Ave Maria University Athletic Insurance Policy and Procedures: Ave Maria University s Insurance Policy Description

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1 AVE MARIA UNIVERSITY Athletic Training Sports Medicine Insurance Policies and Procedures Ave Maria University Athletic Insurance Policy and Procedures: The NAIA provides a Catastrophic Injury Insurance Policy thru Mutual of Omaha which covers student-athletes who are catastrophically injured while participating in covered intercollegiate athletic activities. This policy has a high deductible of $25, and is meant to supplement other insurance coverage that may reach their limits because of the catastrophic level of injury. Ave Maria University s Insurance Policy Description Ave Maria University has purchased a basic accident insurance policy through United States Fire Insurance Company to cover student athletes during their participation in NAIA recognized sporting activities to help cover any gaps that may arise between a primary insurance policy (required for participation), and the Catastrophic Insurance Policy provided by the NAIA. As this is an excess policy, it only covers medical costs associated with an athletic injury that are not covered by any other valid and collectible insurance. The maximum benefits for AMU s policy are set at $25, at which time the NAIA s Catastrophic Insurance Policy would begin to pick up. This policy does cover most standard care for athletic injuries, but nontraditional, experimental, elective or highly specialized treatments/braces may not be covered. It is important to check with our Athletic Training staff before receiving any of these types of treatments. This policy does not provide coverage for general medical conditions/ illnesses/sickness. This policy becomes null and void if the student athlete does not adhere to Ave Maria University Policies for utilizing the secondary athletic insurance policy. These policies are listed below. Ave Maria University Policies for utilizing Ave Maria s Secondary Athletic Insurance We would like to make you aware of our regulations with regard to insurance coverage that must be in place in order for the student athlete to participate in our athletic programs. We want to make sure both the student athlete and the parent or guardian are aware of the potential out of pocket expenses in the case of an injury while participating in intercollegiate athletic sanctioned activities such as practice, conditioning, and games. Injuries must occur in a NAIA sanctioned event to be covered by the school s policy. In other words any voluntary activities such as extra weight lifting sessions, pick-up games, etc. will not be covered under this policy. 1. Each student athlete must have primary insurance coverage for athletic accident/injuries in order to participate in any Ave Maria University Athletic Program. a. This coverage must extend beyond emergency care. b. This insurance may be as a dependent under a parent/guardian or a personal insurance policy. In the case where the student athlete is not currently eligible for coverage under a policy there are many sources available to obtain a compliant insurance policy. AMU athletic trainers or administrators can suggest a few acceptable insurance plans to purchase. Please contact the Athletic Training staff for assistance in the case you are unable to comply with the policy of Ave Maria University. i. If a student athlete s insurance coverage lapses for any reason during the academic year the student athlete will be held responsible for any bills incurred during the time frame that they were uninsured. 1

2 ii. If a student athlete s insurance does not provide coverage for athletic injuries, the student athlete will be held responsible for bills incurred. This will also result in the student athlete being unable to participate in their respective sport until they have purchased the acceptable coverage and presented proof to the training staff. c. All student athletes must provide the school with either a card showing the policy in force in which the student athlete is covered or a front and back copy of the card to be kept on file by the athletic training staff. i. If an athlete s insurance coverage changes during the school year, the athletic training ii. staff must be provided with a new card immediately. If this transition causes the athlete to be uninsured and the athlete continues to participate and sustains an injury, any bills incurred as a result of that injury will be the full financial responsibility of the student athlete. d. Student athletes should be knowledgeable about their insurance procedures and restrictions including but not limited to co-pays required at time of service, pre-certifications, referrals needed for specialists, etc. i. Co-pays must be paid by the student athlete at the time of the appointment. ii. iii. Ave Maria University will not be held responsible if the guidelines of the student athlete s insurance are not followed. If an athlete s primary insurance company denies a claim because proper procedures were not followed the student athlete may be held responsible. 2. Student athletes must notify the athletic trainer of any and all injuries. a. Any medical bills incurred as a result of an injury that has not been reported to the Athletic Training Staff will not be covered. i. If an injury occurs during a practice in which an Athletic Trainer is not present that requires emergency care, the coach will notify the athletic trainer and the student athlete will follow up with the athletic trainer when they are able to. ii. Treatment for the injury must begin within 90 days of onset of the injury with benefits lasting up to 104 weeks after the injury 1. No treatments will be covered after the 104 week period 3. Student athletes should make every effort to notify athletic training staff of any and all medical care they seek outside of the athletic training facility. a. Athletes will be given a letter to take with them to providers with Ave Maria s insurance policy information on it. b. Athletes with medical appointments over school breaks in which they don t have access to the provider letter should contact the athletic training staff and we will send the letter on your behalf. 4. Student athletes should submit any bills that have not been processed through the school s insurance policy with an Explanation of Benefits from student athlete s primary insurance company as quickly as possible to the Head Athletic Trainer. a. Bills submitted must be itemized bills in order for Athletic Training Department to be able to bill the insurance company. Itemized bills can be requested from the medical provider. b. Student athlete may be required to call provider to give them permission to speak to Athletic Trainer. c. Ave Maria University is not responsible for dealings with the athlete s primary insurance claims. We are happy to offer advice to aid students in dealings with their primary insurance company, but ultimately this responsibility will fall on the student athlete and/or parents/guardians. 5. The Ave Maria University Athletic Secondary insurance policy will not cover the primary insurance deductible. However, the Ave Maria secondary insurance policy will cover primary coinsurance amounts with restrictions as per-provider. 2

3 Tips for ensuring lowest possible out of pocket cost and least amount of hassle when dealing with medical bills incurred as a result of athletic injuries 1. Know what is covered so that you know when to have medical bills submitted to Ave Maria Athletics Secondary Insurance 2. Know your primary insurance policy procedures and report any restrictions to the athletic training staff BEFORE you sustain an injury a. If you do not know your insurance restrictions CALL YOUR PARENTS TO FIND OUT 3. If your insurance company has in and out of network benefits, call your company prior to moving to campus to try and set up a temporary network of providers near Ave Maria University for medical care while in Ave Maria. a. This may require student athlete to submit documentation each semester showing full-time enrollment b. If your insurance company will not set up benefits in and around the Ave Maria/Naples, FL area, then your child is essentially uninsured and additional coverage should be purchased, otherwise you run the risk of high out of pocket cost. 4. Report all injuries to the Ave Maria University Athletic Training Staff 5. Inform Athletic Training Staff of all medical appointments a. If appointment is during a school break notify Athletic Training Staff by or phone call. 6. Pick up a provider letter from the Athletic Training staff before any and all medical appointments. a. If appointment is during a school break notify Athletic Training Staff of appointment and contact information for medical office and provider letter will be sent on your behalf. 7. When providing an address to medical providers make sure you give them an address that you will receive the bills in a timely fashion. a. If you plan on giving your parent s address, then inform your parents to be expecting mail from medical providers and give them permission to open any correspondence from those providers that arrives in the mail 8. Always inform Athletic Training staff of outcome of medical appointments so that we can ensure Ave Maria s Athletic Insurance information is also provided to any outside facilities providing care ordered by the doctor (examples-blood work, MRIs, etc) 9. If you decide to hold off on surgeries, etc until a later date make sure that they will occur within the 104 week benefit eligible time frame. a. This is the time frame for coverage under Ave Maria s Secondary Insurance Policy only. You need to be aware of coverage periods for your primary insurance as they may be shorter. 10. Be mature and communicate with all involved, your parents, your Athletic Trainer, your Coach, etc. When everyone is on the same page and informed, everything goes a lot smoother 11. ASK QUESTIONS WHEN YOU ARE NOT SURE. THE ONLY DUMB QUESTIONS ARE THE ONES THAT DON T GET ASKED. SEE BELOW FOR AGREEMENT FORM 3

4 Athletic Pre-participation Screening Checklist 1. Please make sure you have a primary insurance policy that covers intercollegiate sports and that there are in-network insurance providers in this area: Be aware! Ave Maria University offers two student insurances. General student insurance does not cover intercollegiate athletics. The university does offer intercollegiate athlete student insurance. Make sure you select the correct one. 2. Provide legible front and back copy of your primary insurance card. 3. Provide doctors notes for any pre-existing injury, chronic pathology, and prescriptions dictating you are are allowed to participate in college varsity athletics. 4. Completely and legibly fill out the Medical and Insurance Questionnaire. If a minor, please have parent signatures in the designated areas. Please date and sign ALL designated areas. 5. Please provide first and last initials on the lines provided when reviewing each section of the Informed Consent and Medical Release Form. 4 Year in School

5 Ave Maria University Acknowledgement of Insurance Requirements I,, as parent, guardian or legal representative, attest that (Name, please print) has insurance coverage under a current, in force insurance policy for (student-athlete name) injuries that occur while he/she is participating in intercollegiate athletics. If there is a change in coverage or expiration of coverage, I agree to notify Ave Maria University of this development and update the insurance information I have on file with Ave Maria University. I understand that my or my parent health insurance will serve as primary insurance for all injuries and illness. Ave Maria University Athletic Department has a secondary policy that ONLY applies for athletically related injuries which occur during an organized and supervised workout, practice or competition. The Ave Maria University secondary policy is not responsible for any non-athletic injury, illness, primary or secondary insurance deductible. I understand that all bills and related paperwork I or my parents receive from athletically related injuries must be sent to the athletic training staff at Ave Maria University within 10 days from time of receipt. I understand I or my parents are responsible for any and all medical expenses not covered by my primary insurance or the Ave Maria University Athletic secondary policy. (Signature of Parent/ Guardian) (Date) (Signature of student athlete) (Date) YOU MUST INCLUDE A COPY (FRONT AND BACK) OF YOUR CURRENT INSURANCE CARD AND THE COMPLETED EMERGENCY CONTACT AND INSURANCE INFORMATION FORM. 5

6 Informed Consent and Medical Release Form Please initial by each section and sign your name at the bottom to demonstrate that you have read and understood each of the following. If you are under 18 years of age, your parent/guardian must also initial and sign this form. If you refuse to sign any section, please write Refused to Sign, the date, and your initials. Assumption of Risk I am aware participating or practicing to participate in any sport or sport related activity could be a dangerous activity involving MANY RISKS OF INJURY. I understand that the dangers and risks of participating or practicing to participate in sports or sport related activity include, but are not limited to: death; serious neck and spinal injuries that may result in complete or partial paralysis; brain damage; serious injury to virtually all bones, joints, ligaments, muscles, tendons, other aspects of the musculoskeletal system and vital organs; and serious impairment to other aspects of the body, general health, and well- being. I understand the dangers and risks of participating or practicing to participate in any sport or sport related activity may result not only in serious injury, but in a serious impairment of my (the participant s) future abilities to earn a living; to engage in other business, social, and recreational activities; and generally enjoy life. Because of the dangers of participating or practicing to participate in any sport or sport related activity, I recognize the importance of following the coaches, officials and medical staff s instructions regarding playing techniques, training, and other team rules, etc., and agree to obey such instructions. Furthermore, I hereby agree to hold Ave Maria University, its direct and contracted employees, agents, representatives, coaches and volunteers harmless from any and all liability, actions, causes of action, debts, claims, or demands of every kind and nature whatsoever that may arise by or in connection with participation of myself/son/daughter in any activities related to Ave Maria University. The terms hereof will serve as a release for my heirs, estate, executor, administrator, assignees, and for all members of my family. Informed Medical Consent I hereby give my permission to Ave Maria University, its direct and contracted employees, agents, representatives, coaches and volunteers to authorize any emergency action necessary to ensure the safety of the student- athlete. I also hereby authorize the athletic trainers at Ave Maria University who are under the direction and guidance of Ave Maria University athletic team physicians, to render to myself/son/daughter any preventative, first aid, or rehabilitative treatment that they deem reasonably necessary to the health and well- being of the student- athlete. The intention hereof being to grant authority to administer and perform all and singularly any examinations, pre- participation physical examinations, treatments, hospitalizations, anesthetics, operations, and diagnostic procedures which may now, or during the course of this student athlete s care, be deemed advisable or necessary. This does not hold Ave Maria University, its direct and contracted employees, agents, representatives, coaches or volunteers financially responsible for any medical care given. 6

7 Authorization to Obtain Medical Information I hereby authorize any physician, any hospital or medically related facility, or any other individual or organization which has provided health care services to myself/son/daughter to give any and all information about my/son s/daughter s medical history, mental or physical condition, and/or treatment to Ave Maria University, its direct and contracted employees, agents, or representatives, for the purpose of determining eligibility for the benefits I have requested. I understand that a photocopy of this authorization shall be as valid as the original. I know that I, or my authorized representative, may receive a copy of this authorization upon request. This authorization shall remain valid for the duration of my claim. Release of Medical Information Part I General Disclosure: I hereby authorize the Ave Maria University, its direct and contracted employees, agents, and representatives to release information from my medical records for the purpose of payment, treatment or operations to their Business Associate Partner (which includes; the Attending School s Coaching Staff and Administrators) and any Hospital in case of an Emergency Situation. This authorization shall be valid for the duration of the school year. It is subject to revocation by the patient, or the parent/guardian at any time except to the extent that action has been taken in reliance thereon. I am aware that once the Ave Maria University, its direct and contracted employees, agents, or representatives discloses this information per my instructions, the information is subject to re- disclosure and may no longer be protected by the HIPAA (Health Insurance Portability and Accountability Act) of I understand that a photocopy of this authorization shall be as valid as the original. I know that I or my authorized representative may receive a copy of this authorization upon request. Release of Medical Information Part II I hereby authorize the Ave Maria University athletic trainers, team physicians, athletic coaches, and administrators to release to the Ave Maria University Sports Information Department and the media at any time, medical information regarding myself/son/daughter, concerning illness or injury relative to my past, present, or future participation in athletics at the Ave Maria University. Student-Athlete Responsibilities I 1. Understand that it is my responsibility to report all injuries and illness to my coach and/or team athletic trainer as soon as possible. 2. Understand that I am expected to report promptly as scheduled for treatment and/or rehabilitation. 3. Understand that I will continue to receive treatment/rehabilitation until released by my team physician and/or athletic trainer. 4. Understand that Ave Maria University cannot be held responsible for any previous medical condition(s) that I might have. Signature (parent/guardian if a minor) Date Printed Name 7

8 Name SSN DOB Year Sport Athletic Health History Questionnaire 1. What is the date of your last physical examination YES NO 2. Have you had a medical illness or injury since your last checkup or sports physical? 3. Do you have an ongoing or chronic illness? 4. Have you ever been hospitalized overnight? 5. Have you ever had surgery? 6. Are you currently taking any prescription or nonprescription (over-the-counter) medications, pills or using an inhaler? 7. Are you taking any supplements or vitamins to help you gain or lose weight or improve your performance? 8. Do you have any allergies (pollen, medicine, food, or stinging insects)? 9. Have you ever been dizzy or passed out during or after exercise? 10. Have you ever had chest pain during or after exercise? 11. Have you ever had racing of your heart or skipped heartbeats? 12. Have you had high blood pressure or high cholesterol? 13. Have you ever been told you have a heart murmur? 14. Has any family member died of heart problems or of sudden death before age 35? 15. Have you had a severe viral infection (e.g. myocarditis, mononucleosis) within the past 6 months? 16. Have you ever had an electrocardiogram (ECG/EKG) of your heart? 17. Has a physician ever denied or restricted your participation in sports for heart problems? 18. Is there a history of Marfan s Syndrome in your family? 19. Is there a history of premature (prior to age 50) onset of diabetes in your family? 20. Do you have any current skin problems (itching, rashes acne, warts, fungus, or blisters)? 21. Have you ever had a head injury or concussion? 22. Have you ever been knocked out, become unconscious, or lost your memory? 23. Have you ever had a seizure? 24. Do you have frequent or severe headaches? 25. Have you ever had numbness or tingling in your arms, legs, or feet? 8

9 26. Have you ever had a stinger, burner, or pinched nerve? 27. Have you ever become ill from exercising in the heat? 28. Do you cough, wheeze, or have trouble breathing during or after activity? 29. Do you have asthma? 30. Do you have seasonal allergies that require medical treatment? 31. Do you have only one of two paired, functioning organs (e.g. eyes, kidneys, ovaries)? 32. Do you use any special protective or corrective equipment or devices that aren t usually used for your sport or position (e.g. knee brace, neck roll, foot orthotics, retainer, hearing aid)? 33. Have you ever had an injury (e.g. sprain, strain, fracture) to any of the following: Head Neck Back Chest Shoulder Upper Arm Elbow Forearm Wrist Hand Finger Hip Thigh Knee Calf/Shin Ankle 34. Do you want to weigh more or less than you do now? 35. Do you lose weight regularly to meet weight requirements for your sport? 36. Record the dates of your most recent immunizations (shots) for: Tetanus Measles Hepatitis B Chickenpox Explain YES answers here (may use another sheet of paper, also) I, the undersigned, hereby acknowledge, affirm, and represent that all above statements are true and accurate to the best of my knowledge; and that no answers or information have been withheld. If any information and/or statements are false and/or have been omitted in reference to my past and/or present medical history, I fully understand that the Ave Maria University, its direct and contracted employees, agents, representatives, coaches and volunteers disclaim liability, and will not be held liable for any injuries and/or illnesses not noted. Parent/Guardian Signature Date Student-Athlete Signature and 9

10 Name SSN DOB Year Sport Physical Examination Height Weight BP / Pulse Vision R 20/ L 20/ Corrected: Y N Pupils: Equal Unequal MEDICAL Appearance Eyes/Ears/Nose/Throat Lymph Nodes Heart Pulses Lungs Abdomen Genitalia (males only) Skin MUSCULOSKELETAL Neck Back Shoulder/Arm Elbow/Forearm Wrist/Hand Hip/Thigh Knee Leg/Ankle Foot NORMAL ABNORMAL INITIALS MEDICAL CLEARANCE q Cleared q Cleared after completing evaluation/rehabilitation for: q Not Cleared Reason: Recommendations: Name of Physician (print/type): Date Address: Phone Signature of Physician MD or DO 10