PLAN DOCUMENT AND SUMMARY PLAN DESCRIPTION FOR BEREA COLLEGE STUDENT ACCIDENT & SICKNESS PLAN

Transcription

1 PLAN DOCUMENT AND SUMMARY PLAN DESCRIPTION FOR BEREA COLLEGE STUDENT ACCIDENT & SICKNESS PLAN

2 Degree-seeking students attending Berea College are automatically covered by the Berea College Student Accident and Sickness Plan. This document contains an outline of coverage and the provisions of the Plan. No oral interpretations can change this Plan. The Plan described is designed to protect Covered Persons against certain health expenses. Coverage under the Plan will take effect for an eligible Student and designated Dependents when the Student and such Dependents satisfy all the eligibility requirements of the Plan. The College fully intends to maintain this Plan indefinitely. However, it reserves the right to terminate, suspend, discontinue or amend the Plan at any time and for any reason. Changes in the Plan may occur in any or all parts of the Plan including benefit coverage, deductibles, maximums, exclusions, limitations, definitions, eligibility and the like. ELIGIBILITY: All degree-seeking students attending Berea College on a full-time basis must participate in the Berea College Student Accident and Sickness Plan. The cost of the coverage will automatically be included with a student s college bill. Students who participate in this Plan may also enroll their eligible dependents. Eligible dependents are the spouse of the covered student and dependent children under the age of twenty-six (26). Students who wish to enroll their eligible dependents may do so by completing an enrollment form and submitting the same with required premium to: ARC Administrators P.O. Box Lexington, Kentucky EFFECTIVE DATE: This Plan becomes effective August 14, 2013 and individual student coverage becomes effective during the period for which Eligibility requirements are fulfilled, any applicable premium is paid and proper enrollment forms are completed. COST OF COVERAGE: The cost of coverage is as follows per coverage period. 8/14/2013 1/5/2014 1/6/2014 8/13/2014 Student Only $250 $250 Spouse $509 $509 Child(ren) $509 $509 EXTENSION OF BENEFITS: The coverage provided under this Plan ceases on the termination date or on the date that the eligibility requirement is no longer met. However, if a Covered Person is Hospital Confined on the termination date from a covered injury or sickness for which benefits were paid before the termination date, Covered Medical Expenses for such Injury or Sickness will continue to be paid as long as the condition continues for the duration of recovery not to exceed thirty-one (31) days from the expiration date of coverage. If the Covered Person is also a covered under the succeeding Plan offered by the Plan Sponsor the Extension of Benefits provision shall not apply. After the Extension of Benefits provision has been exhausted, all benefits cease to exist, and under no circumstances will further benefit payments be made and the total payments made in respect of the Covered Person for each condition both before and after the termination date will never exceed the maximum benefit.

3 TERMINATION OF COVERAGE: Coverage shall terminate for a Covered Person immediately on the earliest of: The date to which premium has been paid; The expiration date of the Plan year as shown on the Schedule of Benefits, subject to the Extension of Benefits After Termination provision; The date of entrance into the armed forces of any country, a pro-rata portion of the cost of coverage paid will be returned; or The date the Covered Person no longer meets the conditions of eligibility for coverage. Termination will be made without prejudice to any existing expense. Coverage for any Covered Person who leaves the College before the end of the semester will continue in force through the end of the period for which coverage has been paid. DEFINED TERMS ELECTIVE SURGERY: Any surgery or treatment that is not Medically Necessary, including any service, treatment or supply that is deemed by us to be research or experimental; or is not recognized as generally accepted medical practice in the United States. Elective Surgery and Elective Treatment do not include any procedures deemed a Medical Necessity. Elective Surgery does not mean a Cosmetic Procedure required to correct an Injury for which benefits are otherwise payable under the Plan. Elective Surgery and Elective Treatment includes, but is not limited to, surgery and/or treatment for acne; acupuncture; allergy and allergy vials (including allergy testing); biofeedback type services; birth control; breast implants; breast reduction; circumcision; corns; calluses and bunions; cosmetic procedures; deviated nasal septum; family planning; fertility tests; hair growth/removal; impotence (organic or otherwise); infertility; learning disabilities; nonmalignant warts, moles and lesions; morbid obesity including related conditions resulting there from including hernias; premarital examinations; preventive medicines or vaccines except where required for the treatment of a covered Injury; sexual reassignment surgery; sleep disorders; smoking cessation; tubal ligation; vasectomy and weight loss or reduction. INJURY: Any bodily Injury caused by an accident. The accident must occur while the Covered Person s coverage is in effect under this Plan. Treatment received within seventy-two (72) hours from all Injuries sustained by a Covered Person in any one accident, including all related conditions and recurrent symptoms of these Injuries, are considered a single covered Injury. The Injury must be the direct cause of loss and must be independent of all other causes. The injury must not be caused by or contributed to by Sickness. MEDICALLY NECESSARY: The care which a Physician has determined to be certifiably essential for the diagnosis or treatment of a Sickness or Injury. This determination must be based on the objective results produced by an examination of the Covered Person s demonstrable symptoms. The Physician s treatment plan may be reviewed for determination of appropriateness or if the treatment plan is covered by the provisions of the Plan. Any fees associated with said review shall be paid as a claim under the Plan. SICKNESS: An illness or disease or trauma related disorder due to Injury which first manifests or causes a loss while a Covered Person is covered under the Plan and which results in Covered Medical Expenses paid by the Plan. All related conditions and recurrent symptoms of the same or a similar condition will be considered the same Sickness. This shall also include Pregnancy and Complications of Pregnancy. PRE-EXISTING CONDITION LIMITATION: No benefits will be payable by the Plan for a Covered Person s Pre-Existing Conditions. They are defined as an Injury sustained or a Sickness for which the Covered Person was medically diagnosed, treated (including medication) or advised by a Physician within six months immediately prior to the effective date of coverage under the Plan.

4 Covered Medical Expenses resulting from Pre-Existing Conditions will not be covered unless: Six consecutive months have elapsed during which no medical treatment or advice is given by a physician for such condition; or The Covered Person has been covered under the Plan and the College s prior plans or policies for twelve months; or The Covered Person has been receiving benefits under the College s prior plans or policies and has been continuously covered since the date of accident, Injury or Sickness, whichever occurs first. CREDIT FOR PRIOR COVERAGE: The Plan provides portability of coverage as it relates to pre-existing conditions and the pre-existing condition limitation set forth by the Plan will be reduced to the extent that a Covered Person was covered under a Qualifying Previous Coverage if: The person is not a late enrollee; and The prior coverage was continuous to a date not more than sixty-three (63) days prior to the effective date of the new coverage, exclusive of any applicable waiting period. Any pre-existing limitation is reduced by the aggregate of the periods of creditable coverage, if any, applicable to the Covered Person as of the enrollment date, for similar services covered under this Plan and the prior coverage. BASIC INJURY AND SICKNESS BENEFITS When a Covered Person receives medical treatment within thirty (30) days of the occurrence or an Injury or the onset of Sickness, eligible benefits will be provided for a continuous period beginning from the date of occurrence or such Injury or from the first date or treatment of a Sickness. The Plan will pay the Covered Medical Expenses incurred within fifty-two (52) weeks of the date of the first medical treatment for a covered Injury or covered Sickness. HOSPITAL ROOM AND BOARD: When a Covered Person is hospital confined, the Plan will pay the hospital semi-private room rate for a maximum of three (3) days. INTENSIVE CARE UNIT: When a Covered Person is confined in the Intensive Care Unit, the Plan will pay related charges, including twenty-four (24) hour nursing care. This benefit is NOT payable in addition to the room and board charges incurred on the same date. INPATIENT PHYSICIAN FEE EXPENSE: When a Covered Person is admitted to the hospital on an inpatient basis and requires the services of a physician other than the surgeon the Plan will pay the expense of said services up to $45 per visit, limited to one visit per day, with a Plan Year aggregate maximum limit of $450. CONSULTANT OR SPECIALIST EXPENSE: When the covered Injury or Sickness of a Covered Person requires the services of a consultant or specialist requested by the Physician to confirm or determine a diagnosis the Plan will pay the expense up to a maximum of $100 per Injury or Sickness. DIAGNOSTIC X-RAY/LABORATORY EXPENSE: When the covered Injury or Sickness of a Covered Person requires diagnostic x-rays or laboratory services, when referred by the Student Health Services or the attending physician, the Plan will pay the expense up to $450 per Injury or Sickness. CHIROPRACTIC: When the covered Injury or Sickness of a Covered Person requires the services of a licensed Chiropractor, the Plan will pay the expense for such services up to a Plan Year aggregate maximum limit of $1,000.

5 SURGICAL EXPENSE: When the covered Injury or Sickness of a Covered Person requires surgery, the Plan will pay up to a maximum of $2,000 per operation. If two or more surgical procedures are performed through the same incision or in immediate succession at the same operative session, the Plan will pay a benefit equal to the benefit payable for the procedure with the highest benefit value. This benefit is not payable in addition to Physician s visits. INPATIENT MISCELLANEOUS HOSPITAL EXPENSE/DAY SURGERY MISCELLANEOUS: The Plan will pay expenses incurred by a Covered Person during a hospital confinement or as an Outpatient for day surgery up to a maximum of $2,000. COVERED INPATIENT MISCELLANEOUS HOSPITAL EXPENSES: Operating Room Facility Administered Drugs/Medicines Laboratory Tests Therapeutic Services X-Ray Examinations Casts/Temporary Surgical Appliances Anesthesia Miscellaneous Supplies COVERED DAY SURGERY MISCELLANEOUS EXPENSES: Operating Room Facility Administered Drugs/Medicines Laboratory Tests Therapeutic Services X-Ray Examinations Miscellaneous Supplies Anesthesia Assistant Surgeon MAJOR MEDICAL BENEFIT When the covered Injury or Sickness of a Covered Person requires treatment by a currently licensed physician or surgeon, hospital confinement, x-ray examination, surgical or medical supplies and services, medicines, use of an ambulance or the service of a licensed nurse, and the medical expenses incurred exceed the amount paid under the Basic Injury and Sickness Benefits of the Plan by more than $100, then the Plan will pay up to 80% of any eligible expenses in excess of the $100 of the network negotiated or Usual and Customary expenses incurred within fifty-two (52) weeks of the date of a covered Injury or date of first treatment of a covered Sickness. The aggregate maximum medical expense payment under the Major Medical Injury and Sickness Benefit when combined with the Basic Injury and Sickness Expense Benefit shall not exceed $10,000 as the result of a covered Injury or covered Sickness. COORDINATION OF BENEFITS Coordination of benefits sets out rules for the order of payment of Covered Charges when two or more plans -- including Medicare -- are paying. When a Covered Person is covered by this Plan and another plan, or the Covered Person's Spouse is covered by this Plan and by another plan or the couple's Covered children are covered under two or more plans, the plans will coordinate benefits when a claim is received.

6 The Berea College Student Accident and Sickness Plan will pay secondary in all situations where other coverage exists. The secondary and subsequent plans will pay the balance up to each one's plan formula minus whatever the primary plan paid. This is called non-duplication of benefits. The total reimbursement will never be more than the amount that would have been paid if the secondary plan had been the primary plan. The balance due, if any, is the responsibility of the Covered Person. Benefit plan. This provision will coordinate the medical benefits of a benefit plan. The term benefit plan means this Plan or any one of the following plans: (1) Group or group-type plans, including franchise or blanket benefit plans. (2) Individual or individual-type plans. (3) Group practice and other group prepayment plans. (4) Federal government plans or programs. This includes, but is not limited to, Medicare. (5) Other plans required or provided by law. This does not include Medicaid or any benefit plan like it that, by its terms, does not allow coordination. (6) No Fault Auto Insurance, by whatever name it is called, when not prohibited by law. Allowable Charge. For a charge to be allowable it must be a Usual and Reasonable Charge and at least part of it must be covered under this Plan. Automobile limitations. When medical payments are available under vehicle insurance, the Plan shall always be considered the secondary carrier regardless of the individual's election under PIP (personal injury protection) coverage with the auto carrier. Benefit plan payment order. When two or more plans provide benefits for the same Allowable Charge, benefit payment will follow these rules: (1) All other Plans, regardless of whether they contain a coordination provision, or one like it, will be considered primary coverage and shall be the first to pay. (2) Plans with a coordination provision will pay their benefits up to the Allowable Charge: (a) (b) (c) The benefits of the plan which covers the person directly (that is, as a member or subscriber) ("Plan A") are determined before those of the plan which covers the person as a dependent or student ("Plan B"). The benefits of a benefit plan which covers a person as an Employee who is neither laid off nor retired or a Dependent of an Employee who is neither laid off nor retired are determined before those of a plan which covers the person as a COBRA beneficiary. When a child is covered as a Dependent and the parents are not separated or divorced, these rules will apply: (i) (ii) The benefits of the benefit plan of the parent whose birthday falls earlier in a year are determined before those of the benefit plan of the parent whose birthday falls later in that year; If both parents have the same birthday, the benefits of the benefit plan which has covered the parent for the longer time are determined before those of the benefit plan which covers the other parent.

7 (e) When a child's parents are divorced or legally separated, these rules will apply: (i) (ii) (iii) (iv) (v) This rule applies when the parent with custody of the child has not remarried. The benefit plan of the parent with custody will be considered before the benefit plan of the parent without custody. This rule applies when the parent with custody of the child has remarried. The benefit plan of the parent with custody will be considered first. The benefit plan of the stepparent that covers the child as a Dependent will be considered next. The benefit plan of the parent without custody will be considered last. This rule will be in place of items (i) and (ii) above when it applies. A court decree may state which parent is financially responsible for medical and dental benefits of the child. In this case, the benefit plan of that parent will be considered before other plans that cover the child as a Dependent. If the specific terms of the court decree state that the parents shall share joint custody, without stating that one of the parents is responsible for the health care expenses of the child, the plans covering the child shall follow the order of benefit determination rules outlined above when a child is covered as a Dependent and the parents are not separated or divorced. For parents who were never married to each other, the rules apply as set out above as long as paternity has been established. (f) If there is still a conflict after these rules have been applied, the benefit plan which has covered the patient for the longer time will be considered first. When there is a conflict in coordination of benefit rules, the Plan will never pay more than 50% of Allowable Charges when paying secondary. (3) Medicare will pay primary, secondary or last to the extent stated in federal law. When Medicare would be the primary payer if the person had enrolled in Medicare, this Plan will base its payment upon benefits that would have been paid by Medicare under Parts A and B regardless of whether or not the person was enrolled under any of these parts. The Plan reserves the right to coordinate benefits with respect to Medicare Part D. The Plan Administrator will make this determination based on the information available through CMS. If CMS does not provide sufficient information to determine the amount Medicare would pay, the Plan Administrator will make reasonable assumptions based on published Medicare fee schedules. (4) If a Plan Participant is under a disability extension from a previous benefit plan, that benefit plan will pay first and this Plan will pay second. MEDICAL EVACUATION BENEFIT: Upon receipt of due proof that a Covered Person incurred expenses for Physician ordered emergency medical evacuation, including medically appropriate transportation and Medically Necessary Care en route to the nearest suitable hospital or a facility operated pursuant to law for the care and treatment of ill or injured persons or to the Covered Person s home country, when the Covered Person is critically ill or injured, and appropriate local care is not available, the Plan will pay the actual charges incurred not to exceed $7,500 subject to the prior approval of the Plan. Payment of a benefit under this provision is in lieu of all benefits otherwise payable under the Plan and coverage for the Covered Person ends upon the evacuation.

8 REPATRIATION BENEFIT: Upon receipt of due proof of a Covered Person s death, the Plan will pay actual charges for preparation and transportation of the body to the home country or country of regular domicile, subject to prior approval of the Plan. If applicable, such action will be in accordance with any international standards. The benefit payable is not to exceed $7,500 and death must occur at least 100 miles away from a Covered Person s city of residence. Benefits provided by this provision are paid in addition to any other benefits payable by the Plan. COLLEGE HEALTH SERVICES If a Covered Person is ill or injured while on campus, contact College Health Services. In the event that College Health Services is not available or the Covered Person is away from campus, consult a doctor and follow the advice provided. CLAIM PROCEDURE In the event of a covered expense (claim) for a Covered Person for a covered Injury or Sickness the following procedures are to be followed: Present your Plan ID Card to the medical provider. Itemized billings must be submitted within ninety (90) days of treatment for consideration of payment by the Plan. All correspondence, claims and other inquiries should be submitted to: ARC Administrators P.O. Box Lexington, Kentucky (877)

9 EXCLUSIONS Benefits will not be paid under the Plan for any expenses which result from: 1. Expenses incurred as the result of normal dental treatment, except as specifically provided for treatment resulting from Injury to natural teeth while covered by the Plan; 2. Services that are normally provided without charge by the College s health center, infirmary or Hospital; or by any person employed by the College; 3. Eyeglasses, contact lenses, radial keratotomy, hearing aids or prescriptions or examinations except as required for repair caused by a covered Injury; 4. Suicide, attempted suicide or intentionally self-inflicted Injury regardless of mental capacity; 5. Pharmacy and prescription drugs other than those prescribed, dispensed and utilized in a facility or hospital and considered a part of treatment during facility or hospital confinement and billed directly by the facility or hospital; 6. Cosmetic surgery, except for the correction of birth defects, correction or deformities resulting from cancer surgery, or surgery that is required as a result of an Injury which necessitates medical treatment within twenty-four (24) hours of the accident. Correction of deviated nasal septum shall be considered Cosmetic surgery by the Plan; 7. Declared or undeclared war, riot, civil disorder, civil commotion or acts of terrorism; 8. Injury or Sickness for which benefits are payable under a Worker s Compensation or Occupational Disease Law; 9. Injury sustained or Sickness contracted while in the service of the Armed Forces of the United States or any country. When a Covered Person enters the armed forces, the Plan will refund any unearned pro-rata payment with respect to such person; 10. Treatment provided in a government hospital unless there is a legal obligation to pay such charges in the absence of other insurance; 11. Injury resulting from the playing, practice, participating, or conditioning in any intercollegiate sport, contest or competition sponsored by the College, any professional or semi-professional sport or Injury sustained while traveling to or from such sport, contest or competition as a participant; 12. Routine physical examinations, preventive testing or treatment, screening exams other than for tuberculosis or testing in the absence of Sickness or Injury, pre-marital examinations, preemployment examinations, health examinations including routine care or a newborn infant, well baby nursery and related Physician charges, other than Hospital nursery expense of a newborn baby, and any associated laboratory work, not including mammograms and routine Papanicolaou cytology test; 13. Committing or attempting to commit an assault or felony; or fighting, except in self defense; 14. Injury resulting from racing or speeding contests, skin diving or sky diving, mountaineering, operation of all terrain vehicles or any other hazardous hobby or sport; 15. Elective abortion; 16. Treatment for family planning; infertility, including any services or services rendered for the purpose or with intent of inducing conception; tubal ligation; and vasectomy; 17. Expenses incurred within the Covered Person s home country or country of regular domicile other than the United States unless they are under a Berea College course or program; 18. Accident sustained or Sickness contracted as a result of the use of alcohol or the misuse of drugs, medicines or narcotics, unless taken in the dosage and for the purpose prescribed by the Covered Person s physician.

10 GENERAL PLAN INFORMATION TYPE OF ADMINISTRATION The Plan is a self-funded Student Accident and Sickness Plan and the administration is provided through a Third Party Claims Administrator. The funding for the benefits is derived from the funds of the College and contributions made by Covered Students. The Plan is not insured. PLAN NAME BEREA COLLEGE STUDENT ACCIDENT AND SICKNESS PLAN PLAN SPONSOR INFORMATION Berea College CPO 2172 Berea, Kentucky (859) PLAN ADMINISTRATOR Berea College CPO 2172 Berea, Kentucky (859) NAMED FIDUCIARY President CPO 2214 Berea, Kentucky AGENT FOR SERVICE OF LEGAL PROCESS President CPO 2214 Berea, Kentucky CLAIMS ADMINISTRATOR ARC Administrators P.O. Box Lexington, Kentucky (877)