2012-2361-1-interim brochure-v1_2004_592_1_brochure_v1.qxd

Student Injury and SicknessInsurance Plan Designed Especially for Students of
Columbus State
University
IMPORTANT: Please see the Notice on the first page of
this plan material concerning student health insurance
coverage.
Notice Regarding Your Student Health Insurance Coverage
Your student health insurance coverage, offered by
UnitedHealthcare Insurance Company, may not meet the
minimum standards required by the health care reform law
for 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, 2014. Restrictions on 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, 2014. Your student health insurance coverage
puts a policy year limit of $100,000 that applies to the
essential benefits provided in the Schedule of Benefits
unless otherwise specified. If you have any questions or
concerns about this notice, contact Customer Service at
1-866-403-8267. 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.
Table of Contents
Privacy Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Effective and Termination Dates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Extension of Benefits after Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 Pre-Admission Notification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 Schedule of Medical Expense Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 UnitedHealthcare Network Pharmacy Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Preferred Provider Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Maternity Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Coordination of Benefits Provision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Mandated Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Benefits for Mammography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Benefits for Pap Smears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Benefits for Prostate-Specific Antigen (PSA) Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Benefits for Mental Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Benefits for Bone Marrow Transplants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Benefits for Mastectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 Benefits for Bone Mass Measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 Benefits for Colorectal Cancer Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 Benefits for Dental Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 Benefits for the Management and Treatment of Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 Benefits for Surveillance Tests for Ovarian Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 Benefits for Telemedicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 Benefits for Drug Treatment of Children’s Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17 Benefits for Postpartum Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17 Benefits for Chlamydia Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 Exclusions and Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 Collegiate Assistance Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 Scholastic Emergency Services: Global Emergency Medical Assistance . . . . . . . . . . . . . . . . . . . . .20 Online Access to Account Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21 Notice of Appeal Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22 Claim Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 Privacy Policy
We know that your privacy is important to you and we strive to protect the confidentiality of yournonpublic personal information. We do not disclose any nonpublic personal information about ourcustomers or former customers to anyone, except as permitted or required by law. We believe wemaintain appropriate physical, electronic and procedural safeguards to ensure the security of yournonpublic personal information. You may obtain a detailed copy of our privacy practices by calling ustoll-free at 1-866-403-8267 or by visiting us at www.uhcsr.com/usg.
Eligibility
All students enrolled for six (6) or more credits per term or participating in OPT are eligible to enrollin this insurance Plan, excluding those students that are required to enroll in the plan as stated below.
The students required to enroll in the plan are as follows: 1. All undergraduate and ESL international students holding F or J visas.
2. All undergraduate students enrolled in programs that require proof of health insurance.
3. All graduate students receiving a full tuition waiver as part of their graduate assistantship 4. All graduate international students and visiting scholars holding F or J visas.
5. All graduate students enrolled in programs that require proof of health insurance.
6. All graduate students receiving fellowships that fully fund their tuition.
Accident coverage for Intercollegiate Sports injuries is provided under a separate policy. Contact yourinstitution for information on the Intercollegiate Sports Plan.
Students must actively attend classes for at least the first 31 days after the date for which coverageis purchased. Home study and correspondence do not fulfill the Eligibility requirements that thestudent actively attend classes. The Company maintains its right to investigate Eligibility or studentstatus and attendance records to verify that the policy Eligibility requirements have been met. If theCompany discovers the Eligibility requirements have not been met, its only obligation is to refundpremium.
Eligible students who do enroll may also insure their Dependents. Eligible Dependents are thestudent’s spouse and dependent children under 26 years of age.
Dependent Eligibility expires concurrently with that of the Insured student.
Effective and Termination Dates
The Master Policy becomes effective at 12:01 a.m., August 13, 2012. The individual student’scoverage becomes effective on the first day of the period for which premium is paid or the date theenrollment form and full premium are received by the Company (or its authorized representative),whichever is later. The Master Policy terminates at 11:59 p.m., August 12, 2013. Coverage terminateson that date or at the end of the period through which premium is paid, whichever is earlier.
Dependent coverage will not be effective prior to that of the Insured student or extend beyond thatof the Insured student.
Refunds of premiums are allowed only upon entry into the armed forces.
The Policy is a Non-Renewable One Year Term Policy.
Extension of Benefits after Termination
The coverage provided under the Policy ceases on the Termination Date. However, if an Insured isHospital Confined on the Termination Date from a covered Injury or Sickness for which benefits werepaid before the Termination Date, Covered Medical Expenses for such Injury or Sickness will continueto be paid as long as the condition continues but not to exceed 90 days after the Termination Date.
The total payments made in respect of the Insured for such condition both before and after theTermination Date will never exceed the Maximum Benefit.
After this “Extension of Benefits” provision has been exhausted, all benefits cease to exist, and underno circumstances will further payment be made.
Pre-Admission Notification
UnitedHealthcare should be notified of all Hospital Confinements prior to admission.
1. PRE-NOTIFICATION OF MEDICAL NON-EMERGENCY HOSPITALIZATIONS: The
patient, Physician or Hospital should telephone 1-877-295-0720 at least five working daysprior to the planned admission.
2. NOTIFICATION OF MEDICAL EMERGENCY ADMISSIONS: The patient, patient’s
representative, Physician or Hospital should telephone 1-877-295-0720 within two workingdays of the admission to provide notification of any admission due to Medical Emergency.
UnitedHealthcare is open for Pre-Admission Notification calls from 8:00 a.m. to 6:00 p.m. C.S.T.,Monday through Friday. Calls may be left on the Customer Service Department’s voice mail afterhours by calling 1-877-295-0720.
IMPORTANT: Failure to follow the notification procedures will not affect benefits otherwise payable
under the policy; however, pre-notification is not a guarantee that benefits will be paid.
Schedule of Medical Expense Benefits
Injury and Sickness
Maximum Benefit: $100,000 Paid as Specified Below
(Per Insured Person) (Per Policy Year)
Deductible Preferred Provider: $300 (Per Insured Person) (Per Policy Year)
Deductible Preferred Provider: $750 (For all Insureds in a Family) (Per Policy Year)
Deductible Out-of-Network: $500 (Per Insured Person) (Per Policy Year)
Deductible Out-of-Network: $900 (For all Insureds in a Family) (Per Policy Year)
Coinsurance Preferred Provider: 80% except as noted below
Coinsurance Out-of-Network: 60% except as noted below
Out-of-Pocket Maximum Preferred Providers: $4,500
(Per Insured Person, Per Policy Year)
Out-of-Pocket Maximum Preferred Providers: $15,000
(For all Insureds in a Family, Per Policy Year)
Out-of-Pocket Maximum Out of Network: $7,500
(Per Insured Person, Per Policy Year)
Out-of-Pocket Maximum Out of Network: $24,000
(For all Insureds in a Family, Per Policy Year)
The Policy provides benefits for the Covered Medical Expenses incurred by an Insured Person forloss due to a covered Injury or Sickness up to the Maximum Benefit of $100,000.
The Preferred Provider for this plan is UnitedHealthcare Choice Plus.
If care is received from a Preferred Provider any Covered Medical Expenses will be paid at thePreferred Provider level of benefits. If the Covered Medical Expense is incurred due to a MedicalEmergency, benefits will be paid at the Preferred Provider level of benefits. In all other situations,reduced or lower benefits will be provided when an Out-of-Network provider is used.
Out-of-Pocket Maximum: After the Out-of-Pocket Maximum has been satisfied, Covered Medical
Expenses will be paid at 100% up to the policy Maximum Benefit subject to any benefit maximums
that may apply. Separate Out-of-Pocket Maximums apply to Preferred Provider and Out-of-Network
benefits. The policy Deductible, Copays and per service Deductibles, and services that are not
Covered Medical Expenses do not count toward meeting the Out-of-Pocket Maximum. Even when
the Out-of-Pocket Maximum has been satisfied, the Insured Person will still be responsible for
Copays and per service Deductibles.
Student Health Center Benefits: The Deductible will be waived for Covered Medical Expenses
incurred when treatment is rendered at the Student Health Center.
UnitedHealthcare Pharmaceutical Solutions is the vendor the company contracts with to provide anetwork of pharmacies.
Benefits are subject to the policy Maximum Benefit unless otherwise specifically stated. Benefitswill be paid up to the maximum benefit for each service as scheduled below. All benefit maximumsare combined Preferred Provider and Out-of-Network unless otherwise specifically stated. CoveredMedical Expenses include: PA = Preferred Allowance
U&C = Usual & Customary Charges
INPATIENT
Preferred
Out-of-Network
Providers
Providers
Hospital Expense, daily semi-private room rate when
confined as an Inpatient; general nursing care providedby the Hospital; Hospital Miscellaneous Expenses, suchas the cost of the operating room, laboratory tests, x-rayexaminations, anesthesia, drugs (excluding take homedrugs) or medicines, therapeutic services, and supplies.
In computing the number of days payable under thisbenefit, the date of admission will be counted, but notthe date of discharge.
Intensive Care
Routine Newborn Care, while Hospital Confined; and
routine nursery care provided immediately after birth.
(See also Benefits for Postpartum Care) Physiotherapy
Surgeon’s Fees, if two or more procedures are
performed through the same incision or in immediatesuccession at the same operative session, themaximum amount paid will not exceed 50% of thesecond procedure and 50% of all subsequentprocedures.
Assistant Surgeon
Anesthetist, professional services administered in
Registered Nurse’s Services, private duty nursing
Physician’s Visits, non-surgical services when
confined as an Inpatient. Benefits are limited to one visitper day and do not apply when related to surgery.
Pre-Admission Testing, payable within 3 working
OUTPATIENT
Preferred
Out-of-Network
Providers
Providers
Surgeon’s Fees, if two or more procedures are
performed through the same incision or in immediatesuccession at the same operative session, the maximumamount paid will not exceed 50% of the secondprocedure and 50% of all subsequent procedures.
Day Surgery Miscellaneous, related to scheduled
surgery performed in a Hospital, including the cost ofthe operating room; laboratory tests and x-rayexaminations, including professional fees; anesthesia;drugs or medicines; and supplies. Usual and CustomaryCharges for Day Surgery Miscellaneous are based onthe Outpatient Surgical Facility Charge Index.
Assistant Surgeon
Anesthetist, professional services administered in
Physician’s Visits, benefits are limited to one visit per
day. Benefits for Physician’s Visits do not apply when $20 Copay per visitrelated to surgery or Physiotherapy.
Physiotherapy, benefits are limited to one visit per day.
Physiotherapy includes but is not limited to thefollowing: 1) physical therapy; 2) occupational therapy;3) cardiac rehabilitation therapy; 4) manipulativetreatment; and 5) speech therapy. Speech therapy willbe paid only for the treatment of speech, language,voice, communication and auditory processing whenthe disorder results from Injury, trauma, stroke, surgery,cancer or vocal nodules. (30 visits maximum Per PolicyYear) Medical Emergency Expenses, facility charge for
use of the emergency room and supplies. Treatmentmust be rendered within 72 hours from time of Injury orfirst onset of Sickness.
Diagnostic X-ray Services
Radiation Therapy
Chemotherapy
OUTPATIENT
Preferred
Out-of-Network
Providers
Providers
Laboratory Services
Tests & Procedures, diagnostic services and medical
procedures performed by a Physician, other thanPhysician’s Visits, Physiotherapy, X-Rays and LabProcedures. The following therapies will be paid underthis benefit: inhalation therapy, infusion therapy,pulmonary therapy and respiratory therapy.
Injections, when administered in the Physician's office
and charged on the Physician's statement.
Prescription Drugs
Preferred
Out-of-Network
Providers
Providers
Ambulance Services
Durable Medical Equipment, a written prescription
must accompany the claim when submitted. Benefitsare limited to the initial purchase or one replacementpurchase per Policy Year. Durable Medical Equipmentincludes external prosthetic devices that replace a limbor body part but does not include any device that is fullyimplanted into the body.
Consultant Physician Fees, when requested and
Dental Treatment, made necessary by Injury to Sound,
Natural Teeth only. (Benefits are not subject to the$100,000 Maximum Benefit.) Dental Treatment, benefits paid for the removal of
Maternity, (See also Benefits for Postpartum Care)
Complications of Pregnancy
Mental Illness Treatment, services received on an
Inpatient and outpatient basis. Benefits are limited toone visit per day. Institutions specializing in or primarilytreating Mental Illness and Substance Use Disordersare not covered. (See also Benefits for Mental Illness) Substance Use Disorder Treatment, services
received on an Inpatient and outpatient basis. Benefitsare limited to one visit per day. Institutions specializingin or primarily treating Mental Illness and SubstanceUse Disorders are not covered.
Preferred
Out-of-Network
Providers
Providers
Elective Abortion
Reconstructive Breast Surgery Following
Mastectomy, in connection with a covered
Mastectomy. (See Benefits Mastectomy)
Diabetes Services
TMJ Disorder
Needle Stick/Blood & Body Fluid and Infectious
Disease Exposure, (Benefits are limited to Insured
students for an exposure to blood/body fluid/infectious
disease during a clinical rotation by any route.)
Preventive Care Services, medical services that have
been demonstrated by clinical evidence to be safe andeffective in either the early detection of disease or inthe prevention of disease, have been proven to have abeneficial effect on health outcomes and are limited tothe following as required under applicable law: 1)Evidence-based items or services that have in effect arating of “A” or “B” in the current recommendations ofthe United States Preventive Services Task Force; 2)immunizations that have in effect a recommendationfrom the Advisory Committee on ImmunizationPractices of the Centers for Disease Control andPrevention; 3) with respect to infants, children, andadolescents, evidence-informed preventive care andscreenings provided for in the comprehensiveguidelines supported by the Health Resources andServices Administration; and 4) with respect to women,such additional preventive care and screeningsprovided for in comprehensive guidelines supported bythe Health Resources and Services Administration.
No Deductible, Copays or Coinsurance will be appliedwhen the services are received from a Preferred Provider.
UnitedHealthcare Network Pharmacy Benefits
Benefits are available for outpatient Prescription Drugs on our Prescription Drug List (PDL) whendispensed by a UnitedHealthcare Network Pharmacy. Benefits are subject to supply limits andCopayments that vary depending on which tier of the PDL the outpatient drug is listed. There arecertain Prescription Drugs that require your Physician to notify us to verify their use is covered withinyour benefit.
You are responsible for paying the applicable Copayments. Your Copayment is determined by the tierto which the Prescription Drug Product is assigned on the PDL. Tier status may change periodicallyand without prior notice to you. Please access www.uhcsr.com/usg or call 877-417-7345 for the mostup-to-date tier status.
$15 Copay per prescription order or refill for a Tier 1 Prescription Drug up to a 31day supply.
$30 Copay per prescription order or refill for a Tier 2 Prescription Drug up to a 31 day supply.
$50 Copay per prescription order or refill for a Tier 3 Prescription Drug up to a 31 day supply.
Mail order Prescription Drugs are available at 2.5 times the retail Copay up to a 90 day supply.
Please present your ID card to the network pharmacy when the prescription is filled.
If you do not present the card, you will need to pay for the prescription and then submit areimbursement form for prescriptions filled at a network pharmacy along with the paid receipt in orderto be reimbursed. To obtain reimbursement forms, or for information about mail-order prescriptionsor network pharmacies, please visit www.uhcsr.com/usg and log in to your online account or call 877-417-7345.
When prescriptions are filled at pharmacies outside the network, the Insured must pay for the
prescriptions out-of-pocket and submit the receipts for reimbursement to UnitedHealthcare
StudentResources, P.O. Box 809025, Dallas, TX 75380-9025. See the Schedule of Benefits for the
benefits payable at out-of-network pharmacies.
Additional Exclusions
In addition to the policy Exclusions and Limitations, the following Exclusions apply to NetworkPharmacy Benefits: 1. Coverage for Prescription Drug Products for the amount dispensed (days' supply or quantity limit) which exceeds the supply limit.
2. Experimental or Investigational Services or Unproven Services and medications; medications used for experimental indications and/or dosage regimens determined by the Company to beexperimental, investigational or unproven.
3. Compounded drugs that do not contain at least one ingredient that has been approved by the U.S. Food and Drug Administration and requires a Prescription Order or Refill. Compoundeddrugs that are available as a similar commercially available Prescription Drug Product.
Compounded drugs that contain at least one ingredient that requires a Prescription Order orRefill are assigned to Tier-3.
4. Drugs available over-the-counter that do not require a Prescription Order or Refill by federal or state law before being dispensed, unless the Company has designated the over-the-countermedication as eligible for coverage as if it were a Prescription Drug Product and it is obtained witha Prescription Order or Refill from a Physician. Prescription Drug Products that are available inover-the-counter form or comprised of components that are available in over-the-counter form orequivalent. Certain Prescription Drug Products that the Company has determined areTherapeutically Equivalent to an over-the-counter drug. Such determinations may be made up tosix times during a calendar year, and the Company may decide at any time to reinstate Benefitsfor a Prescription Drug Product that was previously excluded under this provision.
5. Any product for which the primary use is a source of nutrition, nutritional supplements, or dietary management of disease, even when used for the treatment of Sickness or Injury.
Definitions
Prescription Drug or Prescription Drug Product means a medication, product or device that has
been approved by the U.S. Food and Drug Administration and that can, under federal or state law, be
dispensed only pursuant to a Prescription Order or Refill. A Prescription Drug Product includes a
medication that, due to its characteristics, is appropriate for self-administration or administration by a
non-skilled caregiver. For the purpose of the benefits under the policy, this definition includes insulin.
Prescription Drug List means a list that categorizes into tiers medications, products or devices that
have been approved by the U.S. Food and Drug Administration. This list is subject to the Company’s
periodic review and modification (generally quarterly, but no more than six times per calendar year).
The Insured may determine to which tier a particular Prescription Drug Product has been assigned
through the Internet at www.uhcsr.com/usg or call Customer Service at 1-877-417-7345.
Preferred Provider Information
“Preferred Providers” are the Physicians, Hospitals and other health care providers who have
contracted to provide specific medical care at negotiated prices. Preferred Providers in the local
school area are: UnitedHealthcare Choice Plus.
The availability of specific providers is subject to change without notice. Insureds should alwaysconfirm that a Preferred Provider is participating at the time services are required by calling us at 1-866-403-8267 and/or by asking the provider when making an appointment for services.
“Preferred Allowance” means the amount a Preferred Provider will accept as payment in full for
Covered Medical Expenses.
“Out of Network” providers have not agreed to any prearranged fee schedules. Insureds may incur
significant out-of-pocket expenses with these providers. Charges in excess of the insurance payment
are the Insured’s responsibility.
Regardless of the provider, each Insured is responsible for the payment of their Deductible. TheDeductible must be satisfied before benefits are paid. The Company will pay according to the benefitlimits in the Schedule of Benefits.
Inpatient Expenses
PREFERRED PROVIDERS - Eligible Inpatient expenses at a Preferred Provider will be paid at the
Coinsurance percentages specified in the Schedule of Benefits, up to any limits specified in the
Schedule of Benefits. Preferred Hospitals include UnitedHealthcare Choice Plus United Behavioral
Health (UBH) facilities. Call (866) 403-8267 for information about Preferred Hospitals.
OUT-OF-NETWORK PROVIDERS - If Inpatient care is not provided at a Preferred Provider, eligible
Hospital expenses will be paid according to the benefit limits in the Schedule of Benefits.
Outpatient Hospital Expenses
Preferred Providers may discount bills for outpatient Hospital expenses. Benefits are paid accordingto the Schedule of Benefits. Insureds are responsible for any amounts that exceed the benefitsshown in the Schedule, up to the Preferred Allowance.
Professional & Other Expenses
Benefits for Covered Medical Expenses provided by UnitedHealthcare Choice Plus will be paid at theCoinsurance percentages specified in the Schedule of Benefits or up to any limits specified in theSchedule of Benefits. All other providers will be paid according to the benefit limits in the Scheduleof Benefits.
Maternity Testing
This policy does not cover all routine, preventive, or screening examinations or testing. The followingmaternity tests and screening exams will be considered for payment according to the policy benefitsif all other policy provisions have been met.
Initial screening at first visit:
Pregnancy test: urine human chorionic gonatropin (HCG) Pregnancy-associated plasma protein-A (PAPPA) (first trimester only)
Free beta human chorionic gonadotrophin (hCG) (first trimester only)
Each visit: Urine analysis
Once every trimester: Hematocrit and Hemoglobin
Once during first trimester: Ultrasound
Once during second trimester
Triple Alpha-fetoprotein (AFP), Estriol, hCG or Quad screen test Alpha-fetoprotein (AFP),Estriol, hCG, inhibin-a Once during second trimester if age 35 or over: Amniocentesis or Chorionic villus sampling (CVS)
Once during second or third trimester: 50g Glucola (blood glucose 1 hour postprandial)
Once during third trimester: Group B Strep Culture
Pre-natal vitamins are not covered. For additional information regarding Maternity Testing, please callthe Company at 1-866-403-8267.
Coordination of Benefits Provision
Benefits will be coordinated with any other eligible medical, surgical or hospital plan or coverage sothat combined payments under all programs will not exceed 100% of allowable expenses incurredfor covered services and supplies.
Mandated Benefits
Benefits for Mammography
Benefits will be paid the same as any other Sickness for a mammogram subject to all of the termsand conditions of the policy and according to the following guidelines: 1. Once as a baseline mammogram for any female who is at least 35 but less than 40 years 2. Once every two years for any female who is at least 40 but less than 50 years of age; 3. Once every year for any female who is at least 50 years of age; and 4. When ordered by a Physician for a female at risk.
For purpose of this benefit, "Female at risk" means a woman: a. Who has a personal history of breast cancer; b. Who has a personal history of biopsy proven benign breast disease; c. Whose grandmother, mother, sister, or daughter has had breast cancer; or d. Who has not given birth prior to the age of 30.
Reimbursement will be made only if the facility in which the mammogram was performed meetsaccreditation standards established by the American College of Radiology or equivalent standardsestablished by the state of Georgia.
Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Pap Smears
Benefits will be paid the same as any other Sickness for an annual "Pap smear" or "Papanicolaousmear" examination for the purpose of detecting cancer, or more frequently if ordered by a Physician.
The examination must be performed in accordance with standards established by the AmericanCollege of Pathologists.
Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Prostate-Specific Antigen (PSA) Tests
Benefits will be paid the same as any other Sickness for prostate-specific antigen (PSA) test todetect the presence of prostate cancer. The test will be covered on an annual basis for an Insuredmales who is 45 years of age or older. The test will also be covered for an Insured male 40 years ofage or older, when ordered by a Physician. All tests must be performed in accordance with standardsestablished by the American College of Pathologists.
Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Mental Illness
Benefits will be paid the same as any other Sickness for Mental Illness treatment.
Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations or any otherprovisions of the policy.
Benefits for Bone Marrow Transplants
Benefits will be paid the same as any other Sickness for bone marrow transplants.
Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Mastectomy
Benefits will be paid the same as any other Sickness for a mastectomy including breastreconstructive surgery of the breast on which the mastectomy was performed, surgery andreconstruction of the other breast to produce a symmetrical appearance, prostheses, treatment ofphysical complications for all stages of the mastectomy, including lymphedemas, and at least twoexternal postoperative prostheses incidental to the covered mastectomy. Coverage will be providedin a manner determined in consultation with the attending Physician.
Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Bone Mass Measurement
Benefits will be paid the same as any other Sickness for Qualified Insured Persons for scientificallyproven Bone Mass Measurement (bone density testing) for the prevention, diagnosis, and treatmentof osteoporosis.
1. "Bone mass measurement" means a radiologic or radioisotopic procedure or other technologies approved by the United States Food and Drug Administration and performedon an individual for the purpose of identifying bone mass or detecting bone loss.
2. “Qualified Insured Person" means an: a. Estrogen-deficient woman or individual at clinical risk of osteoporosis as determined directly or indirectly by a physician and who is considering treatment; b. (B) Individual with osteoporotic vertebral abnormalities; c. (C) Individual receiving long-term glucocorticoid (steroid) therapy; d. Individual with primary hyperparathyroidism; or e. Individual being monitored directly or indirectly by a physician to assess the response to or efficacy of approved osteoporosis drug therapies.
Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Colorectal Cancer Screening
Benefits will be paid the same as any other Sickness for colorectal cancer screening, examinationsand laboratory tests in accordance with the most recently published guidelines andrecommendations established by the American Cancer Society, in consultation with the AmericanCollege of Gastroenterology and the American College of Radiology, for the ages, family histories,and frequencies referenced in such guidelines and recommendations and deemed appropriate by theattending physician after conferring with the patient. Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Dental Anesthesia
Benefits will be provided for general anesthesia and associated hospital and ambulatory surgicalfacility charges in conjunction with dental care provided to an Insured, if such person is: 1. Seven years of age or younger or is developmentally disabled; 2. An individual for which a successful result cannot be expected from dental care provided under local anesthesia because of a neurological or other medically compromising conditionof the Insured; or 3. An individual who has sustained extensive facial or dental trauma, unless otherwise covered by workers’ compensation insurance.
Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations, or any otherprovisions of the policy.
Benefits for the Management and Treatment of Diabetes
Benefits will be provided for all Covered Medical Expenses related to the medically appropriate andnecessary medical equipment, supplies, pharmacologic agents, and outpatient self-managementtraining and education, including medical nutrition therapy, for an Insured Person with insulin-dependent diabetes, insulin-using diabetes, gestational diabetes, and noninsulin-using diabetes whoadhere to the prognosis and treatment regimen prescribed by a Physician.
1. Insulin of each class approved by the federal Food and Drug Administration (FDA) including formulations available either in a vial or cartridge; 2. Prescription insulin of each class approved by the FDA including formulations available either in a vial or cartridge formulation; 3. Prescription oral medications of each class approved by the FDA for the management of 4. Oral products approved by the FDA for the management of diabetes; 5. Glucagon kits; and Pharmacologic agents approved by the FDA for the management of “Medical equipment” includes the following medical equipment, non-disposable and durable medicalequipment when prescribed by a Physician: 1. Blood glucose monitors and glucose monitors, including commercially available blood 2. Blood glucose monitors and glucose monitors for the legally blind or visually impaired due to diabetes, including commercially available blood glucose monitors with adaptive devicesfor the blind; 3. Injection aids, including those adaptable to meet the needs of the legally blind, to assist with 4. Insulin pumps, which includes insulin infusion pumps; 5. Medical supplies for use with or without insulin pumps and insulin infusion pumps, including durable devices to assist with the injection of insulin and infusion sets; 6. Therapeutic shoes, custom fitted inserts and related orthopedic footwear associated with the prevention and treatment of diabetes and diabetes related complications; 7. Pen-like insulin injection devices designed for multiple use; 8. Lancing devices associated with the drawing for blood samples for use with blood glucose 9. Other medical equipment, non-disposable and durable medical equipment that is Medically Necessary and consistent with the current standards of care of the American DiabetesAssociation.
“Supplies” means the following single-use medical supplies when prescribed by a Physician: 1. Test strips for glucose monitors, which include test strips whose performance achieved 2. Visual reading and urine testing strips, which includes visual reading strips for glucose, urine testing strips for ketones, or urine test strips for both glucose and ketones; 3. Lancets and single use lancing devices used in conjunction with the monitoring of glycemic 4. Syringes, which includes insulin syringes, insulin injection needles for use with pen-like insulin injection devices and other disposable parts required for insulin injection aids; 5. Medical supplies for use with insulin pumps and insulin infusion pumps to include disposable devices to assist with the injection of insulin and infusion sets, alcohol swabs and relatedpreparations and other similar compounds associated with the cleansing of injection sitesprior to the administration of insulin; and 6. Such other single-use medical supplies that are Medically Necessary and consistent with the current standards of care of the American Diabetes Association.
Diabetes self-management training and medical nutrition therapy services must be prescribed by aPhysician. The diabetes self-management training program must be: 1. Provided under a training program that is recognized by the federal Centers for Medicare & 2. Approved, accredited or certified by a national organization assessing standards of quality in the provision of diabetes self-management education.
Diabetes self-management training programs shall be provided when the following criteria are met: 1. Upon a Physician’s diagnosis that the Insured Person has diabetes; 2. Upon a significant change in an Insured Person’s diabetes related condition; 3. Upon a change in an Insured Person’s diagnostic levels; 5. Upon an Insured Person’s initiation of insulin therapy; 6. Upon identification of inadequate diabetes control as evidenced by diagnostic laboratory tests falling outside of acceptable ranges; 7. Upon determination that an Insured Person is at high risk for complications based on inadequate glycemic control documented by acute episodes of severe hypoglycemia oracute severe hyperglycemia occurring in the Insured Person’s history during which theinsured Person needed emergency room visits or hospitalization; 8. Upon determination that an Insured Person is at high risk based on at least one of the documented diabetes related complications, including: a. Lack of feeling in the foot or other foot complications such as foot ulcers, deformities, or b. Pre-proliferative or proliferative retinopathy or prior laser treatment of the eye; c. Kidney complications related to diabetes, when manifested by albuminuria without other Medical nutrition therapy services shall be provided in addition to diabetes self-management trainingwhen the following are met: 1. Upon a Physician’s diagnosis that an Insured Person has diabetes; 2. Upon a significant change in an Insured Person’s diabetes related condition; 3. Upon a change in an Insured Person’s diagnostic levels; 5. Upon an Insured Person’s initiation of insulin therapy; 6. Upon identification of inadequate diabetes control as evidenced by diagnostic laboratory tests falling outside of acceptable ranges; 7. Upon determination that an Insured Person is at high risk for complications based on inadequate glycemic control documented by acute episodes of severe hypoglycemia oracute severe hyperglycemia occurring in the Insured Person’s history during which theinsured Person needed emergency room visits or hospitalization; 8. Upon determination that an Insured Person is at high risk based on at least one of the documented diabetes related complications, including: a. Lack of feeling in the foot or other foot complications such as foot ulcers, deformities, or b. Pre-proliferative or proliferative retinopathy or prior laser treatment of the eye; c. Kidney complications related to diabetes, when manifested by albuminuria without other Instructions in diabetes self-management training shall be provided by a healthcare professional whois either: (1) a certified diabetes educator; and/or (2) a certified, registered or licensed healthprofessional with expertise in diabetes satisfying criteria for Medicare coverage for diabeteseducation and training pursuant to 42 CFR Part 410. Instruction in medical nutrition therapy shall beprovided by a healthcare professional who is either: (1) a registered dietitian; and/or (2) a certified,registered, or licensed health professional with expertise in medical nutrition therapy satisfying criteriafor Medicare coverage for medical nutrition therapy pursuant to 42 CFR Part 410.
Primary or initial diabetes self-management training and medical nutrition therapy services shall beprovided in group settings for a total of 10 hours in the initial year after diagnosis unless the followingcriteria are met: (1) a group session is not available within two months of the date diabetes self-management training or medical nutrition therapy are ordered; or (2) the Insured Person’s Physiciandocuments that the Insured Person has special needs that will hinder effective participation in agroup training session. Secondary or follow-up diabetes self-management training and medicalnutrition therapy shall be provided during individual patient meetings or sessions within the firsttwelve months after a primary or initial diabetes self-management training or medical nutrition therapygroup session.
Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Surveillance Tests for Ovarian Cancer
Benefits will be paid the same as any other Sickness for surveillance tests for ovarian cancer for anInsured Person age 35 and older at risk for ovarian cancer.
At risk for ovarian cancer means having a family history: with one or more first or second degreerelatives with ovarian cancer; of clusters of women relatives with breast cancer; of nonpolyposiscolorectal cancer; or testing positive for BRCA1 or BRCA2 mutations.
Surveillance tests means annual screening using: CA-125 serum tumor marker testing, transvaginalultrasound and pelvic examination.
Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Telemedicine
Benefits will be paid the same as any other Sickness for Telemedicine. "Telemedicine" means thepractice, by a duly licensed Physician or other health care provider acting within the scope of suchprovider's practice, of health care delivery, diagnosis, consultation, treatment, or transfer of medicaldata by means of audio, video, or data communications which are used during a medical visit with apatient or which are used to transfer medical data obtained during a medical visit with a patient.
Standard telephone, facsimile transmissions, unsecured electronic mail, or a combination thereof donot constitute telemedicine services.
Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Drug Treatment of Children’s Cancer
Benefits will be paid the same as any other Sickness for routine patient care costs incurred inconnection with the provision of goods or services to Dependent children in connection withapproved clinical trial programs for the treatment of children's cancer with respect to those childrenwho are enrolled in an approved clinical trial program for treatment of children's cancer and are nototherwise eligible for benefits, payments, or reimbursements from any other third party payors orother similar sources.
"Approved clinical trial program for treatment of children's cancer" means a Phase II and III prescriptiondrug clinical trial program in this state, as approved by the federal Food and Drug Administration or theNational Cancer Institute for the treatment of cancer that generally first manifests itself in children underthe age of 19. Such program must: (i) test new therapies, regimens, or combinations thereof againststandard therapies or regimens for the treatment of cancer in children; (ii) introduce a new therapy orregimen to treat recurrent cancer in children; or (iii) seek to discover new therapies or regimens for thetreatment of cancer in children which are more cost effective than standard therapies or regimens. Suchprogram must be certified by and utilize the standards for acceptable protocols established by thePediatric Oncology Group or Children's Cancer Group.
"Routine patient care costs" means those medically necessary costs of blood tests, X-rays, bonescans, magnetic resonance images, patient visits, hospital stays, or other similar costs generallyincurred by the insured party in connection with the provision of goods, services, or benefits todependent children under an approved clinical trial program for treatment of children's cancer whichotherwise would be covered under the supplemental medical accident and sickness insurancebenefit plan, policy, or contract if such medically necessary costs were not incurred in connection withan approved clinical trial program for treatment of children's cancer. Routine patient care costsspecifically shall not include the costs of any clinical trial therapies, regimens, or combinations thereof,any drugs or pharmaceuticals, any costs associated with the provision of any goods, services, orbenefits to dependent children which generally are furnished without charge in connection with suchan approved clinical trial program for treatment of children's cancer, any additional costs associatedwith the provision of any goods, services, or benefits which previously have been provided to theDependent child, paid for, or reimbursed, or any other similar costs. Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Postpartum Care
Benefits for a mother and her newly born child will be paid the same as any other Sickness for aminimum of 48 hours of inpatient care following a normal vaginal delivery and a minimum of 96 hoursof inpatient care following a cesarean section.
Any decisions to shorten the length of stay to less than the minimum specified above shall be madeby the attending Physician, obstetrician, or certified nurse midwife after conferring with the mother. Ifa mother and her newborn are discharges prior to the minimum inpatient stay length specified above,then coverage shall be provided for up to two follow-up visits, provided that the first visit shall occurwithin 48 hours after discharge. Such visits shall be conducted by a Physician, a physician assistant,or a registered professional nurse with experience and training in maternal and child health nursing.
Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations or any otherprovisions of the policy.
Benefits for Chlamydia Screening
Benefits will be paid the same as any other Sickness for one annual chlamydia screening test foreach Insured Person. "Chlamydia screening test" means any laboratory test of the urogenital tractwhich specifically detects for infection by one or more agents of chlamydia trachomatis and whichtest is approved for such purposes by the federal Food and Drug Administration.
Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations, or any otherprovisions of the policy.
Definitions
COPAY/COPAYMENT means a specified dollar amount that the Insured is required to pay for
certain Covered Medical Expenses.
COVERED MEDICAL EXPENSES means reasonable charges which are: 1) not in excess of Usual
and Customary Charges; 2) not in excess of the Preferred Allowance when the policy includes
Preferred Provider benefits and the charges are received from a Preferred Provider; 3) not in excess
of the maximum benefit amount payable per service as specified in the Schedule of Benefits; 4)
made for services and supplies not excluded under the policy; 5) made for services and supplies
which are a Medical Necessity; 6) made for services included in the Schedule of Benefits; and 7) in
excess of the amount stated as a Deductible, if any. Covered Medical Expenses will be deemed
"incurred" only: 1) when the covered services are provided; and 2) when a charge is made to the
Insured Person for such services.
DEDUCTIBLE means if an amount is stated in the Schedule of Benefits or any endorsement or rider
to this policy as a deductible, it shall mean an amount to be subtracted from the amount or amounts
otherwise payable as Covered Medical Expenses before payment of any benefit is made. The
deductible will apply as specified in the Schedule of Benefits.
INJURY means bodily injury which is all of the following:
1) directly and independently caused by specific accidental contact with another body or object.
2) unrelated to any pathological, functional, or structural disorder.
4) treated by a Physician within 30 days after the date of accident.
5) sustained while the Insured Person is covered under this policy.
All injuries sustained in one accident, including all related conditions and recurrent symptoms of theseinjuries will be considered one injury. Injury does not include loss which results wholly or in part,directly or indirectly, from disease or other bodily infirmity. Covered Medical Expenses incurred as aresult of an injury that occurred prior to this policy's Effective Date will be considered a Sicknessunder this policy.
INPATIENT means an uninterrupted confinement that follows formal admission to a Hospital, by
reason of an Injury or Sickness for which benefits are payable under this policy.
OUT-OF-POCKET MAXIMUM means the amount of Covered Medical Expenses that must be paid
by the Insured Person before Covered Medial Expenses will be paid at 100% for the remainder of the
Policy Year according to the policy Schedule of Benefits. The following expenses do not apply toward
meeting the Out-of-Pocket Maximum, unless otherwise specified in the policy Schedule of Benefits:
3) Expenses that are not Covered Medical Expenses.
SICKNESS means illness or disease of an Insured Person which first manifests itself after the
Effective Date of insurance and while the insurance is in force. All related conditions and recurrent
symptoms of the same or a similar condition will be considered one sickness. Covered Medical
Expenses incurred as a result of an Injury that occurred prior to this policy’s Effective Date will be
considered a sickness under this policy.
USUAL AND CUSTOMARY CHARGES means the lesser of the actual charge or a reasonable
charge which is: 1) usual and customary when compared with the charges made for similar services
and supplies; and 2) made to persons having similar medical conditions in the locality of the
Policyholder. The Company uses data from FAIR Health, Inc. to determine Usual and Customary
Charges. No payment will be made under this policy for any expenses incurred which in the judgment
of the Company are in excess of Usual and Customary Charges.
Exclusions and Limitations
No benefits will be paid for: a) loss or expense caused by, contributed to, or resulting from; or b)treatment, services or supplies for, at, or related to any of the following: 1. Biofeedback;2. Congenital conditions, except as specifically provided for Newborn or adopted Infants;3. Cosmetic procedures, except cosmetic surgery required to correct an Injury for which benefits are otherwise payable under this policy or for newborn or adopted children; removal of warts,non-malignant moles and lesions; 4. Dental treatment, except as specifically provided in the Schedule of Benefits;5. Elective Surgery or Elective Treatment;6. Eye examinations, eye refractions, eyeglasses, contact lenses, prescriptions or fitting of eyeglasses or contact lenses, vision correction surgery, or other treatment for visual defectsand problems; except when due to a covered Injury or disease process; 7. Flat foot conditions; supportive devices for the foot, except as specifically provided in Benefits for the Management and Treatment of Diabetes; subluxations of the foot; fallen arches; weakfeet; chronic foot strain; symptomatic complaints of the feet; and routine foot care includingcare, cutting and removal of corns, calluses, toenails and bunions (except capsular or bonesurgery); 8. Hearing examinations; hearing aids; or other treatment for hearing defects and problems, except as a result of an infection or trauma. "Hearing defects" means any physical defect ofthe ear which does or can impair normal hearing, apart from the disease process; 10. Preventive medicines or vaccines, except where required for treatment of a covered Injury or 11. Injury or Sickness for which benefits are paid or payable under any Workers' Compensation or Occupational Disease Law or Act, or similar legislation; 12. Injury sustained while (a) participating in any intercollegiate or professional sport, contest or competition; (b) traveling to or from such sport, contest or competition as a participant; or (c)while participating in any practice or conditioning program for such sport, contest orcompetition; 13. Investigational services;14. Organ transplants, including organ donation;15. Participation in a riot or civil disorder; commission of or attempt to commit a felony;16. Prescription Drugs, services or supplies as follows: a) Therapeutic devices or appliances, including: hypodermic needles, syringes, support garments and other non-medical substances, regardless of intended use, except asspecifically provided in the policy; b) Immunization agents, except as specifically provided in the policy, biological sera, blood or blood products administered on an outpatient basis; c) Drugs labeled, “Caution - limited by federal law to investigational use” or experimental drugs, except as specifically provided in the Benefits for Drug Treatment for Children’sCancer; d) Products used for cosmetic purposes;e) Drugs used to treat or cure baldness; anabolic steroids used for body building; f) Anorectics - drugs used for the purpose of weight control; g) Fertility agents or sexual enhancement drugs, such as Parlodel, Pergonal, Clomid, Profasi, i) Refills in excess of the number specified or dispensed after one (1) year of date of the 17. Reproductive/Infertility services including but not limited to: family planning, except contraceptives; fertility tests; infertility (male or female), except Covered Medical Expensesrelating to diagnosis, including any services or supplies rendered for the purpose or with theintent of inducing conception; premarital examinations; impotence, organic or otherwise;female sterilization procedures, except as specifically provided in the policy; vasectomy; sexualreassignment surgery; reversal of sterilization procedures; 18. Services provided normally without charge by the Health Service of the Policyholder; or services covered or provided by the student health fee; 19. Deviated nasal septum, including submucous resection and/or other surgical correction 20. Skydiving, parachuting, hang gliding, glider flying, parasailing, sail planing, bungee jumping, or flight in any kind of aircraft, except while riding as a passenger on a regularly scheduled flightof a commercial airline; 22. Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices, or gynecomastia; except as specifically provided in the policy; 23. Treatment in a Government hospital, unless there is a legal obligation for the Insured Person to 24. War or any act of war, declared or undeclared; or while in the armed forces of any country (a pro-rata premium will be refunded upon request for such period not covered); and 25. Weight management, weight reduction, nutrition programs, treatment for obesity, surgery for Collegiate Assistance Program
Insured Students have access to nurse advice and health information 24 hours a day, 7 days a weekby dialing the number indicated on the permanent ID card. Collegiate Assistance Program is staffedby Registered Nurses and Licensed Clinicians who can help students determine if they need to seekmedical care, need legal/financial advice or may need to talk to someone about everyday issues thatcan be overwhelming.
Scholastic Emergency Services:
Global Emergency Medical Assistance
If you are a student insured with this insurance plan, you and your insured spouse and minor child(ren)are eligible for Scholastic Emergency Services (SES). The requirements to receive these services areas follows: Domestic Students, insured spouse and insured minor child(ren): You are eligible for SES when 100miles or more away from your campus address and 100 miles or more away from your permanenthome address or while participating in a Study Abroad program.
International Students, insured spouse and insured minor child(ren): You are eligible to receive SESworldwide, except in your home country.
The Emergency Medical Evacuation and Return of Mortal Remains services provided by SES meetU.S. State Department requirements. The Emergency Medical Evacuation services are not meant tobe used in lieu of or replace local emergency services such as an ambulance requested throughemergency 911 telephone assistance. All SES services must be arranged and provided by SES, Inc.;any services not arranged by SES, Inc. will not be considered for payment.
Key Services include:
* Medical Consultation, Evaluation and Referrals * Care for Minor Children Left Unattended Due to a Medical Incident Please log into your online account at www.uhcsr.com/usg for additional information on SES GlobalEmergency Assistance Services, including service descriptions and program exclusions and limitations.
To access services please call:
(877) 488-9833 Toll-free within the United States
(609) 452-8570 Collect outside the United States
Services are also accessible via e-mail at medservices@assistamerica.com.
When calling the SES Operations Center, please be prepared to provide: 1. Caller's name, telephone and (if possible) fax number, and relationship to the patient; 2. Patient's name, age, sex, and Reference Number; 3. Description of the patient’s condition; 4. Name, location, and telephone number of hospital, if applicable; 5. Name and telephone number of the attending physician; and 6. Information of where the physician can be immediately reached.
SES is not travel or medical insurance but a service provider for emergency medical assistanceservices. All medical costs incurred should be submitted to your health plan and are subject to thepolicy limits of your health coverage. All assistance services must be arranged and provided by SES,Inc. Claims for reimbursement of services not provided by SES will not be accepted. Please refer toyour SES brochure or Program Guide at www.uhcsr.com/usg for additional information, includinglimitations and exclusions pertaining to the SES program.
Online Access to Account Information
UnitedHealthcare StudentResources Insureds have online access to claims status, Explanation of
Benefits, correspondence and coverage information via My Account at www.uhcsr.com/usg. Insureds
can also print a temporary ID card, request a replacement ID card and locate network providers from
My Account. You may also access the most popular My Account features from your smartphone at
our mobile site: my.uhcsr.com/usg.
If you don’t already have an online account, simply select the “Create an Account” link from the homepage at www.uhcsr.com/usg. Follow the simple, onscreen directions to establish an online account inminutes. Note that you will need your 7-digit insurance ID number to create an online account. If youalready have an online account, just log in from www.uhcsr.com/usg to access your accountinformation. Notice of Appeal Rights
Right to Internal Appeal
Standard Internal Appeal
The Insured Person has the right to request an Internal Appeal if the Insured Person disagrees withthe Company’s denial, in whole or in part, of a claim or request for benefits. The Insured Person, orthe Insured Person’s Authorized Representative, must submit a written request for an Internal Appealwithin 180 days of receiving a notice of the Company’s Adverse Determination.
The written Internal Appeal request should include: 1. A statement specifically requesting an Internal Appeal of the decision; 2. The Insured Person’s Name and ID number (from the ID card); 5. The reason the claim should be reconsidered; and 6. Any written comments, documents, records, or other material relevant to the claim.
Please contact the Customer Service Department at 866-403-8267 with any questions regarding
the Internal Appeal process. The written request for an Internal Appeal should be sent to:
UnitedHealthcare StudentResources, PO Box 809025, Dallas, TX 75380-9025.
Expedited Internal Appeal
For Urgent Care Requests, an Insured Person may submit a request, either orally or in writing, for anExpedited Internal Appeal.
An Urgent Care Request means a request for services or treatment where the time period forcompleting a standard Internal Appeal: 1. Could seriously jeopardize the life or health of the Insured Person or jeopardize the Insured Person’s ability to regain maximum function; or 2. Would, in the opinion of a Physician with knowledge of the Insured Person’s medical condition, subject the Insured Person to severe pain that cannot be adequately managedwithout the requested health care service or treatment.
To request an Expedited Internal Appeal, please contact Claims Appeals at 888-315-0447. The
written request for an Expedited Internal Appeal should be sent to: Claims Appeals, UnitedHealthcare
StudentResources, PO Box 809025, Dallas, TX 75380-9025.
After exhausting the Company’s Internal Appeal process, the Insured Person, or the Insured Person’sAuthorized Representative, has the right to request an External Independent Review when theservice or treatment in question: 1. Is a Covered Medical Expense under the Policy; and 2. Is not covered because it does not meet the Company’s requirements for Medical Necessity, appropriateness, health care setting, level or care, or effectiveness. Standard External Review
A Standard External Review request must be submitted in writing within 4 months of receiving anotice of the Company’s Adverse Determination or Final Adverse Determination.
Expedited External Review
In the event that the health condition of the Insured Person is such that completing a StandardExternal Review would jeopardize the life or health of the Insured Person or the Insured Person’sability to regain maximum function, as determined by the Insured Person’s treating Physician, anexpedited external review shall be available.
Where to Send External Review Requests
All types of External Review requests shall be submitted on the state’s required Independent Reviewrequest form to the Georgia Department of Community Health at the following address: Office of General Counsel/Division of Health Planning Questions Regarding Appeal Rights
Contact Customer Service at 866-403-8267 with questions regarding the Insured Person’s rights toan Internal Appeal and External Review.
Other resources are available to help the Insured Person navigate the appeals process. For questionsabout appeal rights, your state department of insurance may be able to assist you at: Georgia Office of Insurance and Safety Fire Commissioner http://www.oci.ga.gov/ConsumerService/Home.aspx Claim Procedure
In the event of Injury or Sickness, the student should: 1. Report to the Student Health Center or Infirmary for treatment or referral, or when not in school, to their Physician or Hospital.
2. Mail to the address below all medical and hospital bills along with the patient's name and insured student's name, address, social security number and name of the university underwhich the student is insured. A Company claim form is not required for filing a claim.
3. File claim within 30 days of Injury or first treatment for a Sickness. Bills should be received by the Company within 90 days of service. Bills submitted after one year will not beconsidered for payment except in the absence of legal capacity.
The Plan is Underwritten by:
Submit all Claims or Inquiries to:
UnitedHealthcare StudentResources
Please keep this Certificate as a general summary of the insurance. The Master Policy on file at theUniversity contains all of the provisions, limitations, exclusions and qualifications of your insurancebenefits, some of which may not be included in this Certificate. The Master Policy is the contract andwill govern and control the payment of benefits.
This Certificate is based on Policy Number: 2012-2361-1

Source: http://cie.columbusstate.edu/docs/2012-2013%20Student%20Insurance%20Health%20Plan.pdf