2011-2012 Student Medical Insurance Plan for Underwritten by: Aetna Life Insurance Company (ALIC) Policy Number 474963
WHERE TO FIND HELP In case of an emergency, call 911 or your local emergency hotline, or go directly to an emergency care facility. For non-emergency situations you may contact Aetna Student Health to locate a provider as shown below or call Catholic University of America Student Health Services at (202) 319-5744. For questions about: * Insurance Benefits * Enrollment * Waiver Process * Claims Processing * Pre-Certification Requirements Please contact: Aetna Student Health P.O. Box 981106 El Paso, TX 79998 (866) 577-6692 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. For lost ID cards, contact: Aetna Student Health (866) 577-6692 For questions about: * Enrollment Process * Waiver Process Please contact: The Catholic University of America Student Medical Plan Administrator (202) 319-5050 cua-studentmedins@cua.edu For questions about: * Status of Pharmacy Claim * Pharmacy Claim Forms * Excluded Drugs and Pre-Authorization Please contact: Aetna Pharmacy Management (800) 238-6279 (Available 24 hours) For questions about: * Provider Listings Please contact: Aetna Student Health (866) 577-6692 A complete list of providers can be found using Aetna s DocFind Service at www.aetnastudenthealth.com. 2
For questions about: On Call International 24/7 Emergency Travel Assistance Services Please contact: On Call International at (866) 525-1956 (within U.S.). If outside the U.S., call collect by dialing the U.S. access code plus (603) 328-1956. Please also visit www.aetnastudenthealth.com and visit your school-specific site for further information. The Catholic University of America Student Medical 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 Catholic University of America. 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 University s Student Medical Plan Administrator s office in 170 Leahy Hall during business hours. This student Plan fulfills the definition of Creditable Coverage explained in the Health Insurance Portability and Accountability Act (HIPAA) of 1996. At any time should you wish to receive a certification of coverage, please call the customer service number on your ID card. 3
TABLE OF CONTENTS Page Numbers University Health Services... 5 Policy Period... 5 Rates and Deductibles... 5 Student Coverage Eligibility... 6 Automatic Enrollment... 6 Refund Policy... 7 Waiver Process/Procedure... 7 Continuously Insured... 7 Preferred Provider Network... 8 Pre-Certification Requirements... 8 Pre-Existing Conditions... 9 In-Patient Hospitalization Benefits... 11 Surgical Benefits... 11 Outpatient Benefits... 12 Mental Health & Substance Abuse Benefits... 16 Maternity Benefits... 18 Additional Benefits... 18 Optional Major Medical Coverage... 23 Additional Available Benefits... 24 General Provisions... 26 Extension of Benefits... 27 Termination of Insurance... 27 Exclusions... 28 Definitions... 33 Claim Procedure... 47 Prescription Drug Claim Procedure... 47 Accidental Death & Dismemberment... 48 4
THE CATHOLIC UNIVERSITY OF AMERICA STUDENT HEALTH SERVICES The Catholic University of America Student Health Services is the University's on-campus health facility located behind Centennial Village in the Eugene I. Kane Student Health and Fitness Center. For more information please visit http://health.cua.edu, call (202) 319-5744 or email CUA-studenthealth@cua.edu. In the event of an emergency, call 911 or the Campus Department of Public Safety at (202) 319-5111. CUA offers an assistance program for student that may need help with coordinating care or understanding their medical insurance. For Information about the CUA Health Advocate Program please visit http://studentinsurance.cua.edu. POLICY PERIOD 1. Students: Coverage for all insured students enrolled for the Fall Semester, will become effective at 12:01 AM on August 14, 2011, and will terminate at 11:59 PM on August 13, 2012. 2. New Spring Semester students: Coverage for all insured students enrolled starting in the Spring Semester, will become effective at 12:01 AM on January 1, 2012, and will terminate at 12:01 AM on August 13, 2012. 3. New Summer Semester students: Coverage for all insured students enrolled starting in the Summer Semester, will become effective at 12:01 AM on May 8, 2012, and will terminate at 12:01 AM on August 13, 2012. RATES Annual Plan Rate 8/14/11-8/13/12 Cost Student Medical Insurance Plan Rate for New Spring Semester Students 1/1/12-8/13/12 Rate for New Summer Semester Students 5/8/12-8/13/12 Optional Major Medical Buy Up Rate Student* $1,521 $911 $415 $395** *The rates above include both premium for the student health plan underwritten by Aetna Life Insurance Company, as well as The Catholic University of America s administrative fee and the cost of the Health Advocate Program. **The Optional Major Medical Buy Up Rate is charged in addition to the Student Medical Insurance Plan Rate. You must be in enrolled in the student medical insurance plan to purchase optional major medical. DEDUCTIBLES The following Deductibles are applied before Covered Medical s for Preferred and Non-Preferred Care are payable: $300 Policy Year 5
THE CATHOLIC UNIVERSITY OF AMERICA STUDENT MEDICAL INSURANCE PLAN This is a brief description of the Student Medical benefits available for Catholic University of America students. 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 University s Student Medical Plan Administrator s office in 170 Leahy Hall during business hours. STUDENT COVERAGE ELIGIBILITY All Catholic University of America students with registered credit hours are eligible to enroll in the CUA Medical Insurance Plan. Your method of enrollment or waiver from the Plan will depend on your student registration status as defined by The Catholic University of America. Please contact CUA Student Accounts at (202) 319-5300 if you are unsure of your registration status. Domestic Students (registered for 12 or more credit hours): are automatically enrolled in the insurance plan unless an on-line waiver is submitted and accepted by the posted deadline. All International Students Holding a J1 or F1 Visa (regardless of registered credit hours): are automatically enrolled in the CUA Student Medical Insurance Plan unless proof of other comparable coverage is submitted online and by hard copy to the CUA Insurance Administrator by September 12, 2011. Domestic Students (registered for less than 12 credit hours): are eligible to purchase the CUA Student Medical Insurance Plan on a voluntary basis. John Paul House of Studies and Washington Theological Union Students: are eligible to purchase the CUA Student Medical Insurance Plan on a voluntary basis. Note: If you are defined as a domestic student or an international student with a visa other than F1 or J1 taking less than 12 credit hours at the University, you must proactively enroll yourself through Aetna Student Health s Website www.aetnastudenthealth.com by the posted deadline and the charge will be applied to your CUA Student Account. Home study, correspondence, Internet classes, and television (TV) courses, do not fulfill the eligibility requirement that the student actively attend classes. If it is discovered that this eligibility requirement has not been met, our only obligation is to refund premium, less any claims paid. WAIVER AND ENROLLMENT PROCESS/PROCEDURE ENROLLMENT Eligible students will be automatically enrolled in this plan, unless the completed Online Waiver Form has been received by the University, by the specified enrollment deadline dates listed in the next section of this Brochure. To enroll online for voluntary coverage, log on to www.aetnastudenthealth.com, search for your school and complete the appropriate form or call Aetna Student Health at (866) 577-6692. 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 upon written request received by Aetna within 90 days of withdrawal from school. Aetna Student Health reserves the right to review, at any time, your eligibility to enroll in this plan. If it is determined that you did not meet the school's eligibility requirements for enrollment, your participation in the plan may be rescinded in accordance with its terms. 6
WAIVER Eligible students will be automatically enrolled in this plan, unless the completed Online Waiver Form has been received by the University, by the specified enrollment deadline dates listed in this section of this Brochure. Category Waiver/ Enrollment Deadline Date Students enrolling for the Annual Plan 09/12/2011 New Spring Semester Students enrolling for the Spring Plan 01/20/2012 New Summer Semester Students enrolling for the Summer Plan 06/01/2012 Waiver submissions for all international students holding a J1 or F1 visa must be submitted online and a physical copy presented to the CUA Insurance Administrator located in 170 Leahy Hall during business hours or via email to cua-studentmedins@cua.edu by the posted waiver deadline. REFUND POLICY If you withdraw from school within the first 31 days of a coverage period, you will not be covered under the Policy and the full premium will be refunded, less any claims paid. After 31 days, you will be covered for the full period that you have paid the premium for, and no refund will be allowed. (This refund policy will not apply if you withdraw due to a covered Accident or Sickness.) 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 upon written request received by Aetna Student Health within 90 days of withdrawal from school. CONTINUOUSLY INSURED Persons who have remained continuously insured under this Plan or other policies will be covered for any Pre-Existing Condition, which manifests itself while continuously insured, except for expenses payable under prior policies in the absence of this Plan. Previously Covered Persons must re-enroll for coverage by September 12, 2011, for the Annual Plan, and by January 20, 2012, for the Spring Semester in order to avoid a break in coverage for conditions which existed in prior policy years. Once a break in continuous coverage occurs, the Pre-Existing Conditions Limitation will apply to all covered injuries and sickness that were diagnoses and treated within twelve months prior to the covered person s effective date of insurance with the exception of pregnancy. 7
PREFERRED PROVIDER NETWORK Aetna Student Health has arranged for you to access a Preferred Provider Network in your local community. Acute care facilities and mental health networks are available nationally if you require hospitalization outside the immediate area of the Catholic University campus. To maximize your savings and reduce your out-of-pocket expenses, select a Preferred Provider. It is to your advantage to use a Preferred Provider because savings may be achieved from the Negotiated Charges these providers have agreed to accept as payment for their services. You may also obtain information regarding Preferred Providers by contacting Aetna Student Health at (866) 577-6692, or through the Internet by accessing DocFind at www.aetnastudenthealth.com. 1. Click on Enter DocFind 2. Select zip code, city, or county 3. Enter criteria 4. Select Provider Category 5. Select Provider Type 6. Select Plan Type Student Health Plans 7. Select Start Search or More Options 8. More Options enter criteria and Search 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 certification must be obtained by contacting Aetna Student Health at (866) 577-6692 (attention Managed Care Department). The following inpatient and outpatient services or supplies 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. All partial hospitalization in a hospital, residential treatment facility, or facility established primarily for the treatment of substance abuse. 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. Pre-Certification of Non-Emergency Inpatient Admissions, Partial Hospitalization, Identified Outpatient Services and Home Health Services: 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. 8
PRE-EXISTING CONDITIONS/ CONTINUOUSLY INSURED PROVISIONS Pre-existing Condition A preexisting condition is an injury or disease that was present before your first day of coverage under a group health insurance plan. If you received treatment or services for that injury or disease or you took prescription drugs or medicines for that injury or disease during the 365 days prior to your first day of coverage, that injury or disease will be considered a pre-existing condition. Limitation s incurred by a covered person as a result of a Pre-existing condition will not be considered Covered Medical unless no charges are incurred or treatment rendered for the condition for a period of six months while covered under this Plan. Please note this limitation only applies to students over age 19. Continuously Insured You have been continuously insured if you (i) had creditable health insurance coverage (such as COBRA, HMO, another group or individual policy, Medicare or Medicaid) prior to enrolling in this plan, and (ii) the creditable coverage ended within 63 days of the date you enrolled under this plan. If both of these tests are met, then the preexisting limitation period under this plan will be reduced (and possibly eliminated altogether) by the number of days of your prior creditable coverage. You will be asked to provide evidence of your prior creditable coverage. Once a break in your continuous coverage occurs, the definition of Pre-Existing Conditions will apply. 9
DESCRIPTION OF BENEFITS Please Note: THE CATHOLIC UNIVERSITY OF AMERICA 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 Catholic 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. If you want to look at the full Plan description, which is contained in the Master Policy issued to Catholic University, you may view it at the CUA Insurance Administrator s Office in 170 Leahy Hall or you may contact Aetna Student Health at (866) 577-6692. This Plan will never pay more than $250,000 per condition, per lifetime. 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 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. SUMMARY OF BENEFITS CHART DEDUCTIBLES The following Deductibles are applied before Covered Medical s for Preferred and Non-Preferred Care are payable: $300 per Policy Year COINSURANCE Covered Medical s are payable at the coinsurance percentage specified below, after any applicable deductible, up to a maximum benefit of $250,000 per condition, per lifetime. OUT OF POCKET MAXIMUMS Once the Individual Out-of-Pocket Limit has been satisfied, Covered Medical s will be payable at 100% for the remainder of the Policy Year, up to any benefit maximum that may apply. Coinsurance applies to meeting the Outof-Pocket Limit Preferred Care Individual Out-of-Pocket: $400 Non-Preferred Care Individual Out-of-Pocket: $1,600 All coverage is based on Recognized Charges unless otherwise specified. 10
Inpatient Hospitalization Benefits Hospital Room Covered Medical s are payable as follows: and Board Non-Preferred Care: 60% of the Recognized Charge for a semi-private room. Intensive Care Unit Miscellaneous Hospital Covered Medical s are payable as follows: Non-Preferred Care: 60% of the Recognized Charge for the Intensive Care Room Rate for an overnight stay. Covered Medical s are payable as follows: Non-Preferred Care: 60% of the Recognized Charge. Covered Medical s include, but are not limited to: laboratory tests, X-rays, surgical dressings, anesthesia, supplies and equipment use, and medicines. Physician Hospital Visit/ Consultation s Covered Medical s for charges for the non-surgical services of the attending Physician, or a consulting Physician, are payable as follows: Non-Preferred Care: 60% of the Recognized Charge. Surgical Benefits (Inpatient and Outpatient) Surgical Covered Medical s for charges for surgical services, performed by a Physician, are payable as follows: Non-Preferred Care: 60% of the Recognized Charge. Anesthesia Assistant Surgeon Ambulatory Surgical Covered Medical s for the charges of anesthesia, during a surgical procedure, are payable as follows: Non-Preferred Care: 60% of the Recognized Charge. Covered Medical s for the charges of an assistant surgeon, during a surgical procedure, are payable up to 20% of the amount paid to the surgeon. Benefits are payable for Covered Medical 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. Covered Medical s must be incurred on the day of the surgery or within 48 hours after the surgery. Non-Preferred Care: 60% of the Recognized Charge. Covered Medical s must be incurred on the day of the surgery or within 48 hours after the surgery. 11
Outpatient Benefits Covered Medical 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 Covered Medical s includes treatment rendered in a Hospital Outpatient Department. Covered Medical 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. Benefits are payable as follows: Non-Preferred Care: 80% of the Recognized Charge. Walk-In Clinic Benefits are payable for Covered Medical s incurred by a covered person for diagnostic X-ray and laboratory services; consultants or specialists, etc. Benefits do not include expenses incurred for the use of an outpatient surgical facility. Benefits are payable as follows: Non-Preferred Care: 60% of the Recognized Charge. Emergency Room Urgent Care Covered Medical s incurred for treatment of an Emergency Medical Condition are payable as follows: Non-Preferred Care: 80% of the Recognized Charge. 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 for ambulance and medical assistance. Urgent Care Benefits include charges for an urgent care provider to evaluate and treat an urgent condition. Covered Medical s for urgent care treatment are payable as follows: Non-Preferred Care: 60% of the Recognized Charge. No benefit will be paid under any other part of this Plan for charges made by an urgent care provider to treat a non-urgent condition. Ambulance Pre-Admission Testing Covered Medical s are payable as follows 80% of the Actual Charge 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. Covered Medical s for Pre-Admission testing charges while an outpatient before scheduled surgery are payable as any other Condition. 12
Physician s Office Visits Covered Medical s are payable as follows: Non-Preferred Care: 60% of the Recognized Charge. Benefits are limited to 1 visit per day, when not related to surgery. Laboratory and X-ray High Cost Procedures Covered Medical s are payable as follows: Non-Preferred Care: 60% of the Recognized Charge. Covered Medical s include charges incurred by a covered person are payable as follows: Non-Preferred Care: 60% of the Recognized Charge. For purposes of this benefit, High Cost Procedure means any outpatient procedure costing over $200. Therapy Covered Medical s include charges incurred by a covered person for the following types of therapy provided on an outpatient basis: Physical Therapy, Chiropractic Care, Speech Therapy, Inhalation Therapy, or Occupational Therapy. Covered Medical s are payable as follows: Non-Preferred Care: 60% of the Recognized Charge. Benefits are limited to 1 visit per day, 10 visits per policy year for Physical Therapy. Outpatient Physical Therapy benefits payable only for a condition that required surgery or Hospital Confinement: 1) within the 30 days immediately preceding such Physiotherapy; or 2) within the 30 days immediately following the attending Physician s release for rehabilitation or; when prescribed by the attending Physician and treatment is not following surgery. After the 10th visit we may request verification of medical necessity in order to continue treatment. Plan must cover habilitative services for the treatment of congenital or genetic birth defects (includes autism, autism spectrum disorder and cerebral palsy) to enhance the ability of children to function. Habilitive services defined as PT, OT and ST. Covers children to age 21. Chemotherapy Covered Medical s for chemotherapy, including anti-nausea drugs used in conjunction with the chemotherapy, radiation therapy, tests and procedures, physiotherapy (for rehabilitation only after a surgery), and expenses incurred at a radiological facility. Covered medical expenses also include expenses for the administration of chemotherapy and visits by a health care professional to administer the chemotherapy. Orally administered anticancer drugs prescribed to kill or slow the growth of cancerous cells will be payable on the same basis as chemotherapy that is administered intravenously or by injection. Non-Preferred Care: 60% of the Recognized Charge. 13
Durable Medical Equipment Prosthetic Devices Covered Medical s are payable as follows: Non-Preferred Care: 60% of the Recognized Charge. Benefits include charges for: artificial limbs, or eyes, and other non-dental prosthetic devices, as a result of an accident or sickness. Covered Medical s do not include: eye exams, eyeglasses, vision aids, hearing aids, communication aids, and orthopedic shoes, foot orthotics, or other devices to support the feet. Covered Medical expenses are payable as follows: Non-Preferred Care: 60% of the Recognized Charge. Outpatient Physical Therapy Covered Medical s for physical therapy are payable as follows when provided by a licensed physical therapist: Non-Preferred Care: 60% of the Recognized Charge. Benefits are limited to 1 visit per day, 10 visits per policy year. Outpatient Physical Therapy benefits payable only for a condition that required surgery or Hospital Confinement: 1) within the 30 days immediately preceding such Physiotherapy; or 2) within the 30 days immediately following the attending Physician s release for rehabilitation or; when prescribed by the attending Physician and treatment is not following surgery. After the 10th visit we may request verification of medical necessity in order to continue treatment. Covered Medical s include coverage for children under the age of 21 years for habilitative services for the treatment of congenital or genetic birth defects (including autism, autism spectrum disorder and cerebral palsy) to enhance the ability of children to function. Habilitative services include Physical Therapy, Occupational Therapy and Speech Therapy. Dental Injury Covered Medical 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. 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, Covered Medical 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. 14
Dental Injury (continued) 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. Non-surgical treatment of infections or diseases. This does not include those of, or related to, the teeth. Covered Medical s are payable as follows: 80% of the Actual Charge. Allergy Testing Benefits include charges incurred for diagnostic testing of allergies. Covered Medical 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 other medically necessary supplies and services. Covered Medical s are payable as follows: Non-Preferred Care: 60% of the Recognized Charge. Diagnostic Testing for Attention Disorders and Learning Disabilities Preventive Health Care Covered Medical s for diagnostic testing for: attention deficit disorder, or attention deficit hyperactive disorder are payable as follows: Non-Preferred Care: 60% of the Recognized Charge. The charges below are included as Covered Medical s, even though they are not incurred in connection with a sickness or disease. They are included only for a child under 21 years of age. Preventive Health Care Services s These are the charges for Preventive Health Care Services. Preventive Health Care Services These are the services provided for a routine physical exam of the child. Included are: A review and written record of the child's complete medical history. Taking measurements and blood pressure. Developmental and behavioral assessment. Vision and hearing screening. Appropriate immunizations. Anticipatory guidance. Other diagnostic screening tests, including: o o One series of hereditary and metabolic tests performed at birth, Urinalysis, tuberculin test, and blood tests such as hematocrit and hemoglobin tests, and tests to screen for sickle hemoglobinopathy. Counseling and guidance of the child and the child's parents or guardian on the results of the physical exam. 15
Preventive Health Care (continued) Covered Medical s will only include charges incurred for: An exam performed at birth. All exams performed during the first 12 years of the child's life. Three exams performed during each year of life, up to age 21. Benefits are payable as any other Condition. Coverage includes age appropriate health screening for children from birth to age 21. Consultant or Specialist Covered Medical s include the expenses for the services of a consultant or specialist, when referred by the School Health Services. The services must be requested by the attending physician for the purpose of confirming or determining to confirm or determine a diagnosis. Covered Medical s are covered as follows: Non-Preferred Care: 60% of the Recognized Charge. Mental Health Benefits Clinically Significant Mental Illness Inpatient Covered Medical s include expenses incurred by a covered person while confined as a full-time inpatient in a hospital or residential treatment facility for the treatment of clinically significant mental and nervous disorders. Clinically Significant means the following psychiatric illnesses as defined in the most current edition of the Diagnostic and Statistical Manual (DSM) published by the American Psychiatric Association: anorexia nervosa bulimia nervosa schizophrenia paranoid and other psychotic disorders bipolar disorders (hypomanic, manic, depressive, and mixed) major depressive disorders (single episode or recurrent) schizoaffective disorders (bipolar or depressive) pervasive developmental disorders obsessive-compulsive disorders depression in childhood and adolescence panic disorders post-traumatic stress disorders (acute, chronic, or with delayed onset) Benefits are payable as any other Condition. Clinically Significant Mental Illness Outpatient Covered Medical s include charges for treatment of clinically significant mental and nervous disorders while the covered person is not confined as a full-time inpatient in a hospital. Clinically Significant means the following psychiatric illnesses as defined in the most current edition of the Diagnostic and Statistical Manual (DSM) published by the American Psychiatric Association: anorexia nervosa bulimia nervosa schizophrenia paranoid and other psychotic disorders bipolar disorders (hypomanic, manic, depressive, and mixed) major depressive disorders (single episode or recurrent) schizoaffective disorders (bipolar or depressive) 16
Clinically Significant Mental Illness Outpatient (continued) pervasive developmental disorders obsessive-compulsive disorders depression in childhood and adolescence panic disorders post-traumatic stress disorders (acute, chronic, or with delayed onset) Charges made by marriage and family therapists are not Covered Medical s. Preferred Care: 75% of the Negotiated Charge for the first 40 visits; 60% of the Negotiated Charge thereafter. Non-Preferred Care: 75% of the Recognized Charge for the first 40 visits; 60% of the Recognized Charge thereafter. Mental Illness Inpatient Other Diagnosis Mental Illness Outpatient Other Diagnosis Covered Medical s include expenses incurred by a covered person while confined as a full-time inpatient in a hospital or residential treatment facility for the treatment of nonclinically-significant mental and nervous disorders. Covered Medical s are covered as follows: Non-Preferred Care: 60% of the Recognized Charge. Covered Medical s include charges for treatment of non-clinically-significant mental and nervous disorders while the covered person is not confined as a full-time inpatient in a hospital. Charges made by marriage and family therapists are not Covered Medical s. Covered Medical s are covered as follows: Preferred Care: 75% of the Negotiated Charge for the first 40 visits; 60% of the Negotiated Charge thereafter. Non-Preferred Care: 75% of the Recognized Charge for the first 40 visits; 60% of the Recognized Charge thereafter. Treatment of Alcohol and Drug Addiction Inpatient Treatment of alcohol and drug addiction, including detoxification, received while the covered person is confined as a full-time inpatient in a hospital or residential treatment facility established primarily for the treatment of alcohol and drug addiction will be considered a Covered Medical. Covered on the same basis as any other condition up to a maximum of 12 days per Policy year for detoxification and up to 60 days per policy year for inpatient hospital or non-hospital residential treatment facility. Benefits are payable as any other Condition. This benefit is subject to the same lifetime limits for medical, surgical and mental benefits. 17
Outpatient Covered Medical s include charges for outpatient treatment of alcohol and drug addiction provided by a physician, psychologist or social worker for a minimum of 30 outpatient visits per Policy Year. Preferred Care: 75% of the Negotiated Charge for the first 40 visits; 60% of the Negotiated Charge thereafter. Non-Preferred Care: 75% of the Recognized Charge for the first 40 visits; 60% of the Recognized Charge thereafter. This benefit is subject to the same lifetime limits for medical, surgical and mental benefits. Covered Medical s include charges for outpatient treatment of alcohol and drug addiction provided by a physician, psychologist or social worker for a minimum of 30 outpatient visits per Policy Year. Maternity Benefits Maternity Covered Medical s include inpatient care of the covered person and any newborn child for a minimum of 48 hours after a vaginal delivery and for a minimum of 96 hours after a cesarean delivery. Any decision to shorten such minimum coverages shall be made by the attending Physician in consultation with the mother. In such cases, covered services may include: home visits, parent education, and assistance and training in breast or bottle-feeding. Covered Medical s for pregnancy, childbirth, and complications of pregnancy are payable on the same basis as any other sickness. Well Newborn Nursery Care Benefits include charges for routine care of a covered person s newborn child as follows: hospital charges for routine nursery care during the mother s confinement, but for not more than four days for a normal delivery, physician s charges for circumcision, and physician s charges for visits to the newborn child in the hospital and consultations, but for not more than 1 visit per day. Cover newborn screening tests when charged by the hospital. Covered Medical s are payable as any other Condition. Newborn Hearing Screening Covered Medical s include charges made by a Hospital or a maternity center for newborn hearing screenings, prior to the newborn s date of discharge. Additional Benefits Prescription Drug Prescription Drug Benefits are payable as follows: Benefit Preferred Care Pharmacy: 100% of the Negotiated Rate, following a $20 Copay for Generic Prescription Drugs, a $35 Copay for Preferred Brand Name Prescription Drugs, and a $50 Copay for Non-Preferred Brand Name Drugs. Covered Medical s are payable up to a maximum of $2,000 per Policy Year. Covered Medical s also include orally administered anticancer drugs when prescribed to kill or slow the growth of cancerous cells. These anticancer drugs will be paid on the same basis as any other sickness. 18
Prescription Drug Benefit (continued) This Pharmacy benefit is provided to cover Medically Necessary Prescriptions associated with a covered Sickness or Accident occurring during the Policy Year. Please use your Aetna Student Health ID card when obtaining your prescriptions. Prior Authorization is required for certain Prescription Drugs, including oral contraceptives, Imitrex, certain stimulants, growth hormones and for any Prescription quantities larger than a 30- day supply. (This is only a partial list.) Medications not covered by this benefit include, but are not limited to: allergy sera, all acne medications, drugs whose sole purpose is to promote or to stimulate hair growth, appetite suppressants, immunization agents and vaccines, and non-self injectables. (This is only a partial list.) For assistance or for a complete list of excluded medications, or drugs requiring prior authorization, please contact Aetna Pharmacy Management at (800) 238-6279 (available 24 hours). Aetna Specialty Pharmacy provides specialty medications and support to members living with chronic conditions. The medications offered may be injected, infused or taken by mouth. For additional information please go to www.aetnaspecialtyrx.com. Please Note: Covered Medical s for prescribed supplies for the treatment of diabetes will not be subject to the listed per Policy Year Prescription Drug limit. Diabetic Equipment and Supplies Covered Medical s include charges incurred by a covered person for equipment and supplies for treatment of insulin using diabetes, gestational diabetes and non-insulin using diabetes. Benefits are payable on the same basis as any other Condition. Hypodermic Needles Outpatient Diabetic Selfmanagement Education Programs Non Prescription Enteral Formula Covered Medical s for hypodermic needles and syringes used in the treatment of diabetes are payable as any other Condition. Covered Medical s include charges incurred by a covered person for outpatient diabetic self-management education programs, including medical nutritional therapy, for the treatment of insulin-using diabetes, gestational diabetes and non-insulin-using diabetes. Benefits are payable on the same basis as any other Condition. Benefits include charges incurred by a covered person for non-prescription enteral formulas, for which a physician has issued a written order, and are for the treatment of malabsorption caused by: Crohn s Disease, ulcerative colitis, gastroesophageal reflux, gastrointestinal motility, chronic intestinal pseudoobstruction, and inherited diseases of amino acids and organic acids. Covered Medical s for inherited diseases of amino acids and organic acids, will also include food products modified to be low protein. Covered Medical s are payable as any other Condition. 19
Pap Smear Coverage provided for one annual Pap smear screening (and any other Pap smear which is recommended by a physician) without application of any age restriction. Covered expenses are payable at 100% with waiver of the plan deductible. Mammography Coverage included for one baseline mammogram and for one annual mammogram per Policy Year thereafter. Covered expenses are payable at 100% with waiver of the plan deductible. Mastectomy and Breast Reconstruction Benefit Coverage will be provided to a covered person who is receiving benefits for a necessary mastectomy and who elects breast reconstruction after the mastectomy for: reconstruction of the breast on which a mastectomy has been performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, prostheses, treatment of physical complications of all stages of mastectomy, including lymphedemas, and reconstruction of the nipple/areolar complex following a mastectomy is covered without regard to the lapse of time between the mastectomy and the reconstruction. This is subject to the approval of the attending physician. Covered Medical s are payable as any other condition. This coverage will be provided in consultation with the attending physician and the patient. It will be subject to the same annual deductibles and coinsurance provisions that apply to the mastectomy. Routine Prostate Cancer Screening Covered Medical s include charges incurred by a covered person for the screening of cancer in accordance with the latest screening guidelines issued by the American Cancer Society for the ages, family histories and frequencies referenced in such guidelines. Plans cover one annual (or more frequently if recommended by a physician) digital rectal exam and PSA test. Benefits are payable on the same basis as any other Condition. Surgical Second Opinion Covered Medical s will include expenses incurred for a second opinion consultation by a specialist on the need for surgery which has been recommended by the covered person's physician. The specialist must be board certified in the medical field relating to the surgical procedure being proposed. Coverage will also be provided for any expenses incurred for required X-rays and diagnostic tests done in connection with that consultation. Aetna must receive a written report on the second opinion consultation. Benefits are payable as follows: Non-Preferred Care: 60% of the Recognized Charge. 20
Elective Surgical Second Opinion Covered Medical s will include expenses incurred for a second opinion consultation by a specialist on the need for non-emergency elective surgery which has been recommended by the covered person's physician. The specialist must be board certified in the medical field relating to the surgical procedure being proposed. Coverage will also be provided for any expenses incurred for required X-rays and diagnostic tests done in connection with that consultation. Aetna must receive a written report on the second opinion consultation. Benefits are payable as follows: Non-Preferred Care: 60% of the Recognized Charge. Acupuncture in Lieu of Anesthesia Covered Medical s include acupuncture therapy, when acupuncture is used in lieu of other anesthesia, for a surgical or dental procedure covered under this Plan. The acupuncture must be administered by a health care provider who is a legally qualified physician, practicing within the scope of their license. Benefits are payable as any other Condition. Dermatological Covered Medical s include charges for the diagnosis and treatment of skin disorders, excluding laboratory fees. Related laboratory expenses are covered under the Outpatient Benefit. Benefits are payable as any other Condition. Covered Medical s do not include treatment for acne, or cosmetic treatment and procedures. Podiatric Covered Medical s include charges for podiatric services, provided on an outpatient basis following an injury. Benefits are payable as any other Condition. s for routine foot care, such as trimming of corns, calluses, and nails, are not Covered Medical s. Home Health Care s Covered Medical s include charges incurred by a covered person for home health care services made by a home health agency pursuant to a home health care plan, but only if: (a) The services are furnished by, or under arrangements made by, a licensed home health agency (b) The services are given under a home care plan. This plan must be established pursuant to the written order of a physician, and the physician must renew that plan every 60 days. Such physician must certify that the proper treatment of the condition would require inpatient confinement in a hospital or skilled nursing facility if the services and supplies were not provided under the home health care plan. The physician must examine the covered person at least once a month (c) Except as specifically provided in the home health care services, the services are delivered in the patient's place of residence on a part-time, intermittent visiting basis while the patient is confined (d) The care starts within 7 days after discharge from a hospital as an inpatient, and (e) The care is for the same condition that caused the hospital confinement, or one related to it. 21
Home Health Care s (continued) Home Health Care Services (1) Part-time or intermittent nursing care by: a registered nurse (R.N.), a licensed Practical nurse (L.P.N.), or under the supervision on an R.N. if the services of an R.N. are not available, (2) Part time or intermittent home health aide services, that consist primarily of care of a medical or therapeutic nature by other than an R.N., (3) Physical, occupational. speech therapy, or respiratory therapy, (4) Medical supplies, drugs and medicines, and laboratory services. However, these items are covered only to the extent they would be covered if the patient was confined to a hospital, (5) Medical social services by licensed or trained social workers, (6) Nutritional counseling. Covered Medical s will not include: 1) services by a person who resides in the covered person's home, or is a member of the covered person's immediate family, 2) homemaker or housekeeper services, 3) maintenance therapy, 4) dialysis treatment, 5) purchase or rental of dialysis equipment, or 6) food or home delivered services. Home Health Care benefits are payable as follows: Non-Preferred Care: 60% of the Recognized Charge. A visit means a maximum of 4 continuous hours of home health service Benefits are limited to 40 visits per Policy Year. Transfusion or Dialysis of Blood Hospice Benefit Covered Medical s include charges for the transfusion or dialysis of blood, including the cost of: whole blood, blood components, and the administration thereof. Benefits are payable as any other Condition. Covered Medical s include charges for hospice care provided for a terminally ill covered person during a hospice benefit period. Benefits are payable as follows: Non-Preferred Care: 60% of the Recognized Charge. Please see definitions for more information on Hospice Care s. Licensed Nurse Benefits include charges incurred by a covered person who is confined in a hospital as a resident bed-patient, and requires the services of a registered nurse or licensed practical nurse. Covered s for a Licensed Nurse are covered as follows: Non-Preferred Care: 60% of the Recognized Charge. 22
Skilled Nursing Facility Covered Medical s include charges incurred by a covered person for confinement in a skilled nursing facility for treatment rendered: in lieu of confinement in a hospital as a full time inpatient, or within 24 hours following a hospital confinement and for the same or related cause(s) as such hospital confinement. Covered Medical s are payable as follows: Preferred Care: 80% of the Negotiated Charge for the semi-private room rate. Non-Preferred Care: 60% of the Recognized Charge for the semi-private room rate. Rehabilitation Facility Covered Medical s include charges incurred by a covered person for confinement as a full time inpatient in a rehabilitation facility. Confinement in the rehabilitation facility must follow within 24 hours of, and be for the same or related cause(s) as, a period of hospital or skilled nursing facility confinement. Covered Medical s for Rehabilitation Facility are covered as follows up to a maximum of 50 days per lifetime: Preferred Care: 80% of the Negotiated Charge for the rehabilitation facility s daily room and board maximum for semi-private accommodations Non-Preferred Care: 60% of the Recognized Charge for the rehabilitation facility s daily room and board maximum for semi-private accommodations. HIV Screening Test Covered Medical s include those incurred by a covered person for a voluntary HIV screening test in a hospital emergency department, whether or not the test is necessary for the treatment of the medical emergency which caused the covered person to seek emergency services. Covered expenses are limited to one annual emergency department HIV screening test per calendar year and will not be subject to any copay or deductible, except any copay that would be applicable for an emergency room visit. Supplemental Medical Coverage The Aggregate Maximum benefit under the Student Accident and Sickness Insurance described above is $250,000 per condition, per lifetime. If you have purchased the Basic Student Health Insurance Plan at Catholic University, you are eligible to purchase this Supplemental Plan to extend a combined maximum of $350,000 per condition, per lifetime. 23
ADDITIONAL SERVICES AND DISCOUNTS As a member of the Plan, you can also take advantage of the following services, discounts, and programs. These are not underwritten by Aetna and are not insurance. Please note that these programs are subject to change. To learn more about these additional services and search for providers visit, www.aetnastudenthealth.com. Aetna Book SM discount program: Access to discounts on books and other items from the American Cancer Society Bookstore, the MayoClinic.com Bookstore and Pranamaya. Aetna Fitness SM discount program: Access to preferred rates on gym memberships and discounts on at-home weight loss programs, home fitness options and one-on-one health coaching services through GlobalFit TM. Aetna Hearing SM discount program: Access to discounts on hearing aids and hearing tests from HearPO. Guaranteed lowest pricing* on over 1000 models from seven leading manufacturers. *Competitor copy required for verification of price and model. Limited to manufacturers offered through the HearPO program. Local provider quotes only will be matched, no internet quotes Aetna Natural Products and Services SM discount program: Access to reduced rates on services from participating providers for acupuncture, chiropractic care, massage therapy and dietetic counseling. Also, access to discounts on overthe-counter vitamins, herbal and nutritional supplements and natural products. All products and services are provided through American Specialty Health Incorporated (ASH) and its subsidiaries. Aetna Vision SM discount program: Access to discounts on vision exams, lenses and frames when a member utilizes a provider participating in the EyeMed Select Network. Aetna Weight Management SM discount program: Access to discounts on ediets diet plans and products, Jenny Craig weight loss programs and products, and Nutrisystem weight loss meal plans. Oral Health Care discount program: Access to discounts on oral health care products. Save on xylitol mints, mouth rinses, gum, candies and toothpaste from Epic. Additionally, receive exclusive savings on Waterpik dental water jets and sonic toothbrushes. Zagat discounts: Discount off a one-year online membership to ZAGAT.com, with access to ratings and reviews of over 40,000 restaurants, hotels and more in hundreds of cities worldwide. At Home Products discount program: Access to discounts on health care products that members can use in the privacy and comfort of their home. Aetna Specialty Pharmacy: Provides specialty medications and support to members living with chronic conditions and illnesses. These medications are usually injected or infused, or some may be taken by mouth. Custom compounded doses and forms are also available. For additional information please go to www.aetnaspecialtyrx.com. Quit Tobacco Cessation Program: Say good-bye to tobacco and hello to a healthier future! The one-year Quit Tobacco program is provided by Healthyroads, a leading provider of tobacco cessation programs. You ll get personal attention from health professionals that can help find what works for you. Beginning Right Maternity Program: Make healthy choices for you and your baby. Learn what decisions are good ones for you and your baby. Our Beginning Right maternity program helps prepare you for the exciting changes pregnancy brings. Health programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health/dental care professional. The availability and terms of specific discount programs and wellness services are subject to change without notice. Not all programs are available in all states. 24