rice university basic plan

7/29/2019 Rice University Basic Plan

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Aetna Student Health: Rice University Coverage Period: beginning on or after 8/15/2013Summary of Benefits and Coverage:What this Plan Covers & What it Costs Coverage for: Individual Plan Type: PPO

Questions: Call 1-877-375-7908 or visit us athttp://www.aetnastudenthealth.com/rice. 500499-912071-900196If you arent clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossaryatwww.healthreformplanSBC.com.

Common

Medical EventServices You May Need

Your cost if you use an

Limitations & ExceptionsPreferred Provider

Non-PreferredProvider

If you have outpatientsurgery

Facility fee (e.g., ambulatory surgerycenter)

25% Coinsurance 50% Coinsurance ---none---

Physician/surgeon fees 25% Coinsurance 50% Coinsurance ---none---

If you needimmediate medicalattention

Emergency room services$150 Copay/25% Coinsurance

$150 Copay/25% Coinsurance

---none---

Emergency medical transportation 25% Coinsurance 25% Coinsurance ---none---

Urgent care 25% Coinsurance 50% Coinsurance ---none---If you have a hospitalstay

Facility fee (e.g., hospital room) 25% Coinsurance 50% Coinsurance Requires pre-certification.

Physician/surgeon fee 25% Coinsurance 50% Coinsurance ---none---

If you have mentalhealth, behavioralhealth, or substanceabuse needs

Mental/Behavioral health outpatientservices

25% Coinsurance 50% CoinsuranceCoverage is limited 60 visits perPolicy Year.

Mental/Behavioral health inpatientservices

25% Coinsurance 50% CoinsuranceCoverage is limited to 30 days percondition per Policy Year. Requirespre-certification.

Substance use disorder outpatientservices

25% Coinsurance 50% CoinsuranceCoverage is limited 60 visits perPolicy Year.

Substance use disorder inpatient services 25% Coinsurance 50% CoinsuranceCoverage is limited to 30 days percondition per Policy Year. Requirespre-certification.

If you are pregnant

Prenatal and postnatal care

Prenatal NoCharge, Postnatal -

$20 Copay per visit/25% Coinsurance,Diagnostic Tests-25% Coinsurance

Prenatal andpostnatal - $20

Copay per visit/50% Coinsurance,Diagnostic Tests-50% Coinsurance

---none---

Delivery and all inpatient services

Inpatient-25% CoinsuranceDelivery-25% Coinsurance

Inpatient-50% CoinsuranceDelivery-50% Coinsurance

Requires pre-certification.


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Common

Medical EventServices You May Need

Your cost if you use an

Limitations & ExceptionsPreferred Provider

Non-PreferredProvider

If you need helprecovering or haveother special healthneeds

Home health care 25% Coinsurance 50% CoinsuranceCoverage is limited to 40 visits perPolicy Year.

Rehabilitation services 25% Coinsurance 50% CoinsuranceIncludes physical, occupational, andspeech

Habilitation services 25% Coinsurance 50% CoinsuranceIncludes physical, occupational, andspeech

Skilled nursing care 25% Coinsurance 50% Coinsurance Requires pre-certification.

Durable medical equipment 25% Coinsurance 50% Coinsurance ---none---

Hospice service 25% Coinsurance 50% Coinsurance Requires pre-certification.

If your child needsdental or eye care

Eye exam Not Covered Not Covered ---none---

Glasses Not Covered Not Covered ---none---

Dental check-up Not Covered Not Covered ---none---

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isnt a complete list. Check your policy or plan document for otherexcluded services.)

Acupuncture Bariatric surgery Cosmetic surgery Dental care (Adult) Dental care (Child)

Glasses Hearing aids Infertility treatment Long term care

Private-duty nursing Routine eye care (Adult) Routine eye care (Child) Routine foot care Weight loss programs


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Other Covered Services (This isnt a complete list. Check your policy or plan document for other covered services and your costs for these services.)

Chiropractic care

Non-emergency care when travelingoutside the U.S.

Your Rights to Continue Coverage:

Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay yourpremium. There are

exceptions, however, such as if: You commit fraud The insurer stops offering services in the State You move outside the coverage area

For more information on your rights to continue coverage, contact the insurer at 1-877-375-7908. You may also contact your state insurance departmentat1-800-252-3439.

Your Grievance and Appeals Rights:If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. Forquestions about your rights, this notice, or assistance, you can contact Aetna at1-877-375-7908. You may also contact your state insurance department at1-800-252-3439.

Language Access Services:

Para obtener asistencia en Espaol, llame al 1-877-375-7908.Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-877-375-7908.

1-877-375-7908.Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-877-375-7908.

To see examples of how this plan might cover costs for a sample medical situation, see the next page.


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Having a baby

(normal delivery)

Managing type 2 diabetes

(routine maintenance ofa well-controlled condition)

About these Coverage

Examples:These examples show how this plan might covermedical care in given situations. Use theseexamples to see, in general, how much financialprotection a sample patient might get if they arecovered under different plans.

Amount owed to providers:$7,540Plan pays$5,410Patient pays$2,170

Sample care costs:

Hospital charges (mother) $2,700

Routine obstetric care $2,100

Hospital charges (baby) $900

Anesthesia $900

Laboratory tests $500

Prescriptions $200

Radiology $200

Vaccines, other preventive $40Total $7,540Patient pays:

Deductibles $250

Co-pays $60

Co-insurance $1,710

Limits or exclusions $150

Total $2,170

Amount owed to providers:$5,400Plan pays$3,920Patient pays$1,500

Sample care costs:

Prescriptions $2,900

Medical Equipment and Supplies $1,300

Office Visits and Procedures $700

Education $300

Laboratory tests $100

Vaccines, other preventive $100

Total $5,400

Patient pays:

Deductibles $250

Co-pays $620

Co-insurance $550

Limits or exclusions $80

Total $1,500

This isnot a costestimator.

Dont use these examples to

estimate your actual costsunder this plan. The actualcare you receive will bedifferent from theseexamples, and the cost ofthat care will also bedifferent.

See the next page forimportant information aboutthese examples.


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rice university basic plan

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