Microsoft word - umaine 1314 int'l brochure clean draft 1 062513

We are required by HIPAA and certain state laws to maintain the privacy of Our members' protected health information and to provide members with notice of Our legal duties and privacy practices with respect to Your protected health information. For more details please refer to the Consolidated Health Plans, Inc. Al official y sponsored University of Maine International students and scholars who are engaged in international educational activities; and are temporarily located outside his/her Home Country as a non-resident alien; and have not obtained permanent residency status are eligible for enrol ment in the University of Maine Student Injury and Sickness Insurance Plan Effective August 1, 2013 through July 31, 2014 for International Students and Scholars. The University of Maine must be the official sponsor of the student/scholar and have access to their SEVIS immigration record for at least 31 days after the date for which coverage begins. Students must actively attend classes for at least the first 31 days after the date for which coverage is purchased. The minimum standards required by the health Accidental Death & Dismemberment . 4 Company maintains its right to investigate student status and attendance records to verify that the Policy Eligibility requirements have been met. If the Company discovers the annual dollar limits for health insurance Eligibility requirements have not been met, its only obligation is plans other than Student Health Insurance to refund premium, less any claims paid. Minimum restrictions for policy year dollar Al official y sponsored University of Maine International students and scholars wil be automatical y enrol ed unless proof of comparable medical insurance is provided. Once enrolled, coverage cannot be cancelled and premium Sickness policy year limit of $500,000. Be Covered students may also enrol their lawful spouse/domestic partner* and dependent children under age 26. The student must be enrol ed in the plan in order for Dependents to be coverage under your parents' plan if you eligible for enrol ment. Dependent eligibility expires concurrently are under the age of 26. If you have any questions or concerns about this notice, Once enrolled, coverage cannot be cancelled and premium contact Consolidated Health Plans, 1-800- *Domestic partners must also submit an “Affidavit of Domestic Partnership” with the dependent enrol ment form. The affidavit is available at www.crossagency.com/umaineint. "Preferred Allowance" means the amount a Preferred Provider The Master Policy becomes effective at 12:01 a.m., August 1, Benefits wil be coordinated with any other group medical, wil accept as payment in ful for Covered Medical Expenses. 2013. Coverage becomes effective on the first day of the period surgical or hospital plan so that combined payments under al "Out-of-Network" providers have not agreed to any for which premium is paid or the date the enrol ment form and programs wil not exceed 100% of charges incurred for covered prearranged fee schedules. Insured's may incur significant out- ful premium are received by the Company (or its authorized of-pocket expenses with these providers. Charges in excess of representative), whichever is later. The Master Policy the insurance payment are the Insured's responsibility. terminates at 11:59 p.m. July 31, 2014. Coverage terminates on ACCIDENTAL DEATH AND DISMEMBERMENT BENEFIT that date or at the end of the period through which premium is If such Injury shal independently of al other causes and within Covered Persons are also entitled to any mandated benefits Refunds of premiums are al owed only upon entry into the 180 days from the date of Injury solely result in any one of the required by the State of Maine, which include coverage for 1) armed forces. The Policy is a Non-Renewable One Year Term fol owing specific losses, the Insured Person or beneficiary may Amino Acid Based Elemental Formula 2) Breast Cancer Treatment Policy. Except for medical withdrawal, any student withdrawing request the Company to pay the applicable amount below. and Reconstructive Surgery; 3) Chiropractic Services; 4) Cancer from school during the first 31 days of the period for which Payment under this benefit wil not exceed the policy Maximum Clinical Trials; 5) Colorectal Screenings; 6) Prescription coverage is purchased shal not be covered under the Policy Contraceptives; 7) Diabetes Supplies; 8) Anesthesia and Facility and a ful refund of premium wil be made. Students withdrawing Charges for Dental Procedures; 9) Children’s Hearing Aide after such 31 days wil remain covered under the Policy for the Benefit; 10) Home Health Care Services; 11) Hospice Care; 12) period for which premium has been paid. No refund wil be Mental Il ness (including Alcoholism and Drug Dependency); 13) Medical Food (Modified Low-Protein Food Products) 14) Off label Use of Prescriptions Drugs for Cancer, HIV/AIDS 15) Prostate Member means hand, arm, foot, leg, or eye. Loss shal mean Cancer Screening; 16) Prosthetic Devices; 17) Screening with regard to hands or arms and feet or legs, dismemberment Mammograms and Pap tests and 18) Domestic Partners; and by severance at or above the wrist or ankle joint; with regard to (19) Maternity benefits for unmarried women. eyes, entire and irrecoverable loss of sight. Only one specific Please see the Master Policy on file with the College for loss (the greater) resulting from any one Injury wil be paid. more information or call Customer Service By enrol ing in this Insurance Program, you have the Cigna *The above rates include an administrative service fee. COINSURANCE means the ratio by which We and the Insured PPO Network of Participating Providers, providing access to share in the payment of Usual and Customary expenses for quality health care at discounted fees. To find a complete listing Medical y Necessary treatment. The coinsurance percentage of Cigna PPO Network of Participating Providers, go to that we wil pay is stated in the Schedule of Benefits. www.cigna.com, or contact Consolidated Health Plans at (413) The coverage provided under this policy ceases on the 733-4540, tol -free at (800) 633-7867, or www.chpstudent.com COVERED MEDICAL EXPENSES means reasonable charges Termination Date. However, if an Insured is Total y Disabled on which are: 1) not in excess of Usual and Customary Charges; 2) the Termination Date from a covered Injury or Sickness for not in excess of the maximum benefit amount payable per which benefits were paid before the Termination Date, Covered "Preferred Providers" are the Physicians, Hospitals and other service as specified in the schedule of benefits; 3) made for Medical Expenses for such Injury or Sickness wil continue to be health care providers who have contracted to provide specific services and supplies not excluded under the Policy; 4) made paid as long as the condition continues but not to exceed 6 for services and supplies which are Medical Necessity; 5) made If care is received within the Network from a Preferred Provider, for services included in the Schedule of Benefits; and 6) in The total payments made in respect of the Insured for such al Covered Medical Expenses wil be paid at the Preferred excess of the amount stated as a Deductible, if any. condition both before and after the Termination Date wil never Provider level of benefits found on the Schedule of Benefits. Covered Medical Expenses wil be deemed “incurred” only: 1) exceed the Maximum Benefit. After this “Extension of Benefits” If a Preferred Provider is not available in the Network Area, or when the covered services are provided; and 2) when a charge provision has been exhausted, al benefits cease to exist, and an Insured is out of the Country, benefits wil be paid at the level is made to the Insured Person for such services. under no circumstances wil further payments be made. of benefits shown on the Schedule of Benefits as a Preferred DEPENDENT means the spouse (husband or wife) or domestic recommended for treatment within the 6 months immediately infirmaries or places mainly for domiciliary or custodial partner of the Named Insured and their dependent children. prior to the Insured's Effective Date under the policy. care; extended care in treatment or substance abuse Children shal cease to be a dependent at the end of the month SICKNESS means sickness or disease of the Insured Person facilities for domiciliary or custodial care. in which they wil attain the age of twenty-six (26). which causes loss, and originates while the Insured Person is 3. Dental treatment, except as specifical y provided in the The attainment of the limiting age wil not operate to terminate covered under this policy. Al related conditions and recurrent the coverage of such child while the child is and continues to be symptoms of the same or a similar condition wil be considered 4. Elective Surgery or Elective Treatment; one sickness. Covered Medical Expenses incurred as a result of 5. Eye examinations, eye refractions, eyeglasses, contact 1. Incapable of self-sustaining employment by reasons of an Injury that occurred prior to this policy's Effective Date wil be lenses, prescriptions or fitting of eyeglasses or contact mental retardation or physical handicap; and considered a sickness under this policy. lenses, vision correction surgery, or other treatment for 2. Chiefly dependent upon the Insured Person for support USUAL AND CUSTOMARY (U&C) CHARGES means a visual defects and problems; except when due to a disease reasonable charge which is: 1) usual and customary when Proof of such incapacity and dependency shal be furnished to compared with the charges made for similar services and supplies; 6. Foot care including: flat foot conditions, supportive devices the Company: 1) by the Named Insured; and 2) within thirty-one and 2) made to persons having similar medical conditions in the for the foot, subluxations of the foot, care of corns, bunions (31) days of the child’s attainment of the limiting age. locality of the Policyholder locality where service is rendered. No (except capsular or bone surgery), cal uses, toenails, fal en Subsequently, such proof must be given to the Company payment wil be made under this Policy for any expenses incurred arches, weak feet, chronic foot strain, and symptomatic annual y fol owing the child’s attainment of the limiting age. which in the judgment of the Company (as determined by Ingenix) complaints of the feet, except as specifical y provided in the are in excess of Usual and Customary Charges. The Insured may If a claim is denied under the Policy because the child has be bil ed for any charges which exceed the Usual and Customary attained the limiting age for dependent children, the burden is on 7. Injury or Sickness for which benefits are paid or payable the Insured Person to establish that the child is and continues to under any Workers' Compensation or Occupational be handicapped as defined by subsections (1) and (2). WE, OUR or US means Nationwide Life Insurance Company. Disease Law or Act, or similar legislation INJURY means bodily injury which is: 1) directly and YOU, YOUR, YOURS means the Insured Student. 8. Injury sustained by reason of motor vehicle accident to the independently caused by specific accidental contact with extent that benefits are paid or payable by any other valid another body or object; 2) unrelated to any pathological, (Does not apply to Covered Persons under age 19) functional, or structural disorder; 3) a source of loss; 4) treated The Policy does not cover Pre-existing Conditions during the 9. Injury sustained while a) participating in any professional by a Physician within 30 days after the date of accident; and 5) first six (6) months of continuous coverage. sport, contest or competition; b) traveling to or from such sustained while the Insured Person is covered under this policy. sport, contest or competition as a participant; or c) while However, this provision wil not limit benefits for a Pre-existing Al injuries sustained in one accident, including al related participating in any practice or conditioning program for Condition if, during the period immediately preceding the conditions and recurrent symptoms of these injuries wil be Insured’s becoming insured under the Policy, or within ninety considered one injury. Injury does not include loss which results (90) days of enrol ment under this plan, he or she was enrol ed 10. Participation in a riot or civil disorder; commission of or whol y or in part, directly or indirectly, from disease or other under another Policy or plan that provided similar benefits for six attempt to commit a felony; or fighting, except for self- bodily infirmity. Covered Medical Expenses incurred as a result (6) consecutive months. Prior coverage of less than six (6) of an injury that occurred prior to this policy's Effective Date wil months wil be credited toward satisfying the Pre-existing 11. Pre-existing Conditions, except for individuals who have be considered a Sickness under this policy. Condition limitation. Pre-existing Conditions of an adopted child been continuously insured under the school's student OUT-OF-POCKET EXPENSES include Deductibles, Co- insurance policy for at least six (6) consecutive months. payments and Co-Insurance of Covered Medical Expenses. The Pre-existing Condition exclusionary period wil be Charges above the Usual and Customary (U&C) and over reduced by the total number of months that the insured internal maximum benefit amounts payable per service, as No benefits wil be paid for: a) loss or expense caused by, provides documentation of continuous coverage under a specified in the schedule of benefits, are not considered Out of contributed to, or resulting from; or b) treatment, services or prior health insurance policy which provided benefits similar to this policy. Credit wil be given if the prior coverage was PRE-EXISTING CONDITION means: 1) the existence of 1. Cosmetic procedures, except cosmetic surgery required to continuous to a date within 90 days prior to the Insured symptoms which would cause an ordinarily prudent person to correct an Injury for which benefits are otherwise payable Person’s effective date of coverage under this policy. seek diagnosis, care or treatment within the 6 months under this policy; removal of warts, non-malignant moles 12. Prescription Drugs, services or supplies as fol ows, immediately prior to the Insured's Effective Date under the policy; except as specifical y provided in the Policy: or, 2) any condition which originates, is diagnosed, treated or 2. Custodial care; care provided in: rest homes, health Drugs labeled, "Caution - limited by federal law to resorts, homes for the aged, halfway houses, col ege investigational use" or experimental drugs, except as specifical y provided in the Benefits for Off-Label Drug 22. Hearing examinations or hearing aids; or other treatment for hearing defects and problems, except as specifical y provided in the Policy. “Hearing defects” means any b. Drugs used to treat or cure baldness; anabolic physical defect of the ear which does or can impair normal c. Anorectics - drugs used for the purpose of weight 23. Suicide, attempted suicide, intentional y self-inflicted Injury or attempted self-inflicted Injury, while sane or insane. d. Fertility agents or sexual enhancement drugs, such 24. For Intercol egiate sports Injuries, no benefits wil be paid as Parlodel, Pergonal, Clomid, Profasi, Metrodin, for: Infections, except pyogenic infections caused whol y by a covered Injury; Cysts, blisters, or boils; Overexertion; e. Refil s in excess of the number specified or dispensed heat exhaustion; fainting; or Hernia, regardless of how after one (1) year of date of the prescription. 13. Reproductive/Infertility services including but not limited 25. Weight management, weight reduction, nutrition programs, to:fertility tests; infertility (male or female), including any and surgery for removal of excess skin or fat. services or supplies rendered for the purpose or with the intent of inducing conception; premarital examinations; impotence, organic or otherwise; vasectomy;; reversal of In the event of Injury or Sickness, students should: 1. Report to the Cutler health center or when not in school log 14. Sexual/gender reassignment surgery; any treatment of on to www.chpstudent.com to find the nearest participating gender identity disorders, including hormone replacement therapy except as provided herein. This exclusion does 2. All itemized medical and hospital bills should be not include related mental health counseling. mailed promptly to Cigna at the address listed below 15. Services provided normal y without charge by the Health within 30 days of Injury or first treatment of a Sickness. Al bil s should include the patient’s name and insured 16. Skeletal irregularities of one or both jaws, including student’s name, address, member identification number and name of the university under which the student is temporomandibular joint dysfunction; deviated nasal septum, including submucous resection and/or other surgical correction thereof; nasal and sinus surgery, except for treatment of chronic purulent sinusitis; 17. Skydiving, parachuting, hang gliding, glider flying, parasailing, sail planing, bungee jumping, or flight in any kind of aircraft, except while riding as a passenger on a 3. A company claim form is not required, however, after regularly scheduled flight of a commercial airline; review; Consolidated Health Plans may contact the student and ask them to complete a claim form or a questionnaire Brochures, enrol ment forms, request ID Cards, and for FAQ’s. 18. Supplies, except as specifical y provided in the policy; to get further information about the claim. Please Visit Consolidated Health Plans Website at 19. Surgical breast reduction, breat augmentation, breat 4. Al Prescriptions must be fil ed at a RESTAT Participating www.chpstudent.com to view and print Brochures, (printable implants or breast prosthetic devices, or gynecomastia; Pharmacy. Present your ID card to the pharmacist when using Adobe Acrobat), Coverage Receipts, ID Cards, Claims except as specifical y provided in the policy; purchasing your prescription. If a prescription needs to be 20. Treatment in a Government hospital, unless there is a fil ed prior to receiving an ID card, reimbursement wil be Please keep this Brochure as a general summary of the legal obligation for the Insured Person to pay for such made upon receipt of a completed prescription drug claim insurance. The Master Policy on file at the University contains form. Claim Forms can be found online at al of the provisions, limitations, exclusions and qualifications of 21. War or any act of war, declared or undeclared; or while in www.crossagency.com/umaineint or at www.restat.com or your insurance benefits, some of which may not be included in the armed forces of any country (a pro-rata premium wil by cal ing the claims administrator below. this Brochure. The Master Policy is the contract and wil govern be refunded upon request for such period not covered); For Vision Discount Benefits please go to: FrontierMEDEX ACCESS services is a comprehensive program providing You with 24/7 emergency medical and travel assistance services including emergency security or political evacuation, repatriation services and other travel assistance services when you are outside Your home country or 100 or more miles away from your permanent residence. FrontierMEDEX is your key to travel security. For general inquiries regarding the travel access assistance services coverage, please call Consolidated If you have a medical, security, or travel problem, simply cal FrontierMEDEX for assistance and provide your name, school name, the group number shown on your ID card, and a description of your situation. If you are in North America, cal the Assistance Center tol -free at: 1-800-527-0218 or if you are in a foreign country, cal col ect at: 1-410-453-6330. If the condition is an emergency, you should go immediately to the nearest physician or hospital without delay and then contact the 24-hour Assistance Center. FrontierMEDEX will then take the appropriate action to assist You and monitor Your care until the situation is If a premium has been paid, the Student whose name appears above has been insured under a Policy issued to: The University of Maine – International International Students and Scholars of The University of Maine 2013-2014 Schedule of Medical Expense Benefits Maximum per Injury or Sickness per Policy Year Policy Year Deductible per Covered Person* Maximum Out-of-Pocket per Covered Person per Policy Year (including deductible and co-payments). Note: Prescription drug co-payments do not apply to the out-of-pocket (Note: Medical expenses, which exceed the internal plan benefit maximums, are not covered and are not applicable towards satisfying the Out-of-pocket Maximum.) *Covered Medical Expenses incurred at the Cutler Health Center wil be paid at 100% of U&C with no co-payment or Deductible. This includes coverage for non-malignant moles, warts and lesions, and treatment of al ergic rhinitis. Room and Board/Hospital Miscellaneous, daily semi-private room rate; and general nursing care provided by the Hospital. Miscel aneous expenses such as the cost of the operating room, laboratory tests, x-ray examinations, pre-admission testing, anesthesia, drugs (excluding take home drugs) or medicines, therapeutic services, and supplies. In computing the number of days payable under this benefit, the date of admission wil be counted, but not the date of discharge. Routine Newborn Care, while Hospital Confined and routine nursery care provided immediately after birth. The Deductible does not apply for benefits provided under Paid as any other Sickness/4 days Hospital Confinement Expense Maximum this benefit. Surgeon’s Fees, in accordance with data provided by Fair Health, Inc. If two or more procedures are performed through the same incision or in immediate succession at the same operative session, the maximum amount paid wil not exceed 50% of the second procedure and 50% of al subsequent procedures. Assistant Surgeon’s Fee Anesthetist, professional services administered in connection with inpatient surgery. Registered Nurse’s Services, private duty nursing care. Physician’s Visits, benefits are limited to one (1) visit per day and do not apply when related to surgery Pre-Admission Testing, This benefit is payable within 3 working days prior to Surgeon’s Fees, in accordance with data provided by Fair Health, Inc. If two or more procedures are performed through the same incision or in immediate succession at the same operative session, the maximum amount paid wil not exceed 50% of the second procedure and 50% of al subsequent procedures. Day Surgery Miscellaneous, related to scheduled surgery performed in a Hospital, including the cost of the operating room; laboratory tests and x-ray examinations, including professional fees; anesthesia; drugs or medicines; and supplies. Usual and Customary Charges for Day Surgery Miscel aneous are based on the Outpatient Surgical Facility Charge Index. Assistant Surgeon’s Fees Anesthetist, professional services administered in connection with outpatient surgery Physician’s Visits, benefits are limited to one (1) visit per day. (Co-pay is waived if treatment is received at the Cutler Health Center or if the initial treatment is received at the Cutler Health Center).
Wellness/Preventive and Immunization Services
(For more information, please visit: www.healthcare.gov/prevention)
Medical Emergency Expenses, use of the emergency room and supplies. Treatment must be rendered within 72 hours from time of Injury or first onset of Sickness. If admitted, the Medical Emergency Expense co-pay wil be waived and the Inpatient co-pay wil apply. Diagnostic X-ray and Laboratory Services Tests & Procedures, diagnostic services and medical procedures preformed by a Physician, other than Physician’s Visits, Physiotherapy, X-ray and lab procedures. $12 co-pay per prescription for Generic Drugs Prescription Drugs, Prescriptions must be purchased through a participating $0 co-pay per prescription for Generic Contraceptives pharmacy. Participating Pharmacies can be found on-line at www.RESTAT.com $25 co-pay per prescription for Brand Name Drugs NOTE: Use of RX card replaces need for submission of claim receipts. Mental Illness, Benefits are limited to one (1) visit per day. Physiotherapy, including acupuncture is limited to one (1) visit per day. Durable Medical Equipment, a written prescription must accompany the claim when Dental Treatment, Covered expenses for Injury to Sound, Natural Teeth. 100% of U&C, $100 maximum per tooth, up to a $500 maximum per Policy Year Maternity and Complications of Pregnancy Elective: 90% of U&C, up to a $500 maximum $100 Deductible per Injury, then 90% of U&C, up to a $10,000 maximum per Injury Motor Vehicle Injury, up to $25,000 maximum per injury Medical Treatment in Student’s Home Country (If not covered by another plan) 90% of U&C / $1,000 Maximum Lifetime Benefit

Source: http://www2.crossagency.com/2013-2014/pdf/umaineint.pdf