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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
Erfahrungsbericht über eine Katarakt (“Grauer Star”) -Operation und Einsatz einer Multifokallinse - aus der Sicht des Patienten Durchgeführt in der Augenklinik Berlin-Marzahn, Brebacher Weg 15, 12683 Berlin im Februar 2002 Behandelnder Arzt und Operateur: Dozent Dr. med. habil. Dietze, Ärztlicher Direktor dieser Klinik Vorbemerkung: Auch als aufgeklärter Patient ist man bei der
Comparación entre Fludarabina y Clorambucil comoTratamiento Primario de la Leucemia Linfocítica CrónicaRai KR, Peterson BL, Appelbaum FR y colaboradores. Long Island Jewish Medical Center, Nueva York, EE.UU. [Fludarabine Compared with Chlorambucil as Primary Therapy for Chronic Lymphocytic Leukemia]The New England Journal of Medicine 343:1750-1757, Ref.: 1750, Decembrer 14, 2000. Utiliz