption and pay the required additional premium in order to have coverage for the adopted child continue beyond such sixty-one (61) day period. HOW DO I WAIVE/ENROLL? All GAs will be automatically enrolled in the GA SHIP, unless a waiver has been completed by the specified deadline dates listed. The GA s responsibility of the premium for the Plan will be added to the tuition bill. Eligible students who enroll may also insure their eligible dependent(s). To enroll dependent(s), please contact the Bailey Agencies Inc., 15 Thames Street, Suite 100, Groton, CT 06340, or or go to If after review of the coverage a GA wants to formally decline (waive) the CHP/Cigna GA Student Health Plan, an online waiver must be completed. The online Waiver is accessed through 5 6

4 The deadlines to waive coverage are: Fall/Annual Plan - September 23, 2014 Spring Term (new students only) - February 15, 2015 If you submit a waiver for the Fall Semester, coverage is automatically waived for the Spring semester; you don t need to submit the waiver again. Only new Graduate Assistants need to complete the waiver request for the Spring semester when other health insurance is in place. Waiver submissions may be audited by the University of Connecticut, the Bailey Agencies, and/or their contractors or representatives. You may be required to provide, upon request, any coverage documents and/or other records demonstrating that you meet the school s requirements for waiving the student health insurance plan. By submitting the waiver request, you agree that your current insurance plan may be contacted for confirmation that your coverage is in force for the applicable policy year and that it meets the school s waiver requirements. INVOLUNTARY LOSS OF OTHER COVERAGE If You are eligible for Coverage but do not enroll in Coverage under this Policy when You first meet the definition of Eligible Person as a result of coverage under another Policy, You may be eligible to enroll in Coverage under this Policy provided enrollment and Premium are received within 31 days of Involuntary Loss of Other Coverage. For purposes of this section, Involuntary Loss of Other Coverage means that prior coverage is involuntarily terminated due to no fault of the Eligible Person, which includes coverage that terminates due to a loss of employment by the Eligible Person or the Eligible Person s spouse or parent. This definition does not include coverage that has a predetermined termination date, or expiration of COBRA eligibility, and does not apply to coverage that has been voluntarily terminated. Coverage is effective upon enrollment and receipt of Premium by Us or Our authorized representative. EFFECTIVE DATES AND COSTS 1. Students: Coverage for all insured students enrolled for the Fall Semester will become effective at 12:01 a.m. on August 15, 2014, and will terminate at 12:01 a.m. on August 14, New Spring Semester Students: Coverage for all insured students enrolled for the Spring Semester will become effective at 12:01 a. m. on January 1, 2015, and will terminate at 12:01 a.m. August 14, Insured Dependents: Coverage will become effective on the same date the insured student s coverage becomes effective, or the day after the postmarked date when the completed application and premiums are sent, if later. Coverage for insured dependents terminates in accordance with the Termination Provisions as described in the Master Policy. Examples include, but are not limited to, the date the Insured student s coverage terminates and the date the dependent no longer meets the definition of a dependent. ANNUAL Total GA Cost** 8/15/14-8/15/15 Student* $4,257 $200 1 Dependent (Additional) $6,245 $1,240 2 or more Dependents (Additional) $9,005 $1,622 FALL Total GA Cost** 8/15/14-12/31/14 Student* $1,662 $75 1 Dependent (Additional) $2,392 $465 2 or more Dependents (Additional) $3,427 $608 SPRING Total GA Cost** 1/1/15 8/15/15 Student* $2,700 $125 1 Dependent (Additional) $3,933 $775 2 or more Dependents $5,658 $1,014 (Additional) *Student Premium includes a University Administration Fee **The UConn provided subsidy may be subject to taxation TERMINATION OF BENEFITS The insurance of any Covered Person will terminate on the earliest of: 1. The termination date of the Policy; 2. The last day of the Policy term for which Premium is paid; 3. The date a Covered Person enters full-time active military service. Upon written request within 90 days of leaving school, we will refund any unearned pro-rata Premium with respect to such person. 4. The last date of the period for which Premium has been paid following the date a Dependent ceases to be a Dependent as defined. 7 8

5 Termination will be made without prejudice to any existing expense. Coverage for any Covered person who leaves The University of Connecticut before the end of the semester will continue in force through the end of the period for which a premium was paid. Termination is subject to the Extension of Benefits Provision. EXTENSION OF BENEFITS The coverage provided under the Policy ceases on the termination date. However, if a Covered Person is: 1. Hospital confined on the Termination Date from a covered Injury or Sickness for which benefits were paid before the Termination Date, Covered Expenses for such Injury or Sickness will continue to be paid for a period of thirty-one (31) days until date of discharge or whichever is earlier. 2. Being treated on the Termination Date, for an Injury or Sickness for which Benefits were paid under this Policy prior to the Termination Date, Covered Expenses for such Injury or Sickness will continue to be paid for a period of thirty-one (31) days until the Injury or Sickness ends, whichever is earlier. 3. Totally disabled on the Termination Date from a covered Injury or Sickness for which Benefits were paid before the Termination Date, Covered Expenses for such Injury or Sickness will continue to be paid for a period of ninety (90) days until the date the disability ends, whichever is earlier. Totally Disabled means, with respect to the Insured, the inability to attend classes at the location where he is enrolled. With respect to a Dependent, or the Insured if such classes are not in session, disability means the inability to engage in any of the usual activities of a person of like age and sex whose health is comparable to that of the Covered Person immediately prior to the Injury or Sickness. The total payments made in respect of the Insured for such condition both before and after the termination date will never exceed the Maximum Benefit. After this Extension of Benefits provision has been exhausted, all Benefits cease to exist and under no circumstances will further benefits be made. received by Consolidated Health Plans within ninety (90) days of withdrawal from school. DEFINITIONS Accident means an event that is sudden, unexpected, and unintended, and over which the Covered Person has no control. Coinsurance means the percentage of the expense for which the Covered Person is responsible for a Covered Service. The Coinsurance is separate and not a part of the deductible and Co-payment. Company means Nationwide Life Insurance Company. Also hereinafter referred to as We, Our and Us. Co-payment means a specified dollar amount a Covered Person must pay for specified charges. The Co-payment is separate from and not a part of the Deductible or Coinsurance. Coverage means the right of the Covered Person to receive Benefits subject to the terms, conditions, limitations and exclusions of the Policy. Covered Charge(s) or Covered Expense as used herein means those charges for any treatment, services or supplies: (a) for Preferred Providers not in excess of the Preferred Allowance; (b) for Out-of-Network Providers not in excess of the Reasonable and Customary expense; and (c) not in excess of the charges that would have been made in the absence of this insurance; and (d) not otherwise excluded under this Policy; and (e) incurred while this Policy is in force as to the Covered Person. Covered Person means a person: Who is eligible for Coverage as the Insured or as a Dependent; Who has been accepted for Coverage or has been automatically added; For whom the required Premium has been paid; and Whose Coverage has become effective and has not terminated. Covered Services means the services and supplies, procedures and treatment described herein, subject to the terms, conditions, limitations, and exclusions of the Policy. Deductible means the amount of expenses for Covered Services and supplies which must be incurred by the Covered Person before specified Benefits become payable. Effective Date means the date Coverage becomes effective at 12:01 on this date. Coverage for Dependents will never be effective prior to the Insured s Coverage. Emergency means an Illness, Sickness or Injury for which immediate medical treatment is sought at the nearest available facility. The Condition must be one which manifests itself by acute symptoms which are sufficiently severe that a reasonable person would seek care right away to avoid severe harm. Emergency does not include the recurring symptoms of a chronic Condition unless the onset of such symptoms could reasonably be expected to result in the above listed complications. PREMIUM REFUND POLICY Except for medical withdrawal due to a covered Injury or Sickness, any student withdrawing from school during the first thirty-one (31) days of the period for which coverage is purchased shall not be covered under the Policy and a full refund of the premium will be made, minus this cost of any claim paid. Students withdrawing after such thirty-one (31) days will remain covered under the Policy for the full period for which premium has been paid. No refund will be allowed. A Covered Person entering the armed forces of any country 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, and any covered dependents, upon written request 9 10

6 Emergency Medical Transportation Services means charges that are payable whenever a Covered Person is transported, when medically necessary, by ambulance to a hospital. Any ambulance provider submitting a bill for direct payment shall stamp the following statement on the face of each bill: NOTICE: This bill is subject to mandatory assignment pursuant to Connecticut general statutes. Injury means a bodily injury due to a sudden, unforeseeable, external event which, results independently of disease, bodily infirmity or any other causes. All injuries sustained in any one Accident, including all related conditions and recurrent symptoms of these injuries are considered a single injury. In-Network Benefit means the level of payment made by Us for Covered Services received by a Preferred Provider under the terms of the Policy. Payment is based on the Preferred Allowance unless otherwise indicated. Maximum Benefit means the maximum payment We will make under the Policy for each Covered Person for Covered Services. This amount is shown on the Schedule of Benefits, as applicable. Mental Condition(s) means Nervous, emotional, and mental disease, Illness, syndrome or dysfunction classified in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) or its successor, as a Mental Condition on the date of medical care or treatment is rendered to a Covered Person. Out-of-Pocket Maximum means the most You pay during a Policy Year before Your Coverage begins to pay 100% of the allowed amount. This limit will never include Premium, balance-billed charges or health care Your Policy does not cover. Your Co-payments, Deductibles, Out-of-Network payments do count toward this limit, excludes non-covered medical expenses and Elective services. Physician: A health care professional practicing within the scope of his or her license and is duly licensed by the appropriate State Regulatory Agency to perform a particular service which is covered under the Policy, and who is not: 1. the Insured Person; 2. a Family Member of the Insured Person; or 3. a person employed or retained by the Policyholder. Policy means the agreement between Us and the Policyholder which states the terms, Conditions, limitations and exclusions regarding coverage. Policy Year means the period of twelve (12) months following the Policy s Effective Date. Policyholder means the entity shown as the Policyholder on the Policy face page. Preferred Allowance means the amount a Preferred Provider has agreed to accept as payment in full for Covered Charges. Preferred Providers means Physicians, Hospitals and other healthcare Providers who have contracted to provide specific medical care at negotiated prices. Prescription Drugs means drugs which may only be dispensed by written prescription under Federal law and is: 1. Approved for general use by the U.S. Food and Drug Administration (FDA); and 2. Prescribed by a licensed Physician for the treatment of a Life- Threatening Condition, or prescribed by a licensed physician for the treatment of a Chronic and Seriously Debilitation Condition, the drug is Medically Necessary to treat that Condition and the drug is on the Formulary, if any; and 3. The drug has been recognized for treatment of that Condition by one of the Standard Medical Reference compendia or in the Medical Literature as recommended by current American Medical Association (AMA) policies, even if the prescribed drug has not been approved by the FDA for the treatment of that specific Condition. The Drugs must be dispensed by a licensed pharmacy Provider for out of Hospital use. Prescription Drug Coverage shall also include Medically Necessary supplies associated with the administration of the drug. Provider means a Physician, Health Care Facility, or Urgent Care Facility that is licensed or certified to provide medical services or supplies. Reasonable and Customary (R&C) means the most common charge for similar professional services, drugs, procedures, devices, supplies or treatment within the area in which the charge is incurred. The most common charge means the lesser of: The actual amount charged by the Provider; or The fee often charged for in the geographical area where the service was performed. The Reasonable Charge is determined by comparing charges for similar services to a national database adjusted to the geographical area where the services or procedures are performed, by reference to the 80 th percentile of Fair Health Inc. schedules. The Insured Person may be responsible for the difference between the Reasonable Charge and the actual charge from the Provider. Sickness means Illness, disease or condition, including pregnancy and Complications of Pregnancy that impairs a Covered Person s normal functioning of mind or body and which is not the direct result of an Injury or Accident. All related Conditions and recurrent symptoms of the same or a similar Condition will be considered the same Sickness. Termination Date means the date a Covered Person s Coverage under this Policy ends. Coverage ends at 12:01 a.m. on this date. We, Our, or Us means Nationwide Life Insurance Company. You, Your, Yours means the insured student. Male pronouns whenever used include female pronouns

7 PREFERRED PROVIDER NETWORK Consolidated Health Plans has arranged for you to access a Preferred Provider Network in your local community. Acute care facilities and mental health networks are available nationally if you require hospitalization outside the immediate area of The University of Connecticut Storrs & Regional Campuses. The University of Connecticut Student 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. It is to your advantage to utilize a Preferred Provider because significant savings can be achieved from the substantially lower rates these providers have agreed to accept as payment for their services. By enrolling in this Insurance Program, you have the Cigna PPO Network of Participating Providers, providing access to quality health care at discounted fees. To find a complete listing of Cigna PPO Network of Participating Providers, go to or contact Consolidated Health Plans at (413) , toll-free at (800) , or for assistance. PRE-CERTIFICATION POLICY All inpatient hospital admissions, all partial hospitalizations, home health care services, convalescent facility, skilled nursing facility, a facility established primarily for the treatment of substance abuse, or a residential treatment, all inpatient maternity care after the initial 48/96 hours require pre-certification. If you do not secure pre-certification for non-emergency inpatient admissions, or provide notification for emergency admissions, or if you do not secure precertification for partial hospitalizations, or home health care services, your Covered Medical Expenses will be subject to a $200 per admission charge. Pre-certification may be done by you, your doctor, a hospital administrator, or one of your relatives. All requests for pre-certification must be obtained by calling Pre-certification does not guarantee the payment of benefits. Each claim is subject to medical policy review, in accordance with the exclusions and limitations contained in the Policy, as well as review of eligibility, adherence to notification guidelines, and benefits coverage under the Student Health Insurance Plan. Pre-Notification of Medical Non-Emergency Hospitalizations: The Covered Person, Physician or Health Care Facility must telephone at least three (3) business days prior to the planned admission or prior to the date the services are scheduled to begin. Notification of Medical Emergency Admissions: The patient, patient s representative, Physician or hospital must telephone within two (2) business days of the admission to provide notification of any admission due to a Medical Emergency. STUDENT HEALTH INSURANCE PLAN The following benefits are subject to the imposition of Policy limits and exclusions. All coverage is based on Reasonable and Customary Charges unless otherwise specified. Maximum Benefits Unlimited Out-of-Pocket, per person/family, per policy year Coinsurance $2,500 per individual $12,500 per Family In-Network 90% of Preferred Allowance (PA) Out-of- Network 70% of Reasonable & Customary (R&C) Deductible, per person per policy year Deductible is waived: At UConn/SHS; $250 $500 For Outpatient Laboratory Expenses; For In-network Prescriptions; and For Preventive/Wellness & Immunization Services. INPATIENT HOSPITALIZATION BENEFITS (Precertification Applies) Hospital Room & Board at the daily semi-private room rate; general nursing care provided by the hospital 90% of Preferred Allowance (PA) 70% of (R&C) Intensive Care Unit Miscellaneous Hospital Expense, covered medical expenses include, but are not limited to, use of an operating room, anesthesia, surgical dressings and supplies, laboratory tests, x-rays, drugs (excluding take home drugs) and medicines. Physician Hospital Visit Expense, covered medical expenses for charges for the nonsurgical services of the attending Physician or a consulting Physician, not to exceed one (1) visit per day. Licensed Nurse Expense Skilled Nursing Facility Expense, covered expenses must be in lieu of inpatient hospital confinement or within 24 hours after discharge from the hospital. Rehabilitation Facility Expense 13 14

8 SURGICAL BENEFITS (Inpatient and Outpatient) Surgical Expense, covered medical expenses for charges for surgical services performed by a Physician. Anesthesia, covered medical expenses for charges of an anesthetist during a surgical procedure. Assistant Surgeon Expense, covered medical expenses for charges of an assistant surgeon 20% of Surgeon s payment during a surgical procedure. Ambulatory Surgical Expense, covered medical expenses must be incurred on the day of the surgery or within 48 hours after the surgery. Second Surgical Opinion 100% of PA after $25 co-pay 70% of R&C Acupuncture in Lieu of Anesthesia must be administered by a health care provider who is a legally qualified physician, practicing within the scope of their license. OUTPATIENT BENEFITS Covered Medical Expenses include, but are not limited to, Physician s office visits, diagnostic x-rays, MRI and laboratory services, hospital emergency room or outpatient department services, and physical therapy. Hospital Outpatient Department Expense Walk-In Clinic Visit Expense $25 co-pay per visit, then 70% of R&C 100% of PA Physician s Office Visit, including visits to a Specialist. $25 co-pay per visit, then 70% of R&C (Co-pay waived at UConn/SHS) 100% of PA Consultant Expense Emergency Room Expense (co-pay waived if admitted as an inpatient) (Note: The In-Network deductible applies to Out-of-Network Emergency Expenses). $150 co-pay per visit, then 100% of PA $150 co-pay per visit, then 100% of R&C Urgent Care Expense $25 co-pay per visit, then 70% of R&C 100% of PA Please Note: A Covered Person should not seek medical care or treatment from an urgent care provider if their illness, injury or condition, is an emergency condition. The Covered Person should go directly to the emergency room of a hospital or call 911 (or the local equivalent) for ambulance and medical assistance. OUTPATIENT BENEFITS (continued) Allergy Testing and Treatment Expense include, but are not limited to: Laboratory tests; Physician office visits; including visits to administer injections; Prescribed medications for testing and Paid the same as any other Sickness. treatment of the allergy, including any equipment used in the administration of prescribed medications; and Other medically necessary supplies and services. Laboratory and X-ray Expense (Note: Deductible waived for Laboratory expenses only.) Pre-Admission Testing Expense, this benefit is payable within seven (7) working days prior to admission. High Cost Procedures include: - Computed Axial Tomography (C.A.T. Scan); - Magnetic Resonance Imaging (MRI); - Positron Emission Tomography (PET Scan); and - Contrast Materials for these tests. (Note: per service co-payment for MRI s or CAT Scans will not exceed $400 annually.) Therapy Expense, including: a) Physical Therapy b) Chiropractic Care c) Speech Therapy (limited to 40 visits per policy year) d) Inhalation Therapy e) Occupational Therapy Radiation Therapy and Chemotherapy Expense Durable Medical Equipment does not include eye glasses, vision aids, hearing aids, and orthotics. Prosthetic Devices Expense, Covered medical expenses do not include, eye exams, eyeglasses, vision aids, hearing aids, communication aids or orthopedic shoes, foot orthotics or other devices to support the feet. 90% of PA after $75 per service co-pay for MRI s or CAT scans and $100 per service co-pay for PET scans $25 co-pay per visit, then 100% of PA 70% of R&C 70% of R&C 15 16

9 TREATMENT OF MENTAL AND NERVOUS DISORDERS EXPENSE Biologically Based Mental or Nervous Conditions Inpatient Expense includes charges for partial hospitalization in a hospital treatment facility (2 days of partial hospitalization equals to 1 day of full hospitalization). Non-Biologically Based Mental or Nervous Conditions Inpatient Expense includes charges for partial hospitalization in a hospital treatment facility (2 days of partial hospitalization equals to 1 day of full hospitalization). Biologically Based Mental or Nervous Conditions Outpatient Expense (Co-pay waived at UConn/SHS) Non-Biologically Based Mental or Nervous Conditions Outpatient Expense (Co-pay waived at UConn/SHS) Diagnostic Testing for Learning Disabilities $25 co-pay per visit, then 70% of R&C 100% of PA $25 co-pay per visit, then 70% of R&C 100% of PA Paid the same as any other Sickness. ALCOHOLISM AND DRUG ADDICTION TREATMENT EXPENSE Inpatient Expense includes charges for partial hospitalization in a hospital treatment facility (2 days of partial hospitalization equals to 1 day of full hospitalization). Outpatient Expense $25 co-pay per visit, then 70% of R&C 100% of PA MATERNITY BENEFITS Maternity Expenses, Covered Medical Expenses for pregnancy, childbirth, and complications of pregnancy. In the event of an inpatient confinement, such benefits will be payable for inpatient care of the Covered Paid the same as any other Sickness. Person and any newborn child for a minimum of 48 hours following a vaginal delivery and a minimum of 96 hours following a cesarean delivery. Well Newborn Nursery Care Provided during Paid the same as any other Sickness. Mother s confinement but for not more than four (4) days for a normal delivery. OTHER SERVICES Preventive/Wellness Care Expense 100% of PA 100% of R&C Well Baby Care Expense 100% of PA 100% of R&C Immunization Expense, for the administration of appropriate and medically necessary immunizations and testing for tuberculosis. 100% of PA 100% of R&C Dental (limited to): a) Dental Injury, limited to $250 per tooth per Policy Year, per Accident. b) Impacted Wisdom Teeth Temporomandibular Joint Dysfunction (TMJ) Expense Elective Abortion, limited to $400 per occurrence. Family Planning Expense, include charges by a physician or hospital for tubal ligation for voluntary sterilization. Does not include the reversal of a sterilization procedure. Dermatological Expense includes charges for diagnosis and treatment of skin disorders (does not include cosmetic treatment and procedures). Podiatric Expense includes charges for podiatric services, provided on an outpatient basis following an injury or diabetic. Note: routine foot care, such as trimming of corns, calluses and nails are not covered. Prescription Drug Expense Up to a thirty (30) day supply can be dispensed at any time; One (1) copayment per thirty (30) day supply; Copayments apply to the out-ofpocket; Prescriptions must be filled at an Express Scripts participating pharmacy. 90% of Actual Charge Paid the same as any other Sickness. 100% of PA 70% of R&C Paid the same as any other Sickness. Paid the same as any other Sickness. 100% after: $15 Co-pay for Generic Drug per 30-day supply ($0 co-pay for Generic Contraceptives) $30 Co-pay for Brand Name drug per 30-day supply. Note: Policy year deductible does not apply. 100% after: $15 co-pay for Generic Drugs $30 co-pay for Brand Name drugs, Note: you are required to pay in full at the time of service and submit receipts for reimbursement. Hospice Benefit Ambulance Expense, Covered Medical Expenses for the services of a professional ambulance to and from a hospital when 100% of Actual Charge required due an emergency of a covered Injury or Sickness. Routine Vision Exam for Covered Persons under age nineteen (19). One pair of glasses 100% up to $150, 50% thereafter (lenses and frames) per Policy Year. Sport Clubs and Intramural Activities 17 18

10 Medical Evacuation and Repatriation 100% of R&C Accidental Death & Dismemberment For Loss of: Benefit Amount Insured Life $10,000 Both hands or both feet $5,000 One hand and one foot $5,000 One hand or one foot $2,500 Note: Loss shall mean, with regard to hands, or arms and feet or legs, dismemberment by severance at or above the wrist or ankle joint. Only the largest benefit will be paid if more than one Loss results from any one Accident. MANDATED BENEFITS Infertility Treatment, when the following conditions are met, is a demonstrated cause of infertility, has been recognized by a gynecologist or infertility specialist, is not caused by voluntary sterilization or Paid the same as any other Sickness. hysterectomy for a covered person under the age of 40 and unable to conceive or produce conception, or sustain a successful pregnancy during a one year period. Accidental Ingestion of Controlled Substance Expense Inpatient: Maximum of 30 days per Policy Year. Outpatient: Maximum benefit of $500 per Policy Year. Bone Marrow Transplant Antigen Testing Expense includes coverage for expenses arising from human leukocyte antigen testing, also referred to as histocompatibility locus antigen testing, for A, B and DR antigens for 80% of PA 80% of R&C utilization in bone marrow transplantation. Benefits are limited to one testing per lifetime. Child Early Intervention Services/Birth to age 3 Program Expense with a maximum of $6,400 per child per year and an aggregate benefit of $19,200 per child over the total three (3) year period. For a child with Autism Spectrum Disorder who is receiving early 100% of PA 100% of R&C intervention, the maximum benefit per year will be $50,000 per child and an aggregate benefit of $150,000 per child over a three (3) year period Outpatient Contraceptive Drugs and Devices Expense and Outpatient Contraceptive 100% of PA 70% of R&C Services Expense Hearing Aids for Children Expense, for children (12) twelve years of age or younger. Limited to $1,000 within a (24) twenty-four month period. Home Health Care Expense, visits are covered for 100 visits per any calendar year or in any continuous 12 months for each person covered under the Policy, except in the case of a covered person diagnosed by a Physician as terminally ill with a prognosis of six (6) months or less to live, the yearly benefit for medical social services shall not exceed $200. Each visit by a representative of a home health agency shall be considered as one (1) home health care visit; four (4) hours of home health aide service shall be considered one (1) home health care visit. Lyme Disease Treatment Expense Not less than 30 days of intravenous antibiotic therapy. 60 days of oral antibiotic therapy, or both. Ostomy Appliances and Supplies Expense, limited to $2,500 per Policy Year. Diabetic Treatment, Testing Supplies and Self Management Expense Tumor and Leukemia Expense includes charges incurred by a covered person for the surgical removal of tumors, or for the treatment of leukemia. Note: Up to a maximum yearly benefit of $350 for a wig is provided to patients who suffer hair loss as a result of chemotherapy. $50 per visit co-payment then 75% of PA $50 per visit co-pay then 75% of R&C Paid the same as any other Sickness. Payable on the same basis as any other Sickness. Paid the same as any other Sickness. GENERAL PROVISIONS STATE MANDATED BENEFITS The Plan will pay benefits, up to policy limits, for the following Mandated Benefits and any other applicable mandate in accordance with Connecticut insurance laws. (Note: Wellness/preventive benefits under the Affordable Care Act (ACA) are required to meet federal regulations. Under ACA, states retain the ability to mandate benefits beyond those established by the federal mandate. Please see the Schedule of Benefits for Coverage details.) Accidental Ingestion of Controlled Drugs, Ambulance Services Benefit, Amino Acid Modified Preparation and Low Protein Modified Food Products, Autism Spectrum Disorder, Bone Marrow Testing, Cancer Clinical Trials, Chiropractic Care, Colorectal Cancer Screening, Contraceptives, Coverage for Newborns, 19 20

11 Craniofacial Disorders, Cytological Screening, Diabetes Treatment, Diagnosis and Treatment of Infertility, Early Intervention, Elevated Blood Alcohol Content, Epidermolysis Bullosa, Experimental Treatments, Hearing Aids for Dependent Children 12 Years of Age or Younger, Home Health Care, Hypodermic Needles or Syringes, In-hospital dental services, Isolation Care and Emergency Services, Lyme Disease Treatment, Mammography Examination, Mastectomy or Lymph Node Dissection, Maternity Benefits and Postpartum Care, Medical Complications of Alcoholism, Mental or Nervous Disorder/Drug Abuse/Alcoholism, Neuropsychological Testing, Off Label Drugs, Occupational Therapy, Ostomy Appliances and Supplies, Obstetric and Gynecological Services, Outpatient Self-Management training for treatment of Diabetes, Pain Management, Pediatric Preventive, Prescription Eye Drop, Prostate Cancer Screening, Psychotropic Drug Availability, and Treatment of Leukemia and Removal of Tumors. ACCIDENTAL DEATH AND DISMEMBERMENT BENEFIT If the Eligible Person, within ninety (90) days from the date of an Accident which occurs while Coverage is in force, dies as the result of Injury from such Accident, We will pay the Eligible Person s beneficiary the amount for Loss of life as shown on the Schedule of Benefits. If the Eligible Person, ninety (90) days from the date of an Accident, which occurs while Coverage is in force, suffers dismemberment as the result of Injury from such Accident, We will pay the Eligible Person the amount set opposite such Loss, as shown on the Schedule of Benefits. If more than one (1) such Loss is sustained as the result of one (1) Accident, We will pay only one (1) amount, the largest to which the Eligible Person or his or her beneficiary would be entitled. Loss of hand or foot means Loss by severance at or above the wrist or ankle joint. Loss of sight must be entire and irrecoverable. Loss of a thumb and index fingers means Loss by severance at or above the metacarpophalangeal joints, which are the joints between the fingers and the hand. This Benefit is subject to all the terms, Conditions and exclusions of this Policy. MEDICAL EVACUATION BENEFIT If the Insured cannot continue his academic program because he sustains an Accidental Injury or Emergency Sickness while Insured under the Policy or if a Covered Dependent sustains an Accidental Injury or Emergency Sickness and is more than a 100 mile radius from his current place of primary residence or outside of his Home Country, We will pay for the actual charge Incurred for an emergency medical evacuation of the Covered Person to or back to the Insured s home state, country, or country of regular domicile subject to the Coinsurance, Deductible, Copayment, as stated in the Schedule of Benefits, and the Exclusions and Limitations provisions. No payment will be made under this provision unless the evacuation follows a Hospital Confinement of at least five (5) consecutive days. Before We make any payment, We require written certification by the Attending Physician that the evacuation is necessary. Any expense for medical evacuation requires Our prior approval and coordination. For international students, once evacuation is made outside the country, Coverage terminates. This Benefit does not include the transportation expense of anyone accompanying the Covered Person or visitation expenses. REPATRIATION BENEFIT If the Covered Person dies while Insured under the Policy and is more than 100 miles from his permanent residence or outside of his Home Country, We will pay for the actual charge incurred for embalming, and/or cremation and returning the body to his place of permanent residence in his home state, country or country of regular domicile, up to the benefit amount shown in the Schedule of Benefits, subject to the Coinsurance, Deductible, Copayment, as stated in the Schedule of Benefits, the maximum Benefit limit shown above, and the Exclusions and Limitations provisions. Expenses for repatriation of remains require the Policyholder s and Our prior approval. If You are a United States citizen, Your Home Country is the United States. This Benefit does not include the transportation expense of anyone accompanying the body, visitation or lodging expenses or funeral expenses. EXCLUSIONS Benefits will not be paid for any expenses which result from: 1. Treatment on or to the teeth or gums (except as provided herein; 2. Services provided normally without charge by the health service of the Policyholder, or services covered or provided by a Student health fee; 3. Eyeglasses, contact lenses, including but not limited to routine eye refractions, eye exams except as in the case of Injury or Sickness. Orthoptic Therapy, visual training or radial keratotomy or similar surgical procedures to correct vision, except as provided herein; 4. Hearing Screenings or hearing examinations or hearing aids and the fitting or repairing of hearing aids, unless specifically provided; 5. Services for the treatment of any Injury or Illness incurred while committing or attempting to commit a felony; or while taking part in an insurrection or riot (a noisy, violent public disorder caused by a group or crowd of persons); or fighting, except in self-defense, unless such loss is alleged to have occurred or occur under circumstances in which you have an elevated blood alcohol content as defined under the laws of the jurisdiction in which your loss occurred, or you have sustained such loss while under the influence of intoxicating liquor or any drug or both; 6. Injury occurring in consequence of riding or otherwise being in any vehicle or device of aerial navigation, except as a fare-paying passenger on a regularly scheduled flight of a commercial airline; 7. Injury or Sickness for which Benefits are paid or payable under any workers compensation or occupation disease law or act, or similar legislation; 21 22

12 8. War or any act of war, declared or undeclared; or while in the armed forces of any country; 9. Treatment in a government Hospital, unless there is a legal obligation for the Covered Person to pay for such treatment; 10. Cosmetic treatment, Cosmetic surgery, Plastic surgery, resulting complications, consequences and after effects or other services and supplies that We determine to be furnished primarily to improve appearance rather than a physical function or control of organic disease or for treatment of an Injury that is covered under the Policy. Improvements of physical function does not include improvement of self-esteem, personal concept of body image, or relief of social, emotional, or psychological distress. Procedures not covered include, but are not limited to: face lifts, sagging eyelids, prominent ears, skin scars, baldness, and correction of breast size, asymmetry or shape by means of reduction, augmentation, or breast implants including gynecomastia (except for correction or deformity resulting from mastectomies or lymph node dissections), rhinoplasty, nasal and sinus surgery, except when Medically Necessary for treatment of acute purulent sinusitis. This exclusion does not include Reconstructive Surgery when the service is incidental to or follows surgery resulting from trauma, Injury, infection or other diseases of the involved part; 11. For an Injury sustained by reason of a motor vehicle accident to the extent that Benefits are paid or payable by any other valid and collectible insurance whether or not claim is made for such Benefits; 12. Services received after the Insured s Coverage ends, except as specifically provided under the Extension of Benefits provision; 13. Any services of a Doctor, Nurse, or Health Care Practitioner who lives with You or Your Dependent(s) or who is related to You or Your Dependent(s) by blood or marriage; 14. Treatments which are considered to be unsafe, Experimental, or Investigational by the American Medical Association (AMA), and resulting complications. Upon written request, claims denied under this provision may be reviewed by an independent medical review entity if You or Your Dependent has a terminal Condition that, according to the health care Provider s current diagnosis, has a high probability of causing death within two years from the date of the request for medical review; 15. Hospital Confinement or any other services or treatment: That You or Your Dependent(s) are not legally obligated to pay; or a. For which no charge is made; 16. Custodial Care; 17. Vaccines and immunizations (except as specifically provided in the Policy): a) required for travel; and b) required for employment; 18. Under the Prescription Drug Benefit, when included, any drug or medicine: a. Obtainable Over the Counter (OTC); b. For the treatment of alopecia (hair Loss) or hirsutism (hair removal); c. For the purpose of weight control; d. Anabolic steroids used for body building; e. Sexual enhancement Drugs; f. Cosmetic, including but not limited to, the removal of wrinkles or other natural skin blemishes due to aging or physical maturation, or treatment of acne, except as specifically provided in this Policy; g. Legend vitamins or food supplements; h. Refills in excess of the number specified or dispensed after one (1) year of date of the prescription; i. For an amount that exceeds a 30 day supply for retail or 90 day supply for mail order; j. Drugs labeled, Caution limited by federal law to Investigational use or Experimental Drugs; k. Purchased after Coverage under the Policy terminates; l. Consumed or administered at the place where it is dispensed; m. If the FDA determines that the drug is: i. Contraindicated for the treatment of the Condition for which the drug was prescribed; or ii. Experimental for any reason. 19. Treatment (other than surgery) of chronic Conditions of the foot including weak feet, fallen arches, flat foot, pronated foot, subluxations of the foot, care of corns, calluses, and toenails; 20. Sterilization reversal; 21. Services of a private duty Nurse; 22. Modifications made to dwellings, property, or automobiles such as ramps, elevators, stair lifts, swimming pools, spas, air Conditioners or air-filtering systems, equipment that may increase the value of the residence, or car hand controls, whether or not their installation is for purposes of providing therapy or easy access, or are portable to other locations; 23. Expense incurred for injury resulting from the play or practice of intercollegiate sports (participating in sports clubs; or intramural athletic activities; is not excluded); 24. Acupuncture; except where specifically provided, acupressure, aroma therapy, hypnosis, rolfing, and hyperhidrosis; 25. Vocational recreation, art, dance, poetry, music, or other similar-type therapies, including regression therapy; personal enhancement or selfactualization therapy; 26. Voluntary, elective or prophylactic treatment (medical, surgical or pharmacological) for a condition that is not presently exhibiting symptoms, or is in absence of a disease state or condition that is presently creating pathological changes to any body structure or function; 23 24

13 27. Treatment, service, or supply which is not Medically Necessary as determined for the diagnosis, care or treatment of the Sickness or Injury involved. This applies even if they are prescribed, recommended or approved by the Student Health Center or by the person s Attending Doctor or dentist; and 28. Obesity treatment Services and associated expenses for the treatment of obesity, except nutrition counseling specifically provided in the Policy, and any resulting complications, consequences and after effects of treatment that involves surgery and any other associated expenses, including, but not limited to: Gastric or intestinal bypasses; Gastric balloons; Stomach stapling; Wiring of the jaw; Panniculectomy; Appetite suppressants; or Surgery for removal of excess skin or fat. Any exclusion above will not apply to the extent that coverage is specifically provided by name in the Policy, or coverage of the charges is required under any law that applies to the coverage. SUBROGATION AND RECOVERY RIGHTS Right of Recovery: If the amount of the payment made by US is more than We should have paid under this Policy, We may recover the excess from one or more of: a) The person We have paid; b) The person for whom We have paid; c) Insurance companies or any other plan; or d) other organization. The amount of the payments made includes the reasonable cash value of any benefit provided in the form of services. Right to Subrogation: If the Insured suffers an Injury or Sickness through the act or omission of another person, and if Benefits are paid under this Policy due to such Injury or Sickness, then We will be entitled to a refund of all Benefits We have paid from such recovery, as permitted by law. The refund of Benefits shall be allowable to the extent the Insured recovers or may recover for the same Injury or Sickness from another plan, including a third party, its insurer, or the Insured s uninsured motorist insurance. Further, We have the right to offset subsequent Benefits payable to the Insured under the Policy against such recovery. Upon Our request, the Insured must complete the required forms and return them to Us or to Our administrator. The Insured must notify Us of any pending or contemplated claims against third parties. The Insured must cooperate fully with Us in asserting a right to recover. The Insured will be personally liable for reimbursement to Us to the extent of any recovery obtained by the Insured from any third party. If it is necessary for Us to institute legal action against the Insured for failure to repay Us, the Insured will be personally liable for all costs of collection, including reasonable attorney s fees. We may file a lien in an Insured s action against the third party and have a lien upon any recovery that the Insured receives whether by settlement, judgment, or otherwise, and regardless of how such funds are designated. We shall have the right to recovery of the full amount of Benefits paid under the Policy for the Injury or Sickness, and that amount shall be deducted first from any recovery made by the Insured. We will not be responsible for the Insured s attorney s fees or other costs. Right to Reimbursement: If Benefits are paid under this plan and any person recovers from a third party by settlement, judgment or by operation of primary Coverage, We have a right to recover from that person an amount equal to the amount We paid. However, We will reimburse the Covered Person from any charges on a pro-rata basis for any expense Incurred in securing the settlement, judgment or otherwise. Limitation to Our Recovery Rights: We may exercise Our Right to Subrogation against third parties unless We are precluded from enforcing such right where a responsible third party has extinguished its liability or has been relieved of liability by contract or operation of law. If We are precluded from exercising Our Right to Subrogation, We may exercise Our Right to Reimbursement. We, in exercising Our Right to Subrogation, will not seek to recover more than We paid under this plan. We, in exercising Our Right to Reimbursement, will not seek to recover more than the amount recovered from a third party. PRIMARY PROVISION This provision applies if a covered student is covered by any other group or blanket health care plan, and if their parents or guardians pay any portion of the premium for this plan. In this case, this plan will always pay primary without regard to any other payer s payment. CLAIM PROCEDURES In the event of Covered Accident or Sickness: 1. Itemized billings (Written Proof of Loss) should be submitted by Your health care provider or the Covered Person within ninety (90) days of treatment, or as soon as reasonably possible. Itemized medical bills should be mailed promptly to Cigna at the address listed. SUBMIT ALL CLAIMS TO: Cigna 1000 Great West Drive Kennett, MO 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 Springfield, MA (413) or Toll Free (800)

14 Servicing Broker: Bailey Agencies, Inc. 15 Thames Street, Suite 100 Groton, CT Telephone (860) Web: or The Plan is underwritten by: Nationwide Life Insurance Company Columbus, Ohio Policy Number: Group Number: S For a copy of the Company s privacy notice, go to: CLAIM APPEAL PROCESS To appeal a claim, send a letter stating the issues of the appeal to Consolidated Health Plan s Appeal Department at the above address. Include your name, phone number, address, school attended, and address, if available. Claims will be reviewed and responded to within 60 days by Consolidated Health Plans. 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