2010-1990-brochure-v7.qxp

Limited Benefit Plan. Please Read Carefully Privacy Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Effective And Termination Dates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Extension of Benefits After Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Pre-Admission Notification- Plan 1 & 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Schedule of Medical Expense Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3UnitedHealthcare Network Pharmacy Benefits- Plan 1 & 4 . . . . . . . . . . . . . . . . . . . . . . . . .6Maternity Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Coordination of Benefits- Plan 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Mandated Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Benefits for Mammographic Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Benefits for Newborn Infants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Benefits for Medical Foods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Benefits for Women’s Preventive Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Benefits for Serious Mental Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Benefits for Alcohol/Drug Abuse and Dependency Treatment . . . . . . . . . . . . . . . . .11Benefits for Management and Treatment of Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . .12Benefits for Post Partum Home Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13Benefits for Childhood Immunizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13Benefits for Autism Spectrum Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13Benefits for Mastectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Benefits for Colorectal Cancer Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 Exclusions And Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15Scholastic Emergency Services: Plan 1 & 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17Claim Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 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 800-767-0700 or by visiting us at www.uhcsr.com.
To determine which plan is available at your school, contact your school.
PLAN 1 - All international students registered for credit courses are automatically enrolledin Plan 1 of this insurance plan at registration, unless proof of comparable coverage isfurnished. All Domestic students registered for credit courses are eligible to enroll in eitherPlan 1 or 2 of this insurance plan.
PLAN 2 - All Domestic students registered for credit courses are eligible to enroll in eitherPlan 1 or 2 of this insurance plan.
PLAN 4 - At schools that only offer the Plan 4 International Plan. All international studentsregistered for credit courses are automatically enrolled in Plan 4 of this insurance plan atregistration, unless proof of comparable coverage is furnished. (Plan 1 & 2 are not available)Students must actively attend classes for at least the first 31 days after the date for whichcoverage is purchased. The Company maintains its right to investigate student status andattendance 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 torefund premium.
Alternative Coverage - If you do not meet the Eligibility requirements of the Plan, please call1-800-980-7395 for information on alternative coverage. This information can also beaccessed at http://www.goldenrulehealth.com/studentresources The Master Policy on file at the school becomes effective at 12:01 a.m., August 15, 2010.
Coverage becomes effective on the first day of the period for which premium is paid or thedate the enrollment form and full premium are received by the Company (or its authorizedrepresentative), whichever is later. The Master Policy terminates at 12:01 a.m., August 15,2011. Coverage terminates on that date or at the end of the period through which premiumis paid, whichever is earlier. Refunds of premiums are allowed only upon entry into thearmed forces.
The Policy is a Non-Renewable One Year Term Policy.
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 12 months 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 of Benefits” provision has been exhausted, all benefits cease to exist,and under no circumstances will further payment be made.
Pre-Admission Notification- Plan 1 & 4 UMR Care Management should be notified of all Hospital Confinements prior to admission.
PRE-NOTIFICATION OF MEDICAL NON-EMERGENCY HOSPITALIZATION: Thepatient, Physician or Hospital should telephone 1-877-295-0720 at least five workingdays prior to the planned admission.
NOTIFICATION OF MEDICAL EMERGENCY ADMISSIONS: The patient, patient'srepresentative, Physician or Hospital should telephone 1-877-295-0720 within twoworking days of the admission to provide notification of any admission due to MedicalEmergency.
UMR Care Management is open for Pre-Admission Notification calls from 8:00 a.m. to 6:00p.m. C.S.T., Monday through Friday. Calls may be left on the Customer Service Department'svoice mail after hours by calling 1-877-295-0720.
IMPORTANT: Failure to follow the notification procedures will not affect benefits otherwisepayable under the policy; however, pre-notification is not a guarantee that benefits will bepaid.
Schedule of Medical Expense Benefits - Injury and Sickness Plan 1 & 4 - Up to $250,000 Maximum Benefit (For each Injury or Sickness) Plan 2 - Up to $10,000 Maximum Benefit for each Injury; Up to $2,500 Maximum Benefit for each Sickness Usual & Customary Charges are based on data provided by Ingenix using the 90thpercentile based on location of provider. Plan 1 & 4: Benefits will be paid for 100% of Covered Medical Expenses incurred up to$7,500. After the Company has paid $7,500, benefits will be paid for 80% of additionalCovered Medical Expenses not to exceed $50,000. After the Company has paid$50,000, benefits will be paid for 100% of additional Covered Medical Expenses incurrednot to exceed the $250,000 Maximum Benefit for each Injury or Sickness. Plan 2: Injury Only - Benefits will be paid for 100% of Covered Medical Expenses incurredup to $500. After the Company has paid $500, benefits will be paid for 80% of additionalCovered Medical Expenses not to exceed the Maximum Benefit of $10,000 for eachInjury. Plan 2: Sickness Only - Benefits will be paid for 100% of Covered Medical Expenses notto exceed the Maximum Benefit of $2,500 for each Sickness. Benefits will be paid up to the Maximum Benefit for each service scheduled below.
Covered Medical Expenses include: Room & Board Expense, daily semi-private U&C S e m i - Pr i v a t e S e m i - Pr i v a t e room rate; and general nursing care provided Hospital Miscel aneous Expenses, such as U&C the cost of the operating room, laboratorytests, x-ray examinations, anesthesia, drugs(excluding take home drugs) or medicines,therapeutic services, and supplies. Incomputing the number of days payable underthis benefit, the date of admission will becounted, but not the date of discharge.
Surgeon’s Fees, in accordance with data U&C provided by Ingenix. If two or moreprocedures are performed through the sameincision at the same operative session, themaximum amount paid will not exceed 50%of the second procedure and 50% of allsubsequent procedures.
30% of Surgery 30% of Surgery 30% of SurgeryAllowance Registered Nurse’s Services, private duty U&C Physician’s Visits, benefits are limited to one U&C visit per day and do not apply when related tosurgery.
Pre-Admission Testing, payable within 7 U&C Psychotherapy, Benefits are limited to one Paid as any OUTPATIENT
Surgeon’s Fees, in accordance with data U&C provided by Ingenix. If two or moreprocedures are performed through the sameincision at the same operative session, themaximum amount paid will not exceed 50%of the second procedure and 50% of allsubsequent procedures.
Day Surgery Miscellaneous, related to U&C 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 andCustomary Charges for Day SurgeryMiscellaneous are based on the OutpatientSurgical Facility Charge Index.
OUTPATIENT
30% of Surgery 30% of Surgery 30% of SurgeryAllowance administered in connection with outpatientsurgery.
Physician’s Visits, benefits are limited to one U&C visit per day. Benefits for Physician’s Visitsdo not apply when related to surgery orPhysiotherapy.
Physiotherapy, benefits are limited to one U&C Medical Emergency Expenses, use of the U&C emergency room and supplies. Treatmentmust be rendered within 72 hours from timeof Injury or first onset of Sickness. Diagnostic X-ray & Laboratory Services Tests & Procedures, diagnostic services and U&C medical procedures performed by aPhysician, other than Physician’s Visits,Physiotherapy, x-rays and lab procedures. Injections, when administered in the U&C Physician’s office and charged on thePhysician’s statement. For Plan I: UnitedHealthcare Network (Per Policy Year) $750 max Pharmacy, $0 copay per prescription tier 1, tier 2, tier 3 / up to a 31 day supply perprescription.
Psychotherapy, benefits are limited to one Paid as any visit per day. Includes all related or ancillary other Sickness charges incurred as a result of a Mental orNervous Disorder.
Durable Medical Equipment, a written U&C prescription must accompany the claimwhen submitted. Replacement equipment isnot covered.
Consultant Physician Fees, when requested U&C and approved by the attending Physician.
Dental Treatment, made necessary by Injury U&C Maternity & Complications of Pregnancy United Healthcare Network Pharmacy Benefits- Plan 1 & 4 Benefits are available for outpatient Prescription Drugs on our Prescription Drug List (PDL)when dispensed by a UnitedHealthcare Network Pharmacy. Benefits are subject to supplylimits and copayments that vary depending on which tier of the PDL the outpatient drug islisted. There are certain Prescription Drugs that require your Physician to notify us to verifytheir use 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 or call877-417-7345 for the most up-to-date tier status.
$0 copay per prescription or refill for tier 1 Prescription Drug up to 31 day supply.
$0 copay per prescription or refill for tier 2 Prescription Drug up to 31 day supply.
$0 copay per prescription or refill for tier 3 Prescription Drug up to 31 day supply.
Your maximum al owed benefit is $1,500.
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 paidreceipt in order to be reimbursed. To obtain reimbursement forms, or for information aboutnetwork pharmacies, please call 877-417-7345.
Additional ExclusionsIn addition to the policy Exclusions and Limitations, the following Exclusions apply toNetwork 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 determined bythe 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 Prescription Order or Refill.
Compounded drugs that are available as a similar commercially available PrescriptionDrug Product. Compounded drugs that contain at least one ingredient that requires aPrescription 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 designated theover-the counter medication as eligible for coverage as if it were a Prescription DrugProduct 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 comprised ofcomponents 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 to sixtimes during a calendar year, and the Company may decide at any time to reinstateBenefits for a Prescription Drug Product that was previously excluded under thisprovision.
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 Injuryexcept as required by state mandate.
DefinitionsPrescription Drug or Prescription Drug Product means a medication, product or device thathas been approved by the U.S. Food and Drug Administration and that can, under federalor state law, be dispensed only pursuant to a Prescription Order or Refill. A PrescriptionDrug 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 benefitsunder the policy, this definition includes insulin.
Prescription Drug List means a list that categorizes into tiers medications, products ordevices that have been approved by the U.S. Food and Drug Administration. This list issubject to the Company’s periodic review and modification (generally quarterly, but no morethan six times per calendar year). The Insured may determine to which tier a particularPrescription Drug Product has been assigned through the Internet at www.uhcsr.com or callCustomer Service 1-877-417-7345.
This policy does not cover routine, preventive or screening examinations or testing unlessmedical necessity is established based on medical records. The following maternity androutine tests and screening exams will be considered if all other policy provisions have beenmet. This includes a pregnancy test, CBC, Hepatitis B Surface Antigen, Rubella Screen,Syphilis Screen, Chlamydia, HIV, Gonorrhea, Toxoplasmosis, Blood Typing ABO, RH BloodAntibody Screen, Urinalysis, Urine Bacterial Culture, Microbial Nucleic Acid Probe, AFPBlood Screening, Pap Smear, and Glucose Challenge Test (at 24-28 weeks gestation). Oneultrasound will be considered in every pregnancy, without additional diagnosis. Anysubsequent ultrasounds can be considered if a claim is submitted with the PregnancyRecord and Ultrasound report that establishes Medical Necessity. Additionally, thefollowing tests will be considered for women over 35 years of age: Amniocentesis/AFPScreening and Chromosome Testing. Fetal Stress/Non-Stress tests are payable. Pre-natalvitamins are not covered. For additional information regarding Maternity Testing, please callthe Company at 1-800-767-0700.
Definitions:(1) Allowable Expenses: Any necessary, reasonable, and customary item of expense, a part of which is covered by at least one of the Plans covering the Insured Person.
An Allowable Expense to a Secondary Plan includes the value or amount of anyDeductible Amount or Coinsurance Percentage or amount of otherwise AllowableExpenses which was not paid by the Primary or first paying Plan.
(2) Plan: A group insurance plan or health service corporation group membership plan or any other group benefit plan providing medical or dental care treatment benefits orservices. Such group coverages include: (a) group or blanket insurance coverage, orany other group type contract or provision thereof; this will not include school accidentcoverage or group hospital indemnity plan of $100 per day or less; (b) service plancontracts, group practice and other pre-payment group coverage; (c) any coverageunder labor-management trustees plans, union welfare plans, employer and employeeorganization plans; and (d) coverage under governmental programs, includingMedicare, and any coverage required or provided by statute; this will not include a stateplan under Medicaid, and will not include a law or plan when, by law, its benefits areexcess to those of a private insurance plan or other non-governmental plan.
(3) Primary: The Plan which pays regular benefits.
(4) Secondary: The Plan which pays a reduced amount of benefits which, when added to the Primary Plan's benefits will not be more than the Allowable Expenses.
(5) We, Us or Our: The Company named in the policy.
Effect on Benefits - If an Insured Person has medical and/or drug coverage under anyother Plan, all of the benefits provided are subject to coordination of benefits.
During any policy year or benefit period, the sum of the benefits that are payable by Us andthose that are payable from another Plan may not be more than the Allowable Expenses.
During any policy year or benefit period, We may reduce the amount We will pay so that thisreduced amount plus the amount payable by the other Plans will not be more than theAllowable Expenses. Allowable Expenses under the other Plan include benefits whichwould have been payable if a claim had been made.
However, if: (1) the other Plan contains a section which provides for determining its benefitsafter Our benefits have been determined; and (2) the order of benefit determination statedherein would require Us to determine benefits before the other Plan, then the benefits ofsuch other Plan will be ignored in determining the benefits We will pay.
This Plan determines its order of benefits using the first of the following rules which applies: If your other Plan does not have Coordination of Benefits, that Plan pays first.
Non-Dependent/Dependent. The benefits of the Plan which covers the person as anemployee, member or subscriber are determined before those of the Plan whichcovers the person as a Dependent.
Dependent Child/Parents Not Separated or Divorced. When This Plan and anotherPlan cover the same child as a Dependent of different persons, called "parents": the benefits of the Plan of the parent whose birthday falls earlier in a year exclusive of year of birth are determined before those of the Plan of the parent whose if both parents have the same birthday, the benefits of the Plan which covered the parent longer are determined before those of the Plan which covered the other parent for a shorter period of time.
However, if the other Plan does not have the rule described in a. above, but instead has arule based upon the gender of the parent, and if, as a result, the Plans do not agree on theorder of benefits, the rule in the other Plan will determine the order of benefits. (4) Dependent Child/Separated or Divorced Parents. If two or more Plans cover a person as a Dependent child of divorced or separated parents, benefits for the child aredetermined in this order: first, the Plan of the parent with custody of the child; then, the Plan of the spouse of the parent with the custody of the child; and finally, the Plan of the parent not having custody of the child.
However, if the specific terms of a court decree state that one of the parents is responsible for the health care of the child, and the entity obligated to pay or provide the benefits of the Plan of that parent has actual knowledge of these terms, the benefits of that (5) Longer/Shorter Length of Coverage. If none of the above rules determines the order of benefits, the benefits of the Plan which covered an employee, member orsubscriber longer are determined before those of the Plan which covered that personfor the shorter time.
Right to Recovery and Release of Necessary Information - For the purpose of determiningapplicability of and implementing the terms of this Provision, We may, without furtherconsent or notice, release to or obtain from any other insurance company or organizationany information, with respect to any person, necessary for such purposes. Any personclaiming benefits under Our coverage shall give Us the information We need to implementthis Provision. We will give notice of this exchange of claim and benefit information to theInsured Person when any claim is filed.
Facility of Payment and Recovery - Whenever payments which should have been madeunder our Coverage have been made under any other Plans, We shall have the right to payover to any organizations that made such other payments, any amounts that are needed inorder to satisfy the intent of this Provision. Any amounts so paid will be deemed to bebenefits paid under Our coverage. To the extent of such payments, We will be fullydischarged from Our liability.
Whenever We have made payments with respect to Allowable Expenses in total amount atany time, which are more than the maximum amount of payment needed at that time tosatisfy the intent of this Provision, We may recover such excess payments. Such excesspayments may be received from among one or more of the following, as We determine: anypersons to or for or with respect to whom such payments were made, any other insurers,service plans or any other organizations.
This Coordination of Benefits Provision will not be applied to the first $100 of medicalexpenses incurred.
If the policy contains a Deductible provision, the Deductible provision will not be applied tothe first $100 of medical expenses incurred.
Injury means bodily injury: 1) causing loss directly or independently of all other causes 2)treated by a Physician within 30 days after the date of accident; and 3) which is sustainedon or after the Effective Date of insurance as to the Insured Person during the term of thepolicy. Covered Medical Expenses incurred as a result of an injury that occurred prior to thispolicy's Effective Date will be considered a Sickness under this policy.
Sickness means sickness or disease of the Insured Person which causes loss while theInsured Person is covered under this policy. All related conditions and recurrent symptomsof the same or a similar condition not separated by more than six months will be consideredone sickness. Covered Medical Expenses incurred as a result of an Injury that occurred priorto this policy's Effective Date will be considered a sickness under this policy.
Usual and Customary Charges means a reasonable charge which is: 1) usual andcustomary when compared with the charges made for similar services and supplies; and 2)made to persons having similar medical conditions in the locality where service is rendered.
No payment will be made under the Policy for any expenses incurred which in the judgmentof the Company are in excess of Usual and Customary Charges.
Benefits for Mammographic Examination Benefits will be paid the same as any other Sickness for mammographic examinations asfollows: 1) every year for an Insured 40 years of age or older; and 2) any mammogrambased on a Physician's recommendation for an Insured under 40 years of age.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
Newborn Infants will be covered under the policy for the first 31 days after birth. Coveragefor such a child will be for Injury or Sickness, including medically diagnosed congenitaldefects, birth abnormalities, prematurity and nursery care; benefits will be the same as forthe Insured Person who is the child's parent.
Benefits will be paid the same as any other Sickness for the cost of nutritional supplements(formulas) as medically necessary for the therapeutic treatment of Phenylketonuria (PKU),branched-chain ketonuria, galactosemia and homocystinuria that are aminoacidopathies,rare hereditary genetic metabolic disorders, and administered under the direction of aPhysician. Benefits are not for normal food products used in dietary management of thesedisorders, but are for formulas that are equivalent to a prescription drug, medicallynecessary for the therapeutic treatment of such rare hereditary genetic metabolic disordersand administered under the direction of a Physician.
Benefits shall be subject to all copayment, coinsurance, limitations, or any other provisionsof the policy. The policy Deductible will not be applied to this benefit.
Benefits for Women’s Preventive Health Services Benefits will be paid the same as any other Sickness for: 1) an annual gynecologicalexamination, including a pelvic examination and clinical breast examination; and 2) routinepap smears in accordance with the recommendations of the American College ofObstetricians and Gynecologists.
The policy Deductible and dollar limitations will not be applied to this benefit. Benefits shallbe subject to copayment, coinsurance, limitations, or any other provisions of the policy.
Benefits for Serious Mental Il ness Benefits will be paid the same as any other Sickness for treatment of Serious Mental Illnesslimited to 30 inpatient days annually and 60 days outpatient annually. The Insured Personmay convert inpatient days to outpatient days on a one-to-two basis.
"Serious Mental Illness" means any of the following mental illnesses as defined by theAmerican Psychiatric Association in the most recent edition of the Diagnostic and StatisticalManual: Benefits are subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Alcohol/Drug Abuse and Dependency Treatment Benefits will be provided for treatment of Alcohol or Drug Abuse and dependency on thesame basis as any other Sickness subject to the following:Inpatient detoxification will be provided in a Hospital or in an inpatient non-hospital facilitywhich has a written affiliation agreement with a Hospital for emergency, medical andpsychiatric or psychological support services, meets minimum standards for client-to-staffratios and staff qualifications that are established by the Department of Health and islicensed as an alcoholism and/or drug addiction treatment program. Inpatient detoxificationis limited to no more than four (4) admissions per lifetime. Benefits are limited to seven (7)days of treatment per admission. The following services are covered under inpatientdetoxification: Physician, psychologist, nurse, certified addictions counselor and trained staffservices.
Psychiatric, psychological and medical laboratory testing.
Drugs, medicines, equipment use and supplies.
Non-Hospital residential care will be provided for (30) days per policy year in a facility thatmeets minimum standards for client-to-staff ratios and staff qualifications that areestablished by the Office of Drug and Alcohol programs and is appropriately licensed by theDepartment of Health as an alcoholism or drug addiction treatment program. Insureds mustbe referred to the program by a Physician. Benefits are subject to lifetime maximum of (90)days per person. The following services are covered under residential care: Physician, psychologist, nurse, certified addictions counselor and trained staffservices.
Rehabilitation therapy and counseling.
Psychiatric, psychological and medical laboratory tests.
Drugs, medicines, equipment use and supplies. Outpatient care shall be provided in a facility appropriately licensed by the Department ofHealth as an alcoholism or drug addiction treatment program. Before an Insured may qualifyto receive benefits under this section, a licensed Physician or licensed psychologist mustcertify the Insured as a person suffering from alcohol or other drug abuse or dependencyand refer the Insured for the appropriate treatment. The following services shall be provided: Physician, psychologist, nurse, certified addictions counselor and trained staffservices.
Rehabilitation therapy and counseling.
Psychiatric, psychological and medical laboratory tests.
Drugs, medicines, equipment use and supplies.
Treatment shall be provided for a minimum of (30) outpatient, full-session visits orequivalent partial visits per policy year. These visits may not be exchanged for non-hospital,residential alcohol treatment services. In addition, treatment shall be provided for a minimum of (30) outpatient, full-session visitsor equivalent partial hospitalization services per policy year. These visits may be exchangedon a two-for-one basis up to (15) non-hospital, residential alcohol treatment days.
Benefits are limited to (120) outpatient, full session visits or equivalent partial visits.
Definitions:"Alcohol or Drug Abuse" means any use of alcohol or other drugs which produces a patternof pathological use causing impairment in social or occupational functioning or whichproduces physiological dependency evidenced by physical tolerance or withdrawal. "Detoxification" means the process whereby an alcohol-intoxicated or drug-intoxicatedperson is assisted, in a facility licensed by the Department of Health, through the period oftime necessary to eliminate, by metabolic or other means, the intoxicating alcohol or otherdrugs, alcohol and other drug dependency factors or alcohol in combination with drugs asdetermined by a licensed Physician, while keeping the physiological risk to the patient at aminimum.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Management and Treatment of Diabetes Benefits will be paid the same as any other Sickness for the equipment, supplies andoutpatient self-management training and education, including medical nutrition therapy forthe treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetesand non-insulin-using if prescribed by a Physician legally authorized to prescribe such itemsunder law.
Benefits shall be provided for equipment and supplies including the following: bloodglucose monitors, monitor supplies, insulin, injection aids, syringes, insulin infusion devices,pharmacological agents for controlling blood sugar and orthodics.
Diabetes outpatient self-management training and education shall be provided under thesupervision of a licensed Physician with expertise in diabetes to ensure that persons withdiabetes are educated as to the proper self-management and treatment of their diabetes,including information on proper diets. Coverage for self-management education andeducation relating to diet and prescribed by a licensed Physician shall include: (1) visits medically necessary upon the diagnosis of diabetes;(2) visits under circumstances whereby a Physician identifies or diagnoses a significant change in the patient's symptoms or conditions that necessitates changes in a patient'sself-management; and (3) a new medication or therapeutic process relating to the person's treatment and/or management of diabetes has been identified as medically necessary by a licensedPhysician.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Post Partum Home Health Care Benefits will be paid the same as any other Sickness for at least one home health care visitwithin 48 hours after discharge from inpatient care when discharge occurs prior to the timeof 48 hours of inpatient care following a normal vaginal delivery and 96 hours of inpatientcare following a cesarean delivery. Such visits shall be made by a Physician whose scopeof practice includes post partum care. Home health care visits shall include parenteducation, assistance and training in breast and bottle feeding, infant screening and clinicaltests and the performance of any necessary maternal and neonatal physical assessments.
At the mother's sole discretion, any visits may occur at the facility of the provider. The policy Deductible, copayment, coinsurance will not be applied to this benefit. Benefitsshall be subject to all other limitations or any other provisions of the policy.
Benefits for Childhood Immunizations Benefits will be paid the same as any other Sickness for the Named Insured who is under21 years of age, or the Named Insured's spouse who is under 21 years of age, or aDependent Child for those childhood immunizations, including the immunizing agents,which as determined by the Department of Health conform with the standards of the(Advisory Committee on Immunization Practices of the Center for Disease Control) U.S.
Department of Health and Human Services. The benefit will provide coverage for the costof the immunization of a child, up to 150% of the average wholesale price (AWP), which, asdetermined by the Department of Health, conform with the standards of the AdvisoryCommittee on Immunization Practices of the Center for Disease Control, the United StatesDepartment of Health and Human Services.
The policy Deductible and dollar limitations will not be applied to this benefit. Benefits shallbe subject to copayment, coinsurance, limitations, or any other provisions of the policy.
Benefits for Autism Spectrum Disorder Benefits will be paid the same as any other Sickness for assessment and treatment ofAutism Spectrum Disorder for Insured Persons under the age twenty-one not to exceed amaximum benefit of $36,000 per policy year. However, benefits are not subject to amaximum number of visits to an autism services provider.
“Autism Spectrum Disorders” means any of the pervasive developmental disorders definedby the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders(DSM), or its successor, including autistic disorder, Asperger’s disorder and pervasivedevelopmental disorder not otherwise specified.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
Benefits will be paid the same as any other Sickness for inpatient care following aMastectomy for the length of stay that the treating Physician determines is necessary tomeet generally accepted criteria for safe discharge.
Benefits will be paid the same as any other Sickness for a home health care visit that thetreating Physician determines is necessary within forty-eight (48) hours after dischargewhen the discharge occurs within forty-eight (48) hours following admission for theMastectomy.
Benefits will be paid the same as any other Sickness for Prosthetic Devices, physicalcomplications including lymphedemas, and Reconstructive Surgery incident to anyMastectomy in a manner determined in consultation with the attending Physician and theInsured Person.
Mastectomy means the removal of all or part of the breast for medically necessary reasons,as determined by a licensed Physician. Prosthetic devices means the use of initial andsubsequent artificial devices to replace the removed breast or portions thereof, pursuant toan order of the Insured's Physician.
Reconstructive surgery means a surgical procedure performed on one breast or bothbreasts following a Mastectomy, as determined by the treating Physician, to reestablishsymmetry between the two breasts or alleviate functional impairment caused by theMastectomy. Reconstructive surgery shall include, but is not limited to, augmentationmammoplasty, reduction mammoplasty and mastopexy. Symmetry between breasts meansapproximate equality in size and shape of the nondiseased breast with the diseased breastafter definitive reconstructive surgery on the diseased or nondiseased breast has beenperformed.
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 a medically recognized screeningexamination for the detection of colorectal cancer for an Insured age 50 years of age orolder and at normal risk for developing colon cancer. Benefits shall include, but not belimited to: a) a fecal occult blood test performed annually;b) a flexible sigmoidoscopy and a screening barium enema every five years; andc) a colonoscopy performed every 10 years; Benefits for an Insured at high risk for colorectal cancer shall include but not be limited to:colorectal cancer screening examinations and laboratory tests as recommended by thetreating Physician.
Benefits for a nonsymptomatic Insured who is at a high or increased risk for colorectalcancer and who is under fifty years of age shall include but not be limited to: a colonoscopy,sigmoidoscopy, or any combination of colorectal cancer screening tests in accordance withthe American Cancer Society guidelines on screening for colorectal cancer published as ofJanuary 1, 2008.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
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:1.
Congenital conditions for cosmetic purposes only; except as specifically provided forNewborn Infants; 7a. For Plan 1 & 4: Cosmetic procedures, except cosmetic surgery required to correct an Injury for which benefits are otherwise payable under this policy; or for newborn children; 7b. For Plan 2: Cosmetic procedures, except cosmetic surgery required to correct an Injury for which benefits are otherwise payable under this policy, or for newborn children;removal of warts, non-malignant moles and lesions; Dental treatment, except for accidental Injury to Sound, Natural Teeth; Elective Surgery or Elective Treatment as defined in the policy; except cosmetic surgerynecessitated by a covered Injury; 10. Elective abortion;11. Eye examinations, eyeglasses, contact lenses, prescriptions or fitting of eyeglasses or contact lenses, or other treatment for visual defects and problems; except wheretreatment is a Medical Necessity due to a covered Injury or; except when due to adisease process; 12. Foot care including: care of corns, bunions (except capsular or bone surgery), calluses;13. Hearing examinations or hearing aids; or other treatment for hearing defects and problems; except where treatment is a Medical Necessity due to a covered Injury.
"Hearing defects" means any physical defect of the ear which does or can impairnormal hearing, apart from the disease process; 14. Hirsutism; Alopecia;15. Immunizations, except as specifically provided in the policy; preventive medicines or vaccines, except where required for treatment of a covered Injury; 16. Injury caused by, contributed to, or resulting from the Insured’s being intoxicated or under the influence of any narcotic unless administered on the advice of a Physician; 17. Injury or Sickness for which benefits are paid under any Workers' Compensation or Occupational Disease Law or Act, or similar legislation; 18. No benefits under the policy will duplicate any benefits provided by the Pennsylvania Motor Vehicle Financial Responsibility Law; 19. Experimental organ transplants;20. Participation in a riot or civil disorder; commission of or attempt to commit a felony;21. Prescription Drugs, services or supplies as follows, except as specifically provided in Therapeutic devices or appliances, including: hypodermic needles, syringes, support garments and other non-medical substances, regardless of intended use; except as specifically provided in the Benefits for Diabetes; Birth control and/or contraceptives, oral or other, whether medication or device, Immunization agents, biological sera, blood or blood products administered on an Drugs labeled, "Caution - limited by federal law to investigational use" orexperimental drugs; Drugs used to treat or cure baldness; anabolic steroids used for body building; Anorectics - drugs used for the purpose of weight control; Fertility agents or sexual enhancement drugs, such as Parlodel, Pergonal, Clomid,Profasi, Metrodin, Serophene, or Viagra; Refills in excess of the number specified or dispensed after one (1) year of dateof the prescription.
22. 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; tubal ligation; vasectomy; sexual reassignment surgery; 23. Routine Newborn Infant Care, well-baby nursery and related Physician charges in excess of 48 hours for vaginal delivery or 96 hours for cesarean delivery; except asspecifically provided in the policy; 24. Routine physical examinations and routine testing; preventive testing or treatment; screening exams or testing in the absence of Injury or Sickness; except as specificallyprovided in the policy; 25. Services provided normally without charge by the Health Service of the Policyholder;26a For Plan 1 & 4: Skeletal irregularities of one or both jaws, including orthognathia and mandibular retrognathia; temporomandibular joint dysfunction; 26b For Plan 2: Skeletal irregularities of one or both jaws, including orthognathia and mandibular retrognathia; temporomandibular joint dysfunction; nasal and sinus surgery; 27. Skydiving, recreational parachuting, hang gliding, glider flying, parasailing, sail planing, bungee jumping, or flight in any kind of aircraft, except while riding as a passenger ona regularly scheduled flight of a commercial airline; 28. Sleep disorders;29. Suicide or attempted suicide; or intentionally self-inflicted Injury;30. Supplies, except as specifically provided in the policy;31. Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices, or gynecomastia; except as specifically provided in the policy; 32. Treatment in a Government hospital, unless there is a legal obligation for the Insured 33. 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 34a.For Plan 1 & 4: Weight management, weight reduction, nutrition programs, treatment for obesity, surgery for removal of excess skin or fat, and treatment of eating disorderssuch as bulimia and anorexia, except as specifically provided in the policy. Exception:benefits will be provided for the treatment of dehydration and electrolyte imbalanceassociated with eating disorders.
34b.For Plan 2: Weight management, weight reduction, nutrition programs, treatment for obesity, surgery for removal of excess skin or fat. Global Emergency Medical Assistance-Plan 1 & 4 Through participation in the Private Secondary Schools insurance plan, each Insured iseligible for global emergency medical assistance services when traveling 100 miles or morefrom his/her permanent home or campus address or abroad. Non U.S. students are noteligible for services in their home country. Services are accessible 24 hours a day, 365 daysa year and are provided by Scholastic Emergency Services (SES), Inc. Key Services include: Medical Consultation, Evaluation and Referrals Visit www.uhcsr.com for service descriptions.
To access services please call:(877) 488-9833 Toll-free within the United States(609) 452-8570 Collect outside the United StatesServices are also accessible via e-mail at [email protected].
When calling SES Operations Center, please be prepared to provide:1. Caller’s name, telephone and (if possible) fax number, and relationship to patient2. Patient’s name, age, sex, and Reference Number3. Description of the patient’s condition4. Name, location and telephone number of hospital, if applicable5. Name and telephone number of the attending physician6. Information of where the physician can be immediately reachedSES is not travel or medical insurance but a service provider for emergency medicalassistance services. All medical costs incurred should be submitted to your health plan andare subject to the policy limits of your health coverage. All SES services must be arrangedand provided by SES. Claims for reimbursement of services not provided by SES will not beaccepted.
In the event of Injury or Sickness, students should:1) Report at once to the Student Health Service or Infirmary for treatment or referral, or when not in school, to the nearest Physician or Hospital.
2) Secure a Company claim form from the Student Health Service or from the address below, fill out the form completely, attach all medical and hospital bills and mail to theaddress below.
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 willnot be considered for payment except in the absence of legal capacity.
805 Executive Center Drive West, Suite 220 Please keep this Certificate as a general summary of the insurance. The Master Policy onfile at the school contains all of the provisions, limitations, exclusions and qualifications ofyour insurance benefits, some of which may not be included in this Certificate. The MasterPolicy is the contract and will govern and control the payment of benefits.
This Certificate is based on Policy Form # COL-06-PA (Rev 07-08) Plan 1 - 2010-1990-1& Plan 2 - 2010-1990-2 & Plan 4-2010-1990-4

Source: http://www.ancss.org/storage/pdf/ANC%20InternationalInsurance%2010.pdf