New England Conservatory Student Health PPO Plan Underwritten by Tufts Insurance Company. Policy Number: SP100104 2015-2016 Form Number: 100104-1-1R3
New England Conservatory Health and Counseling Services Our priority is the health and wellness of our students. Our mission is to provide student centered care that optimizes student health and enhances academic achievement and performance excellence. Health Center 295 Huntington Avenue, Room 309 Please call to reach a member of the staff or to schedule an appointment. Phone: 617-585-1284 Fax: 617-585-1208 Hours of Operation, Academic Year Monday - Wednesday, Friday 9am 4pm* Thursday 8:30am 5pm *Wednesday 2pm 3:30pm and Friday 10am-12pm for urgent walk-in visits without appointment first come, first served! Health Center Staff Medical Director: Dr. Eileen Reale Health Services Coordinator, Nurse Practitioner: Leah McKinnon-Howe, MS, ANP-BC Nurse Practitioner: Lisa Howe-Kaufer, MS, ANP-BC Counseling Center 295 Huntington Avenue, Room 309 Please call to reach a member of the staff or to schedule an appointment. Phone: 617-585-1398 Fax: 617-585-1208 Walk-in Hours Monday, Tuesday, Thursday 12pm 1pm Wednesday, Friday 1pm 2pm Counseling Staff Director of Counseling: Dr. Jan Lerbinger Counselor: Dr. Penelope Metropolis Counselor: Eleanor Schmidt Psychiatrist: Dr. Fernando Rodriguez-Villa Clinical Social Worker: Amy Engle Useful contact info: Gallagher Student Health & Special Risk Customer Service: (800) 404-9036 Christie Student Health Customer Care: (844) 603-6194 CVS Health (Prescription Drug Information): (866) 760-4274 Europ Assistance (Worldwide Travel Assistance): (866) 296-7069 24 Hour Nurse Line: (866) 201-7919 Mail claims to: Christie Student Health PO Box 226586 Dallas, TX 75222 Search for a provider: www.christiestudenthealth.com/nec/find-a-provider *This plan is underwritten by Tufts Insurance Company (TIC), and administered by Christie Student Health Plans LLC (CSHP). Christie Student Health is the brand name for the student health products and services provided by TIC and CSHP. 1
Top 5 things you need to know about your student health insurance #1 The Christie Student Health PPO Plan provides coverage for basic care and prescription drugs which includes, but is not limited to the following: Primary Care Care for many specialists Urgent Care Mental and behavioral health care/counseling Lab testing and screenings #2 The Christie Student Health PPO Plan provides worldwide travel assistance for when you are studying abroad or simply exploring another destination. #3 International students are enrolled on a mandatory basis and can only waive coverage with comparable coverage based in the United States. #4 Massachusetts law mandates that all full-time and three quarter time students have health insurance coverage. Eligible students are automatically enrolled in and billed for the Student Health PPO Plan which meets the requirements of the Commonwealth of Massachusetts. #5 To learn more about the benefits available to you through the Student Health Insurance Plan or to enroll or waive the Student Health Insurance Plan, please visit www.gallagherstudent.com/nec. Online Tools Our Student Portal provides students with one central location for all of your student health insurance needs, including accessing a copy of your ID card, viewing claims, searching for a provider or hospital and viewing benefit documents. 2
Are you eligible? All students enrolled in a degree program (regardless of the number of credit hours) and nondegree-seeking students at least 75% of full-time are automatically enrolled in this insurance plan at registration. The premium for coverage is added to your tuition billing, unless proof of comparable coverage is furnished. Students must actively attend classes for the first 31 days after the date for which coverage is purchased. Home study and correspondence courses do not fulfill the eligibility requirements that the student actively attend classes. Christie Student Health maintains the right to investigate student status and attendance records to verify that eligibility requirements have been met and maintained. If we discover that the eligibility requirements have not been met and maintained, our only obligation is a refund of premium, less any claims paid. Dependent Coverage Eligible students who enroll in the Plan may also insure their Eligible Dependents. Eligible Dependents are the student s spouse or Domestic Partner and dependent children under 26 years of age. Students can enroll their eligible dependents by visiting www.gallagherstudent.com/nec. On the left toolbar, click Dependent Enroll. Log in (if you haven t already) and follow the instructions to complete the form and submit payment. Enrollment and Waiver Details Did you know? The cost of the NEC Student Health Insurance Plan may be less expensive than coverage as a dependent under your Parent s Plan. Eligible students are automatically enrolled in and billed for the Student Health PPO Plan. Students who have comparable health insurance can elect to waive the Student Health PPO Plan. To provide proof of comparable coverage, an online waiver form must be completed and submitted by the date below. To waive the Student Health Insurance Plan, visit www.gallagherstudent.com/nec. On the left toolbar, click Student Waive/Enroll. Log in (if you haven t already) then click the I want to Enroll/Waive button and follow the instructions to complete the form. Waiver Deadline The deadline for students to complete the waiver form for annual coverage is August 14, 2015. Students who do not submit an online waiver form by the deadline will be enrolled in and billed for the Student Health PPO Plan. New England Conservatory reserves the right to audit and subsequently reject a waiver request. If it is determined that a student waived coverage with a health insurance plan that was not comparable coverage, the student will be automatically enrolled in the Student Health PPO Plan. 3
New England Conservatory Student Health PPO Plan The New England Conservatory Student Health PPO Plan is a fully insured student health insurance plan underwritten by Tufts Insurance Company ( TIC ), and administered by Christie Student Health. Your Plan is a Preferred Provider Organization or PPO Plan. It provides you with a higher level of coverage when you receive covered medical expenses from physicians who are part of the Plan s network referred to as In-Network. The In-Network providers participate in the Cigna network outside of MA and RI, and in the Tufts Health Plan network in MA and RI. The Plan also provides coverage when you obtain Covered Medical Expenses from physicians who are not part of the Plan s network, referred to as Out-of-Network. The premium rates and the list of Covered Services are illustrated in the tables below. Please contact Gallagher Student Health & Special Risk for eligibility and enrollment questions or Christie Student Health for benefit or claims questions you may have about the Plan. Member Rates Below are the effective and termination dates for the 2015-2016 Policy Year: Did you know? Medical Evacuation could cost $10,000 or more and is an included benefit in the Travel Assistance Program included with this Plan Classification Annual 8/25/2015 8/24/2016 Spring/Summer 1/7/2016 8/24/2016 Undergraduate Student $1,273 $725 Graduate Student $1,500 $853 Spouse/Domestic Partner $3,165 $1,793 Child $2,067 $1,173 The rates above include both premium and administrative fees. 4
Covered Services: The covered services below are for students and their dependents. For a full description of covered benefits, please visit www.gallagherstudent.com/nec to learn more. If there is a conflict between this overview and the PPO Certificate, the PPO Certificate is the governing document. Annual Deductible Out of Pocket Maximum Plan Maximum In-Network: $50 per member Out-of-Network: $200 per member In-Network: $5,000 per member $10,000 per family Out-of-Network: None Unlimited Benefit type In-Network Out-of-Network Inpatient Hospital Expense (including Intensive Care Unit) Inpatient Miscellaneous Expense Inpatient Physician or RN Visit Expense Surgical Expense (Inpatient and Outpatient) Anesthesia Expense (Inpatient and Outpatient) Assistant Surgeon Expense (Inpatient and Outpatient) Ambulatory Surgical Expense Emergency Room Expense Urgent Care Expense 90% of allowed amount, following a $100 copay (waivedif admitted) 100% of allowed amount following a $50 copay 90% of reasonable charges, following a $100 copay (waived if admitted) 80% of reasonable charges following a $50 copay Ambulance Service Expense 100% of allowed amount 100% of reasonable charges Physician Office Visit Expense (including Consultant) 100% of allowed amount following a $25 copay 80% of reasonable charges Diagnostic Labs 90% of allowed amount 80% of reasonable charges Diagnostic Radiology 90% of allowed amount 80% of reasonable charges High-Tech Imaging (including MRI, CT Scan) Physical, Speech and Occupational Therapy Expense 90% of allowed amount 80% of reasonable charges 90% of allowed amount 80% of reasonable charges Chiropractic Therapy Expense 90% of allowed amount 80% of reasonable charges Durable Medical Equipment Expense 90% of allowed amount 80% of reasonable charges Routine Pap Smears Expense* 100% of allowed amount 80% of reasonable charges Mammogram Expense* 100% of allowed amount 80% of reasonable charges Immunizations Expense * 100% of allowed amount 80% of reasonable charges Routine Physical Exams Expense* 100% of allowed amount 80% of reasonable charges Routine Colorectal Cancer Screening Expense* 100% of allowed amount 80% of reasonable charges Routine Prostate Cancer Screening* 100% of allowed amount 80% of reasonable charges Pediatric Vision Care Expense Exam* 100% of allowed amount 80% of reasonable charges Inpatient Mental Health Care Outpatient Mental Health Care 5
Annual Deductible Out of Pocket Maximum Covered Services: Plan Maximum Important Note: If you have an urgent medical need and cannot reach your provider, you should seek care at the nearest emergency room. If needed, call 911 for emergency medical assistance. If 911 services are not available in your area, call the local number for emergency medical services. *The annual deductible is waived for these services. In-Network: $50 per member Out-of-Network: $200 per member In-Network: $5,000 per member $10,000 per family Out-of-Network: None Unlimited Benefit type In-Network Out-of-Network Inpatient Mental Health Care Outpatient Mental Health Care 100% of allowed amount following a $25 copay Some benefits above may require prior authorization. Please refer to your Certificate of Insurance for additional details. 80% of reasonable charges Inpatient Substance Abuse Outpatient Substance Abuse Maternity Expense (including complications of pregnancy) Prescription Drug Expense Dental Injury Expense Limited to $500 per Policy Year Elective Abortion Expense Limited to $500 per Policy Year Diabetic Treatment and Supplies Expense Outpatient Diabetic Self-management Education Program Expense 100% of allowed amount following a $25 copay 100% following: $15 copay for Generic drugs $30 copay for Preferred Brand Name drugs $50 copay for Non-Preferred 80% of reasonable charges 70% of reasonable charges 90% of allowed amount 90% of reasonable charges Hospice Expense Home Health Care Expense Skilled Nursing Facility Expense Rehabilitation Facility Expense Performance Therapy Expense Limited to $500 per Policy Year Exclusions: For a full description of exclusions, please view the New England Conservatory Certificate by visiting www.gallagherstudent.com/nec. Certain services are not covered under this plan including but not limited to Cosmetic surgery, procedures, supplies and appliances; Custodial Care; Expenses incurred for experimental or investigational treatment, except as specifically provided in the Plan; Care for conditions for which benefits are available under workers compensation or other government programs other than Medicaid; Preventive dental care, except as provided under Pediatric dental care for Members under age 19 benefit ; Reversal of voluntary sterilization; A service, supply or medication which is not medically necessary. If there is a conflict between this overview and the PPO Certificate, the PPO Certificate is the governing document. If you have questions please contact Gallagher Student Health & Special Risk: (800) 404-9036. 6
Commonly Used terms: Claim: A request for payment that is submitted to your health insurance company for services received. Co-insurance: Your share of the costs of covered health care services calculated as a percent (for example, 20%) of the allowed amount for the service. Copayment (copay): The fixed amount you pay for a certain covered health care services, paid at the time of service. Deductible: The amount you pay for Covered Services before any payments will be made by your insurance company. Eligibility: Terms of an insurance policy that define the requirements to become a member on the insurance plan. Exclusions: Expenses for which the plan does not cover nor provide benefits for. Did you know? The Student Health Insurance Plan includes worldwide travel assistance. In-Network: Refers to a provider or facility that has a contract with your health insurance company or plan to provide services to you at a discount. Inpatient Care: Medical services provided after a patient is admitted to a facility such as a hospital. Out-of-Network: Refers to a provider or facility that does not have a contract with your health insurance company and therefore you may incur higher costs. Out-of-Pocket Maximum: The maximum amount that you pay during your plan s policy period before your health insurance company will pay 100% of the allowed amount. Negotiated Rate: An agreed upon amount between the insurance company and in-network providers and facilities for covered services. The Negotiated Rate is used to determine the allowed amount. Premium: The amount you pay to purchase your health insurance plan. Primary Care Physician (PCP): A general or family practitioner who provides and manages your care and refers you to specialists. Reasonable Charge: The lesser of the amount charged by the Non-Network Provider; or the amount paid for a medical service in a geographic area based on nationally accepted means and amounts of claims payment. The Reasonable Charge amount is used to determine the allowed amount. Waiver: Showing proof of adequate health care coverage in order to opt-out of the student health plan. 7
Your plan also includes: 24 Hour Nurse Help Line Nurse24 will provide participants with immediate and reliable health advice and information. Registered nurses are available 24 hours a day, 7 days a week to answer any health questions. Worldwide Assistance This plan includes worldwide travel assistance through Europ Assistance. Whether you are studying abroad or traveling on vacation, you can have the comfort of knowing that help is only a phone call away. Discounts and Wellness Exclusively from Gallagher Student Health & Special Risk, insured students have access to a menu of vision & dental discounts at no additional cost. To learn more, go to www.gallagherstudent.com/nec and click on Discounts and Wellness. Member Perks: Dietary & Nutritional Supplement Discounts You can save 15% or more off of the manufacturers suggested retail price on a wide variety of vitamins, supplements and popular energy and protein bars through ChooseHealthy. com Discount on Glasses & Eye Care You are eligible for discounts on vision correction services and eyewear from participating EyeMed providers. Fitness Rebate You may be eligible for a rebate for the cost of 4 months of fitness club fees for using a qualified fitness club. Discounts at Jenny Craig You can choose a FREE 30-day program or 25% off any premium program. In addition reimbursements are offered for up to three months of certain Jenny Craig programs. *Programs do not include the cost of food, or shipping, if applicable. At participating locations only. Additional restrictions apply. 8