plan year 2020/2021 student insurance plan 2021 student insurance brochure.pdfeligibility section of...
TRANSCRIPT
STUDENT INSURANCE PLANSUPPLEMENTAL COVERAGE FOR STUDENTS
PLAN YEAR 2020/2021
1 •Introduction
2 •YourPrivacyRights •Eligibility
3 •CoverageEffectiveDates •Cost •Part-timeEligibility •SummerCoverage
4 •StudentInsuranceWaiver
5 •Reinstatement •TerminationofMedicalCoverage
6 •HowtoSubmitaClaim •ClaimDenialandAppealsProcedure
7 •Definitions
8-11 •DescriptionofBenefits
12 •CoordinationofBenefits
13-16 •Exclusions
16 •Subrogation
Medical ID Card Inside Back Cover
TA B L E O F C O N T E N T S
The Student Insurance Plan or costs associated with the plan may change periodically. Please contact Student Insurance for current plan and rates. This is a limited policy. Read the contents carefully.
To the Parents and Students of Eastern Illinois University
EasternIllinoisUniversityprovidesasupplementalplanofmedicalcover-ageforinjuryandillnessforwhichthefeeisautomaticallyassessedalongwithtuitionandfeesforalleligiblestudentsenrolledinanon-campusprogramtaking9ormorehours.Studentsenrolledpart-time(anyprogramformat)with5ormorehoursareeligibletopurchasecoverage.Refertotheeligibilitysectionofthisbrochureforenrollmentprocedures.
ThePlancoordinateswiththestudent’sprimarycarrierandprovidesthestudentworldwideprotection,24hoursaday.StudentInsuranceisan economicalwaytoreduceoreliminateout-of-pocketexpenseswhen familyhealthplansdonotcover100%ofmedicalcostsbecauseofdeductibles,co-paymentamounts,limitationsonspecificbenefits,andout-of-networkpenalties.
ThePlanhasa$100deductibleperdiagnosis,perPlanyear,andpaysupto70%ofeligibleexpensesforphysicianandhospitalexpenses,labandx-ray,surgery,ambulancetransport,physicaltherapy,maternityexpenses,mentalhealthandsubstanceabusetreatment.
Intheeventofanon-emergencyinjuryorillness,theCoveredStudentisencouragedtoreporttotheHealth&CounselingServicesMedicalClinicforpropermedicaltreatmentorreferral.IfawayfromtheUniversity,consultaphysician.EmergencyRoomvisitstoSarahBushLincolnHealthCenterfornon-emergencytreatmentmaynotbeconsideredwithoutareferralfromaphysician.
ThePlanissecondaryifthestudentisentitledtobenefitsbyanyotherpolicy.PleaseseetheCoordinationofBenefitssectionofthisbrochureforfurtherinformation.
ThisbrochurecontainsspecificPlanbenefitinformation.Studentsshouldfamiliarizethemselveswiththeproperprocedurestoutilizethebenefitsavailable.
ConsulttheStudentInsuranceOfficeforinformationregardingenrollment,eligibility,benefits,limitationsorexclusions.
Angela R. Campbell, MSHI,RHIA,MedicalInsuranceManagerEric S. Davidson,Interim Director,Health&CounselingServicesDr. Anne Flaherty,VicePresidentforStudentAffairs
www.eiu.edu/studentinsurancePhone (217) 581-5290 • Fax (217) 581-7507
YOUR PRIVACY RIGHTS
EasternIllinoisUniversityknowsthattheprivacyofprotectedhealthinforma-tion(PHI)isanimportantissueforyou.TheHealthInsurancePortabilityandAccountabilityActof1996(HIPAA)hasbeenrevisedtoprotectyourPHIevenmore.TheseruleswillensurestrongerprotectionofyourPHIwithoutinterfer-ingwithyouraccesstoqualityhealthcare.ThenewlawallowsustoshareyourPHIwithotherhealthcareproviders,healthplans,hospitals,orotherhealthcareentities(“coveredentities”)fortreatment,payment,andotherhealthcareopera-tions.Tomanageyourhealthinsurancebenefits,theStudentInsuranceOfficemayneedtoaccessyourPHI.Weoftenusethisdatatofacilitatetreatment,coordinatecare,measurequalityimprovement,andpayclaimscorrectly. Under the revised HIPAA privacy law • Coveredentitiesmustprovidepatientswithwrittennoticeoftheir privacypracticesandpatient’sprivacyrights.Thenoticewillcontain informationthatdescribesyourrights,includingyourrighttoaccessorto restrictusesanddisclosuresofyourPHI. • YouwillgenerallyhaveaccesstoyourPHIandcanrequestamendments ofyourPHItocorrecterrors.Youcanalsorequestanaccountingofnon- routineusesanddisclosuresofyourPHI.
FormoredetailedinformationaboutourHIPAAprivacypoliciesseeourNoticeofPrivacyPracticesavailableonourwebsiteorinouroffice.
STUDENT ELIGIBILITY
EnrollmentinthePlanisautomaticforstudentsinthefollowingcategories: • Enrolledinanon-campusprogram,taking9ormorehoursonCountDay(firsttenclassdaysFall/Spring,firstfiveclassdaysSummer)oftheacademicterm; • GraduateAssistantsundercontracttotheUniversity; • Internationalstudentsenrolledinanon-campusprogram,taking3ormorehours.
TheStudentInsuranceFeewillbeincludedinallsucheligiblestudents’tuitionandfeebill.StudentsarerequiredtomeettheirtuitionandfeeobligationstotheUniversity,otherwisesubmittedclaimswillbedenied.
Studentsenrolledin5ormorehours(anyprogramformat)areeligibletopur-chasecoverageaspart-timestudentsandqualifyforreinstatement.RefertothesespecificsectionsinthebrochureorcontacttheStudentInsuranceOfficeformoreinformation.
EFFECTIVE DATE OF STUDENT MEDICAL COVERAGECoverageforeachTermisbasedonprogramformatandenrolledhoursasofCountDay(firsttenclassdaysFall/Spring,firstfiveclassdaysSummer)aspertheUniversityAcademicCalendar.
Studentsenrolledinanon-campusprogramwhopre-registerforatleast9hoursandcontinuetobeenrolledinatleastninehoursasofCountDayareassessedthefeeforcoverage.ThePlanprotectstheseeligibleCoveredStudents24hoursadayfrom12:01a.m.thedaytheCoveredStudentcompletesregistrationorthecoverageeffectivedateofeachTerm,whicheverislater,andcontinuesuntil12:00midnightonthedaybeforethecoverageeffectivedateofthenextsucceedingTermoftheUniversityAcademicCalendar.
Studentsenrolledinanon-campusprogramwhopre-registerforatleast9hoursbutdroptolessthan9hoursasofCountDaywillhavethefeerefundedandnocoverageisineffectthatTerm.Studentsinthiscategorymaybeeligibletopurchasecoverage.Refertothesection“Part-TimeEnrollment”foreligibilityrequirementsandapplicationdeadlines.
StudentsrequiredandnotifiedbytheUniversitytoarrivepriortothecoverageeffectivedateoftheTermwillbeallowedcoverage.DepartmentsmustnotifytheStudentInsuranceOfficeinadvanceandthefeeswillbeadjustedaccordingly.
EffectiveDateofStudentMedicalCoverage Cost CoveragePeriod CountDayFall2020 $109.95 8/18/20-12/31/20 9/04/20Spring2021 $109.95 1/1/21-5/16/21 1/25/21Summer2021 $87.45 5/17/21-8/15/21 5/24/21
PART-TIME ENROLLMENT Studentsregisteredfor5ormorehours(anyprogramformat),areeligibleforcoveragebutarenotautomaticallyenrolledinthePlan.ThesestudentsmustcompleteanonlineEnrollmentFormpriortoCountDay(firsttenclassdaysFall/Spring,firstfiveclassdaysSummer)ofeachTerm.EligibilityisbasedonprogramformatandenrolledhoursasofCountDay.Coverageisnotcontinuous;studentsmustre-applyeachsemester.
SUMMER COVERAGESummercoverageisavailableforstudentsinthefollowingcategories:• AllstudentscoveredduringtheSpringTerm(anyprogramformat)• StudentsnotcoveredintheSpringTermbutenrolled(anyprogramformat) inaminimumof5hoursforSummerTerm.
EligiblestudentsnotenrolledintheSummerTermhaveuntilMay16,2021tocompletetheonlineEnrollmentFormandmakepayment.EligiblestudentsenrolledintheSummerTermhaveuntilCountDay(fifthclassday),May24,2021tocompletetheonlineEnrollmentFormandmakepayment.CoverageunderthisextensioniseffectiveMay17,2021(ordateofpayment,whicheverislater)andterminatesatmidnightonAugust15,2021.Costis$87.45
STUDENT INSURANCE WAIVERStudentsmayapplyforawaiveroftheStudentInsuranceFee.WeurgethatthisactionbeconsideredonlyaftercarefulstudyofthePlanbenefitsandconsulta-tionwiththeStudentInsuranceOfficestaff.StudentsmustcompleteanInsuranceWaiverFormbyCountDay(firsttenclassdaysFall/Spring,firstfiveclassdaysSummer).ThewaiverformisavailableintheStudentInsuranceOffice,canbemaileduponrequest,orcanbedownloadedfromourwebsitewww.eiu.edu/stu-dentinsurance.
ThecompletedwaiverformmustbereturnedtoourofficePOSTMARKED NO LATER THAN THE WAIVER DEADLINE OF THE SEMESTER THE STUDENT IS REQUESTING A WAIVER FOR. Please note that students participating in the Intercollegiate Athletic Programs or Cheer Teams are ineligible for the medical coverage cancellation.
Waiver DeadlineFallTerm2020isSeptember4,2020SpringTerm2021isJanuary25,2021SummerTerm2021isMay24,2021
REINSTATEMENTReinstatementinthePlanwillonlybegrantedtostudentswhobecomeinvolun-tarilyineligibleforcoverageunderagroupinsuranceplan(e.g.,marriage,lossofemployment,etc.).ArequestforreinstatementinthePlanmustbesubmitted,withevidenceofinvoluntarylossofcoverage,totheStudentInsuranceOfficewithin31daysofthelossofcoverageunderthegroupinsuranceplan.Thisoptionisonlyavailabletostudentswhoareenrolledinandhavepaidtuitionandfeesfor5ormorehours.
PremiumrateswillnotbeproratedandtheeffectivedateofthecoveragewillbethedatethattheapplicationforreinstatementandpremiumaresubmittedtotheStudentInsuranceOfficeordateofterminationoftheotherinsurance,which-everislater.AdditionalinformationisavailableintheStudentInsuranceOfficeorbycalling581-5290.
TERMINATION OF MEDICAL COVERAGEThemedicalcoverageoftheCoveredStudentshallterminateat12:01a.m.,ontheearliestofthefollowingdates: 1.OnthedatethePlanends; 2.At12:01a.m.onthedayofthecoverageeffectivedateforthe nextsucceedingTermoftheUniversityyear; 3.OnthedateofentryoftheCoveredStudentintomilitaryservice, exceptfortemporarydutyof30daysorless.
IntheeventtheCoveredStudentceasestobeastudentattheUniversityandnorefundhasbeenmade,coverageshallendonthesamedatesasshownintheparagraphabove,fortheTerminwhichthecoveragewaseffective,asifthestudenthadnotlefttheUniversity.
Studentswhoreceivealate/retroactivewithdrawalfromtheUniversity,effectiveonorbeforeCountDay,witharefundoftuitionandfeesinaccordancewiththeUniversityStudentWithdrawalPolicy,willalsoreceivearefundoftheinsurancefeeandnocoverageisineffectthatTerm.
ThediscontinuanceofthePlanshallimmediatelyterminateallcoverageunderthePlanDocument.Suchterminationshallbewithoutprejudicetoanyclaimexpenseoriginatingpriorthereto.ThediscontinuanceofanycoverageprovidedhereundershallimmediatelyterminatethecoverageofallCoveredStudentsex-ceptwhentheCoveredStudentisconfinedintheHospitalonthedatecoveragewouldotherwiseterminate,coveragewillcontinueasdescribedhereinuntildateofdischarge,butnotmorethanthirty(30)days.
HOW TO SUBMIT A CLAIM1. ContacttheStudentInsuranceOfficeforverificationofcoverage.2. CompletetheStudentInsuranceClaimFormandsubmittoouroffice.Ifthe
formisnotcompleted,theclaimwillbedenied.Theclaimformandcompletefilinginstructionsareavailableonourwebsite eiu.edu/studentinsurance
3. ItistheCoveredStudent’sresponsibilitytoprovideprimaryandsecondary(ifapplicable)insuranceinformationtoallmedicalproviders.WhenHospitalchargesareincurred,theHospitalmustsubmitthestandardform(UB04anditemizedcharges).ForPhysicianchargesandotherexpenses,thestandardform,(CMS1500)mustbesubmittedfromeachprovider.Claimscannotbepaidfrom“statements”.
4. IftheCoveredStudentisentitledtobenefitsunderanyotherinsurancepol-icy,thatpolicyisprimary.RequirementsoftheprimarycarriermustbemetandanExplanationofBenefits(EOB)documentingpayment/denialfromtheprimarycarrierisrequiredbeforebenefitsarepayablebythisPlan.
5. Thecompletedclaimformandallrequireddocumentationreferencedabove;anyadditionalinformationrequestedbytheStudentInsuranceOffice;andpaymentoftuitionandfeeobligationstotheUniversityfortheTerm/Termsinwhichthemedicalexpenseoccurred;mustbemadewithin52weeksfromthedateofthefirstmedicalexpenseforanyonediagno-sis,orclaimswillbedenied.Ifinformationisreceivedand/orpaymentoftuitionandfeesismadewithinthespecifiedtimeperiod,theclaimwillbereopenedandclaimsreprocessed.Innoeventwillaclaimbeprocessedforpaymentbeyondthe52-weekperiod.TheUniversityisnotresponsibleforlost,stolen,ormis-directedmail.
CLAIM DENIALInmostcases,theStudentInsuranceOfficewillfurnishawrittennoticeofdenialofaclaimwithinninety(90)daysaftertheclaimisfiled.Ifadditionaltimeisneeded,anoticewillbesenttotheCoveredStudentexplainingtheneedforad-ditionaltimewhichmayextendupto180days.In the event the claim is denied, the notice will state: 1)Thespecificreasonorreasonsforthedenial. 2)ThespecificreferencetothepertinentPlanprovisionswhich promptedthedenial. 3)Whenappropriate,adescriptionofanyadditionalmaterialorinfor- mationthatisneeded,andanexplanationofwhyitisnecessary. 4)InformationonhowtocontacttheStudentInsuranceOfficeif theCoveredStudenthasanyquestionsregardingtheclaim.
CLAIMS APPEALSIfaclaimhasbeenpartiallyorfullydenied,theclaimantisentitledtoafurtherreview.TheCoveredStudentortheCoveredStudent’sdulyauthorizedrepre-sentativemayrequestareviewofpertinentdocuments,andsubmitissuesandcommentsinwritingtosupporttheCoveredStudent’sposition.Allappealsmustbesubmittedinwritingnomorethansixty(60)daysafterthedenialto:StudentInsurance,600LincolnAvenue,Charleston,IL61920.
TheStudentInsuranceOfficewillacknowledgereceiptoftheappeal,conductthereviewandnotifytheCoveredStudentofthedecisionwithinsixty(60)days.Intheeventthatadditionaltimetoreviewtheclaimisnecessary,theStudentInsuranceOfficewillnotifytheCoveredStudentthatanadditionalsixty(60)daysisnecessarytocompletethereviewoftheappeal.
DEFINITIONS(a)ACCIDENTAL BODILY INJURY/INJURY,referstoasuddenphysicalInjurycausedbyanexternalforcewhichisindependentofsickness,disease,andallothercauses,sustainedwhilecoveredunderthisPlan.
(b)COUNT DAY,referstotheFirstCensusDateofeachTermaspertheUniver-sityAcademicCalendar.10thclassdayFall/SpringTerm,5thclassdaySummerTerm.
(c)COVERED STUDENT,meansastudentofEasternIllinoisUniversitywhoisenrolledandassessedtheStudentInsurancefeeoriseligibletopurchasecoverage.
(d)DEDUCTIBLE,meanstheamountofexpensewhichmustbeincurredbeforeanybenefitsarepayablehereunder.ThePlanhasadisappearingdeductiblemeaningpaymentsbyanotherinsurancecarriercanbeusedtoreduceorsatisfytheplandeductible.
(e)ELIGIBLE EXPENSES,meanschargesfortreatment,services,orsupplieswhichare:(a)notinexcessoftheUsualandCustomaryCharges;(b)notinex-cessofthechargesthatwouldhavebeenmadeintheabsenceofthiscoverage;(c)incurredwhilethePlanisinforceastotheCoveredStudent.
(f)HOSPITAL,meansadulylicensedinstitutionforthecareofthesickwhichprovidesserviceunderthecareofaPhysicianincludingtheregularprovisionofbedsidenursingbyregisterednurses.Itdoesnotmeanhealthresorts,resthomes,nursinghomes,skillednursingfacilities,convalescenthomes,custodialhomesoftheagedorsimilarinstitutions.
(g)ILLNESS,meansabodilydisorder,disease,physicalillness,mentalinfirmity,orfunctionalnervousdisorder.
(h)MEDICALLY NECESSARY,meansaspecificserviceorsupplyprovidedtoaCoveredStudentwhichisprescribedororderedbyaPhysicianconsistentwiththeCoveredStudent’sIllness,Injuryorcondition,andrequiredfordefinitivemedicaldiagnosisandtreatment.
(i)PHYSICIAN/PROVIDER,meansanindividuallicensedtopracticemedicineunderthe“IllinoisMedicalPracticeAct”orundersimilarlawsofIllinoisorotherstatesorcountries.
(j)PLAN YEAR,shallbethesameastheacademicyear.
(k)SUBROGATION,meanstherightofthePlantoenforceaclaimagainstathirdpartyforreimbursementwhenThirdPartyLiabilityhasbeenestablishedforeligibleexpensespaidunderthisPlan.Therecoverywillnotexceedtheamountoftheaward.
(l)TERM,shallbeconsideredtheacademicperiod,semesterorsummerses-sioninwhichtheStudentisenrolled.
(m)USUAL AND CUSTOMARY,isbasedontheusualchargeforthesameserviceorsupplywithintherangeofotherPhysiciansorhealthcareprovidersofsimilartrainingandexperienceinthesamegeographicareaundersimilarorcomparablecircumstances.
BENEFIT SECTIONWhenaCoveredStudentreceivesbenefitsforthecoveredserviceslistedintheScheduleofBenefits,theyaresubjecttotheconditions,limitationsandexclusionsinthisbrochureandthedeductible,maximumbenefitamountandotherlimitationsspecified.BenefitsareprovidedonlywhentheCoveredStu-dentreceivessuchservicesonoraftertheCoveredStudent’seffectivedateofcoverage.Ifinpatientservicesareprovidedbyahealthcarefacility,theCoveredStudent’sadmissiontosuchfacilitymustoccuronoraftertheeffectivedateofcoverage.Inaddition,benefitsareprovidedonlyifrequiredinthereasonablejudgmentofthisPlanandareprovidedbyaPhysician(unlessotherwisespecified).
Schedule of BenefitsAnnualmaximumbenefit $15,000.00
OnlyoneDeductiblewillbetakenperInjuryorIllness.Allrelatedconditionsandrecurrentsymptomsofthesameorasimilarcondition,orinjuriesasaresultofthesameaccident,willbeconsideredoneillnessoroneinjury.
A. HOSPITAL OUTPATIENT/INPATIENT COVERED MEDICAL EXPENSES$100Deductiblethen70%ofreasonablechargeforHospitalRoomandBoard,(semi-privateorintensivecareaccommodations),andthefollowingitemsofMiscellaneousExpenseprovidedbyorunderthedirectionofaPhysician,Physi-cian’sAssistant,orNursePractitioner:
(a)x-rays*,includingx-ray,radiumtherapyandmammograms,routineatage35andover;(b)laboratorytests;(c)anestheticsandadministrationthereof;(d)useofoperatingroom;(e)temporarysurgicalappliances;(f)hospitalprovidedmedicines,drugsandtheadministrationthereof;(g)bloodtransfusionsandtheadministrationthereof;(h)bloodplasma;(i)oxygenandtherentalofequipmentfortheadministrationthereof;(j)anyotherneces-saryandprescribedmiscellaneoushospitalexpenses;and(k)medicalandsurgicalsupplies.
NOTE:Itemsa-jmaybecoveredoneitheraninpatientoroutpatientbasis.Itemk(medicalsupplies)maybecoveredoneitheraninpatientoroutpatientbasis;however,temporarysurgicalappliancesandsurgicalsuppliesmaybecoveredonlyconcurrentwithasurgicalprocedure.
Free-standing,licensedradiologycentersarepayablesameascategoryA.
*Specific Diagnostic procedures are limited to the following Schedule of Benefits.
A1. PHYSICIAN INPATIENT/OUTPATIENT DIAGNOSTIC PROCEDURE EXPENSE BENEFITIncludesradiology,cardiology,pathology,oncologyandlaboratorycharges.ChargesarepayablesameascategoryA.CT/MRIandnuclearorboneimagingarepaidat50%.
B. ANESTHESIA EXPENSE BENEFIT$100Deductiblethen70%ofananesthesiologist’s(licensedphysicianorCerti-fiedRegisteredNurseAnesthetist)reasonablecharge.
C. SURGICAL EXPENSE BENEFITIfaCoveredStudent,whileinsuredundertheseprovisions,undergoesacov-eredsurgicalprocedurewhichresultsfromIllness,AccidentalBodilyInjuryorpregnancy,thePlanwillpay70%oftheActualChargeor70%oftheUsualandCustomaryCharge,whicheverisless,nottoexceedtheactualchargeforsuchprocedure.Pre-andpost-operativecareisexcluded.IfasurgicalprocedureisperformedbytheemergencyroomPhysicianandonefollow-upvisitisrequiredbyanoutsidePhysician,thePlanwillpayaccordingtothePhysician’sExpenseBenefit.
AsurgicalprocedureperformedbytheEmergencyRoomPhysicianandbilledbythehospitalwillbepaidaccordingtotheSurgicalExpenseBenefit.
Ifduringasinglesurgicalsessiontwoormoreoperationsareperformedinsepa-rateoperativefieldsandthroughseparateincisions,thelimitofpaymentwillbe70%ofthelargestUsualandCustomaryChargeforanyoneoftheoperationssoperformed,plus40%oftheUsualandCustomaryChargeforeachlesserprocedure.
Ifduringasinglesurgicalsessiontwoormoreoperationsareperformedeitherinthesameoperativefieldorthroughthesameincision,thelimitofpaymentwillbe70%ofthelargestUsualandCustomaryChargeforanyoneoftheopera-tionssoperformed.
OralSurgerybenefitsprovidedonlyforthefollowingservices:a)excisionoftumor/cyst;b)tocorrectinjurieswhentheinjuryoccursonorafterthecoveragedate;orc)treatmentoffractures/dislocations;incisionanddrainageofcellulitis;orabscess,unlesscausedbyanoffendingtooth.
D. IN-HOSPITAL PHYSICIAN’S EXPENSE BENEFIT$100Deductiblethen50%foreachdayofconfinement,includingadmittingchargesforhistoryandphysical,withamaximumofonevisitperday.
Nobenefitsshallbepayableforexpensesincurredbyreasonofasurgicalprocedure.VisitsbyaspecializedPhysicianorconsultingPhysicianwillbeconsideredforadditionalpaymentbasedonareportbytheattendingPhysician.Maximumbenefitpaymentshallbe50%ofthespecializedPhysician’sreason-ablechargewithalimitofonevisitperhospitalconfinement.
IntheeventofconfinementinanIntensiveCareUnitorCriticalCareUnit,Physician’s(Specialist/Consultant)chargesforvisitswhilesoconfinedshallbepayableat50%ofthePhysician’sreasonablefee.MaximumofoneSpecialist/Consultantvisitperdayofconfinementallowed.
E. OUTPATIENT PHYSICIAN’S EXPENSE BENEFIT$100Deductiblethen70%ofanyreasonablechargepervisitwithalimitofonevisitperdayforchargesbyaPhysician,Physician’sAssistant,NursePracti-tioner,Podiatrist,Dentistand/oralicensedClinicalPsychologist,(includingLicensedClinicalSocialWorkers,underthesupervisionofaPhysician),otherthanduringaperiodofconfinement.
IftheexaminingPhysicianrefersthecoveredstudenttoaspecializedPhysician,andtreatmentisrenderedonthesameday,benefitswillbepaidat50%ofthespecializedPhysician’sreasonablecharge.Maximumofonevisitperdiagnosisisallowed.Benefitsalsoinclude,whennecessaryinthetreatmentofanInjuryorIllness,Physicianbilledorprescribedmedicaland/orsurgicalsuppliesanddressingsthatarerenderedinconnectionwithacoveredsurgicalprocedure.
The Emergency Room is not to be used as a doctor’s office.EmergencyRoomvisitstofornon-emergencytreatmentwillnotbeconsideredwithoutareferralfromaphysician.
F. AMBULANCE EXPENSE BENEFITTheexpenseofacommunity,hospital,orprivateambulanceservicewhenrequiredtotransportaCoveredStudenttoahospitalshallbe70%uptoamaxi-mumof$300perinjuryorillness.Iftransferredtoadifferenthospital,thePlanwillprovideforoneadditionaltransportat70%uptoa$300maximum.
G. DENTAL EXPENSE BENEFITAfter$100Deductible,upto$100perinjuredtoothwhentheCoveredStudentshallrequiretheservicesofalegallyqualifieddentalPhysicianorsurgeonastheresultofacoveredAccidentalBodilyInjurytosoundnaturalteethoccurringwhileinsured.
H. MATERNITY EXPENSE BENEFIT Maternityexpenses(routineand/orcomplicationsofpregnancy)willbecoveredthesameasanyothercondition.BenefitsareprovidedunderHospital,Surgical,andAnesthesiabenefitsaccordingtotheScheduleofBenefits.SurgicalBenefitincludeschargesfortotalobstetricalcare.TheUsualandCustomarysurgicalbenefitwillreflectanypriorpaymentspaidtotheProvider.
I. PSYCHIATRIC AND/OR SUBSTANCE ABUSE TREATMENT EXPENSE BENEFITInpatient–willbepaidthesameasanyothercondition,subjectto$100Deductible.
Outpatient–$100Deductible,then70%.Psychiatricevaluationandtestingpaidat70%ofthereasonablechargeupto$100perPlanYear.
Thetreatmentcentermustbelicensedorapprovedbytheregulatoryagencyhavingresponsibilityforsuchlicensingorapprovalunderthelawsinthejuris-dictioninwhichitislocated.
Please Note:Court-orderedtreatmentofAlcohol/SubstanceAbuseand/orDUIevaluation/remedialservicesisnotcovered.
J. PHYSIOTHERAPY EXPENSE BENEFITInpatient–$100Deductiblethen70%ofthereasonablecharge.
Outpatient–Expensesincurredforphysiotherapy,diathermy,heattreatment,manipulationormassageonanoutpatientbasisinanyformforanyoneInjuryorIllnessispayableat70%ofreasonablechargeafter$100deductibleuptoamaximumof$500perPlanyear.Outpatientphysiotherapy,renderedbyalicensedphysicaltherapistoraDoctorofChiropractic,mustfollowasurgicalprocedure(whilecovered)andbeprescribedbythesurgeon.Physiotherapymustoccurwithin52weeksfromdateofsurgery.IftheattendingphysicianisalsotheproviderofPhysicalTherapy,thentheCombinedMaximumPayablewillbe$500perdiagnosis,perPlanyear.
K. HEALTH & COUNSELING SERVICES ON-CAMPUS PHARMACY BENEFIT
Medication Cost without Coverage
Student Insurance Savings Final Cost
Tier I $15 $10 $5Tier II $25 $15 $10Tier III $50 $30 $20
Contraceptives $25 $25 $0No Deductible on Campus
COORDINATION OF BENEFITS (Reduction)ThePlanprovidesbenefitsinaccordancewithallofitsprovisionsonlytotheextentthatbenefitsarenotprovidedbyanyothervalidandcollectibleinsurance.IftheCoveredStudentisentitledtobenefitsbyothervalidandcollectibleinsurance,allbenefitspayablebysuchinsurancewillbedeterminedbeforebenefitswillbepaidbythePlan.ThePlanisthesecondpayortoanyotherinsurance(s)havingprimarystatusornocoordinationofbenefitsprovision.
IftheCoveredStudentiscoveredundergrouporblanketinsurancewhichisalsoexcesstoothercoverageandacopyoftheircoordinationofbenefitsisonfile,thisPlanpaysamaximumof50%ofthebenefitsotherwisepayable.
BenefitspaidbythisPlanwillnotexceed:(1)anyapplicablePlanmaximums;and(2)100%ofthecompensableexpensesincurredwhencombinedwithbenefitspaidbyanyothervalidandcollectibleinsurance.
“Othervalidcoverage”shallbedeemedascoverageprovidedbyanyorganizationsubjecttotheregulationsofinsurancelaworinsuranceauthoritiesofanystateoftheUnitedStatesoranyprovinceofCanada,oranyothercountry,andbyanyHospitalormedicalserviceorganization,andbyanygroupinsurance,automobilemedicalpaymentsinsur-ance,orcoverageprovidedbyaunionwelfareplanoremployer,oranyemployeebenefitorganization.ForthepurposeofapplyingtheforegoingPlanprovisionwithrespecttoanyCoveredStudent,anyamountofbenefitprovidedforsuchCoveredStudentpursuanttoanycompulsorystatute(includingemployer’sliabilitystatute)whetherprovidedbyagov-ernmentalagencyorotherwiseshallinallcasesbedeemedtobe“othervalidcoverage.”
Ifbenefitsareoverpaid,wehavetherighttorecovertheamountoverpaidbyeitherofthefollowingmethods:(1)Arequestforlumpsumpaymentoftheoverpaidamount;(2)Areductionofanyamountspayableundertheplan.
EXCLUSIONSNobenefitswillbeprovidedunderthisPlanfor:1.ServicesandsuppliesnotspecificallyprovidedforinthisPlan,andcomplicationsthereof;
2.ServicesandsupplieswhicharenotrequiredinthereasonablejudgmentofthePlan;
3.ServicesorsuppliesthatarefurnishedtotheCoveredStudentbythelocal,stateorfederalgovernmentandforanyservicesorsuppliestotheextentpaymentorbenefitsareprovidedoravailablefromthelocal,stateorfederalgovernment(forexample,Medicare)whetherornotthatpaymentorbenefitsarereceived,exceptasotherwiseprovidedbylaw;
4.ServicesandsuppliesforanyIllnesscontractedorInjurysustainedafterthecoveragedateasaresultofwar,declaredorundeclared,oranyactofwar,orbyparticipatinginariot,orastheresultofattemptingorcommittingacriminalact,orconditionscausedbyatomicexplosionsorradiation;
5.Servicesandsuppliesreceivedfromadentalormedicaldepartmentmaintainedbyoronbehalfofanemployer,amutualbenefitassociation,laborunion,trusteeorsimilarpersonorgroup;
6.Servicesandsupplieswhichdonotmeetacceptedstandardsofmedicalordentalpracticeincluding,butnotlimitedto,investigationalservicesandsupplies,andservicesandsuppliesrelatedthereto;
7.ServicesandsuppliesforwhichtheCoveredStudentisnotrequiredtomakepaymentorforwhichtheCoveredStudentwouldhavenolegalobligationtopayintheabsenceofthisoranysimilarcoverage;
8.Chargesforfailuretokeepascheduledvisit,chargesforcompletionofaclaimform,chargesformedicalrecords,x-raycopies,telephoneconsultations,andanyhandlingfees;
9.Servicesandsuppliesrenderedduringaninpatientadmissionwhichisprimarilyforcustodialcare,(i.e.,theprovisionofinpatientservicesandsuppliestoaCoveredStudentwhoisnotreceivingskillednursingservices);
10.Servicesandsuppliesusedtotreatconditionsrelatedtoautism,hyperkineticsyn-dromes,learningdisabilities,behavioralproblems,mentalretardation,orseniledeteriora-tion,beyondtheperiodnecessarytodiagnosethecondition,subjectto$100.00maximumbenefitfortesting;
11.Routinephysicalexaminations,includingroutinepapsmears,screeningexams,ortestingintheabsenceofInjuryorSickness;
12.Personalhygiene,comfortandconvenienceitemssuchasairconditioners,humidi-fiers,physicalfitnessequipment,correctiveshoesoradmissionkits;
13.Procurementoruseofprostheticdevices,specialappliances,specialbraces,ambula-toryapparatus,durablemedicalequipment,specializedequipmentandsurgicalimplants,exceptasspecificallyprovidedinthisPlan;however,nobenefitsareprovidedforrentalofanyoftheabovelistedsupplies;
14.Cosmeticsurgery(includingrhinoplasty)andrelatedservicesandsupplies,nasalandsinussurgery,exceptforthecorrectionofconditionsresultingfromAccidentalInjurieswhichoccurwhileinsured;
15.Servicesandsupplies,includingsurgery,forthetreatmentofobesityand/orweightcontrol;nutritionaleducationandotherpatienteducation;
16.Servicesandsuppliesrelatedtobiofeedback;
17.Maintenanceoccupationaltherapyandmaintenancephysicaltherapy;
18.Speechtherapy;
19.Visiontherapy,radialkeratotomy,eyeglassesorcontactlenses(exceptcataractlensesasspecificallyprovidedinthisplan)andtheexaminationforprescribingorfittingeyeglassesorcontactlensesorfordeterminingtherefractivestateofeyes;
20.Expensesincurredforacupuncture;alternative,holisticmedicine,and/ortherapy;includingbutnotlimitedtoyogaandhypnotherapy.
21.Hearingaidsorexaminationsfortheprescriptionorfittingofhearingaids;
22.Careofflatfeet,supportivedevicesforthefoot(orthotics),careofcorns;orcalluses,careoftoenailsandfallenarches,weakfeetorchronicfootstrainexceptifmedicallynecessaryduetodiabetesorcirculatoryproblems;
23.Immunizationinjections,includingallergyshotsandserum;therapeuticanddiagnosticinjections;injectionsforpainmanagementandrelatedservicesandsupplies;
24.ExpensesincurredforchargesmadebyaPhysicianorphysiotherapistifsuchpersonisrelatedtoorordinarilyresideswiththeCoveredStudent;
25.Dentaltreatmentordentalsurgery,exceptasspecificallyprovidedinthisPlan;
26.Injurysustainedwhile(a)participatinginanyintercollegiateorprofessionalsport,contestorcompetition;(b)travelingtoorfromsuchsport,contestorcompetitionasapar-ticipant;or(c)whileparticipatinginanypracticeorconditioningprogramforsuchsport,contestorcompetition;
27.Servicesrelatedtothediagnosisandtreatmentoftemporomandibularjoint(TMJ)disordersorsyndromesorothermyofunctionaldisorders;
28.Expensesresultingfromvoluntaryterminationofpregnancy,sterilizationprocedureorreversal,infertilitytreatment(maleorfemale)includinganyservices,testingorsuppliesrenderedforthepurposeorwiththeintentofinducingconception;
29.Outpatientprescriptiondrugs;
30.Servicesforassistantsurgery;
31.Electivesurgeryandelectivetreatment;
32.Losscausedbyskydiving,parachuting,hanggliding,gliderflying,parasailing,sailplaning,bungeejumping,orflightinanykindofaircraft,exceptwhileridingasapassen-geronaregularlyscheduledflightofacommercialairline;
33.Expensesincurredforcare,treatment,services,testing,orsuppliesfordiagnosisoforrelatedtoobstructivesleepapneaandsleepdisorders;
34.HumanOrganTransplantsotherthancornea,kidney,bonemarrow,heartvalve,muscular-skeletal,andparathyroidhumanorganortissuetransplants;
35.DiagnosticServiceaspartofroutinephysicalexaminationsorcheck-ups,pre-maritalexaminations,determinationoftherefractiveerrorsoftheeyes,auditoryproblems,sur-veys,casefinding,researchstudies,screeningorsimilarproceduresandstudies,ortestswhichareInvestigational;
36.AmedicalfacilityownedandoperatedbyaPhysicianwhichdoesnotmeetthedefini-tionofahospital;
37.Genderreassignmentsurgeryandrelatedservicesandsupplies;
38.ExpensesfortreatmentofMentalIllnessorSubstanceAbuseprovidedbyanEasternIllinoisUniversityStaffMember/orindividualundercontracttotheUniversity,inprivatepractice;
39.ExpensesfortreatmentofanInjurywhichistheresultofanautomobileaccidentwillnotbecoveredtotheextentofminimumcoveragerequiredbyanyapplicablestate“no-fault”lawforinjuriessufferedbyaCoveredStudentiftheCoveredStudentistheownerofthevehicleandisoperatingorridinginthevehicle,andthevehicleisnotcoveredbyno-faultinsuranceasrequiredbylaw;
40.ChargesincurredforservicesintheEmergencyRoom,ObservationorInpatientCarewhenthestudentleavesagainstmedicaladvice;
41.ChargesincurredintheEmergencyRoomwhichwereforadiagnosiswhichwasnotanEmergency.
42.ServicesandsuppliesforanyInjuryorIllnessarisingoutofandinthecourseofem-ploymentforwhichbenefitsand/orcompensationareavailableinwholeorinpartundertheprovisionsofanyWorker’sCompensationLaw,OccupationalDiseasesLaworsimilarLegislationoftheUnitedStatesofAmericaorofanyforeigncountryorofanyagencyorpoliticalsubdivisionofanyoftheforegoing,whetherornottheCoveredStudentclaimssuchcompensationorreceivessuchbenefitsandwhetherornotanyrecoveryishadbytheCoveredStudentagainstsuchthirdpartyfordamagesresultingfromsuchInjuryorIllness;
SUBROGATIONItisunderstoodandagreedthatthePlantowhichthisprovisionisattachedincludesthefollowing:
Thisprovisionapplieswhenaperson,otherthantheCoveredStudentforwhomaclaimismade,isconsideredresponsibleforanInjuryorIllness.TotheextentpaymentfortheInjuryorIllnessismade,ormaybemadeinthefuture,byorforthatresponsibleperson
(asasettlementjudgmentorinanyotherway)charges,arisingfromthatInjuryorIllnessarenotcovered.
IfaclaimisreceivedbyEasternIllinoisUniversitybenefitswouldbepayableif:
1.Paymentbyorfortheresponsiblepersonhasnotyetbeenmade;and
2.TheCoveredStudentinvolved,orifincapable,thatCoveredStudent’slegalrepresenta-tive,agreesinwritingtopaybackpromptlythebenefitspaidasaresultofInjuryorIllnesstotheextentofanyfuturepaymentsmadebyorfortheresponsiblepersonfortheInjuryorIllness.Theagreementistoapplywhetherornot:
(a)liabilityforthepaymentsisadmittedbytheresponsibleperson;and
(b)suchpaymentsareitemized.
3.TheCoveredStudentsubmitsasignedEIUsubrogationformtotheStudentInsuranceOffice.
AreasonableshareoffeesandcostsincurredtoobtainsuchpaymentsmaybedeductedfromamountstoberepaidtoEIUStudentInsurance.
AmountsdueEasternIllinoisUniversitytorepaybenefits,agreedtoasdescribedabove,maybedeductedfromotherbenefitspayablebyEasternIllinoisUniversityafterpaymentsbyorfortheresponsiblepersonaremade.
ThisprovisiontakeseffectandexpiresconcurrentlywiththePlantowhichitisattached.Thisprovisionissubjecttoalltheterms,limitationsandprovisionsofthisPlan.
ThisbrochurecontainstheprincipalprovisionsofthePlan.AcopyofthegoverningPlanDocumentisavailableattheStudentInsuranceOffice.IntheeventofaconflictbetweenthePlanandthisbrochure,thePlanDocumentwillprevail.
E-NUMBER
STUDENTNAME(PLEASEPRINT)
This card is for identification only. it is not a guarantee of coverage.
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Claims address:StudentInsurance,600LincolnAve,Charleston,IL61920
Claim may be faxed:217-581-7507
Forclaiminquires,verificationofeligibilityofbenefits,notificationofemergencyservicesreceivedorotherquestionspleasecall:Student Insurance 217-581-5290
Any other insurance coverage is used in determining the amount of benefits payable under this Plan.
STUDENT INSURANCE PLAN 82198600LINCOLNAVENUECHARLESTON,IL61920-3099PHONE:(217)581-5290