2013-200418-73 brochure-v8 noc1_layout

2013-2014
STUDENT
INJURY AND SICKNESS
INSURANCE PLAN
Monterey Institute of
International Studies
Important: Please see the Notice on the first page
of this plan material concerning student health
insurance coverage.
12-BR-CA 04-200418-73
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 $500,000 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-
800-767-0700. 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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Effective and Termination Dates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Premium Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Extension of Benefits After Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3Pre-Admission Notification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3Schedule of Medical Expense Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4UnitedHealthcare Pharmacy Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Preferred Provider Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Maternity Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Accidental Death and Dismemberment Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Excess Provision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Mandated Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Benefits for Telehealth Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Benefits for Mammography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Benefits for Upper or Lower Jawbone Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13Benefits for Reconstructive Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13Benefits for Prosthetic Devices for Speaking Post Laryngectomy . . . . . . . . . . . . . .13Benefits for Severe Mental Illnesses and Serious Emotional Disturbances . . . . .13Benefits for Behavioral Health Treatment for Pervasive Developmental Disorder or Autism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 Benefits for Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15Benefits for Phenylketonuria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Benefits for Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17Benefits for Cancer Clinical Trials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17Benefits for Breast Cancer Screening and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . .17Benefits for Aids Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17Benefits for Human Immunodeficiency Virus (HIV) Tests . . . . . . . . . . . . . . . . . . . . . .17Benefits for Prostate Cancer Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18Benefits for Cancer Screening Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18Benefits for Cervical Cancer Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18Benefits for Out-Patient Contraceptive Drugs and Methods . . . . . . . . . . . . . . . . . . .18 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18Exclusions and Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21Collegiate Assistance Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24FrontierMEDEX: Global Emergency Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24Notice of Appeal Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25Online Access to Account Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27UnitedHealth Allies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27Claim Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 Privacy Policy
We know that your privacy is important to you and we strive to protect the confidentiality ofyour nonpublic personal information. We do not disclose any nonpublic personal informationabout our customers or former customers to anyone, except as permitted or required by law.
We believe we maintain appropriate physical, electronic and procedural safeguards toensure the security of your nonpublic personal information. You may obtain a copy of ourprivacy practices by calling us toll-free at 1-800-767-0700 or by visiting us atwww.uhcsr.com/miis.
Eligibility
Students enrolled for six (6) or more credit hours for Fall or Spring and four (4) or morecredit hours for Summer semesters are required to be insured, unless proof of comparablecoverage is furnished. All international students, possessing and maintaining a currentpassport and valid visa status (J-1), engaged in educational activities at the Institute arerequired to be insured, unless proof of comparable coverage is furnished. Studentsengaged in practical training, on campus internships, and off campus internships located atschool approved locations may participate in this plan. Contact Student Services for moreinformation. Students must actively attend classes for at least the first 31 days after the date for whichcoverage is purchased. Home study, correspondence, and online courses do not fulfill theEligibility requirements that the student actively attend classes. The Company maintains itsright to investigate Eligibility or student status and attendance records to verify that thepolicy Eligibility requirements have been met. If the Company discovers the Eligibilityrequirements have not been met, its only obligation is to refund premium.
Eligible students who do enroll may also insure their Dependents. Eligible Dependents arethe student’s spouse (husband or wife) or Domestic Partner and dependent children under26 years of age. See the Definitions section of the Brochure for the specific requirementsneeded to meet Domestic Partner eligibility.
Dependent eligibility expires concurrently with that of the insured student.
Effective and Termination Dates
The Master Policy on file at the school becomes effective at 12:01 a.m., August 26, 2013.
The individual student’s coverage becomes effective on the first day of the period for whichpremium is paid or the date the enrollment form and full premium are received by theCompany (or its authorized representative), whichever is later. The Master Policy terminatesat 11:59 p.m., August 24, 2014. Coverage terminates on that date or at the end of the periodthrough which premium is paid, whichever is earlier. Dependent coverage will not beeffective prior to that of the Insured student or extend beyond that of the Insured student. You must meet the Eligibility requirements each time you pay a premium to continueinsurance coverage. To avoid a lapse in coverage, your premium must be received within 14days after the coverage expiration date. It is the student’s responsibility to make timelyrenewal payments to avoid a lapse in coverage.
Refunds of premiums are allowed only upon entry into the armed forces.
The Policy is a Non-Renewable One Year Term Policy.
Premium Rates
Premium Period Rates
Session 1
Spring/Summer 1
(1st Special)
(Spring 1)
Session 2
Spring/Summer 2
Session 3
(2nd Special)
(Spring/Summer)
(3rd Special)
Summer Intensive
Session 4
(4th Special)
(Special Cov Period)
Premium Periods
Session 1 (1st Special)
Spring/Summer 1 (Spring 1)
Session 2 (2nd Special)
Spring/Summer 2
Session 3 (3rd Special)
Session 4 (4th Special)
Summer Intensive English
NOTE: The amounts stated above include certain fees charged by the school you arereceiving coverage through. Such fees include amounts which are paid to certain non-insurer vendors or consultants by, or at the direction, of your school.
Extension of Benefits After Termination
The coverage provided under the Policy ceases on the Termination Date. However, if anInsured is Hospital Confined on the Termination Date from a covered Injury or Sickness forwhich benefits were paid before the Termination Date, Covered Medical Expenses for suchInjury or Sickness will continue to be paid as long as the condition continues but not toexceed 90 days after the Termination Date.
The total payments made in respect of the Insured for such condition both before and afterthe Termination Date will never exceed the Maximum Benefit. After this “Extension ofBenefits” provision has been exhausted, all benefits cease to exist, and under nocircumstances will further payments 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 fiveworking days prior to the planned admission.
2. NOTIFICATION OF MEDICAL EMERGENCY ADMISSIONS: The patient,
patient’s representative, Physician or Hospital should telephone 1-877-295-0720within two working days of the admission to provide notification of any admissiondue 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 after hours 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: $500,000 (Per Insured Person) (Per Policy Year)
Paid As Specified Below
Deductible Preferred Provider: $250 (Per Insured Person) (Per Policy Year)
Deductible Out-of-Network: $500 (Per Insured Person) (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 Provider: $3,500
(Per Insured Person, Per Policy Year)
Out-of-Pocket Maximum Out-of-Network: $7,000
(Per Insured Person, Per Policy Year)
The Preferred Provider for this plan is UnitedHealthcare Choice Plus.
If care is received from a Preferred Provider any Covered Medical Expenses will be paidat the Preferred Provider level of benefits. If a Preferred Provider is not available in theNetwork Area, benefits will be paid at the level of benefits shown as Preferred Providerbenefits. If the Covered Medical Expense is incurred due to a Medical Emergency,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.
The Policy provides benefits for the Covered Medical Expenses incurred by an InsuredPerson for loss due to a covered Injury or Sickness up to the Maximum Benefit of$500,000.
Out-of-Pocket Maximum: After the Out-of-Pocket Maximum has been satisfied, CoveredMedical Expenses will be paid at 100% up to the policy Maximum Benefit subject to anybenefit maximums that may apply. Separate Out-of-Pocket Maximums apply to PreferredProvider and Out-of-Network benefits. The Copays and per service Deductibles andservices that are not Covered Medical Expenses do not count toward meeting the Out-of-Pocket Maximum. The policy Deductible will be applied to the Out-of-PocketMaximum. Even when the Out-of-Pocket Maximum has been satisfied, the InsuredPerson will still be responsible for Copays and per service Deductibles.
Benefits are subject to the policy Maximum Benefit unless otherwise specifically stated.
Benefits will be paid up to the maximum benefit for each service as scheduled below. Allbenefit maximums are combined Preferred Provider and Out-of-Network unlessotherwise specifically stated. Covered Medical Expenses include: PA = Preferred Allowance
U&C = Usual & Customary Charges
Preferred
Out-of-Network
INPATIENT
Providers
Providers
Room and Board Expense, daily semi-private
room rate when confined as an Inpatient; andgeneral nursing care provided by the Hospital.
Intensive Care
Preferred
Out-of-Network
INPATIENT
Providers
Providers
Hospital Miscellaneous Expense, such as the
cost of the operating room, laboratory tests, x-rayexaminations, anesthesia, drugs (excluding takehome drugs) or medicines, therapeutic services,and supplies. In computing the number of dayspayable under this benefit, the date of admissionwill be counted, but not the date of discharge.
Routine Newborn Care,
Confined; and routine nursery care provided immediately after birth for an Inpatient stay of at least 48 hours following a vaginal delivery or 96 hours following a cesarean delivery. If the mother agrees, the attending Physician may discharge Physiotherapy
Surgeon’s Fees, if two or more procedures are
performed through the same incision or in immediate succession at the same operative session, the maximum amount paid will not exceed 50% of the second procedure and 50% Assistant Surgeon
Anesthetist, professional services administered
in connection with Inpatient surgery.
Registered Nurse’s Services, private duty
Physician’s Visits, non-surgical services when
confined as an Inpatient. Benefits do not applywhen related to surgery.
Pre-Admission Testing, payable within 3
OUTPATIENT
Surgeon’s Fees, if two or more procedures are
performed through the same incision or in immediate succession at the same operative session, the maximum amount paid will not exceed 50% of the second procedure and 50% Day Surgery Miscellaneous,
scheduled surgery performed in a Hospital, including the cost of the operating room; laboratory tests and x-ray examinations, including professional fees; anesthesia; drugs or medicines; and supplies. Usual and Customary Charges for Day Surgery Miscellaneous are based on the Outpatient Surgical Facility Charge Index.
Preferred
Out-of-Network
OUTPATIENT
Providers
Providers
Assistant Surgeon
Anesthetist, professional services administered
in connection with outpatient surgery.
Physician’s Visits, Benefits for Physician’s Visits
do not apply when related to surgery orPhysiotherapy.
Physiotherapy, Physiotherapy includes but is not
limited to the following: 1) physical therapy; 2)occupational therapy; 3) cardiac rehabilitationtherapy; 4) manipulative treatment; and 5) speechtherapy, unless excluded in the policy. Review of Medical Necessity will be performedafter 12 visits per Injury or Sickness.
Medical Emergency Expenses, facility charge
for use of the emergency room and supplies.
Treatment must be rendered within 72 hours from time of Injury or first onset of Sickness. (Copay / per visit Deductible is in addition to the PolicyDeductible ) (The Copay / per visit Deductible will bewaived if admitted to the Hospital.) Diagnostic X-ray Services
Radiation Therapy
Chemotherapy
Laboratory Services
Tests & Procedures, diagnostic services and
medical procedures performed by a Physician,other than Physician’s Visits, Physiotherapy, x-raysand lab procedures. The following therapies willbe paid under this benefit: inhalation therapy,infusion therapy, pulmonary therapy andrespiratory therapy.
Injections, when administered in the Physician's
office and charged on the Physician's statement.
Prescription Drugs,
(Mail order Prescription Drugs through UHCP at Pharmacy (UHCP)2.5 times the retail Copay up to a 90 day supply.) Preferred
Out-of-Network
Providers
Providers
Ambulance Services
Durable Medical Equipment,
prescription must accompany the claim whensubmitted. Benefits are limited to the initialpurchase or one replacement purchase per PolicyYear. Durable Medical Equipment includesexternal prosthetic devices that replace a limb orbody part but does not include any device that isfully implanted into the body. ($1,000 maximum (Per Policy Year)) (DurableMedical Equipment benefits payable under the$1,000 maximum are not included in the$500,000 Maximum Benefit.) (See also Benefitsfor Prosthetic Devices for Speaking PostLaryngectomy.) Consultant Physician Fees, when requested
and approved by attending Physician.
Dental Treatment, made necessary by Injury to
Sound, Natural Teeth only.
($1,000 maximum (Per Policy Year)) (Benefitspaid on Injury to Natural Teeth only. Benefits arenot subject to the $500,000 Maximum Benefit.) Mental Illness Treatment, services received on
an Inpatient and outpatient basis. Institutionsspecializing in or primarily treating Mental Illnessand Substance Use Disorders are not covered.
(See also Benefits for Severe Mental Illnesses andSerious Emotional Disturbances.) Substance Use Disorder Treatment, services
received on an Inpatient and outpatient basis.
Institutions specializing in or primarily treatingMental Illness and Substance Use Disorders arenot covered.
Maternity, benefits will be paid for an Inpatient
stay of at least 48 hours following a vaginaldelivery or 96 hours following a cesarean delivery.
If the mother agrees, the attending Physician maydischarge the mother earlier.
Complications of Pregnancy
Elective Abortion
Preferred
Out-of-Network
Providers
Providers
Reconstructive Breast Surgery Following
Mastectomy, in connection with a covered
Mastectomy for 1) all stages of reconstruction of
the breast on which the mastectomy has been
performed; 2) surgery and reconstruction of the
other breast to produce a symmetrical
appearance; and 3) prostheses and physical
complications of mastectomy, including
lymphedemas.
Diabetes Services, in connection with the
treatment of diabetes.
(See Benefits for Diabetes) Preventive Care Services, medical services that
have been demonstrated by clinical evidence tobe safe and effective in either the early detectionof disease or in the prevention of disease, havebeen proven to have a beneficial effect on healthoutcomes and are limited to the following asrequired under applicable law: 1) Evidence-baseditems or services that have in effect a rating of “A”or “B” in the current recommendations of theUnited States Preventive Services Task Force; 2)immunizations that have in effect arecommendation from the Advisory Committee onImmunization Practices of the Centers for DiseaseControl and Prevention; 3) with respect to infants,children, and adolescents, evidence-informedpreventive care and screenings provided for in thecomprehensive guidelines supported by theHealth Resources and Services Administration;and 4) with respect to women, such additionalpreventive care and screenings provided for incomprehensive guidelines supported by theHealth Resources and Services Administration.
No Deductible, Copays or Coinsurance will beapplied when the services are received from aPreferred Provider.
UnitedHealthcare Pharmacy Benefits
Benefits are available for outpatient Prescription Drugs on our Prescription Drug List (PDL)when dispensed by a UnitedHealthcare Pharmacy. Benefits are subject to supply limits andCopayments that vary depending on which tier of the PDL the outpatient drug is listed.
There are certain Prescription Drugs that require your Physician to notify us to verify theiruse is covered within your benefit.
You are responsible for paying the applicable Copayments. Your Copayment is determinedby the tier to which the Prescription Drug Product is assigned on the PDL. Tier status maychange periodically and without prior notice to you. Please access www.uhcsr.com/miis orcall 1-855-828-7716 for the most up-to-date tier status.
$15 Copay per prescription order or refill for a Tier 1 Prescription Drug up to 31 day supply.
$35 Copay per prescription order or refill for a Tier 2 Prescription Drug up to 31 day supply.
$70 Copay per prescription order or refill for a Tier 3 Prescription Drug up to 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 use a network pharmacy, you will be responsible for paying the full cost for the
prescription. If you do not present the card, you will need to pay for the prescription and then
submit a reimbursement form for prescriptions filled at a network pharmacy along with the
paid receipt in order to be reimbursed. To obtain reimbursement forms, or for information
about mail-order prescriptions or network pharmacies, please visit www.uhcsr.com/miis and
log in to your online account or call 1-855-828-7716.
Additional Exclusions
In addition to the policy Exclusions and Limitations, the following Exclusions apply to
Network Pharmacy 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 determinedby the Company to be experimental, 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 prescriptionorder or refill. Compounded drugs that are available as a similar commerciallyavailable Prescription Drug Product. Compounded drugs that contain at least oneingredient that requires a prescription order or refill 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 designatedthe over-the-counter medication as eligible for coverage as if it were a PrescriptionDrug Product and it is obtained with a prescription order or refill from a Physician.
Prescription Drug Products that are available in over-the-counter form or comprisedof components that are available in over-the-counter form or equivalent. CertainPrescription Drug Products that the Company has determined are TherapeuticallyEquivalent 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 toreinstate Benefits for a Prescription Drug Product that was previously excludedunder 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 treatmentof Sickness or Injury, except as required by state mandate.
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/miis
or call Customer Service at 1-855-828-7716.
PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOMOR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED.
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
always confirm that a Preferred Provider is participating at the time services are required by
calling the Company at 1-800-767-0700 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.
“Network Area” means the 50 mile radius around the local school campus the Named
Insured is attending.
Regardless of the provider, each Insured is responsible for the payment of their Deductible.
The Deductible must be satisfied before benefits are paid. The Company will pay according
to the benefit limits 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 (800) 767-0700 for information about
Preferred Hospitals.
OUT-OF-NETWORK PROVIDERS - If Inpatient care is not provided at a Preferred
Provider, eligible Inpatient 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
according to the Schedule of Benefits. Insureds are responsible for any amounts that
exceed the benefits shown 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 the Coinsurance percentages specified in the Schedule of Benefits or up to any
limits specified in the Schedule of Benefits. All other providers will be paid according to the
benefit limits in the Schedule of Benefits.
MEDICAL EMERGENCY
For the purposes of PPO Coverage, Medical Emergency shall include Active Labor. ActiveLabor means a labor at a time at which either of the following would occur: 1) there isinadequate time to effect safe transfer to another hospital prior to delivery. 2) a transfer maypose a threat to the health and safety of the Insured or the unborn child.
Maternity Testing
This policy does not cover all routine, preventive, or screening examinations or testing. Thefollowing maternity tests and screening exams will be considered for payment according tothe policy benefits if 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 call the Company at 1-800-767-0700.
Accidental Death and Dismemberment Benefits
Loss of Life, Limb or Sight
If such Injury shall independently of all other causes and within 180 days from the date of
Injury solely result in any one of the following specific losses, the Insured Person or
beneficiary may request the Company to pay the applicable amount below in addition to
payment under the Medical Expense Benefits.
For Loss of:
Member means hand, arm, foot, leg, or eye. Loss shall mean with regard to hands or armsand feet or legs, dismemberment by severance at or above the wrist or ankle joint; withregard to eyes, entire and irrecoverable loss of sight. Only one specific loss (the greater)resulting from any one injury will be paid.
Excess Provision
Even if you have other insurance, the Plan may cover unpaid balances, Deductibles and pay
those eligible medical expenses not covered by other insurance.
Benefits will be paid on the unpaid balances after your other insurance has paid. No benefits
are payable for any expense incurred for Injury or Sickness which has been paid or is payable
by other valid and collectible insurance except for automobile medical payments insurance.
However, this Excess Provision will not be applied to the first $100 of medical expenses
incurred.
Covered Medical Expenses exclude amounts not covered by the primary carrier due to penalties
imposed as a result of the Insured’s failure to comply with policy provisions or requirements.
Important: The Excess Provision has no practical application if you do not have other
medical insurance or if your other insurance does not cover the loss.
Mandated Benefits
Benefits for Telehealth Services
Benefits for appropriately provided Telehealth services will be paid on the same basis asservices provided through a face-to-face contact between a Physician and Insured. “Asynchronous store and forward” means the transmission of a patient’s medicalinformation from an originating site to the health care Provider at a distant site without thepresence of the patient.
“Synchronous interaction” means a real-time interaction between a patient and a healthcare provider located at a distant site.
“Telehealth” means the mode of delivering health care services and public health viainformation and communication technologies to facilitate the diagnosis, consultation,treatment, education, care management, and self-managements of a patient’s health carewhile the patient is at the originating site and the health care provider is at a distant site.
Telehealth facilitates patient self-management and caregiver support for patients andincludes synchronous interactions and asynchronous store and forward transfers.
Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Mammography
Benefits will be paid the same as any other Covered Medical Expense as shown in theSchedule of Benefits for screening by low-dose mammography for the presence of occultbreast cancer, upon the referral of a nurse practitioner, certified nurse midwife, or Physician,subject to the following guidelines: 1. A baseline mammogram for women thirty-five to thirty-nine years of age, inclusive.
2. A mammogram every two years for women forty to forty-nine years of age or more frequently based on the woman’s Physician’s recommendation.
3. An annual mammogram for women fifty years of age or older.
Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Upper or Lower Jawbone Surgery
Benefits will be paid the same as any other Injury or Sickness not to exceed $500 maximumfor surgical procedures for those covered conditions directly affecting the upper or lowerjawbone, or associated bone joints provided the service is considered a Medical Necessityand does not include dental procedures other than those identified in the Schedule ofBenefits.
Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Reconstructive Surgery
Benefits will be paid the same as any other Injury or Sickness for reconstructive surgeryperformed to correct or repair abnormal structures of the body caused by congenitaldefects, developmental abnormalities, trauma, infection, tumors, or disease to do either ofthe following (1) to improve function; or (2) to create a normal appearance, to the extentpossible.
This benefit does not include cosmetic surgery or surgery performed to alter or reshapenormal structures of the body in order to improve the Insured’s appearance.
Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Prosthetic Devices for Speaking Post Laryngectomy
Benefits will be paid the same as any other prosthetic device for Prosthetic Devices torestore a method of speaking incident to a laryngectomy. For the purposes of this section “prosthetic devices” means and includes the provision ofinitial and subsequent prosthetic devices, including installation accessories, pursuant to anorder of the Insured’s Physician and surgeon. “Prosthetic devices” does not includeelectronic voice producing machines.
Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Severe Mental Illnesses and Serious Emotional Disturbances
Benefits will be paid the same as any other Sickness for the diagnosis and MedicallyNecessary treatment of Severe Mental Illnesses of an Insured of any age and of SeriousEmotional Disturbances of an Insured child as specified below: 1. Outpatient services.
2. Inpatient hospitalization services. 3. Partial hospitalization services.
4. Prescription Drugs, if the policy includes coverage for Prescription Drugs.
1. Schizophrenia.
2. Schizoaffective disorder.
3. Bipolar disorder (manic-depressive disorder).
4. Major depressive disorders.
5. Panic disorder.
6. Obsessive-Compulsive disorder.
7. Pervasive developmental disorder or Autism. 8. Anorexia nervosa.
9. Bulimia nervosa.
“Serious emotional disturbance of a child” means a child under the age of 18 years whohas one or more mental disorders as identified in the most recent edition of the Diagnosticand Statistical Manual of Mental Disorders, other than a primary substance use disorder ordevelopmental disorder, that result in behavior inappropriate to the child’s age according toexpected developmental norms. Members of this target population must meet one or moreof the following criteria: 1. As a result of the mental disorder the child has substantial impairment in at least two of the following areas: self-care, school functioning, family relationships, orability to function in the community; and either of the following occur: (i) the childis at risk of removal from home or has already been removed from the home. (ii)The mental disorder and impairments have been present for more than 6 monthsor are likely to continue for more than one year without treatment. 2. The child displays one of the following: psychotic features, risk of suicide or risk of 3. The child meets special education eligibility requirements under Chapter 26.5 of division 7 of Title 1 of the Government Code.
Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations, or anyother provisions of the policy.
Benefits for Behavioral Health Treatment for Pervasive
Developmental Disorder or Autism
Benefits will be paid the same as any other Sickness for the diagnosis and MedicallyNecessary Behavioral Health Treatment for Pervasive Developmental Disorder or Autism.
“Behavioral Health Treatment” means professional services and treatment programs,including applied behavioral analysis and evidence-based behavior intervention programs,that develop or restore, to the maximum extent practicable, the functioning of an individualwith Pervasive Developmental Disorder or Autism, and that meet all the following:1. The treatment is prescribed by a licensed Physician or Psychologist.
2. The treatment is provided under a treatment plan prescribed by a Qualified Autism Service Provider that is administered by: A Qualified Autism Service Provider.
b. A Qualified Autism Service Professional supervised and employed by the Qualified c. A Qualified Autism Service Paraprofessional supervised and employed by a 3. The treatment plan has measurable goals over a specific timeline that is developed and approved by the Qualified Autism Service Provider for the specific Insured Person beingtreated. The treatment plan shall be reviewed no less than once every six months bythe Qualified Autism Service Provider and modified whenever appropriate. In the plan,the Qualified Autism Service Provider shall: a. Describe the Insured Person’s behavioral health impairments to be treated.
b. Design an intervention plan that includes the service type, number of hours, and parent participation needed to achieve the plan’s goals and objectives, and thefrequency at which the Insured Person’s progress is evaluated and reported.
c. Provide intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating Pervasive Developmental Disorder or Autism.
d. Discontinue intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate.
4. The treatment plan is not used for the purposes of provided or for the reimbursement of respite, day care, or educational services and is not used to reimburse a parent forparticipating in the treatment program. The treatment plan shall be made available tothe Company upon request.
“Qualified Autism Service Provider” means either of the following:1. A person, entity, or group that is certified by a national entity, such as the Behavior Analyst Certification Board, that is accredited by the National Commission for CertifyingAgencies, and who designs, supervises, or provides treatment for PervasiveDevelopmental Disorder or Autism, provided the services are within the experience andcompetence of the person, entity, or group that is nationally certified.
2. A person licensed as a physician and surgeon, physical therapist, occupational therapist, psychologist, marriage and family therapist, educational psychologist, clinical socialworker, professional clinical counselor, speech-language pathologist, or audiologistpursuant to Division 2 of the Business and Professions Code, who designs, supervises,or provides treatment for Pervasive Developmental Disorder or Autism, provided theservices are within the experience and competence of the licensee.
“Qualified autism service professional” means an individual who meets all of the followingcriteria:1. Provides behavioral health treatment.
2. Is employed and supervised by a Qualified Autism Service Provider.
3. Provides treatment pursuant to a treatment plan developed and approved by the 4. Is a behavioral service provider approved as a vendor by a California regional center to provide services as a Associate Behavior Analyst, Behavior Analyst, BehaviorManagement Assistant, Behavior Management Consultant, or BehaviorManagement Program as defined in Section 54342 of Title 17 of the CaliforniaCode of Regulations.
5. Has training and experience in providing services for Pervasive Developmental Disorder or Autism pursuant to Division 4.5 of the Welfare and Institutions Code orTitle 14 of the Government Code.
“Qualified autism service paraprofessional” means an unlicensed and uncertifiedindividual who meets all of the following criteria:1. Is employed and supervised by a Qualified Autism Service Provider.
2. Provides treatment and implements services pursuant to a treatment plan developed and approved by the Qualified Autism Service Provider.
3. Meets the criteria set forth in the regulations adopted pursuant to Section 4686.3 of the Welfare and Institutions Code.
4. Has adequate education, training, and experience, as certified by a Qualified Autism Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations, or anyother provisions of the policy.
Benefits for Diabetes
Benefits will be paid the same as any other Sickness for the following equipment andsupplies for the management and treatment of insulin using diabetes, non-insulin usingdiabetes, and gestational diabetes as Medically Necessary even if the items are availablewithout a prescription: 1. Blood glucose monitors and blood glucose testing strips.
2. Blood glucose monitors designed to assist the visually impaired.
3. Insulin pumps and all related necessary supplies.
4. Ketone urine testing strips.
5. Lancets and lancet puncture devices.
6. Pen delivery systems for the administration of insulin.
7. Podiatric devices to prevent or treat diabetes-related complications.
8. Insulin syringes.
9. Visual aids, excluding eyewear, to assist the visually impaired with proper dosing of Benefits will also be provided for diabetes outpatient self-management training, education,and medical nutrition therapy necessary to enable the Insured to properly use theequipment, supplies and medications noted above. The same policy limits will apply as applyto any other Physician’s Visits.
If the Policy provides Prescription Drug benefits, then benefits will be paid the same as anyother Prescription Drug for the following Medically Necessary prescriptions: 1. Insulin.
2. Prescriptive medications for the treatment of diabetes.
3. Glucagon.
Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Phenylketonuria
Benefits will be paid for the Usual and Customary Charges for the testing and treatment ofPhenylketonuria (PKU). Benefits include those Formulas and Special Food Products that are part of a dietprescribed by a Physician and managed by a health care professional in consultation witha Physician who specializes in the treatment of metabolic disease, provided that the diet isdeemed Medically Necessary to avert the development of serious physical or mentaldisabilities or to promote normal development or function as a consequence of PKU.
Benefits are not required except to the extent that the cost of necessary Formulas andSpecial Food Products exceeds the cost of a normal diet.
“Formula” means an enteral product for use at home prescribed by a Physician or nursepractitioner or ordered by a registered dietician upon referral by a health care providerauthorized to prescribe dietary treatments as Medically Necessary for the treatment ofPKU.
“Special food product” means a food product that is both: a) prescribed by a Physician or nurse practitioner for the treatment of PKU and is consistent with the recommendations and best practices of qualified healthprofessional with expertise germane to, and experienced in the treatment and careof, PKU. It does not include a food that is naturally low in protein, but may includea food product that is specifically formulated to have less than one gram of proteinper serving; b) used in place of normal food products, such as grocery store foods, used by the The Deductible, Copayment and Coinsurance provisions of the Policy shall not apply;however, all other policy limitations and provisions will apply.
Benefits for Osteoporosis
Benefits will be paid for the Usual and Customary Charges for the diagnosis, treatment andappropriate management of Osteoporosis. Benefits include all Food and DrugAdministration approved technologies, including bone mass measurement technologies asdeemed medically appropriate.
The Deductible, Copayment and Coinsurance provisions of the Policy shall not apply;however, all other policy limitations and provisions will apply.
Benefits for Cancer Clinical Trials
Benefits will be paid the same as any other Sickness for all routine patient care costsrelated to the clinical trial for an insured diagnosed with cancer and accepted into a phaseI, phase II, phase III, or phase IV clinical trial for cancer.
“Routine patient care costs” means the costs associated with the provision of health careservices, including drugs, items, devices and services that would otherwise be coveredunder the plan or contract if those drugs, items, devices and services were not provided inconnection with an approved clinical trial program.
Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Breast Cancer Screening and Treatment
Benefits will be paid the same as any other Sickness for the screening for, diagnosis of, andtreatment for breast cancer, consistent with generally accepted medical practice andscientific evidence, upon the referral of the insured’s participating physician.
Treatment for breast cancer shall include coverage for prosthetic devices or reconstructivesurgery to restore and achieve symmetry for the patient incident to a mastectomy. “Mastectomy” means the removal of all or part of the breast for medically necessaryreasons, as determined by a licensed Physician and surgeon.
“Prosthetic device” means the provision of initial and subsequent devices as ordered by anInsured Person’s Physician and surgeon.
Benefits for prosthetic devices and reconstructive surgery shall be subject to all Deductible,Copayment, Coinsurance, limitations, or any other provisions of the policy.
Benefits for Aids Vaccine
Benefits will be paid for the Usual and Customary Charges for a vaccine for acquiredimmune deficiency syndrome (AIDS) that is approved for marketing by the federal Food andDrug Administration (excluding an investigational new drug application) and that isrecommended by the United States Public Health Service.
The Deductible, Copayment and Coinsurance provisions of the Policy shall not apply;however, all other policy limitations and provisions will apply.
Benefits for Human Immunodeficiency Virus (HIV) Tests
Benefits will be paid the same as any other Sickness for Human Immunodeficiency Virus(HIV) testing, regardless of whether the test is related to a primary HIV diagnosis. Thetesting method shall be that which is approved by the federal Food and Drug Administrationand is recommended by the United States Public Health Service.
Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Prostate Cancer Screening
Benefits will be paid the same as any other Sickness for screening and diagnosis ofprostate cancer, including, but not limited to prostate-specific antigen testing (PSA) anddigital rectal examinations when medically necessary and consistent with good professionalpractice. Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Cancer Screening Tests
Benefits will be paid the same as any other Sickness for all generally medically acceptedcancer screening tests.
Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Cervical Cancer Screening
Benefits will be paid the same as any other Sickness for an annual cervical cancerscreening test, upon the referral of a nurse practitioner, certified nurse midwife, or Physician,subject to the following guidelines:An annual screening test will include the conventional Pap test, a human papilloma virusscreening test that is approved by the federal Food and Drug Administration and the optionof any cervical cancer screening test approved by the federal Food and DrugAdministration, upon referral by the Insured’s health care provider.
Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Out-Patient Contraceptive Drugs and Methods
If the policy provides for out-patient prescription drugs, then benefits will be paid the sameas any other Sickness for prescribed contraceptive drugs and methods which are: 1. approved by the Federal Food and Drug Administration;2. prescribed by the Insured’s Physician; and 3. the drug or method is medically appropriate for the Insured Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations, or any otherprovisions of the policy.
Definitions
COINSURANCE means the percentage of Covered Medical Expenses that the Company
pays.
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 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.
DEPENDENT means the spouse (husband or wife) or Domestic Partner of the Named
Insured and their dependent children. Children shall cease to be dependent at the end of
the month in which they attain the age of 26 years.
The attainment of the limiting age will not operate to terminate the coverage of such child
while the child is and continues to be both:
1) Incapable of self-sustaining employment by reason of mental retardation or physical 2) Chiefly dependent upon the Insured Person for support and maintenance.
Proof of such incapacity and dependency shall be furnished to the Company: 1) by the
Named Insured; and, 2) within 31 days of the child's attainment of the limiting age.
Subsequently, such proof must be given to the Company annually following the child's
attainment of the limiting age.
If a claim is denied under the policy because the child has attained the limiting age for
dependent children, the burden is on the Insured Person to establish that the child is and
continues to be handicapped as defined by subsections (1) and (2).
DOMESTIC PARTNER means a person who has filed a Declaration of Domestic
Partnership with the California Secretary of State and who meets all of the following:
1) Is unmarried or is not a member of another domestic partnership.
2) Is not related by blood to the Insured person in a way that would prevent marriage 3) Is at least 18 years of age; or, if under age 18, has, in accordance with California Law, obtained:a. Written consent from the underage person’s parents and a court order granting permission to establish a domestic partnership; or b. A court order establishing a domestic partnership if the underage person does not have a parent or legal guardian or a parent or legal guardian capable ofconsenting to the domestic partnership.
4) Is mentally capable of consenting to the domestic partnership.
INJURY means bodily injury which is all of the following:
1) directly and independently caused by specific accidental contact with another body 2) unrelated to any pathological, functional, or structural disorder. 3) a source of loss.
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 recurrentsymptoms of these injuries will be considered one injury. Injury does not include loss whichresults wholly or in part, directly or indirectly, from disease or other bodily infirmity. CoveredMedical Expenses incurred as a result of an injury that occurred prior to this policy’sEffective Date will be considered a Sickness under 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.
MEDICAL EMERGENCY means the occurrence of a sudden, serious and unexpected
Sickness or Injury. In the absence of immediate medical attention, a reasonable person
could believe this condition would result in any of the following:
1) Death.
2) Placement of the Insured's health in jeopardy.
3) Serious impairment of bodily functions.
4) Serious dysfunction of any body organ or part.
5) In the case of a pregnant woman, serious jeopardy to the health of the fetus.
Expenses incurred for "Medical Emergency" will be paid only for Sickness or Injury which
fulfills the above conditions. These expenses will not be paid for minor Injuries or minor
Sicknesses.
MEDICAL NECESSITY means those services or supplies provided or prescribed by a
Hospital or Physician which are all of the following:
1) Essential for the symptoms and diagnosis or treatment of the Sickness or Injury.
2) Provided for the diagnosis, or the direct care and treatment of the Sickness or Injury.
3) In accordance with the standards of good medical practice.
4) Not primarily for the convenience of the Insured, or the Insured's Physician.
5) The most appropriate supply or level of service which can safely be provided to the The Medical Necessity of being confined as an Inpatient means that both: 1) The Insured requires acute care as a bed patient.
2) The Insured cannot receive safe and adequate care as an outpatient.
This policy only provides payment for services, procedures and supplies which are a Medical
Necessity. No benefits will be paid for expenses which are not a Medical Necessity,
including any or all days of Inpatient confinement.
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:
1) Deductibles.
2) Copays.
3) Expenses that are not Covered Medical Expenses.
PRE-EXISTING CONDITION means any condition for which medical advice, diagnosis,
care or treatment, including the use of Prescription Drugs, is recommended or received
from a Physician within the 6 months immediately prior to the Insured's Effective Date
under the policy. Pregnancy will not be considered to be a Pre-Existing Condition.
SICKNESS means sickness or disease of the Insured Person which causes loss, and
originates while the Insured Person is covered under this policy. 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 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. Acne; 2. Acupuncture; 3. Allergy, including allergy testing;4. Addiction, such as: nicotine addiction, except as specifically provided in the policy; and caffeine addiction; non-chemical addiction, such as: gambling, sexual, spending,shopping, working and religious; codependency; 5. Milieu therapy, learning disabilities, behavioral problems, parent-child problems, conceptual handicap, developmental delay or disorder or mental retardation, except asspecifically provided in the policy; 8. Congenital conditions, except as specifically provided in benefits for Reconstructive Surgery or except as specifically provided for Newborn or adopted Infants; 9. 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; 10. Custodial Care; care provided in: rest homes, health resorts, homes for the aged, halfway houses, college infirmaries or places mainly for domiciliary or Custodial Care;extended care in treatment or substance abuse facilities for domiciliary or CustodialCare; 11. Dental treatment, except for accidental Injury to Natural Teeth; 12. Elective Surgery or Elective Treatment; 13. Elective abortion;14. Eye examinations, eye refractions, eyeglasses, contact lenses, prescriptions or fitting of eyeglasses or contact lenses, vision correction surgery, or other treatment for visualdefects and problems; except when due to a covered Injury or disease process; 15. Flat foot conditions; supportive devices for the foot; fallen arches; weak feet; chronic foot strain; symptomatic complaints of the feet; and routine foot care including thecare, cutting and removal of corns, calluses, toenails, and bunions (except capsular orbone surgery); 16. Health spa or similar facilities; strengthening programs; 17. Hearing examinations or hearing aids; or cochlear implants; or other treatment for hearing defects and problems, except as a result of an infection or trauma. "Hearingdefects" means any physical defect of the ear which does or can impair normalhearing, apart from the disease process; 20. Immunizations, except as specifically provided in the policy; preventive medicines or vaccines, except where required for treatment of a covered Injury or as specificallyprovided in the policy; 21. Injury or Sickness for which benefits are paid or payable under any Workers' Compensation or Occupational Disease Law or Act, or similar legislation; 22. Injury or Sickness outside the United States and its possessions, Canada or Mexico, except for a Medical Emergency when traveling for academic study abroad programs,business or pleasure; 23. Injury sustained while (a) participating in any intercollegiate, or professional sport, contest or competition; (b) traveling to or from such sport, contest or competition asa participant; or (c) while participating in any practice or conditioning program for suchsport, contest or competition; 24. Investigational services;25. Lipectomy;26. Loss sustained or contracted in consequence of the Insured’s being intoxicated or under the influence of any controlled substance unless administered on the advice ofa Physician; 27. Participation in a riot or civil disorder; commission of or attempt to commit a felony; or 28. Pre-Existing Conditions, except for individuals who have been continuously insured for at least 6 consecutive months under any health insurance plan or policy oremployer-provided health benefit arrangement. Credit for time served will be givenwhen covered under Creditable Coverage provided the individual becomes eligibleand enrolls under this policy within 63 days of termination of the prior plan. Thisexclusion will not be applied to an Insured Person who is under age 19; 29. Prescription Drugs Services - no benefits will be payable for: a) Therapeutic devices or appliances, including hypodermic needles, syringes, support garments and other non-medical substances, regardless of intendeduse, except as specifically 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 d) Products used for cosmetic purposes;e) Drugs used to treat or cure baldness, and anabolic steroids used for body f) Anorectics - drugs used for the purpose of weight control;g) Fertility agents, or sexual enhancement drugs, such as Parlodel, Pergonal, Clomid, Profasi, Metrodin, Serophene; or Viagra; i) Drugs used for tobacco cessation, except as specifically provided in the policy; j) Refills in excess of the number specified or dispensed after one (1) year of date 30. Reproductive/Infertility services including but not limited to: family planning; fertility tests; infertility (male or female), including any services or supplies rendered for thepurpose or with the intent of inducing conception; premarital examinations;impotence, organic or otherwise; female sterilization procedures, except asspecifically provided in the policy; vasectomy; sexual reassignment surgery; reversalof sterilization procedures; 31. Research or examinations relating to research studies, or any treatment for which the patient or the patient’s representative must sign an informed consent documentidentifying the treatment in which the patient is to participate as a research study orclinical research study; except as specifically provided in the policy; 32. Routine Newborn Infant Care, well-baby nursery and related Physician charges except as specifically provided in the policy; 33. Preventive care services; routine physical examinations and routine testing; preventive testing or treatment; screening exams or testing in the absence of Injury or Sickness;except as specifically provided in the policy; 34. Services provided normally without charge by the Health Service of the Policyholder; or services covered or provided by the student health fee; 35. Deviated nasal septum, including submucous resection and/or other surgical correction thereof; nasal and sinus surgery, except for treatment of a covered Injury ortreatment of chronic purulent sinusitis; 36. 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 aregularly scheduled flight of a commercial airline; 38. Speech therapy; naturopathic services;39. Suicide or attempted suicide while sane or insane (including drug overdose); or 40. Supplies, except as specifically provided in the policy; 41. Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices, or gynecomastia; except as specifically provided in the policy; 42. Treatment in a Government hospital, unless there is a legal obligation for the Insured 43. 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 notcovered); and 44. Weight management, weight reduction, nutrition programs, treatment for obesity, surgery for removal of excess skin or fat.
Collegiate Assistance Program
Insured Students have access to nurse advice, health information, and counseling support24 hours a day by dialing the number listed on the permanent ID card. CollegiateAssistance Program is staffed by Registered Nurses and Licensed Clinicians who can helpstudents determine if they need to seek medical care, need legal/financial advice or mayneed to talk to someone about everyday issues that can be overwhelming.
FrontierMEDEX: Global Emergency Services
If you are a student insured with this insurance plan, you and your insured
spouse/Domestic Partner and minor child(ren) are eligible for FrontierMEDEX. The
requirements to receive these services are as follows:
Domestic Students, insured spouse/Domestic Partner and insured minor child(ren): You
are eligible for FrontierMEDEX services when 100 miles or more away from your campus
address and 100 miles or more away from your permanent home address or while
participating in a Study Abroad program.
International Students, insured spouse/Domestic Partner and insured minor child(ren): You
are eligible to receive FrontierMEDEX services worldwide, except in your home country.
FrontierMEDEX includes Emergency Medical Evacuation and Return of Mortal Remains
that meet the US State Department requirements. The Emergency Medical Evacuation
services are not meant to be used in lieu of or replace local emergency services such as an
ambulance requested through emergency 911 telephone assistance. All services must be
arranged and provided by FrontierMEDEX; any services not arranged by FrontierMEDEX
will not be considered for payment.
Key Services include:
Please visit www.uhcsr.com/frontiermedex for the FrontierMEDEX brochure which
includes service descriptions and program exclusions and limitations.
To access services please call:
(800) 527-0218 Toll-free within the United States
(410) 453-6330 Collect outside the United States
Services are also accessible via e-mail at operations@frontiermedex.com.
When calling the FrontierMEDEX Operations Center, please be prepared to provide: 1. Caller's name, telephone and (if possible) fax number, and relationship to the 2. Patient's name, age, sex, and FrontierMEDEX ID Number as listed on your 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; and6. Information of where the physician can be immediately reached.
FrontierMEDEX is not travel or medical insurance but a service provider for emergencymedical assistance services. All medical costs incurred should be submitted to your healthplan and are subject to the policy limits of your health coverage. All assistance servicesmust be arranged and provided by FrontierMEDEX. Claims for reimbursement of servicesnot provided by FrontierMEDEX will not be accepted. Please refer to the FrontierMEDEXinformation in MyAccount at www.uhcsr.com/MyAccount for additional information,including limitations and exclusions.
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 Persondisagrees with the Company’s denial, in whole or in part, of a claim or request for benefits.
The Insured Person, or the Insured Person’s Authorized Representative, must submit awritten request for an Internal Appeal within 180 days of receiving a notice of theCompany’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);3. The date(s) of service;4. The Provider’s name;5. The reason the claim should be reconsidered; and6. Any written comments, documents, records, or other material relevant to the claim.
Please contact the Customer Service Department at 800-767-0700 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 inwriting, for an Expedited Internal Appeal.
An Urgent Care Request means a request for services or treatment where the time periodfor completing 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 adequatelymanaged without 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.
Right to External Independent Medical Review
An Insured Person may apply to the Department of Insurance for an External Independent
Medical Review when the Insured Person receives a Final Adverse Benefit Determination
which denies, modifies, or delays health care services based, in whole or in part, on a finding
that the disputed health care services are not Medically Necessary or are not Covered
Medical Expenses under the Policy. The Insured’s request for an External Independent
Medical Review must be submitted to the Department within six months after the Insured
receives the Final Adverse Benefit Determination notice. However, the Commissioner may
extend the application deadline beyond six months if the circumstances of a case warrant
the extension.
As part of its notification to the Insured regarding a disposition of the Insured’s Final
Adverse Benefit Determination, the Company shall provide an application form approved by
the Department, and an addressed envelope, which the Insured may return to initiate an
External Independent Medical Review.
Where to Send Requests for External Independent Medical Review
All requests for External Independent Medical Review shall be submitted to the stateinsurance department at the following address: California Department of InsuranceHealth Claims Bureau, IMR Unit300 S. Spring Street11th FloorLos Angeles, CA 90013Inside State Toll-Free: (800) 927-4357Outside State: (213) 897-8921Fax: (213) 897-9641 Questions Regarding Appeal Rights
Contact Customer Service at 800-767-0700 with questions regarding the Insured Person’srights to an Internal Appeal and External Independent Medical Review.
Other resources are available to help the Insured Person navigate the appeals process. Forquestions about appeal rights, your state consumer assistance program may be able toassist you at: Department of Managed Health Care Help Center980 Ninth Street, Suite 500Sacramento, CA 95814-2725Toll-Free: (888) 466-2219Fax: (916) 255-5241Website: www.healthhelp.ca.govEmail: helpline@dmhc.ca.gov Online Access to Account Information
UnitedHealthcare StudentResources Insureds have online access to claims status, EOBs,
ID Cards, network providers, correspondence and coverage information by logging in to My
Account at www.uhcsr.com/myaccount. Insured students who don’t already have an online
account may simply select the “create My Account Now” link. Follow the simple, onscreen
directions to establish an online account in minutes using your 7-digit Insurance ID number
or the email address on file.
As part of UnitedHealthcare StudentResources’ environmental commitment to reducing
waste, we’ve introduced a number of initiatives designed to preserve our precious
resources while also protecting the security of a student’s personal health information.
My Account has been enhanced to include Message Center - a self-service tool that
provides a quick and easy way to view any email notifications we may have sent. In Message
Center, notifications are securely sent directly to the Insured student’s email address. If the
Insured student prefers to receive paper copies, he or she may opt-out of electronic delivery
by going into My Email Preferences and making the change there.
UnitedHealth Allies
Insured students also have access to the UnitedHealth Allies® discount program. Simply
log in to My Account as described above and select UnitedHealth Allies Plan to learn more
about the discounts available. When the Medical ID card is viewed or printed, the
UnitedHealth Allies card is also included. The UnitedHealth Allies Program is not insurance
and is offered by UnitedHealth Allies, a UnitedHealth Group company.
Claim Procedure
In the event of Injury or Sickness, students should:1) Report to the Student Health Service for treatment, or when not in school, to their 2) Mail to the address below all medical and hospital bills along with the patient's name and insured student's name, address and name of the university under which thestudent 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 yearwill not be considered for payment except in the absence of legal capacity.
The Plan is Underwritten by
Direct Eligibility, Enrollment and General Questions to the Plan Administrator:
Wells Fargo Insurance Services USA, Inc.
Submit Claims to:
UnitedHealthcare StudentResources
Please keep this Brochure as a general summary of the insurance. The Master Policy onfile at the Institute contains all of the provisions, limitations, exclusions and qualifications ofyour insurance benefits, some of which may not be included in this Brochure. The MasterPolicy is the contract and will govern and control the payment of benefits.
This Brochure is based on Policy #2013-200418-73

Source: http://www.miis.edu/media/view/33586/original/final_brochure_from_united.pdf