Student Health Insurance Plan THE OHIO STATE UNIVERSITY

Transcription

1 Student Health Insurance Plan THE OHIO STATE UNIVERSITY Your student health insurance coverage, offered by Aetna Student Health*, may not meet the minimum standards required by the health care reform law for the restrictions on annual dollar limits. The annual dollar limits ensure that consumers have sufficient access to medical benefits throughout the annual term of the policy. Restrictions for annual dollar limits for group and individual health insurance coverage are $1.25 million for policy years before September 23, 2012; and $2 million for policy years beginning on or after September 23, 2012 but before January 1, Restrictions for annual dollar limits for student health insurance coverage are $100,000 for policy years before September 23, 2012, and $500,000 for policy years beginning on or after September 23, 2012, but before January 1, Your student health insurance coverage includes an annual limit of $2,000,000 on all covered services including Essential Health Benefits. There is also a separate annual limit of $2,000,000 for Prescription Drug Benefits. Other internal maximums (on Essential Health Benefits and certain other services) are described more fully in the benefits chart included inside this Plan summary. If you have any questions or concerns about this notice, contact (855) Be advised that you may be eligible for coverage under a group health plan of a parent s employer or under a parent s individual health insurance policy if you are under the age of 26. Contact the plan administrator of the parent s employer plan or the parent s individual health insurance issuer for more information. * Fully insured Aetna Student Health Insurance Plans are underwritten by Aetna Life Insurance Company (Aetna) and administered by Chickering Claims Administrators, Inc. Aetna Student Health is the brand name for products and services provided by these companies and their applicable affiliated companies. Underwritten by: Aetna Life Insurance Company (ALIC) Policy Number NOTICE: IF YOU OR YOUR FAMILY MEMBERS ARE COVERED BY MORE THAN ONE HEALTH CARE PLAN, YOU MAY NOT BE ABLE TO COLLECT BENEFITS FROM BOTH PLANS. EACH PLAN MAY REQUIRE YOU TO FOLLOW ITS RULES OR USE SPECIFIC DOCTORS AND HOSPITALS, AND IT MAY BE IMPOSSIBLE TO COMPLY WITH BOTH PLANS AT THE SAME TIME. READ ALL OF THE RULES VERY CAREFULLY, INCLUDING THE COORDINATION OF BENEFITS SECTION, AND COMPARE THEM WITH THE RULES OF ANY OTHER PLAN THAT COVERS YOU OR YOUR FAMILY.

2 Where to Find Help In case of an emergency, call 911 or go directly to the nearest emergency care facility. For students experiencing a psychological crisis call Counseling and Consultation Service at (614) For non-emergency situations call Student Health Services at (614) or Counseling and Consultation Service at (614) For after hours assistance, call the Informed Health Line at For questions about: Medical Benefits Claims Processing Pre-Certification Requirements Please contact: Aetna Student Health P.O. Box El Paso, TX (855) For questions about: Eligibility Enrollment Waiver Process/Procedure Please contact: The Ohio State University Office of Student Life Student Health Insurance 1100 Lincoln Tower 1800 Cannon Drive Columbus, Ohio (614) shi_info@osu.edu For questions about: ID Cards ID cards will be issued as soon as possible. If you need medical attention before the ID card is received, benefits will be payable according to the Policy. You do not need an ID card to be eligible to receive benefits. Once you have received your ID card, present it to the provider to facilitate prompt payment of your claims. Please make sure you update your local address on buckeyelink. For lost ID cards, contact: Aetna Student Health (855) For questions about: Status of Pharmacy Claim Pharmacy Claim Forms Excluded Drugs and Pre-Authorization Please contact: Aetna Pharmacy Management (888) RX AETNA or (888) (Available 24 Hours) 2

3 For questions about: Provider Listings Please contact: OSU Health Plan (614) , or Aetna Student Health (855) A complete list of providers can be found at osuhealthplan.com/network-access-clients. To find an Aetna provider outside of Franklin County, go to Aetna s DocFind Service at For questions about: On Call International 24/7 Emergency Travel Assistance Services Please contact: On Call International at (866) (within U.S.). If outside the U.S., call collect by dialing the U.S. access code plus (603) Please also visit and visit your school-specific site for further information. Got Questions? Get Answers with Aetna Navigator As an Aetna Student Health insurance member, you have access to Aetna Navigator, your secure member website, packed with personalized claims and health information. You can take full advantage of our interactive website to complete a variety of self-service transactions online. By logging into Aetna Navigator, you can: Review who is covered under your plan. Request member ID cards. View Claim Explanation of Benefits (EOB) statements. Estimate the cost of common health care services and procedures to better plan your expenses. Research the price of a drug and learn if there are alternatives. Find health care professionals and facilities that participate in your plan. Send an to Aetna Student Health Customer Service at your convenience. View the latest health information and news, and more! How do I register? Go to The Ohio State University Student Health Insurance Plan is underwritten by Aetna Life Insurance Company (ALIC) and administered by Chickering Claims Administrators, Inc. Aetna Student Health SM is the brand name for products and services provided by these companies and their applicable affiliated companies. IMPORTANT NOTE Please keep this Brochure, as it provides a general summary of your coverage. A complete description of the benefits and full terms and conditions may be found in the Master Policy issued to The Ohio State University. If any discrepancy exists between this Brochure and the Policy, the Master Policy will govern and control the payment of benefits. The Master Policy may be viewed at The Ohio State University Student Health Insurance office during business hours. This student Plan fulfills the definition of Creditable Coverage explained in the Health Insurance Portability and Accountability Act (HIPAA) of At any time should you wish to receive a certification of coverage, please call the customer service number on your ID card. 3

4 TABLE OF CONTENTS Page Numbers Policy Period... 5 Rates... 5 Student Accident and Sickness Insurance Plan... 5 Student Coverage Eligibility... 6 Enrollment... 6 Waiver Process/Procedure... 7 Refund Policy... 7 Dependent Coverage Eligibility... 7 Coverage Status and Qualifying Events... 8 Provider Network... 9 Pre-Certification Program... 9 Description of Benefits Student Health Services Counseling and Consultation Services On-campus Vision Services Summary of Benefits Chart Surgical Benefits Outpatient Benefits Mental Health & Substance Abuse Benefits Maternity Benefits Additional Benefits General Provisions Subrogation/Reimbursement Extension of Benefits Termination of Insurance Exclusions Definitions Additional Services and Discounts Claim Procedure Appeals Procedure Prescription Drug Claim Procedure Worldwide Travel Assistance Services Accidental Death & Dismemberment

5 POLICY PERIOD 1. Autumn Term Students: Coverage for insured students enrolled for the Autumn Semester, will become effective at 12:00 a.m. on August 14, 2013, and will terminate at 11:59 p.m. on December 31, Spring Term Students: Coverage for insured students enrolled for the Spring Semester, will become effective at 12:00 a.m. on January 1, 2014, and will terminate at 11:59 p.m. on August 19, Summer Term Students: Coverage for new insured students enrolled for the Summer Term, will become effective at 12:00 a.m. on May 5, 2014, and will terminate at 11:59 p.m. on August 19, Insured dependents: Coverage will become effective on the same date that the insured student's coverage becomes effective, or the date of the approved qualifying event. Coverage for insured dependents terminates in accordance with the Termination Provisions described in the Master Policy. For more information on Termination of Covered Dependents see page 36 of this Brochure. Examples include, but are not limited to: the date the student s coverage terminates, the date the dependent no longer meets the definition of a dependent. RATES *Domestic Students Policy Year Autumn 08/14/13-12/31/13 Spring 01/01/14-08/19/14 **Summer 05/05/14-08/19/14 Student Only $1,150 $1,150 $575 Student & Spouse/Domestic Partner $3,370 $3,370 $1,685 Student & Child(ren) $3,416 $3,416 $1,708 Student & Family $4,612 $4,612 $2,306 *Covered benefits provided by the University and Delta Dental of Ohio are included in these rates. **Available to students who were not enrolled at the University during spring semester, but are enrolled in eligible courses summer term. *International Students Policy Year Autumn Spring **Summer 08/14/13-12/31/13 01/01/14-08/19/14 05/05/14-08/19/14 Student Only $1,070 $1,070 $535 Student & Spouse/Domestic Partner $3,182 $3,182 $1,591 Student & Child(ren) $3,257 $3,257 $1,628 Student & Family $4,402 $4,402 $2,201 *Covered benefits provided by the University and Delta Dental of Ohio are included in these rates. **Available to students who were not enrolled at the University during spring semester, but are enrolled in eligible courses summer term. THE OHIO STATE UNIVERSITY STUDENT ACCIDENT AND SICKNESS INSURANCE PLAN This is a brief description of the Accident and Sickness Medical benefits available for The Ohio State University students and their eligible dependents. The plan is underwritten by Aetna Life Insurance Company (called Aetna). The exact provisions governing this insurance are contained in the Master Policy issued to the University and may be viewed at the Student Health Insurance office, 1100 Lincoln Tower, 1800 Cannon Drive, Columbus, Ohio during business hours. 5

6 STUDENT COVERAGE ELIGIBILITY Domestic Students who are enrolled in a degree program are required to be enrolled in at least six (6) credit hours for undergraduates, at least four (4) credit hours for graduate and professional students and at least three (3) credit hours for post-candidacy doctoral students. Exceptions apply to enrolled students taking one of the approved exception course numbers representing co-ops, internship, study abroad, and thesis or dissertation research. These students will be automatically charged and the health insurance premium will be included in their fees regardless of credit hours unless the student waives coverage. The following courses are excluded from being applied towards the minimum credit hour requirement: Courses taken in a Non-degree status. The following programs or plans are considered non-degree: Graduate Non-degree, Graduate Visitor, Undergraduate Non-degree, Undergraduate Visitor, Undergraduate Academy, Law Non-degree, and Law Casual. Students may petition for an exception if the course is a pre-requisite for entrance into a degree status program of study, and if the course is graduate level, the student has a current application on file with the Graduate School. Distance Learning courses (as denoted by mode of instruction ) in absence of eligible on campus courses. Students taking Distance learning courses exclusively will not default into Student Health Insurance coverage, but may petition to enroll in the plan. Courses designated as Continuing Education Courses taken as Audit ENROLLMENT Students who do not meet the minimum credit hour requirements are not eligible to purchase the Student Health Insurance. Students meeting the eligibility requirements are automatically enrolled in the Student Health Insurance Plan each year. Eligible students who do not wish to enroll must waive coverage by providing proof of adequate insurance coverage by the published deadline of their first term of enrollment. This process must be completed online at your Student Center at Exception: A Covered Person entering the armed forces of any country will not be covered under the Policy as of the date of such entry. A pro rata refund of premium will be made for such person, and any covered dependents, upon written request received by Aetna Student Health within 90 days of withdrawal from school. International Students are required to enroll in Student Health Insurance as a condition of their enrollment at The Ohio State University regardless of credit hours. International students cannot waive coverage unless they are fully sponsored by their government and automatically have healthcare coverage insurance provided as a participant in the program; a dependent of a U.S. based employee plan; or the student is covered under a US-based health insurance policy as a US-based employee, or have permanent U.S. residence status. The plans must meet minimum coverage requirements comparable to the Student Health Insurance being offered by The Ohio State University. To request a waiver, submit a Petition to Waive International form located at under Important Forms. Interim Coverage Students enrolling at Ohio State for the first time and meeting the following criteria are eligible to purchase interim insurance in order to have coverage in advance of the effective date of the new term of enrollment: International student Graduate or professional student Undergraduate student required to arrive early to campus by an Ohio State program. Undergraduate student whose personal insurance expires between July 17, 2013 and August 13, Interim insurance provides up to 4 weeks of extended coverage. A pro-rated, weekly premium must be paid to the Office of the University Bursar for this coverage in addition to the standard rate for the upcoming enrolled term. 6

7 WAIVER PROCESS/PROCEDURE Eligible students will be automatically enrolled in this plan, unless coverage is waived online at the Student Center at The student can only waive coverage during the first academic term of enrollment each policy year and by the specified enrollment deadline dates listed below. Coverage Period Waiver Deadline Date Autumn Term 08/14/2013 Spring-Summer Term 12/30/2013 Summer Term 06/09/2014 Waiver submissions may be audited by The Ohio State University, Aetna Student Health, 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. REFUND POLICY Coverage will be terminated and any premium will be refunded on the student s account up through the 2nd Friday of the school term if the student drops below eligible credit hours or withdraws from classes. For students withdrawing from the University after the 2nd Friday of the school term, health insurance premiums will not be refunded. Exception: A Covered Person entering the armed forces of any country will not be covered under the Policy as of the date of such entry. In this case, a pro-rata refund of premium will be made for any such person and any covered dependents upon written request received by Aetna Student Health within 90 days of withdrawal from school. DEPENDENT COVERAGE ELIGIBILITY Covered students may enroll their lawful spouse, domestic partner and dependent children up to the age 26. Covered dependent children are covered until the end of the policy year in which the child reaches the age of 28 if the child: Is a natural, adopted, or step child of the covered student, Is a resident of Ohio or a full-time student, Is not eligible for coverage by an employer based plan, Medicare, or Medicaid, and Has been continuously covered upon the attainment of the limiting age. ENROLLMENT It is the student s responsibility to ensure the timely enrollment and re-enrollment of their eligible dependents. Students are required to enroll their dependents by the deadline in order to have dependent coverage begin at the beginning of that coverage period and to avoid a lapse in coverage if enrolling previously insured dependents. To enroll an eligible dependent, the student must elect coverage online through their Student Center at The Autumn enrollment deadline is August 14, Dependent enrollment will not be accepted after August 14, 2013, unless there is a significant life change, which directly affects their insurance coverage (See Coverage Status and Qualifying Events). 7

8 NEWBORN INFANT AND ADOPTED CHILD COVERAGE A child born to a Covered Person shall be covered for Accident, Sickness, and congenital defects, for 31 days from the date of birth. At the end of this 31 day period, coverage will cease under The Ohio State University Student Health Insurance Plan. To extend coverage for a newborn past the 31 days, the Covered Student must: 1) enroll the child within 31 days of birth, and 2) pay the additional premium, starting from the date of birth. Coverage is provided for a child legally placed for adoption with a Covered Student for 31 days from the moment of placement provided the child lives in the household of the Covered Student, and is dependent upon the Covered Student for support. To extend coverage for an adopted child past the 31 days, the Covered Student must 1) enroll the child within 31 days of placement of such child, and 2) pay any additional premium, if necessary, starting from the date of placement. For information or general questions on dependent enrollment, contact Student Health Insurance at For questions regarding eligibility and benefits for dependents contact Aetna Student Health at COVERAGE STATUS AND QUALIFYING EVENTS There are four types of coverage status available: 1. Student Only 2. Student and Spouse/Domestic Partner 3. Student and Child(ren) 4. Student and Family: Spouse/Domestic Partner, and Child(ren). The default coverage status is for single, Student Only. Students who want to change their coverage status must change coverage online through ( by the deadline for the first term of enrollment each policy year. Students are required to remain in the same coverage status initially selected upon enrollment for each term Student Health Insurance is purchased between Autumn 2013 and Summer 2014, unless the student experiences a qualifying event. Qualifying Event The Student must meet minimum eligibility requirements for the term of the qualifying event. A Qualifying Event is defined as an event that could result in a change of Coverage Status and includes: 1) marriage, divorce or initially meeting requirements of domestic partnership, 2) child birth or adoption, 3) death, 4) dependent reaching the age limit of another health insurance plan, 5) first time arrival of dependent to the United States from a foreign homeland, 6) gain of coverage as result of the student becoming employed, 7) open enrollment of the student, parent, or spouse s employer plan, 8) a change in the student, parent, or spouse s employment resulting in eligibility for benefits or the involuntary loss of coverage, and 9) attainment of minimum eligibility requirements after the 2nd Friday of the term. Note: Eligibility for or loss of university subsidy, government subsidy programs, or other changes in financial circumstance are not qualifying events. Contact the Student Service Center for payment options at (614) If a student experiences a qualifying event, the student must complete and submit a Coverage Status Change Form along with supporting documentation to the Student Health Insurance office within 31 days of the qualifying event. If a student experiences a qualifying event during a term that the student is not enrolled, a Coverage Status Change Form along with supporting documentation should still be sent to the Student Health Insurance office within 31 days of the qualifying event, but the effective date of the requested change will be the first day of the term in which the student returns to The Ohio State University. If the Coverage Status Change Form representing a request to add coverage is made in accordance with this plan, the student must meet the minimum eligibility requirements. If the request is approved, the coverage will be retroactive to the date of the qualifying event. If the Coverage Status Change Form to terminate coverage is made in accordance with the Plan and approved, the termination will be effective the first day of the following coverage period and there will be no pro-rata refund of premium (during the term of the qualifying event). 8

9 If a student misses the 31 day deadline, the next opportunity to change Coverage Status will be at the beginning of the next policy year. Coverage Status Change Forms are available from the Student Health Insurance office, or online at shi.osu.edu under Important Forms. PROVIDER NETWORK (Designated and In-Network Providers) To maximize your savings and reduce your out-of-pocket expenses, select an OSU Health Plan network provider (Designated Care Provider), or an Aetna In-Network Provider if you need care outside of Franklin County (Designated Care Provider). Aetna Student Health has also arranged for you to access In-Network Providers within Franklin County who are not within the OSU Health Plan network, subject to higher co-insurance, deductible, and out-of-pocket limits. It is to your advantage to use a Designated or In Network Provider because savings may be achieved from the Negotiated Charges these providers have agreed to accept as payment for their services. A listing of designated providers is available through the OSU HealthPlan at osuhealthplan.com/network-access-clients and for Aetna providers outside of Franklin County by accessing DocFind at Please note that as Out-of-Network Care Providers do not have a contract with Aetna, the provider may not accept payment of your cost share (your deductible and coinsurance) as payment in full. You may receive a bill for the difference between the amount billed by the provider and the amount paid by this Plan. If the provider bills you for an amount above your cost share, you are not responsible for paying that amount. Please send Aetna the bill at the address listed on the back of your member ID card and Aetna will resolve any payment dispute with the provider over that amount. Make sure your member ID number is on the bill. When traveling out of the U.S.A. eligible incurred claims are paid at the Designated Care level of benefits. Preferred providers are independent contractors and are neither employees nor agents of Aetna Life Insurance Company, Chickering Claims Administrators, Inc. or their affiliates. Neither Aetna Life Insurance Company, Chickering Claims Administrators, Inc. nor their affiliates provide medical care or treatment and they are not responsible for outcomes. The availability of a particular provider(s) cannot be guaranteed and network composition is subject to change. PRE-CERTIFICATION PROGRAM Pre-certification simply means calling Aetna Student Health prior to treatment to obtain approval for a medical procedure or service. 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 contacting Aetna Student Health, Managed Care Department at (855) The following inpatient services require pre-certification: All inpatient admissions, including length of stay, to a hospital, convalescent facility, skilled nursing facility, a facility established primarily for the treatment of substance abuse, or a residential treatment facility. All inpatient maternity care, after the initial 48/96 hours. If you do not secure pre-certification for non-emergency inpatient admissions, or provide notification for emergency admissions, your s will be subject to a $200 penalty per admission. If you do not secure pre-certification for partial hospitalizations or admissions your s will be subject to a $200 penalty per admission. Pre-Certification does not guarantee the payment of benefits for your inpatient admission. Each claim is subject to medical policy review, in accordance with the exclusions and limitations contained in the Policy, as well as a review of eligibility, adherence to notification guidelines, and benefit coverage under the student Accident and Sickness Plan. 9

10 Pre-Certification of Non-Emergency Inpatient Admissions, and Partial Hospitalization: The patient, Physician or hospital 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 Emergency Admissions: The patient, patient s representative, Physician or hospital must telephone within one (1) business day following inpatient (or partial hospitalization) admission. DESCRIPTION OF BENEFITS* Please Note: THE OHIO STATE UNIVERSITY PLAN MAY NOT COVER ALL OF YOUR HEALTH CARE EXPENSES. The Plan excludes coverage for certain services and contains limitations on the amounts it will pay. Please read the Ohio State University Plan Brochure carefully before deciding whether this Plan is right for you. While this document will tell you about some of the important features of the Plan, other features may be important to you and some may further limit what the Plan will pay. The Master Policy issued to The Ohio State University may be viewed at the Student Health Insurance office, 1100 Lincoln Tower, 1800 Cannon Drive during business hours or you may contact Aetna Student Health at (855) This Plan will never pay more than $2,000,000 per Policy Year for students or $2,000,000 per Policy Year for dependents, and will never pay more than $2,000,000 for Prescription Drugs per Policy Year. Additional Plan maximums may also apply. Some illnesses or injuries may cost more to treat and health care providers may bill you for what the Plan does not cover. Subject to the terms of the Policy, benefits are available for you and your eligible dependents only for the coverages listed below, and only up to the maximum amounts shown. Please refer to the Policy for a complete description of the benefits available. All insurance coverage is subject to the terms of the Master Policy and applicable state filings. Under healthcare reform legislation, student health plans may be required to eliminate or modify certain existing benefit plan provisions, including, but not limited to, exclusions and limitations. Aetna reserves the right to modify its products and services in response to federal and/or state legislation, regulation or requests of government authorities. *Benefit descriptions have been added to this brochure to help illustrate new Health Care Reform (HCR) requirements. HCR requirements are currently being filed for support in individual states and will appear in policy contracts and certificates of coverage once approved. Benefits for services rendered by Student Health Services at the Wilce Student Health Center, the Counseling and Consultation Service at the Younkin Success Center, and the College of Optometry are self-funded by The Ohio State University. 10

11 THE OHIO STATE UNIVERSITY STUDENT HEALTH SERVICES Student Health Services is the University's on-campus, outpatient health facility, open Monday Thursday 8:00 am to 6:00 pm, Friday 8:00 am to 5:00 pm and some Saturday hours. To schedule an appointment or speak with an Advice Nurse, call Student Health Services at (614) In the event of an emergency, call 911 or go to the nearest emergency room. Ohio State University Student Health Services Services provided by Student Health Services at the Student Health Center are covered by the University at the Tier 1benefit levels and are not billed to Aetna Student Health. Services at the Wilce Student Health Service are subject to availability and changes in scope of services offered to students. Unlimited Prescription Medicine s are covered by the University at Student Health Services and are not billed to Aetna Student Health for students and any insured dependents. Deductibles There is no annual Deductible applied to s rendered by Student Health Services. THE OHIO STATE UNIVERSITY COUNSELING AND CONSULTATION SERVICE Ohio State University Counseling and Consultation Service Deductibles The first 10 visits for psychotherapy services are provided by the University at no cost to the student. Covered Outpatient Mental Health and Substance Abuse s provided after a covered student s visits exceed 10 visits are covered by the University at 100% following a $15 per visit copay and are not billed to Aetna Student Health. Psychiatry services are covered by the University at 100% after a $15 per visit copay and are not billed to Aetna Student Health. There is no annual Deductible applied to s rendered by Counseling and Consultation Service. THE OHIO STATE UNIVERSITY VISION SERVICES AT STUDENT HEALTH SERVICES AND OSU OPTOMETRY CLINICS Ohio State University Student Health Services and OSU College of Optometry Deductibles Covered Routine Vision Care s are covered by the University at 100% following a $15 per visit Copay and are not billed to Aetna Student Health. A $100 allowance toward the cost of prescription glasses or contact lenses is available for covered students. Covered Routine Vision Care Exam s provided after a covered student becomes covered under the continuation plan are billable to Aetna Student Health, and payable at the TIER 2 benefit levels as specified below for the applicable service being provided. There is no annual Deductible applied to Covered Routine Vision Care s rendered by Student Health Services and OSU Optometry Clinics. 11

12 SUMMARY OF BENEFITS CHART ANNUAL MAXIMUMS DEDUCTIBLES Tier 1 Tier 2 Tier 3 Tier 4 Student Health Services at the Wilce Student Health Center OSU Health Plan Network Providers & Aetna In Network Providers located OUTSIDE of Franklin County Aetna In Network Providers located within Franklin County but are not in the OSU Health Plan Network Out of Network Care $2 Million Per Policy Year Medical & Prescription Drug Annual Maximums are separate $2 Million limits per policy year; Tier 1 services are not accrued to this limit. Waiver of Annual Deductible In compliance with Federal Health Care Reform legislation, the Annual Deductible is waived for Preferred Care s (refer to specific benefit types for list of services) rendered as part of the following benefit types: Routine Physical Exam (Office Visits), Pap Smear Screening, Mammogram, Routine Screening for Sexually Transmitted Disease, Routine Colorectal Cancer Screening, Routine Prostate Cancer Screening, Preventive Care Immunizations (Facility or Office Visits), Well Woman Preventive Visits (Office Visits), Screening & Counseling Services (Office Visits) as illustrated under the Routine Physical Exam benefit type, Routine Cancer Screenings (Outpatient), Prenatal Care (Office Visits), Comprehensive Lactation Support and Counseling Services (Facility or Office Visits), Breast Pumps & Supplies, Family Contraceptive Counseling Services (Office Visits), Female Voluntary Sterilization (Inpatient and Outpatient). The Policy Year deductible is not applicable to the following covered expenses: Female Brand Name and Generic Contraceptive Devices Female Brand Name and Generic Contraceptive Prescription Drugs Female Over-the-Counter Contraceptive Methods In addition to the above, the annual Deductible does not apply to Routine Vision Care Exam, Emergency Care Facility s, Designated Physician s Office Visits, Urgent Care, Outpatient Mental Health, Outpatient Substance Abuse, Outpatient Learning Disabilities/Attention Deficit Disorders and Consultants expenses. Also waived for services that apply a copay. Deductible accruals are separate by Tier where services are rendered and do not cross-apply. COINSURANCE OUT-OF- POCKET MAXIMUMS Tier 2 $100 Per Individual Per Policy year/$300 Per Family Per Policy Year. Tier 3 & Tier 4 (In-Network Care and Out-of- Network) Care has a combined deductible: $500 Per Individual Per Policy Year/ $1,500 Per Family Per Policy Year. at the coinsurance percentage specified below, after any applicable deductible, up to a maximum benefit of $2 Million ($2,000,000) per Policy Year. Once the Individual out-of-pocket maximum has been satisfied, s will be payable at 100% for the remainder of the Policy Year, up to any benefit maximum that may apply. s accrued towards the Tier 2 out-of-pocket also accrue towards the Tier 3 & Tier 4 out-of-pocket limit; Tier 3 & Tier 4 s accrued toward the Tier 3 & Tier 4 out-of-pocket also accrue towards the Tier 2 out-of-pocket limit. Copayments, deductible and coinsurance paid by the member at all tier levels accrue towards Out-of- Pocket Maximums as indicated below. Note: The pre-certification penalty does not apply towards the out-of-pocket maximum. $2,000 per Policy Year per individual $6,000 per Policy Year per individual 12

13 All coverage is based on Recognized Charges unless otherwise specified. The provision below, describing the network coverage levels, is subject to filing approval by the Ohio Department of Insurance. Room and Board Intensive Care Room and Board Miscellaneous Hospital Non-Surgical Physicians Tier 1 Tier 2 Tier 3 Tier 4 Student Health Services at the Wilce Student Health Center OSU Health Plan Network Providers & Aetna In Network Providers located OUTSIDE of Franklin County s are payable as follows: 90% of the s are payable as follows: 90% of the Aetna In Network Providers located within Franklin County but are not in the OSU Health Plan Network as follows: 60% of the as follows: 60% of the Out of Network Care s includes; among others; expenses incurred during a hospital confinement for: anesthesia and operating room; laboratory tests and x-rays; oxygen tent; and drugs; medicines; and dressings. s are payable as follows: 90% of the as follows: 60% of the s for charges for the non-surgical services of the attending Physician, or a consulting Physician. s are payable as follows: 90% of the as follows: 60% of the Surgical s Inpatient Surgical s for charges for surgical services, performed by a Physician. Anesthesia Assistant Surgeon s are payable as follows: 90% of the as follows: 60% of the s for the charges of anesthesia, during a surgical procedure. s are payable as follows: 90% of the as follows: 60% of the s for the charges of an assistant surgeon, during a surgical procedure. s are payable as follows: 90% of the as follows: 60% of the 13

14 Tier 1 Tier 2 Tier 3 Tier 4 Student Health Services at the Wilce Student Health Center OSU Health Plan Network Providers & Aetna In Network Providers located OUTSIDE of Franklin County Aetna In Network Providers located within Franklin County but are not in the OSU Health Plan Network Surgical s Outpatient Surgical s for charges for surgical services, performed by a Physician, at 100% of the Negotiated Charge. s are payable as follows: 90% of the as follows: 60% of the Out of Network Care Anesthesia s for the charges of anesthesia, during a surgical procedure. Not applicable s are payable as follows: 90% of the as follows: 60% of the Assistant Surgeon s for the charges of an assistant surgeon, during a surgical procedure. s are payable as follows: 90% of the as follows: 60% of the Ambulatory Surgical Benefits are payable for s incurred by a covered person for expenses incurred for outpatient surgery performed in a hospital outpatient surgery department or in an ambulatory surgical center. s must be incurred on the day of the surgery or within 48 hours after the surgery. s are payable as follows: 90% of the as follows: 60% of the as follows: 60% of the Recognized Charge. Outpatient Benefits s include but are not limited to: Physician s office visits, hospital or outpatient department or emergency room visits, durable medical equipment, clinical lab, or radiological facility. Hospital Outpatient Department Walk-in Clinic Visit s includes treatment rendered in a Hospital Outpatient Department. s do not include Emergency Room/Urgent Care Treatment, Walk-in Clinic, Therapy s, Chemotherapy and Radiation, and outpatient surgical services, including physician, anesthesia and facility charges, which are covered as outlined under the individual benefit types listed in this schedule of benefits. s are payable as follows: 90% of the as follows: 60% of the s include services rendered in a walk-in clinic. s are payable as follows: Following a $15 copay, 100% of the Negotiated Charge. as follows: 60% of the 14

15 Emergency Room Urgent Care Tier 1 Tier 2 Tier 3 Tier 4 Student Health OSU Health Plan Network Aetna In Network Out of Network Care Services at the Wilce Providers & Aetna Providers located Student Health Center In Network Providers within Franklin County located OUTSIDE of but are not in the OSU Franklin County Health Plan Network s incurred for treatment of an Emergency Medical Condition. Important Note: Please note that as Non-Preferred Care Providers do not have a contract with Aetna, the provider may not accept payment of your cost share (your deductible and coinsurance) as payment in full. You may receive a bill for the difference between the amount billed by the provider and the amount paid by this Plan. If the provider bills you for an amount above your cost share, you are not responsible for paying that amount. Please send Aetna the bill at the address listed on the back of your member ID card and Aetna will resolve any payment dispute with the provider over that amount. Make sure your member ID number is on the bill. s are payable as follows: Following a $100 Copay (waived if admitted), 100% for the first $500 per visit, 90% thereafter. as follows: Following a $100 Copay (waived if admitted), 100% for the first $500 per visit, 90% thereafter. as follows: Following a $100 Copay (waived if admitted), 100% for the first $500 per visit, 90% thereafter. *See above note on Non- Preferred care providers Benefits include charges for treatment by an urgent care provider. 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. Urgent Care Benefits include charges for an urgent care provider to evaluate and treat an urgent condition. s for urgent care treatment are payable as follows: Following a $25 Copay, 100% of the Negotiated Charge. s for urgent care treatment are payable as follows: 60% of the Negotiated Charge. s for urgent care treatment are payable as follows: 60% of the Ambulance Pre-Admission Testing for the services of a professional ambulance to or from a hospital, when required due to the emergency nature of a covered Accident or Sickness. s are payable as follows: 90% of the as follows: 90% of the as follows: 90% of the Actual Charge. s for Pre-Admission testing charges while an outpatient before scheduled surgery. s are payable as follows: 90% of the Negotiated Charge. as follows: 60% of the 15

16 Physician s Office Visit Laboratory and X-Ray Therapy Tier 1 Tier 2 Tier 3 Tier 4 Student Health OSU Health Plan Network Aetna In Network Out of Network Care Services at the Wilce Providers & Aetna Providers located Student Health Center In Network Providers within Franklin County located OUTSIDE of but are not in the OSU Franklin County Health Plan Network This benefit includes visits to specialists. at 100% of the Negotiated Charge. as follows: 100% of the *Academic & Travel Related Screenings and Titers covered at 50% of the Negotiated Charge s are payable as follows: Following a $15 copay, 100% of the Negotiated Charge. s are payable as follows: 90% of the Negotiated Charge. as follows: 60% of the as follows: 60% of the s include charges incurred by a covered person for the following types of therapy provided on an outpatient basis: Chiropractic Care, Speech Therapy, Inhalation Therapy, or Occupational Therapy. s for Chiropractic Care are s, if such care is related to neuromusculoskeletal conditions and conditions arising from: the lack of normal nerve, muscle, and/or joint function. s include charges incurred by a covered person for the following types of therapy provided on an outpatient basis, only if such therapies are a result of injury or sickness: Speech Occupational Medical Massage s for Speech, Occupational, and Medical Massage Therapy are s, only if such therapies are a result of injury or sickness. s also include charges incurred by a covered person for the following types of therapy provided on an outpatient basis: Radiation therapy, Chemotherapy, including anti-nausea drugs used in conjunction with the chemotherapy, Dialysis, and Respiratory therapy. s for these types of therapies are payable as follows: 90% of the s for these types of therapies are payable s for these types of therapies are payable as follows: 60% of the Recognized Charge. 16

17 Durable Medical and Surgical Equipment Breast Feeding Durable Medical Equipment Tier 1 Tier 2 Tier 3 Tier 4 Student Health OSU Health Plan Network Aetna In Network Out of Network Care Services at the Wilce Providers & Aetna Providers located Student Health Center In Network Providers within Franklin located OUTSIDE of County but are not in Franklin County the OSU Health Plan Network Durable Medical and Surgical Equipment are covered as follows: as follows: 100% of the s are payable as follows: 90% of the Recognized Charge Breast Feeding Durable Medical Equipment Coverage includes the rental or purchase of breast feeding durable medical equipment for the purpose of lactation support (pumping and storage of breast milk) as follows: Breast Pump Covered expenses include the following: The rental of a hospital-grade electric pump for a newborn child when the newborn child is confined in a hospital. The purchase of: an electric breast pump (non-hospital grade), if requested within 60 days from the date of the birth of the child. A purchase will be covered once every five years following the date of the birth, or a manual breast pump, if requested within 6-12 months from the date of the birth of the child. A purchase will be covered once every five years following the date of the birth. If an electric breast pump was purchased within the previous one period, the purchase of an electric or manual breast pump will not be covered until a five year period has elapsed from the last purchase of an electric pump. Breast Pump Supplies Coverage is limited to only one purchase per pregnancy in any year where a covered female would not qualify for the purchase of a new pump. Coverage for the purchase of breast pump equipment is limited to one item of equipment, for the same or similar purpose, and the accessories and supplies needed to operate the item. The covered person is responsible for the entire cost of any additional pieces of the same or similar equipment that he or she purchases or rents for personal convenience or mobility. Aetna reserves the right to limit the payment of charges up to the most cost efficient and least restrictive level of service or item which can be safely and effectively provided. The decision to rent or purchase is at the discretion of Aetna. Limitations: Unless specified above, not covered under this benefit are charges incurred for: Services which are covered to any extent under any other part of this Plan. s are payable as follows: 100% of the as follows: 100% of the 17

18 Prosthetic Devices Tier 1 Tier 2 Tier 3 Tier 4 Student Health OSU Health Plan Network Aetna In Network Out of Network Care Services at the Wilce Providers & Aetna Providers located Student Health Center In Network Providers within Franklin located OUTSIDE of County but are not in Franklin County the OSU Health Plan Network Benefits include charges for: artificial limbs, or eyes, and other non-dental prosthetic devices, as a result of an accident or sickness. s will include wigs as required as a result of chemo or radiation therapy. s do not include: eye exams, eyeglasses, vision aids, hearing aids, communication aids, and orthopedic shoes, or other devices to support the feet. Physical Therapy Dental Injury *Please refer to Vision Benefit for details on available vision benefits s covered as follows: 90% of the s covered as follows: 60% of the s covered as follows: 60% of the s for physical therapy are payable as follows when provided by a licensed physical therapist. as follows: 100% of the s are payable as follows: 90% of the as follows: 60% of the s include dental work, surgery, and orthodontic treatment needed to remove, repair, replace, restore, or reposition: Natural teeth damaged, lost, or removed, or Other body tissues of the mouth fractured or cut due to injury. The accident causing the injury must occur while the person is covered under this Plan. Non-surgical treatment of infections or diseases. This does not include those of, or related to, the teeth. Any such teeth must have been: Free from decay, or In good repair, and Firmly attached to the jawbone at the time of the injury. If: Crowns (caps), or Dentures (false teeth), or Bridgework, or In-mouth appliances, are installed due to such injury s include only charges for: The first denture or fixed bridgework to replace lost teeth, The first crown needed to repair each damaged tooth, and An in-mouth appliance used in the first course of orthodontic treatment after the injury. Surgery needed to: Treat a fracture, dislocation, or wound. Cut out cysts, tumors, or other diseased tissues. Alter the jaw, jaw joints, or bite relationships by a cutting procedure when appliance therapy alone cannot result in functional improvement. The treatment must be done in the calendar year of the accident or the next one provided the member remains insured on the plan. 18

19 Dental Injury (continued) Allergy Testing & Treatment Diagnostic Testing For Learning Disabilities Benefits are limited to $250 per Policy Year (Designated Care, In-Network Care, and Out-of- Network Care combined). Tier 1 Tier 2 Tier 3 Tier 4 Student Health OSU Health Plan Network Aetna In Network Out of Network Care Services at the Wilce Providers & Aetna Providers located Student Health Center In Network Providers within Franklin located OUTSIDE of County but are not in Franklin County the OSU Health Plan s are payable as follows: 90% of the Actual Charge. Network as follows: 90% of the Actual Charge. as follows: 90% of the Actual Charge. Benefits include charges incurred for diagnostic testing and treatment of allergies and immunology services. s include, but are not limited to, charges for the following: Laboratory tests, Physician office visits, including visits to administer injections, Prescribed medications for testing and treatment of the allergy, including any equipment used in the administration of prescribed medication, and Other medically necessary supplies and services. on the same basis as any other Sickness. Note: serum not applicable s are payable on the same basis as any other Sickness. s for diagnostic testing for: Attention deficit disorder, or Attention deficit hyperactive disorder on the same basis as any other Sickness. on the same basis as any other Sickness. Once a covered person has been diagnosed with one of these conditions, medical treatment will be payable as detailed under the outpatient Treatment of Mental and Nervous Disorders portion of this Plan. s are payable as follows: 50% of the as follows: 50% of the as follows: 50% of the 19

20 Routine Physical Exam Tier 1 Tier 2 Tier 3 Tier 4 Student Health OSU Health Plan Network Aetna In Network Out of Network Care Services at the Wilce Providers & Aetna Providers located Student Health Center In Network Providers within Franklin located OUTSIDE of County but are not in Franklin County the OSU Health Plan Network Benefits include expenses for a routine physical exam performed by a physician. If charges for a routine physical exam given to a child who is a covered dependent are covered under any other benefit section, those charges will not be covered under this section. A routine physical exam is a medical exam given by a physician, for a reason other than to diagnose or treat a suspected or identified injury or sickness. Included as a part of the exam are: Routine vision and hearing screenings given as part of the routine physical exam. X-rays, lab, and other tests given in connection with the exam, and Materials for the administration of immunizations for infectious disease and testing for tuberculosis. In addition to any state regulations or guidelines regarding mandated Routine Physical Exam services, s include services rendered in conjunction with, Evidence-based items that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force. For females, screenings and counseling services as provided for in the comprehensive guidelines recommended by the Health Resources and Services Administration. These services may include but are not limited to: Screening and counseling services, such as: Interpersonal and domestic violence, Sexually transmitted diseases, and Human Immune Deficiency Virus (HIV) infections. Screening for gestational diabetes. High risk Human Papillomavirus (HPV) DNA testing for women age 18 and older and limited to once every three years. * Sexually transmitted disease counseling expense is limited to two counseling visits per Policy Year. X-rays, lab and other tests given in connection with the exam. Immunizations for infectious diseases and the materials for administration of immunizations that have been recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention If the plan includes dependent coverage, for covered newborns, an initial hospital check up. For a child who is a covered dependent: The physical exam must include at least: A review and written record of the patient's complete medical history, A check of all body systems, and A review and discussion of the exam results with the patient or with the parent or guardian. For all exams given to covered dependent under age 2, s will not include charges for the following: More than 6 exams performed during the first year of the child's life, More than 2 exams performed during the second year of the child's life. For all exams given to a covered dependent from age 2 and over, s will not include charges for more than one exam in 12 months in a row. For all exams given to a covered student or a spouse who is a covered dependent, s will not include charges for more than: One exam in 12 months in a row. s incurred by a woman, are charges made by a physician for, one annual routine gynecological exam. 20