VIEWS: 8 PAGES: 17 POSTED ON: 12/15/2011
Student Accident & Sickness Insurance Plan (“the Policyholder”) 2010-2011 Administrator Policy Number CHH0071061 Underwriter Reference Number CAS9499769 Underwritten by: National Union Fire Insurance Company of Pittsburgh, Pa. with its principal place of business in New York, NY This brochure is a brief description of the Student Accident and Sickness Insurance Plan available under policy series S30494NUFIC-NY. The Policy may con- tain definitions, reductions, limitations, exclusions and termination provisions. Full details of the coverage are contained in the Policy on file with the Policyholder. If there is any conflict between the contents of this docu- ment and the Policy, the Policy will govern in all cases. The Policy does not cover nor provide benefits for treatment arising out of participation in extra-hazardous activities. Extra-hazardous activities means aviation and related activities, such as skydiving and parachuting, and participation as a professional in athletics or sports. RENSSELAER POLYTECHNIC INSTITUTE (RPI) coursework, have passed their qualifying examinations STUDENT ACCIDENT AND SICKNESS PLAN (applies only to Ph.D. students), are physically located This is a brief description of the Student Accident and off campus, and are not eligible to use institutional Sickness Plan available for RPI students and their resources may enroll on a voluntary basis. eligible dependents. The plan is underwritten by National Union Fire Insurance Company of Pittsburgh, Pa. (“the ALL ELIGIBLE STUDENTS: For detailed informa- Company”). The exact provisions governing this tion regarding the enrollment process, please go to insurance are contained in the Policy issued to RPI. www.maksin.com/RPI.aspx. An eligible student must actively attend classes for at STUDENT HEALTH CENTER least the first 31 days of the period for which he or she is The Gallagher Student Health Center is located on the enrolled. Except in the case of withdrawal due to 3000 level of Academy Hall. The Student Health Center Sickness or Injury, any student withdrawing from school is a comprehensive, nationally accredited physician directed program providing outpatient ambulatory health during the first 31 days of the period for which he or she care. Services include medical, gynecology, and allergy is enrolled will not be covered under the Policy and a full clinics, counseling services, and health education and refund of premium will be made, less any claims paid. wellness programs. Specialty consultation and referrals Students who withdraw after such 31 days will remain are available. covered under the Policy and no refund will be made. Home study, correspondence, Internet and television During the academic semester, the Student Health Center (TV) courses do not fulfill the eligibility requirements is open Monday through Friday from 8:00am to 5:00pm that the student actively attended classes. and Saturday and Sunday from 10:00am to 1:30pm. To make a medical appointment, please call (518) 276-6287. Eligibility requirements must be met each time premium The Health Center is open from 8:00am to 4:30pm on is paid to continue coverage. The Company maintains the breaks during and between semesters. In the event of an right to investigate student status and attendance records emergency, call 911 or dial 6611 from any campus phone to verify that the Policy eligibility requirements have to contact RPI’s Department of Public Safety. been met. If it is discovered that the Policy eligibility requirements have not been met, the Company’s only ELIGIBILITY obligation is to refund premium less any claims paid. All Troy campus full-time registered undergraduate and graduate students will be automatically enrolled in the Covered students may also enroll their lawful spouse, Student Accident and Sickness Plan described in this same sex domestic partner and/or dependent children to brochure and the premium will be added to the student age 19 who are unmarried and fully supported by the bill unless proof of other comparable coverage is provid- Covered Student. Dependents must enroll for the same ed. A student, who initially waived coverage under the coverage term for which the Covered Student enrolls. An Policy but subsequently experiences ineligibility under eligible student may enroll his or her dependents for cov- another creditable plan may elect to enroll for coverage erage by the enrollment deadline, or within 30 days of under the Policy within 30 days of the date of ineligibility marriage, birth, or adoption, for which proof is required, under the other creditable plan. Proof is required at time by going to www.maksin.com/RPI.aspx. of enrollment. EFFECTIVE AND TERMINATION DATES Part-time students (matriculated for at least 6 credits), graduate students physically attending classes at RPI The Master Policy becomes effective at 12:01 a.m. on who are registered in a non-credit bearing status while May 1, 2010 and it terminates at 12:01 a.m. on August completing requirements for their degree (e.g., thesis or 15, 2011. Coverage for the Covered Person will be effec- dissertation), and all students registered for classes at the tive on the Policy Effective Date; the Effective Date of Hartford Campus may enroll on a voluntary basis. the coverage term elected; or the day after the date the enrollment form and correct premium are received, TROY CAMPUS ONLY: Graduate students who are whichever is later. Coverage terminates for the Covered primarily engaged in pursuing research-based degrees Person on the earlier of a) the date the Policy terminates; (Ph.D. and certain M.S. degrees), have completed their b) the last day for which premium has been paid; or, c) 2 3 the date he or she enters the armed forces. Covered treatment from a non-participating provider, benefits will Persons entering the armed forces of any country will not be reduced to the percentage shown in the Schedule of be covered under the Policy as of the date of such entry. Benefits. If a Covered Person is referred by a PPO A pro-rata refund of premium will be made to such provider to another provider or facility, it does not mean persons when written request is made within 90 days of that the provider or facility to which the Covered Person leaving school. No other refunds of premiums will be is referred is also a PPO provider. It is the Covered allowed. Person’s responsibility to verify that the provider is part of the PPO. A list of nationwide PHCS Preferred WAIVER PROCESS/PROCEDURE Providers is available for your review via the internet at Students, who are currently insured by a health insurance www.multiplan.com. Click on the logo provided on your policy may waive out of the Student Accident and ID card. NOTE: If treatment is received in a non-net- Sickness Plan with proof of comparable coverage. work facility due to an Emergency Medical Condition, The waiver form must be completed online at benefits for Eligible Expenses are payable at the in-net- www.maksin.com/RPI.aspx. Online waivers must be work level of benefits. completed by the waiver deadline in order to have the premium removed from the student bill. Failure to meet REFERRAL REQUIREMENT the waiver deadline will result in the student being responsible for the insurance premium. A referral from the Student Health Center is required before benefits are payable. This requirement does not Waiver Deadlines apply if: Fall Semester: September 15, 2010 (a) the Student Health Center is closed; *Spring/Summer Semester: February 15, 2011 (b) medical care is received when Student is more than 25 miles from campus; ENROLLMENT PROCESS/DEADLINE AND QUALIFYING EVENTS (c) medical care is obtained by a Student who is not eligible to use the Student Health Center; Students and dependents who are eligible to enroll on a voluntary basis may do so by completing the enrollment (d) for maternity; process online at www.maksin.com/RPI.aspx. Enroll- (e) for two annual primary and preventive obstetric and ment must be completed by the open enrollment dead- gynecologic services examination or any care line. Open enrollment will end September 15, 2010 for related to a pregnancy; or the Fall Semester or February 15, 2011 for the (f) for Emergency Medical Condition however, the Spring/Summer Semester*. No enrollment will be Student must return to the Student Health Center for accepted after these enrollment deadlines. The only referral or necessary follow-up care. exceptions are the following qualifying events with the appropriate documentation: (1) adding a new spouse or Benefits for Eligible Expenses incurred for medical care dependent child within 30 days of marriage, birth or or treatment rendered for which no referral is obtained adoption; or (2) within 30 days of ineligibility under will be excluded from coverage. This referral require- another creditable plan. Premiums are not pro-rated. ment does not apply to the Covered Student’s depen- dents. PREFERRED PROVIDER ORGANIZATION (PPO) DEFINITIONS Private Healthcare Systems (PHCS) Questions regarding PPO providers, call or visit: 1-888-560-7427 Accident means an occurrence which (a) is unforeseen; Website: www.multiplan.com (b) is not due to or contributed to by Sickness or disease The medical benefits stated in this plan are based upon of any kind; and (c) causes Injury. medical treatment being received from a Preferred Provider Organization (PPO). If a Covered Person seeks Actual Charge means the charge for the covered service by the provider who furnishes it. *Spring/Summer Semester available only to new students to RPI. 4 5 Allowable Charges means the charges agreed to by the Emergency Medical Condition means a Sickness or Preferred Provider Organization for specified covered Injury for which immediate medical treatment is sought medical treatment, services and supplies. at the nearest available facility. The condition must be one which manifests itself by acute symptoms which are Biologically based mental illness means a mental, sufficiently severe (including severe pain) that without nervous, or emotional disorder caused by a biological immediate medical care could reasonably be expected to disorder of the brain which results in a clinically result in any of the following: significant, psychological syndrome or pattern that sub- (a) the Covered Person’s life could be in serious stantially limits the functioning of the person with the ill- jeopardy; (b) bodily functions would be seriously ness. The following disorders covered by this definition impaired; or (c) a body organ or part would be seriously are: schizophrenia/psychotic disorders; major depression; damaged; or (d) serious disfigurement. bipolar disorder; delusional disorders; panic disorder; obsessive compulsive disorders; anorexia; and bulimia. Emergency does not include the recurring symptoms of a chronic illness or condition unless the onset of such Covered Person means a Covered Student while cover- symptoms could reasonably be expected to result in the age under the Policy is in effect and those dependents complications listed above. with respect to whom a Covered Student is insured. Experimental/Investigational means a drug, device or Doctor means: (a) legally qualified physician licensed by medical care or treatment that meets the following: the state in which he or she practices; and (b) a practi- (a) the drug or device cannot be lawfully marketed with- tioner of the healing arts performing services within the out approval of the U.S. Food and Drug Administration scope of his or her license as specified by the laws of the and approval for marketing has not been given at the time state of such practitioner; and (c) certified nurse mid- the drug or device is furnished; (b) the informed consent wives and licensed midwives while acting within the document used with the drug, device, medical care or scope of that certification. The term “Doctor” does not treatment states or indicates that the drug, device, include a Covered Person’s immediate family member. medical care or treatment is part of a clinical trial, exper- imental phase or investigational phase, if such a consent Elective Treatment means medical treatment, which is document is required by law; (c) the drug, device, not necessitated by a pathological change in the function medical care or treatment or the patient’s informed or structure in any part of the body, occurring after the consent document used with the drug, device, medical Covered Person’s effective date of coverage. care or treatment was reviewed and approved by the Elective treatment includes, but is not limited to: tubal treating facility’s Institutional Review Board or other ligation; vasectomy; breast reduction unless as a result of body serving a similar function, if federal or state law mastectomy; sexual reassignment surgery; submucous requires such review and approval; (d) reliable evidence resection and/or other surgical correction for deviated shows that the drug, device or medical care or treatment nasal septum, other than necessary treatment of covered is the subject of ongoing Phase I or Phase II clinical acute purulent sinusitis; treatment for weight reduction; trials, is the research, experimental study or investiga- learning disabilities; immunizations; treatment of infer- tional arm of ongoing Phase III clinical trials, or is other- tility and routine physical examinations. wise under study to determine its maximum tolerated dose, its toxicity, its safety, it efficacy or its efficacy as Eligible Expense means a charge for any treatment, compared with a standard means of treatment or service or supply which is performed or given under the diagnosis; or (e) reliable evidence shows that the prevail- direction of a Doctor for the Medically Necessary treat- ing opinion among experts regarding the drug, device, ment of a Sickness or Injury: (a) not in excess of the medical care or treatment is that further studies or clinical Reasonable and Customary charges; or (b) not in excess trials are necessary to determine its maximum tolerated of the charges that would have been made in the absence dose, its toxicity, its safety, its efficacy or its efficacy as of this coverage; (c) is the negotiated rate, if any and compared with standard means of treatment of diagnosis. (d) incurred while the Policy is in force as to the Covered Person except with respect to any expenses payable Reliable evidence means: published reports and articles under the Extension of Benefits Provision. in authoritative medical and scientific literature; written 6 7 protocol or protocols by the treating facility studying A service or supply will not be considered as Medically substantially the same drug, device, medical care or Necessary if: (a) it is provided only as a convenience to treatment; or the written informed consent used by the the Covered Person or provider; or (b) it is not the treating facility or other facility studying substantially appropriate treatment for the Covered Person’s diagnosis the same drug, device or medical care or treatment. or symptoms; or (c) it exceeds (in scope, duration or Covered Expenses will be considered in accordance with intensity) that level of care which is needed to provide the drug, device, medical care or treatment at the time the safe, adequate and appropriate diagnosis or treatment; or Expense is incurred. (d) it is Experimental/Investigational or for research purposes; or (e) could have been omitted without Hospital means a short-term, acute, general hospital, adversely affecting the patient’s condition or the quality which: of medical care; or (f) involves treatment of or the use of (a) is primarily engaged in providing, by or under the a medical device, drug or substance not formally continuous supervision of Doctors, to inpatients, approved by the U.S. Food and Drug Administration diagnostic services and therapeutic services for diag- (FDA); or (g) involves a service, supply or drug not nosis, treatment and care of injured and sick persons; considered reasonable and necessary by the Healthcare (b) has organized departments of medicine and major Financing Administration Medicare Coverage Issues surgery; (c) has a requirement that every patient must be Manual or Center for Medicare and Medicaid Services under the care of a Doctor or dentist; (d) provides 24- Issues Manual; or (h) it can be safely provided to the hour nursing service by or under the supervision of a reg- patient on a more cost-effective basis such as outpatient, istered professional nurse (R.N.); (e) if located in New by a different medical professional or pursuant to a more York State, has in effect a hospitalization review plan conservative form of treatment. applicable to all patients which meets at least the stan- The fact that any particular Doctor may prescribe, order, dards set forth in section 1861(k) of United States Public recommend, or approve a service or supply does not, of Law 89-97, (42 USCA 1395x[k] ); (f) is duly licensed by itself, make the service or supply Medically Necessary. the agency responsible for licensing such hospitals; and (g) is not, other than incidentally, a place of rest, a place Mental or Nervous Disorder(s) means any condition or primarily for the treatment of tuberculosis, a place for the disease regardless of its cause, listed in the most recent aged, a place for drug addicts, alcoholics, or a place for edition of the American Psychiatric Association convalescent, custodial, educational, or rehabilitative Diagnostic and Statistical Manual of Mental Disorders care. (other than those conditions caused by Biologically Hospital also includes tax-supported institutions, which Based Mental Illness, or with respect to a dependent are not required to maintain surgical facilities. child under age eighteen (18), Serious Emotional Disturbance on the date the medical care or treatment is Injury means bodily injury due to an Accident which: rendered to the Covered Person. (a) results solely, directly and independently of disease, bodily infirmity or any other causes; (b) occurs after the Musculoskeletal Therapy means the diagnosis and Covered Person’s effective date of coverage; and treatment, by manual or mechanical means, of the mus- (c) occurs while coverage is in force. All injuries culoskeletal structure due to lack of normal nerve, mus- sustained in any one Accident, including all related cle, and/or joint function following an Injury. conditions and recurrent symptoms of these injuries, are considered one Injury. Pre-Existing Condition means a Sickness, Injury or condition, whether physical or mental, regardless of its Medical Necessity/Medically Necessary means that a cause, for which medical advice, diagnosis, care or drug, device, procedure, service or supply is necessary treatment was recommended or received within the 6 and appropriate for the diagnosis or treatment of a month period ending on the Covered Person’s effective Sickness or Injury based on generally accepted current date of coverage under the Policy or a pregnancy existing medical practice in the United States at the time it is pro- on the Covered Person’s effective date of Coverage under vided. the Policy. Genetic information shall not be treated as a pre-existing condition in the absence of a diagnosis of the condition related to such information. 8 9 Reasonable and Customary (R&C) means the charge, Urgent Condition means a sudden illness, Injury, or fee or expense which is the smallest of: (a) the actual condition, that: (a) is severe enough to require prompt charge; (b) the charge usually made for a covered service medical attention to avoid serious deterioration of the by the provider who furnishes it; (c) the negotiated rate, Covered Person’s health; (b) includes a condition which if any; and (d) the prevailing charge made for a covered would subject the Covered Person to severe pain that service in the geographic area by those of similar profes- could not be adequately managed without urgent care or sional standing. “Geographic area” means the three digit treatment; (c) does not require the level of care provided zip code in which the services, procedure, devices, drugs, in the emergency room of a Hospital; and (d) requires treatment or supplies are provided or a greater area, if immediate outpatient medical care that cannot be necessary, to obtain a representative cross-section of postponed. charge for a like treatment, service, procedure, device, drug or supply. Reasonable and Customary charges also Urgent Care Provider means (a) a freestanding medical means the percentile of the payment system in effect on facility which: (1) provides unscheduled medical the Effective Date shown in the Schedule of Benefits. services to treat an Urgent Condition; (2) routinely pro- vides ongoing unscheduled medical services for more Serious Emotional Disturbances - applicable only to than 8 consecutive hours; (3) makes charges; (4) is children under age eighteen (18), means a child who has licensed and certified as required by any state or federal a diagnosis of attention deficit disorder, disruptive law or regulation; (5) keeps a medical record on each behavior disorder, or pervasive development disorder patient; (6) provides an ongoing quality assurance and one or more of the following: serious suicidal program (this includes reviews by Doctors other than symptoms or other life-threatening self-destructive those who own or direct the facility); (7) is run by a staff behavior; significant psychotic symptoms (hallucina- of Doctors, at least one of whom is on call at all times; tions, delusion, bizarre behavior); behavior caused by (8) has a full-time administrator who is a Doctor; or (b) a emotional disturbance that places the child at risk of Doctor’s office. causing personal injury or significant property damage; or behavior caused by emotional disturbance that places It is not the emergency room or outpatient department of the child at substantial risk of removal from the house- a Hospital. hold. PRE-NOTIFICATION REQUIREMENT Sickness means disease or illness including related All inpatient stays should be reported. conditions and recurrent symptoms of the Sickness. Sickness also includes pregnancy and complications of The Covered Person should report the following pregnancy. All Sicknesses due to the same or a related inpatient services: cause are considered One Sickness. (a) all inpatient admissions, including length of stay, to a Hospital, convalescent facility, skilled nursing Skilled Nursing Facility means a lawfully operating facility, a facility established primarily for the treat- institution engaged mainly in providing treatment for ment of substance abuse, or a residential treatment people convalescing from Injury or Sickness. It must facility; have organized facilities for medical services, 24-hour (b) all inpatient maternity care, after the initial 48/96 nursing service by RNs, a capacity of six or more beds, hours; daily medical records for each patient, and a Doctor (c) all partial hospitalization in a Hospital, residential available at all times. treatment facility, or facility established primarily for the treatment of substance abuse. Totally Disabled and Total Disability means Injury or Sickness which wholly and continuously keeps the The Covered Person is responsible to fulfill the Pre- Covered Person, (a) with respect to a student: from Notification requirement of this plan: attending classes at the location where he or she is • Notification of Emergency Hospitalizations: The enrolled; and (b) with respect to a Dependent, or a patient, patient’s representative, Doctor or Hospital student if such classes are not in session, from doing should telephone 877-795-5430 within 2 working days those activities that are normal for a person in good of admission. health of the same age and sex. 10 11 • Pre-Notification of Non-Emergency Hospitalizations: CONTINUATION OF COVERAGE The patient, Doctor or Hospital should telephone If the Covered Student becomes ineligible under the 877-775-5430 at least 3 days prior to the planned Policy, he or she may continue coverage for himself and admission. his or her covered eligible dependents for up to an addi- tional 6 months. Written request for continued coverage Important: Pre-Notification is NOT a guarantee that and payment of premium must be made within 31 days of benefits will be paid. the date the Covered Student became ineligible under the Policy. Contact Maksin Management Corp at 1-877-775- EXTENSION OF BENEFITS 5430 for assistance. If, on the date coverage terminates, a Covered Person is Totally Disabled as a result of Sickness or Injury and is COORDINATION OF BENEFITS receiving treatment for such Sickness or Injury, benefits Benefits for Accidents and Sickness are coordinated with will be payable for the Eligible Expenses incurred for other health insurance the Covered Person may have in that Sickness or Injury after the date coverage terminates force as described in the Policy. until the earliest of the following: (1) the end of the Sickness or Injury that caused the Total CERTIFICATE OF CREDITABLE COVERAGE Disability; (2) the end of the 3 month period following Coverage under this plan is “Creditable Coverage” under the date coverage terminated; or (3) the date the applica- Federal Law. When coverage terminates, the Covered ble Maximum Amount is reached. Person can request a Certificate of Creditable Coverage, which is evidence of coverage under this plan. In order to If a Covered Person is confined to a Hospital on the date obtain a Certificate of Creditable Coverage, please visit his or her coverage terminates, charges incurred during our website at www.maksin.com or contact Maksin the continuation of that Hospital Confinement shall also Management Corp at (877) 775-5430. be included in the term Eligible Expense, but only while they are incurred during the 31 day period following such CONTINUOUSLY INSURED termination of insurance, subject to the applicable Continuously insured means a person has been Maximum Amounts of the Policy. continuously insured under the Policy and prior Student Health Insurance policies issued to the school. Persons If the covered Person is receiving treatment for a who have remained continuously insured will be covered Sickness or Injury on the date his or her coverage for conditions first manifesting themselves while terminates, Eligible Expenses shall include charges continuously insured except for Expenses payable under incurred for that Sickness or Injury, but only while they prior policies in the absence of the current Policy. are incurred during the 31 day period following such Previously insured dependents and students must re- termination of insurance, subject to the applicable enroll for coverage in order to avoid a break in coverage Maximum Amounts of the Policy. within 30 days of the end of the prior coverage in order to maintain coverage for conditions which existed in In The Event Of Pregnancy. If a Covered Person is prior Policy Years. Once a break in continuous insurance pregnant on the date the Policy terminates and the preg- occurs, the definition of Pre-Existing Condition will nancy commenced while insured while the Policy was in apply in determining coverage of any condition which force, benefits will be payable for Eligible Expenses existed during such break. incurred after the Policy terminates until the earliest of: (a) the date the pregnancy ends; (b) the date the Covered Person becomes insured under another policy; or (c) the date the applicable Maximum Amount is reached. The Extension of Benefits will apply only to the extent the Covered Person will not be covered under the Policy or any other health insurance policy in the ensuing term of coverage. 12 13 BASIC ACCIDENT AND SICKNESS PLAN SCHEDULE OF BENEFITS (Expenses for Elective Treatment or elective surgery will not be covered except as specifically provided elsewhere in the Policy.) Basic Aggregate Maximum per Injury or Sickness per $100,000 Policy Year (In-Network and Out-of-Network Combined): In-Network Out-of-Network Deductible Amount per Injury or Sickness per Policy $0 $100 Year: Out-of-Pocket Limit per Covered Person: This is a $2,500 N/A benefit that will apply in a Policy Year to a Covered Person who in that year reaches the Out-of-Pocket Limit. When this benefit becomes applicable to a Covered Person during a Policy Year, Covered Percentages under the Basic Plan are raised. They are raised to 100% for all Eligible Expenses incurred by the Covered Person in the remainder of that Policy Year. (Not applicable to Out-of-Network) ELIGIBLE EXPENSES INCLUDE: INPATIENT Room and Board Expense, limited to the average semi- 90% of Allowable Charges 75% of R&C private room rate Intensive Care Unit, limited to the intensive care room 90% of Allowable Charges 75% of R&C rate for an overnight stay Hospital Miscellaneous Expense, includes expenses 90% of Allowable Charges 75% of R&C incurred for anesthesia and operating room; laboratory tests and X-rays (including professional fees); oxygen tent; drugs (excluding take-home drugs), medicines, dressings; and other Medically Necessary and prescribed Hospital Expenses. Pre-Admission Testing Paid as any other Sickness Paid as any other Sickness Licensed Nurse (Private Duty Nursing) 90% of Allowable Charges 75% of R&C Physiotherapy 90% of Allowable Charges 75% of R&C Surgical Expense, when Injury or Sickness requires two 90% of Allowable Charges 75% of R&C or more surgical procedures which are performed through the same approach, and at the same time or immediate succession, the Company will pay full value for the most expensive procedure performed and 50% of the value for the second procedure performed. Anesthetist (in connection with surgery) 90% of Allowable Charges 75% of R&C Assistant Surgeon (in connection with surgery) 90% of Allowable Charges 75% of R&C Doctor’s Fees Expense, for non-surgical services of the 90% of Allowable Charges 75% of R&C attending Doctor or a consulting Doctor 14 15 Schedule of Benefits, continued In-Network Out-of-Network Biologically Based Mental Illness/ Serious Emotional Paid as any other Sickness Paid as any other Sickness Disturbances. Mental or Nervous Disorders up to a maximum of 30 90% of Allowable Charges 75% of R&C days per Policy Year Alcoholism And Substance Abuse Expense, limited to: (a) 90% of Allowable Charges 75% of R&C not more than 7 days of active detoxification treatment in any policy year; and (b) not more than 30 days of in- patient rehabilitation services in any policy year. OUTPATIENT Surgical Expense, when Injury or Sickness requires two 90% of Allowable Charges 75% of R&C or more surgical procedures which are performed through the same approach, and at the same time or immediate succession, the Company will pay full value for the most expensive procedure performed and 50% of the value for the second procedure performed. Anesthetist (in connection with surgery) 90% of Allowable Charges 75% of R&C Assistant Surgeon (in connection with surgery) 90% of Allowable Charges 75% of R&C Day Surgery Facility/Miscellaneous, when scheduled 90% of Allowable Charges 75% of R&C surgery is performed in a Hospital or outpatient facility, including the use of the operating room, laboratory tests and x-ray examinations (including professional fees), anesthesia, infusion therapy, drugs or medicines and supplies, therapeutic services (excluding Physiotherapy or take home drugs and medicines). Eligible Expenses must be incurred on the day of surgery or within 48 hours after the surgery. Hospital Emergency Room, for use of Hospital emergency 100% of Allowable Charges 100% of R&C room, operating room, laboratory and x-ray examinations, supplies. A Co-payment Amount of $75 will apply to each visit unless the Covered Person is admitted to the Hospital as an inpatient. Urgent Care Expense, for treatment of an Urgent 90% of Allowable Charges 75% of R&C Condition by an Urgent Care Provider Laboratory and X-Ray Examinations 90% of Allowable Charges 75% of R&C CAT Scan/MRI 90% of Allowable Charges 75% of R&C Chlamydia Screening Test Expense, annual screening test 90% of Allowable Charges 75% of R&C for women who are: under age 20 if they are sexually active; and at least 20 years old if they have multiple risk factors; or men who have multiple risk factors. 16 17 Schedule of Benefits, continued In-Network Out-of-Network Radiation Therapy and Chemotherapy, includes: Paid as any other Sickness Paid as any other Sickness anti-nausea drugs used in conjunction with the chemotherapy, radiation therapy, tests and procedures, Physiotherapy (for rehabilitation only after surgery), and Eligible Expenses incurred at a radiological facility; Eligible Expenses incurred for the administration of chemotherapy and visits by a health care professional to administer the chemotherapy. Tests and Procedures, for diagnostic services and med- 90% of Allowable Charges 75% of R&C ical procedures performed by the Doctor, other than Doctor’s visits, physiotherapy, x-rays and lab procedures. Physiotherapy, up to a maximum of $1,500 per Injury or 90% of Allowable Charges 75% of R&C Sickness. Benefits are payable when provided by a licensed physical therapist and only when physical thera- py begins within 6 months of the onset of symptoms. Doctor’s Fees Expense, includes injections administered 90% of Allowable Charges 75% of R&C in the Doctor’s office Musculoskeletal/Chiropractic Therapy Paid as any other Injury Paid as any other Injury Consultant’s Fees Expense, when such services are 90% of Allowable Charges 75% of R&C deemed Medically Necessary and ordered by the attend- ing Doctor for the purpose of confirming or determining a diagnosis. Prescribed Medicines Expense up to a maximum of 100% of R&C after a No Benefits $1,500 per Policy Year. Prescriptions must be filled by an $10 co-payment per Express Scripts, Inc. participating pharmacy only. A list generic drug or $30 of nationwide participating pharmacies is available for co-payment per brand review at www.express-scripts.com. name drug Biologically Based Mental Illness/ Serious Emotional Paid as any other Sickness Paid as any other Sickness Disturbances. Mental or Nervous Disorders up to a maximum of 20 90% of Allowable Charges 75% of R&C visits per Policy Year Alcoholism And Substance Abuse Expense: 90% of Allowable Charges 75% of R&C (a) up to 60 outpatient visits per Policy Year for the Covered Person in need of treatment; (b) up to a maxi- mum of 20 visits per Policy Year for covered family members, (including visits for remediation through coun- seling and education), provided that the total number of such visits, when combined with those of the Covered Person in need of treatment, does not exceed 60 visits in any Policy Year; (c) up to a maximum of 5 additional vis- its for covered family members if a Covered Person in need of treatment has not received or is not receiving treatment. 18 19 Schedule of Benefits, continued In-Network Out-of-Network OTHER Second Surgical Opinion, when recommended and 90% of Allowable Charges 75% of R&C approved by the attending Doctor. Eligible Expenses also include expenses incurred for required X-rays and diag- nostic tests done in connection with that consultation. Ambulance Expense, for the services of a professional 90% of Actual Charges 90% of Actual Charges ambulance to or from a hospital when required due to the emergency nature of an Accident or Sickness (not subject to the deductible) Prosthetic Devices, includes charges for artificial limbs, 90% of Allowable Charges 75% of R&C or eyes, and other non-dental prosthetic devices, as a result of Injury or Sickness. It does not include: eye exams, eyeglasses, vision aids, hearing aids, communi- cation aids, and orthopedic shoes, foot orthotics, or other devices to support the feet. Durable Medical Equipment and Orthopedic Appliance 90% of Allowable Charges 75% of R&C Dental Expense: for Injury to sound natural teeth up to a maximum of 100% of Actual Charges 100% of Actual Charges $200 per Accident; or for removal of one or more impact- ed wisdom teeth up to a maximum of $50 per tooth Temporomandibular Joint Dysfunction (TMJ) Expense, Paid as any other Sickness Paid as any other Sickness for non-surgical treatment of TMJ when the TMJ is medical in origin. Dermatological Expense, for the diagnosis and treatment Paid as any other Sickness Paid as any other Sickness of skin disorders, excluding laboratory fees. Related lab- oratory expenses are covered under Laboratory and X- ray Examinations. Eligible Expenses do not include treat- ment for cosmetic treatment and procedures. Allergy Testing and Treatment, includes laboratory tests, Paid as any other Sickness Paid as any other Sickness Doctor’s visits (including visits to administer injections), prescribed medications for testing of the allergy (includ- ing any equipment used in the administration of pre- scribed medication), and other Medically Necessary supplies and services. Diagnostic Testing for Attention Deficit Disorders and 90% of Allowable Charges 75% of R&C Learning Disabilities, benefits include diagnostic testing for: (a) attention deficit disorder; or (b) attention deficit hyperactive disorder; or (c) dyslexia. Once a Covered Person has been diagnosed with one of these conditions, medical treatment will be payable as detailed under the outpatient treatment of Mental and Nervous Disorders coverage portion of the Policy. 20 21 Schedule of Benefits, continued In-Network Out-of-Network Acupuncture In Lieu of Anesthesia Expense, when 90% of Allowable Charges 75% of R&C acupuncture is used in lieu of other anesthesia, for a covered surgical or dental procedure. Maternity, including well newborn nursery care, for a Paid as any other Sickness Paid as any other Sickness minimum of 48 hours after a vaginal delivery and for a minimum of 96 hours after a cesarean delivery. Pre- notification is recommended after the 48/96 hours. Transfusion or Dialysis of Blood Expense, benefits 90% of Allowable Charges 75% of R&C include the cost of: whole blood, blood components, and the administration thereof. Skilled Nursing Facility Expense (pre-notification recom- 90% of Allowable Charges 75% of R&C mended), for treatment rendered (a) in lieu of a hospital confinement; or (b) within 24 hours following a hospital confinement and for the same or related cause(s) as such hospital confinement. Rehabilitation Facility Expense (pre-notification recom- 90% of Allowable Charges 75% of R&C mended). Confinement must follow within 24 hours of and be for the same or related cause(s) as a period of hospital confinement or Skilled Nursing Facility confinement. Hospice Expense (pre-notification recommended) 90% of Allowable Charges 75% of R&C Intercollegiate Sports Injury, up to $500 per Accident Paid as any other Injury Paid as any other Injury Accidental Death and Dismemberment Principal Sum $10,000 OPTIONAL SUPPLEMENTAL ACCIDENT AND SICKNESS PLAN (Student Only) If elected by the Covered Student during initial enrollment and the appropriate premium is paid, the Optional Supplemental Accident and Sickness Plan will increase the Aggregate Maximum per Injury or Sickness per Policy Year from $100,000 per Injury or Sickness per Policy Year to $300,000 per Injury or Sickness per Policy Year. The combined maximum benefit payable for Basic Accident and Sickness Plan and Optional Supplemental Accident and Sickness Plan is $300,000 per Injury or Sickness per Policy Year. Not available to early arrival students for the summer semester; may be purchased the following fall semester. 22 23 EXCLUSIONS teeth within 12 months of the accident and except for The Policy does not cover nor provide benefits for dental care or treatment necessary due to congenital Accident, Sickness, or treatment of a medical condition disease or anomaly. arising out of: 7. eyeglasses, hearing aids, and examination for the 1. pregnancy, except as specifically provided under the prescription or fitting thereof. Policy. 8. rest cures, custodial care and transportation. 2. illness, accident, treatment or medical condition aris- ing out of: PRE-EXISTING CONDITIONS a) war or act of war (whether declared or unde- (Applicable to persons enrolling on a voluntary basis only) clared); participation in a felony, riot or insurrec- Pre-existing Conditions are not covered for the first 12 tion; service in the Armed Forces or units auxil- months following a Covered Person’s effective date of iary thereto; and coverage under the Policy. This limitation will not apply b) aviation, other than as a fare-paying passenger on if the individual seeking coverage under the Policy has an a scheduled or charter flight operated by a sched- aggregate of 12 months of prior Creditable Coverage and uled airline. becomes eligible and applies for coverage under the 3. cosmetic surgery, except that cosmetic surgery shall Policy within 63 days of termination of prior Creditable not include reconstructive surgery when such service Coverage. Credit will be given for the time the individual is incidental to or follows surgery resulting from was covered under the prior Creditable Coverage. trauma, infection or other diseases of the involved part, and reconstructive surgery because of congeni- The Pre-existing Conditions limitation does not apply to: tal disease or anomaly of a covered Dependent child (a) a newborn dependent child; or (b) a child adopted by which has resulted in a functional defect. However, the Covered Person or placed with the Covered Person if the policy provides hospital, surgical or medical for adoption, if adoption or placement for adoption expense coverage, this exclusion shall not apply with occurs while covered under the Policy; or (c) pregnancy respect to cosmetic surgery determined, as a result of that begins 10 months from the Covered Person’s effec- utilization review and External Review, to be tive date of coverage under the Policy, subject to a cred- Medically Necessary. it for previous Creditable Coverage. 4. care in connection with the detection and correction by manual or mechanical means of structural imbal- Credit For Prior Coverage: A Covered Person whose ance, distortion or subluxation in the human body for coverage under prior Creditable Coverage ended no more purposes of removing nerve interference and the than 63 days before the Covered Person’s effective date effects thereof, where such interference is the result under the Policy, will have any applicable Pre-Existing of or related to distortion, misalignment or subluxa- Condition limitation reduced by the total number of days tion of or in the vertebral column. This exclusion the Covered Person was covered by such coverage. If shall not apply if coverage of Doctor’s services in there was a break in Creditable Coverage of more than 63 the Doctor’s office are provided under the Policy. days, the Company will credit only the days of such cov- 5. treatment provided in a government hospital; bene- erage after the break. fits provided under Medicare or other governmental Creditable Coverage means coverage under any of the program (except Medicaid), any state or Federal following: workers’ compensation, employers’ liability or occu- (a) a group health plan; pational disease law; benefits to the extent provided (b) health insurance coverage; for any loss or portion thereof for which mandatory (c) Part A or B of Title XVIII the Social Security Act; automobile no-fault benefits are recovered or recov- (d) Title XIX of the Social Security Act, other than cov- erable; services rendered and separately billed by erage consisting solely of benefits under section employees of hospitals, laboratories or other institu- 1928; tions; services performed by a member of the cov- (e) Chapter 55 of Title 10, United States Code; ered person’s immediate family; and services for (f) a medical care program of the Indian Health Service which no charge is normally made. or of a tribal organization; 6. dental care or treatment, except for such care or (g) a state health benefits risk pool; treatment due to accidental Injury to sound natural (h) a health plan offered under chapter 89 of Title 5, United States Code; 24 25 (i) a public health plan (as defined in regulations); TRAVEL GUARD (j) a health benefit plan under section 5(e) of the Peace TRAVEL ASSIST AND STUDENT ASSIST SERVICES Corps Act (22 U.S.C. 2504(e) ). Procedures on How to Access Travel Guard’s 24-hour MANDATED BENEFITS Assistance Call Center How to Contact Travel Guard: Coverage for the following benefits to be paid as any • Inside the US and Canada, dial 1-877-249-5362 toll- other Sickness except under certain coverages wherein free. there are internal limits: Biologically based Mental • Outside the US and Canada: Illness/Serious Emotional Disturbances and Mental and • Request an international operator. Nervous Disorders; Breast Cancer Treatment; Breast • Ask the international operator to connect to an AT&T Reconstruction; Clinical Trials Expense; Outpatient operator. Chemical Abuse and Chemical Dependence; • Request the AT&T operator to place a collect call to the Mammographic Examination; Cytologic Screening; USA at 1-715-295-9625. Cancer Second Opinion; Diagnostic Screening for • Our fax number is 1-713-974-3422. Prostate Cancer; Diabetes Treatment; End of Life Care; Pre-Hospital Medical Emergency Services; Bone When to Contact Travel Guard: Mineral Density Measurements and Tests; Medical • Call Travel Guard when you require medical assistance Foods; and Contraceptive Services. or have a medical emergency. • Call Travel Guard for all non-medical situations (lost In addition to the above benefits, the following benefits luggage, lost documents, legal help, etc.). are applicable to Covered Students attending the • Call Travel Guard whenever there is a question. Hartford, CT campus: Autism Spectrum Disorders; Early Intervention Services; Hearing Aids for Children; Travel Guard is available 24-hours-a-day/7-days-a- Craniofacial Disorders; Blood Lead Screening; Acci- week/365-days-a-year. dental Ingestion of Controlled Drugs; Hypodermic Our multi-lingual/multi-cultural Travel Assistance Needles or Syringes; Prescribed Drugs for Cancer; Coordinators (TACs) are trained professionals ready to Inherited Metabolic Disease Treatment; Lyme Disease help you should the need arise while you are traveling or Treatment; Pain Management; Ostomy Appliances and away from home. The Travel Assist Services Medical Supplies; Colorectal Cancer Screening; Neuro- Staff consists of fulltime, on-site Registered Nurses and psychological Testing; Epidermolysis Bullosa Treatment; Emergency Physicians who work as a team to provide the Home Health Care; Occupational Therapy; Emergency best outcome for our clients. This team is directed by a Ambulance; Surgical Removal of Tumors and Treatment dedicated Medical Director (MD) and Manager of of Leukemia; Cancer Clinical Trials; Infertility Medical Services (RN). Nursing staff is on-site 24- Treatment; Isolation Care and Emergency Services; and hours; a physician has daily responsibility for a 24-hour Medical Complications of Alcoholism. Please see the period and is onsite during daytime hours. Policy on file with the University for complete details and any other applicable mandates. What information will you need to provide to Travel Guard when you call: • Advise Travel Guard who you are insured by. • Provide your Underwriter Reference number. • Advise Travel Guard regarding the nature of your call and/or emergency. Be sure to provide your contact information at your current location in the event Travel Guard needs to call you back. Description of Services Information/General: These services include advice and information regarding travel documentation, immuniza- tion requirements, political/ environmental warnings, and information on global weather conditions. Travel Guard can also provide information on available currency 26 27 exchange rates, local Bank/Government holidays, and, by implementing our databases with the information, Repatriation of Mortal Remains/ provide ATM and Customer Service locations to clients. Medical Evacuation Travel Guard also provides emergency message storage (Benefits provided by National Union Fire Insurance & relay and translation services. Company of Pittsburgh, PA) • Visa & Immunization Repatriation of Mortal Remains: In the event an • Weather & Exchange Rates Injury or Sickness causes death while the Covered • Environmental & Political Warnings Person is outside a 100 mile radius from his or her current place of primary residence, the Company will Technical: These services provide assistance to members reimburse covered expenses incurred for preparation in the event of lost or stolen luggage, personal effects, and transportation of the body remains. documents and tickets. Travel Guard can arrange cash transfers & vehicle return in the event of illness or acci- Medical Evacuation: The Policy will pay for evacu- dent, provide legal referrals, and help with arrangements ation to the nearest adequate medical facility follow- for members who encounter en-route emergencies that ing a covered Injury or Sickness if the Covered Person force them to interrupt their trips. is outside a 100 mile radius from his or her current • Legal Referral place of primary residence and his or her Doctor • Embassy/Consulate Information determines that adequate medical treatment is not • Lost/Stolen Luggage & Personal Effects locally available. • Assistance • Lost Document Assistance Combined Maximum Limit of $1,000,000 • Cash Transfer Assistance Travel Guard must make all arrangements and must • En-route Travel Assistance authorize all expenses in advance for these benefits to • Claims-related Assistance be payable. If it is not reasonably possible to contact • Telephone Interpretation Travel Guard in advance, the Company reserves the right to determine the benefits payable, including any Medical: These services are the most complicated of reductions. those offered and can last up to several weeks. They involve Travel Guard’s Medical Staff in addition to other network providers and often include post-case pay- STUDENT ASSIST SERVICES ment/billing coordination on the traveler’s behalf. These services include physician/dental/hospital referral, med- Concierge Services: You receive the comforts, care, and ical case monitoring, shipment of medical records and attention of Student Assist’s Personal Assistance prescription medications, medical evacuation, repatria- Coordinators available 24/7 to respond to virtually any tion of remains, and insurance/claims coordination. request – large or small. Personal Security Assistance: You can feel safe and Medical Assistance: secure with Travel Guard’s Personal Security Assistance • Medical Referral at home or while traveling. To activate personal security • Out-patient Assistance services, please log on to: • In-patient Assistance www.chartisinsurance.com/us/security. For initial setup, your login is “9499769” and the pass- Medical Transport: word is “security.” • Medical Evacuation For more details visit www.maksin.com/RPI.aspx • Repatriation of Mortal Remains 28 29 AMERICAN HEALTH HOLDING, INC. CLAIM FILING PROCEDURES 24-HOUR STUDENT EMERGENCY Claim forms can be accepted directly from Doctors or CARE HOTLINE facilities if the form includes the name of the Covered (American Health Holding, Inc. is not affiliated Person, Covered Student’s school name, identification with National Union Fire Insurance Company number, date of services, diagnosis, treatment procedure of Pittsburgh, Pa.) and billed charges. Proof of loss must be furnished with- For confidential health care advice and information, 24 in 90 days after the date of such loss. hours a day, 365 days a year, call toll-free (866) 315-8756. A Company claim form may be secured by logging onto Comprehensive Resources and Advice from www.maksin.com/RPI.aspx. Complete and sign the Registered Nurses claim form and mail with itemized hospital and/or med- • Direct access to an extensive Health Information ical bills to the Claim Office at the following address: Library, covering issues ranging from women’s health to pediatrics. Detailed directories with topic codes and Maksin Management Corp instructions for access to health-related topics. P.O. Box 2647 • Choose to talk directly with a nurse. Discuss a current Camden, NJ 08101-2647 illness or health issue, or receive counseling on chronic Toll Free: (877) 775-5430 conditions. Nurses can also educate callers about treat- ments, lifestyle choices and self-care strategies. Only one claim form is required per Injury or Sickness. • Integrated phone access to specially trained personnel, After filing the initial claim form, additional bills may be trained to provide referral services for a number of health forwarded with name, identification number and school related concerns including mental health and/or sub- name/policy number. stance abuse. Questions regarding enrollment and payment or waiver, benefits, eligibility, claims procedures or claims status AMACORE VISION should be directed to: A Product of The Amacore Group, Inc. (The Amacore Group, Inc. is not affiliated Maksin Management Corp with National Union Fire Insurance Company P.O. Box 2647 of Pittsburgh, Pa.) Camden, NJ 08101-2647 Amacore Vision is one of the nation’s largest cost share Toll Free: (877) 775-5430 vision networks with thousands of eye care professionals Local Servicing Agent including Optometrists, Opticians and optical outlets in Austin & Company, Inc. thousands of locations nationwide. It is the only national 20 Corporate Woods Boulevard network that includes Ophthalmologists who discount all Albany, NY 12211-2350 of their services on medical and surgical procedures, 518-465-3591 including cosmetic surgery and LASIK. Amacore Vision also provides substantial discounts on all contact lenses, At Maksin Management Corp, we value the trust our frames and designer sunglasses. customers have placed in us. That is why protecting Member Instructions the privacy of your personal information is of para- • Before scheduling your vision appointment, please mount importance to us. For more information, verify provider participation by calling 1-800-354-8336. please go to our website at www.maksin.com. • Be sure to present your membership card and identify yourself as a valid Amacore Vision member before your It is the Covered Person’s responsibility to maintain exam. continuity of coverage by inquiring about such coverage if he or she has not received the information for the new Visit RPI’s webpage at www.maksin.com/RPI.aspx to Policy Year. learn about additional money-saving discount programs offered to you under the Plan. (These services and prod- ucts are not insurance. They are comprised of indepen- dent vendors not affiliated with National Union Fire Insurance Company of Pittsburgh, Pa.) 30 31 The insurance described in this brochure provides limited benefits only. It does not provide basic hospital, basic medical or major medical insurance as defined by the New York State Insurance Department.
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