Table of Contents
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Introduction
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Special Points to Consider
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Student Eligibility and Enrollment
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Student Eligibility – Domestic Students . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Credit Hour Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Student Eligibility - International Students . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Purchasing/Waiving Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
Off-Term Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
Coverage Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
Interim Coverage: Special Provisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
Dependent Eligibility and Enrollment
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
Dependent Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Late Dependent Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Payment for Late Dependent Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Policy Terms and Costs
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Coverage Term . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Coverage Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Premium Refunds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Student Health Services Benefits
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Counseling and Consultation Service Benefits
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Student Health Insurance Plan Benefits
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
Deductible, Coinsurance, and Copayment Rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
Coinsurance/Copayments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
Out-of-Pocket Maximum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
Order of Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
Waiver of Emergency Room Copayment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
The PPO Arrangement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13Schedule of Benefits
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Description of Covered Services
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21Scholastic Emergency Services: Global Emergency Medical Assistance
. . . . . . . . . . . .28Utilization Review Management
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
Pre-Certification Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
Exclusions and Limitations
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
Pre-Existing Conditions Limitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
Continuous Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33
Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34
Collegiate Assistance Program
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35Coordination of Benefits
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35Subrogation and Recovery Rights
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36Extension of Benefits
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36Termination of Coverage
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36Claim Procedures
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37Conversion Plan
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38Contacts / Questions
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38
We know that your privacy is important to you and we strive to protect the confidentiality ofyour non-public personal information. We do not disclose any non-public personalinformation about our customers or former customers to anyone, except as permitted orrequired by law. We believe we maintain appropriate physical, electronic and proceduralsafeguards to ensure the security of your non-public personal information. You may obtain acopy of our privacy practices by calling us toll-free at 800-767-0700 or visiting us atwww.uhcsr.com.
This is The Ohio State University Comprehensive Student Health Insurance Plan (Plan). This
health benefits plan has been specifically designed for students of The Ohio State University
(OSU). Gallagher Koster has been selected to service the OSU Student Health Insurance Plan.
Gallagher Koster is the account manager and is responsible for the overall servicing of the
Plan. If you have any questions on eligibility, enrollment, available benefits or general service
issues, you should contact Gallagher Koster’s dedicated toll-free phone number, 1-800-254-
2461, or email address, [email protected]
It is important that you retain this booklet for a complete description of coverage providedthrough the Plan. Knowing the terms of this Coverage is your responsibility and not theresponsibility of the health care provider. Questions regarding Coverage should be referred tothe Gallagher Koster customer service department. The Plan has five major benefitcomponents that are outlined below and described in detail in this Plan Description:
1. Coverage for services rendered by OSU Student Health Services at the Wilce Student
2. Coverage for services rendered by OSU Counseling and Consultation Service at the
3. Coverage for services rendered by providers participating in the OSU Managed Health
Care System (OSU MHCS) Provider Network, locally, and by the BeechStreet Provider
Network, outside of Franklin County and nationally.
4. Coverage for services rendered by Providers that do not participate in the OSU MHCS
5. Coverage for the Emergency Medical Evacuation/Repatriation of Remains and
Emergency Travel Assistance Benefits offered through Scholastic Emergency Services
All medical insurance plan benefits, except for services rendered by Student Health Servicesat the Wilce Student Health Center, Counseling and Consultation Service at the YounkinSuccess Center, Delta Dental, and Scholastic Emergency Services, are underwritten by UnitedHealthCare Insurance Company (The Company). Benefits for services rendered by StudentHealth Services at the Wilce Student Health Center and Counseling and Consultation Serviceat the Younkin Success Center are self-funded by OSU.
The Company issues this Plan Description according to the terms of the Master Policy(Policy). It contains some of the provisions of the Master Policy. If there is anymisunderstanding or inconsistency between the Plan Description and the Master Policy, theactual terms of the Master Policy shall govern. The Master Policy is between The Companyand The Ohio State University. OSU is the Policyholder under the Master Policy.
On behalf of an Insured Person, OSU collects the premium required under the Plan and makessuch payments as due to The Company. The Student Health Insurance Program, Office ofStudent Life, or the OSU Student Health Insurance Committee is responsible for making anychanges in coverage, terminating coverage, and doing any other acts required to make yourcoverage active. It is the responsibility of each student to add Dependents when a qualifyingevent occurs during the School Term and to pay prorated premiums to Gallagher Koster.
Subject to the payment of premium, all persons who have satisfied the eligibility conditionsand have not waived coverage according to the terms of this Plan Description, are covered bythis Plan.
Special Points to Consider
This is a brief summary on key provisions. Refer to the specific section for a completeexplanation.
All Columbus campus-based domestic students who are
enrolled at least half time are required to be insured by either The Ohio State University
Comprehensive Student Health Insurance Plan or a health insurance plan of comparable
coverage. Students attending regional campuses are not required, but are eligible to
purchase the Comprehensive Student Health Insurance Plan. In addition, all international
students are required to be insured under the Comprehensive Student Health Insurance
Plan as a condition of enrollment.
Importance of Maintaining Continuous Coverage.
Students and their Dependents who
want to maintain coverage will need to purchase coverage for an Off-Term, or risk a lapse
in coverage. Should your coverage lapse, you will not be covered by the Plan until you re-
purchase the Plan. Keep in mind that a lapse in coverage requires you to re-satisfy the Pre-
Existing Condition Waiting Period.
Pre-Existing Condition Limitation.
A Pre-Existing Condition is any
condition for which
the Insured Person received diagnosis, advice or treatment, including prescription drugs,
during the three-month period immediately prior to the effective date of the Insured
Person’s coverage. Claims for a Pre-Existing Condition will be covered once the
individual has been covered under the Plan for three (3) consecutive months. This
consecutive three (3) month period is known as the Pre-Existing Condition Waiting
Period. Pregnancy is covered as any other condition and will be subject to the Pre-Existing
Condition Limitation. If the Insured Person or covered Dependent has any lapse in
coverage the Pre-Existing Condition Waiting Period must be resatisfied. Therefore,
students are encouraged to maintain continuous coverage including Off-Terms. The Pre-
Existing Condition Waiting Period will be waived for services covered under the OSU
Student Health Services and OSU Counseling and Consultation Service benefits.
Pre-Certification Requirement/Utilization Review.
There are several benefits that
require pre-certification in order for these services to be paid in accordance with plan
provisions. Please refer to page 29-32 for a complete description of the pre-certification
Maintaining Student Information.
Various methods are used to expedite students’
receipt of plan information and updates on a timely basis. ID cards, Explanation of
Benefits, etc. are mailed to students at the address on file at the Registrar’s Office.
Reminder notices and important announcements on the Student Health Insurance Plan are
sent via students’ OSU email address. It is your responsibility to make sure your
address(es) are accurate with the Registrar’s Office.
You may convert to the Conversion Plan after Off-Term Coverage is
exhausted. In order to enroll in this option, you had to be enrolled in the Student Health
Insurance Plan for at least 6 months and you must apply for and purchase the Conversion
Plan within 31 days following the date you lose eligibility under the Student Health
Insurance Plan. This plan has a completely separate benefit, pre-existing condition
limitation and rate structure. Contact Gallagher Koster at 1-800-254-2461 or[email protected]
Student Eligibility and Enrollment
Student Eligibility – Domestic Students
All Domestic Students who are enrolled at OSU at least six (6) credit hours forundergraduates, at least five (5) credit hours for graduate students and at least three (3) credithours for post-candidacy doctoral students are eligible under this Plan. Exceptions apply toenrolled students taking one of the approved exception course numbers representing co-ops,internship, study abroad, and thesis or dissertation research. These students will beautomatically charged and the health insurance premium will be included in their fees, unlessthe student waives coverage.
Credit Hour Requirements
The following courses are excluded from being applied towards the required minimum credithours:
• Courses taken through the College of Continuing Education.
• Distance-learning courses (denoted by a “D” suffix to the course number). Students may
petition the Student Health Insurance Program office to use distance learning hours for
eligibility if taken in conjunction with on-campus courses.
• Courses taken as Audit. • Courses taken as Pass/Non-Pass in excess of the 15 credit hours allowed by the
University to count toward a degree program.
• Courses taken Grad Non-Degree. However upon written request, exceptions may be
granted for Grad Non-Degree under the following conditions:
• The student has a current application on file with the Graduate School; and• The student has no more than 10 accumulated grad non-degree credit hours; and• The course directly relates to the graduate field of study.
Students who do not meet the minimum credit hour requirements are not eligible to purchasethe Comprehensive Student Health Insurance Plan, and can contact Gallagher Koster at1-800-254-2461 or [email protected]
for possible alternative options.
Student Eligibility - International Students
International Students are required to enroll in the Comprehensive Student Health InsurancePlan as a condition of enrollment at OSU. International Students can not waive coverageunless they are currently enrolled in a comparable insurance plan provided through anapproved government-sponsored program or an international organization, or are a covereddependent of a U.S. based employee.
International Students who fall under one of these categories must request an exemption bycompleting an International Student Health Insurance Waiver Form and submitting it prior tothe deadline to: Student Health Insurance Program, 3rd floor, Wilce Student Health Center,1875 Millikin Road, Columbus, OH 43210.
All eligible domestic students who enroll in the Student Health Insurance Plan in the Autumnquarter are automatically enrolled for Annual coverage, which includes the Autumn, Winter,Spring, and Summer Terms. All eligible domestic students who initially enroll in the WinterTerm, are automatically enrolled for Winter, Spring, and Summer Terms, and all eligibledomestic students who initially enroll in the Spring Term, are automatically enrolled in theSpring and Summer Terms.
Please note: In order to be covered automatically for any term, including Summer Term,students must remain enrolled in classes that meet the Student Health Insurance Planeligibility requirements.
Graduate students who receive a premium subsidy from the University, must maintain at leastthe minimum number of credit hours and work hours each quarter as defined by the GraduateSchool to continue to receive the subsidy.
This process does not apply to International Students. International Students, please refer to“Student Eligibility – International Students” above.
It is the student’s responsibility to purchase or waive coverage. The charge for single,Comprehensive Student Health Insurance will be automatically applied to a student’sStatement of Account during the course registration process as part of University Fees, unlessan On-Line Waiver Form is completed by the deadline. Students who are currently enrolledin a plan of comparable coverage can waive the Comprehensive Student Health InsurancePlan. Students must waive coverage through the On-line Course Registration system through(http: //www.buckeyelink.osu.edu), under Web Registration for Courses. Students, upon theirinitial eligibility, have until the deadline (refer to page 8 for the Enroll or Withdraw DeadlineSchedule), as published in the Master Schedule, to waive Student Health Insurance coverage.
When a student waives coverage by the deadline, coverage is waived for the remainder of theschool terms of that policy year for which the student is eligible.
All eligible domestic students who waive out of the Comprehensive Student Health InsurancePlan will need to provide proof of comparable, major medical coverage. If this documentationcannot be provided, students will remain enrolled in the Comprehensive Student HealthInsurance Plan up to a maximum of three consecutive terms. All requests to waive theComprehensive Student Health Insurance Plan received after the deadline of a student’s initialterm of enrollment in the academic year, for whatever reason, require an appeal to be filed.
Students can download an appeal form at http://shi.osu.edu
Information/Important Forms or can receive a form at the Student Health Insurance Program,3rd floor, Wilce Student Health Center.
Students who need to remit payment of the insurance charge must do so by the applicabledeadline each school term. If students fail to pay the insurance charge by the end of the schoolterm, the balance will be referred to the Office of Accounts Receivable.
Coverage may be continued without interruption for one consecutive School Term per PolicyYear for all Insured Students who: 1) graduate, or 2) are not enrolled in classes, or 3) areenrolled in classes, but who have dropped below the minimum credit hour requirement (6credit hours for undergraduate and 5 credit hours for graduate students), or 4) do not meetother eligibility criteria, provided they were enrolled in class and covered by the plan duringthe preceding School Term. Please refer to “Credit Hour Requirements” on page 3 for the listof courses that are excluded from being applied to the minimum credit hour requirement.
Coverage for an Off-Term is not automatic.
Insured Students not enrolled for classes meeting the eligibility criteria during the “Off-Term”,but who want to continue coverage, must elect Off-term coverage online throughwww.treasurer.Ohio-State.edu, under Office of the University Bursar, Off-term Insurance, bythe deadline.
Please refer to the section entitled, “Coverage Dates” on page 8 to confirm term coverage
dates. YOU WILL NOT AUTOMATICALLY BE BILLED FOR OFF-TERM
COVERAGE AND ARE REQUIRED TO ACTIVELY ENROLL FOR OFF-TERM
Students who are eligible to purchase off-term insurance can do so through
the Treasurer’s website: http: //www.treasurer.ohio-state.edu by the deadline.
There are four types of coverage status available for students who have enrolled in theComprehensive Student Health Insurance Plan:
4. Student, Spouse/Domestic Partner, and Child(ren)
The default coverage status is for a single Student Only. Students who want to change theircoverage status must change coverage online through (http://www.buckeyelink.osu.edu),under On-Line Services, Web Registration for Courses. Students have until the deadline of thefirst term of enrollment each academic year, as published in the Master Schedule, to changetheir Student Health Insurance Coverage Status.
Students are required to remain in the same coverage status initially selected upon
enrollment, each academic year, for each term Student Health Insurance is purchased
between Autumn 2008 and Summer 2009, unless the student experiences a qualifying
Qualifying Event Exception:
The Student must meet minimum eligibility requirements for
the term of the qualifying event. If a student experiences a qualifying event, the student needs
to complete a Coverage Status Change Form and submit it and any necessary supporting
documentation to Gallagher Koster within 31 days of the qualifying event. A Qualifying Event
is defined as an event that could result in a change of Coverage Status and includes: marriage,
divorce, initially meeting requirements of domestic partnership, birth or adoption, death,
involuntary loss or involuntary gain of coverage from another health plan, dependent reaching
the age limit of another health insurance plan, or first time arrival of dependent(s) to the
United States from a foreign homeland. If the Coverage Status Change Form to add is made
in accordance with this Plan and the additional applicable premium is paid to Gallagher
Koster, the coverage is retroactive to the date of the qualifying event. If the Coverage Status
Change Form to terminate coverage is made in accordance with the Plan and approved by
Gallagher Koster, the termination will be effective the first day of the following term and there
will be no pro-rata of premium during the term of the Qualifying Event.
Interim Coverage: Special Provisions
Special provisions are made for Medical (MED I and II), Dental II students, new graduatestudents enrolling in the University for the first time, and International Students arriving earlyto begin their studies. Coverage will begin 30 days prior to the effective date of the AutumnQuarter. An interim prorated premium must be paid at the Office of Fees and Deposits forcoverage from 8/11/08-9/16/08.
Dependent Eligibility and Enrollment
The student is responsible for ensuring that Dependents are eligible for coverage according tothe terms set forth in this Plan Description by submitting a completed online DependentEnrollment and Student Change Form to Gallagher Koster and the Affidavit of DomesticPartnership, if appropriate, to the Student Health Insurance Program at Wilce Health Center(see the section entitled “Policy Terms”). The Company reserves the right to confirmeligibility for dependent coverage. If and whenever the Company discovers that the policyeligibility requirements have not been met, its only obligation is refund of premium.
Dependent coverage will not be effective prior to that of the Insured Student or extend beyondthat of the Insured Student.
A Dependent is:
1. The Insured Student’s legal spouse or Domestic Partner.
The definition of Domestic Partner includes same-sex domestic partners and opposite-
sex domestic partners. Domestic partners: 1) must share a permanent residence (unless
residing in different cities, states or countries on a temporary basis); 2) are each other’s
sole domestic partner, have been in this relationship for at least six (6) months, and
intend to remain in this relationship indefinitely; 3) are not currently married to or
legally separated from another person under either statutory or common law; 4) are
responsible for each other’s common welfare; 5) are at least eighteen (18) years of age
and mentally competent to consent to this contract; 6) are not related by blood to a
degree of closeness that would prohibit marriage in the state in which they legally
reside; 7) are either a) financially interdependent
on each other if same-sex domestic
partners in accordance with the plan requirements outlined by Ohio State and the
Comprehensive Student Health Insurance Plan, or b) are financially dependent
each other if opposite-sex domestic partners in accordance with the plan requirements
outlined by Ohio State and the Comprehensive Student Health Insurance Plan.
2. The Insured Student’s unmarried children under the age of nineteen years. The term
“Children” includes an Insured Student’s biological children; step-children; fosterchildren; adopted children from the date of placement in the Insured Student’s homeand who depend on the Insured Student for their support; children which the InsuredStudent has been granted legal custody; children which the Insured Student has legalobligation to provide coverage due to a court order, and children of the DomesticPartner who reside with the Insured Student and for whom the Insured Student orDomestic Partner is responsible to provide coverage.
3. A child born to an Insured Student while this Plan is in force will be covered by this
Plan. Coverage for such newborn children will consist of coverage for Sickness orInjury including necessary care or treatment of congenital defects, birth abnormalities,premature birth, or nursery care. Such coverage will start from the moment of birth, ifthe Insured Student is already insured for dependent coverage (i.e. Student/Child,Student/Spouse or Domestic Partner/Child) when the child is born. However, thestudent is still responsible for notifying Gallagher Koster in order to continue thatdependent’s coverage beyond the first 31 days from the moment of birth. If the InsuredStudent does not have dependent coverage when the child is born, the newborn childis covered for dependent benefits for the first 31 days from the moment of birth. Tocontinue the child’s dependent benefits past the first 31 days, the Insured Student mustcontact Gallagher Koster to obtain a Coverage Status Change Form and submit it andthe required premium to Gallagher Koster within 31 days of the child’s birth.
4. A child’s coverage will not end because the child has reached the age limit of nineteen
(19) years shown above, if he or she: (a) is not able to earn his or her own living as aresult of physical or mental incapacity; and (b) became so incapacitated beforereaching the age limit; and (c) is mainly dependent on the Insured Student for supportand maintenance. Within 31 days of the child reaching the age limit, the InsuredStudent must send Gallagher Koster proof of the child’s dependency or handicap.
Additional proof of the child’s dependency and handicap may be requested, but notmore frequently than annually after the two year period following the child’sattainment of the age limit.
5. Any Dependent on active duty in any military, naval, or air force of any country is not
eligible for coverage under this Plan.
It is the student’s responsibility to ensure the timely enrollment and re-enrollment of theireligible dependents. Students are required to enroll their eligible dependents by the deadlinein order to have dependent coverage begin at the beginning of that coverage period and toavoid a lapse in coverage if enrolling previously insured Dependents. To enroll an eligibledependent, the student must elect coverage online through http://www.buckeyelink.osu.eduunder Web Registration for Courses. To complete the dependent enrollment process, aDependent Enrollment and Student Change Form must be completed and submitted toGallagher Koster. at www.gallagherkoster.com or www.shi.osu.edu, must be submitted to theStudent Health Insurance Program Office. To add a Domestic Partner, a signed and notarizedAffidavit of Domestic Partnership is also required.
Dependent Enrollment and Student Change Forms and Affidavits of Domestic Partnership areavailable online. Eligible Dependents are enrolled online at www.gallagherkoster.com. Clickon “Student Access”, select “The Ohio State University” from the drop-down box and thenclick on “Dependent Enrollment” and select the appropriate form. The Affidavit of DomesticPartnership can be downloaded from www.gallagherkoster.com or obtained at the WilceStudent Health Center. The Affidavit must be returned to the Student Health InsuranceProgram Office at Wilce Student Health Center.
With the exception of Dependents who become eligible during the School Term (after theInsured Student’s effective date), coverage for Dependents becomes effective on the samedate as that of the Insured Student. All claims for Dependents can not be processed untilreceipt of the appropriate form(s).
Late Dependent Enrollment
If eligible Dependents are not enrolled by the deadline and you need to add eligibleDependents during the school term, the following procedures apply:
If you marry and wish to purchase Dependent Coverage, you must complete a
Coverage Status Change Form, including the appropriate documentation, and a Dependent
Enrollment and Student Change Form. Submit these completed forms to Gallagher Koster
within 31 days of the date of marriage in order for Coverage for your spouse to become
effective on the date of marriage.
Insured students who want to enroll their Domestic Partner are required
to complete a Dependent Enrollment and Student Change Form along with a signed and
notarized Affidavit of Domestic Partnership. Submit both completed forms to the Student
Health Insurance Program office, 3rd floor, Wilce Student Health Center.
Birth or Adoption:
If you acquire a Dependent child (through birth, adoption, guardianship
decree or a domestic partnership) and wish to cover this child, you must complete and submit
a Coverage Status Change Form, including the appropriate documentation, and a Dependent
Enrollment and Student Change Form to Gallagher Koster within 31 days of the date you
acquire the child in order for Coverage for the Dependent child to become effective on the
date of birth, adoption or guardianship decree.
Arrival of Dependents from a Foreign Homeland:
If your Dependent(s) will be arriving
from a foreign homeland for the very first time, you must complete and submit a Coverage
Status Change Form, including the appropriate documentation, and a Dependent Enrollment
and Student Change Form to Gallagher Koster within 31 days from your Dependent’s arrival
from the foreign homeland in order for Coverage for the Dependent to become effective on
the date of the Dependent’s arrival following direct travel from the foreign homeland.
Payment for Late Dependent Enrollment
For all late Dependent enrollments, students will be advised of the prorated premium, ifapplicable. Gallagher Koster collects the prorated premiums and handles prorated premiumsfor the School Term in which the Dependent is added during the enrollment period.
Dependent coverage for future terms is payable with general University fees.
If you do not add a new Dependent within 31 days of the date the Dependent initially
becomes eligible for coverage, you must wait until the following Autumn Term to add
the Dependent for coverage.
Policy Terms and Costs
The registration process automatically registers a student in the Comprehensive StudentHealth Insurance Plan with Student-Only coverage. The premium for the coverage will appearon your University Statement of Account each eligible term unless waived.
Coverage may not be purchased after the deadline of each School Term as established byOSU. These dates are as follows:
*Students may only withdraw in the 1st term of enrollment each academic year.
*Students may only withdraw in the 1st term of enrollment each academic year.
The insurance under The Ohio State University’s Student Health Insurance Plan for theAnnual Policy Year begins on September 17, 2008. The Annual Policy terminates onSeptember 15, 2009 or at the end of the period through which premiums are paid. The specificdates for each School Term are outlined above.
Unless fees are refunded due to waiver or withdrawal from class prior to the deadline,coverage remains in effect during the School Term in which the student is enrolled at OSUeven if the student leaves school after the deadline.
This is a non-renewable one year term policy.
Comprehensive Student Health Plan Includes Medical, Dental and Vision Coverage
Coverage will be terminated and any premium paid will be refunded on the student’s accountup through the deadline of the School Term if the student withdraws from classes or waivescoverage. Premiums or requests for disenrollment will not be accepted after the last dayestablished by OSU for University fee payment. For students withdrawing from theUniversity after the deadline, health insurance premiums will not be refunded unlessspecifically requested through an appeal and accompanied by a written statement verifyingthat no claims have been filed and/or paid. However, should an Insured Person receive apremium refund and claims were paid, the Company has the right to recover benefit paymentsmade in connection with Covered Expenses incurred after the dates of termination under thispolicy. In addition to the above premium refund terms, there is no pro-rata of refunds unlessthe Insured enters the Armed Forces and requests a pro-rated refund.
Student Health Services Benefits
Student Health Services at The Ohio State University is located on the Columbus campus inthe Wilce Student Health Center at 1875 Millikin Road. This fully accredited facility servesthe students of The Ohio State University. The services available at the Wilce Student HealthCenter are separate from the benefits available through the Student Health Insurance Plan.
After Student Health Service hours, or on weekends, students should utilize the OSUHospital’s Emergency Department or any other Network Urgent Care Facilities or their ownMHCS provider if after hours are available.
Students are not required to complete a claim form for services rendered at Wilce StudentHealth Center under this portion of the coverage. Student Health Services will file a claim onbehalf of the student for services rendered at Wilce Student Health Center if the service iseligible for consideration under the Student Health Insurance Benefits. It is the student’sresponsibility to verify that a claim has been filed.
To maximize coverage, students covered by the Student Health Insurance Plan should firstseek medical care at the Wilce Student Health Center for non-emergency conditions. Onlystudents enrolled in the Student Health Insurance Plan are eligible for this portion of thecoverage. This means that if you are enrolled as a Dependent, even if you are a student,services will not be covered under Student Health Services benefits, but are eligible for in-network coverage.
Outpatient Services received outside of the Wilce Student Health Center are not covered underthis portion of the Plan.
Maximum Benefits for Medical Services & Prescription Drugs.
The annual maximum
benefit for medical services is $2,000 and the annual maximum benefit for prescription drugs
is $500. There are individual annual benefit maximums for various Covered Services that
accumulate to the annual maximum limit. Once you have exhausted this annual maximum,
coverage for all Covered Services will no longer be provided under this portion of the Plan.
This applies even if you have not utilized the individual maximum benefits. Covered Services
in excess of the annual maximum may be considered under the Network or Non-Network
benefit, and subject to the Pre-Existing Condition Limitation.
Coverage is limited to Medically Necessary services (as determined by the
Student Health Services and subject to approval by the Student Health Insurance Program),
except for covered preventive services. Covered Services will not be subject to the Pre-
Existing Condition limitations up to the annual maximum limit. However, Covered Services
in this section may be subject to special limits that do not apply to the Student Health
Insurance Benefits. Refer to the Schedule of Benefits for details.
The following Outpatient Services include the procedures listed below
when rendered for an Insured Student at the Wilce Student Health Center. Offered services
vary according to student demand and availability of specialists within the community.
1. Office Visits;2. Diagnostic Services. Includes routine x-rays, electrocardiograms, pathology and
laboratory tests approved by Student Health Services
3. Outpatient Surgery. Outpatient surgery is limited to suturing, selected dermatological
4. Complementary and Alternative Medicine Services: Includes physical therapy, athletic
training, osteopathic manipulative treatment, acupuncture and medical nutritiontherapy.
5. Medical Supplies. Durable Medical Equipment and Custom Orthotics. Supplies in
regular stock at Student Health Services are covered if they are prescribed and receivedas a component of treatment rendered by a Student Health Services provider. Coverageis provided for one custom orthotic per plan year.
Coverage is provided for prescription drugs when in regular stock (in
the formulary) dispensed by the Student Health Services pharmacy. There is a 34 day supply
limit per prescription drug. Oral contraceptives may be dispensed in one-month quantities per
number of months remaining in the academic term, up to a 90-day supply.
Coverage is provided to the benefit maximum per academic year.
Preventive Services include the services below when rendered for an Insured Student at the
Wilce Student Health Center.
a. When recommended by the Advisory Committee of Immunization Practices
(ACIP)-recommended vaccines for Teen/Adult to include: Influenza, Hepatitis A,Hepatitis B, Td/Tdap, IPV (Polio), Varicella, Meningococcal, MMR, HPV
b. When required for students to participate in academic programs of The Ohio State
c) When required for students traveling abroad
2. Sexual Health Screen. Includes testing for Syphilis, Chlamydia, HIV and other tests
based on patient history. Coverage is provided for one screening per plan year.
3. Gynecological Examination and Related Tests: Coverage is provided for one routine
gynecological exam and pap smear test per plan year.
4. Allergy Injections. Allergy injections are covered when rendered by Student Health
Services. Allergy injections will not be covered under the Network or Non-Networkbenefit. Covered expenses for allergen extracts will not be covered under the StudentHealth Services benefit, however, Coverage may be available under the Network orNon-Network benefit.
a. When required for students to participate in academic programs of The Ohio State
b. When indicated by family history of mother, father, sister, brother
Note: Many health and fitness screening programs and services are available for students atno or minimal cost thru the Student Wellness Center, Recreation and Physical ActivitiesCenter (RPAC), Physical Activities, Student Health Services and the Counseling ConsultationService. Visit the OSU Student Health Insurance Program website for a directory of services.
Counseling and Consultation Service Benefits
Counseling and Consultation Service at The Ohio State University is located on the fourth(4th) floor of the Younkin Success Center at 1640 Neil Avenue. This fully accredited,outpatient facility serves the students of The Ohio State University by providing accessible,high quality, mental health care necessary to maintain an optimal state of health.
Counseling and Consultation Service is a Preferred Network Provider for adult outpatientpsychotherapy for students enrolled in the Plan and their covered Dependents age 14 and up.
To maximize their available coverage, Insured Students and their covered Dependents shouldfirst seek outpatient mental health services from the OSU Counseling and ConsultationService.
Coverage is limited to Medically Necessary services (as determined by
Counseling and Consultation Service). Covered Services will not be subject to the Deductible,
Coinsurance, or to the Pre-Existing Condition limitations. However, there are applicable
Copayments per visit, but for the Insured Student the Copayment is waived for the first ten
sessions for each academic year if currently enrolled in classes. For Covered Dependents age
14 and up, the Copayment per visit does apply to each session.
At Counseling and Consultation Service, Insured Students and their covered Dependents age14 and up may receive individual and group psychotherapy, couples counseling and urgentcare during normal hours of operation, which includes limited evening hours. Limitedpsychiatry services, based on availability, may also be offered to Insured Students and theirCovered Dependents with an applicable copayment.
Other Mental Health Coverage.
For coverage on child psychotherapy (under age 14) and
other psychiatric services, the Insured Student and covered Dependents should utilize OSU
MHCS or the BeechStreet Network (outside of Franklin County only) to receive Network
Provider benefits. Please refer to the “Student Health Insurance Benefits” section for
Student Health Insurance Plan Benefits
Deductible, Coinsurance, and Copayment Rules
The Insured Person’s per policy year Deductible applies to all Non-Network ProviderCovered Services, unless specified otherwise in this Plan. Any Covered Expense incurredduring the last 3 months of the academic year and credited to your per policy year Deductiblefor that policy year will be applied toward the per policy year Deductible for the next policyyear. If the Insured Person is not enrolled for the Summer Quarter, any Covered Expenseincurred during the last 3 months will not apply to the per policy year Deducible for the nextpolicy year. If two or more family members are hurt in the same Accident, only one per policyyear Deductible needs to be satisfied among them for Covered Expenses relating to theAccident. This special feature applies to Covered Expenses each policy year for the sameAccident.
Some Covered Services are subject to Coinsurance and Copayments. This is the amount youmust pay to the Doctor or Hospital for each procedure, visit or confinement, each time youreceive a Covered Service, including prescription drugs. The Coinsurance is not applied untilafter you have paid any applicable Deductible that may be required under this Plan. See theSchedule of Benefits for the Copayments. The Coinsurance and Copayments apply towardyour Network Provider Out-of-Pocket Maximum.
Covered Services, which are rendered by a Network Provider are subject to a Copayment, butwill not be subject to the Deductible.
The Out-of-Pocket Maximum applies to Covered Services rendered by a Network Provideror a Non-Network Provider. Once you reach the Out-of-Pocket Maximum shown in theSchedule of Benefits, Covered Expenses will be paid at 100% of Covered Charges for theremainder of the Policy Year or until you reach the Lifetime Maximum Benefit as outlined inthe Schedule of Benefits, whichever occurs first. The Out-of-Pocket Maximum is met byaccumulated Deductible, Coinsurance, and Copayments. Covered Expenses incurred aboveReasonable and Customary Expenses, non-covered services, or penalties for non-precertification do not apply. Any amounts accrued under the Non-Network Out of PocketMaximum will be accrued towards the Network Out of Pocket Maximum.
Order of Claims
Regardless of the order claims are incurred, the Deductible and Coinsurance will be appliedto Covered Services in the sequence that claims are submitted and payment processed.
Waiver of Emergency Room Copayment
The Emergency Room Copayment will be waived if the Insured Person is admitted to theHospital immediately following emergency room treatment. The admission must be for thesame condition for which the Insured Person received Medical Emergency care; however theapplicable coinsurance and deductible will apply.
The PPO Arrangement
The Plan’s PPO arrangement is referred to as the OSU Managed Health Care System, Inc.
(OSU MHCS) Provider Network. In or out of Franklin County, students should seek servicesfrom an OSU MHCS Network Provider. Some of the Network Providers included areUniversity Hospital and Children’s Hospital, as well as over 500 primary care providers andnearly 3,000 specialists and ancillary providers. Outside of Franklin County, the Plan alsoaffiliates with the BeechStreet Network. The most efficient way to get a complete list of allNetwork Providers is by going to www.osumhcs.com.
You should be aware that Network Hospitals may be staffed with Non-Network Providers.
Receiving services from a Network Provider at a Non-Network Hospital does not guaranteethat all charges will be paid at the Network Provider level of benefits.
It is important to verify that your providers are Network Providers each time you call for anappointment or at the time of service.
means a specific unforeseen event, which happens while the Insured Person is
covered under this Plan and which directly, and from no other cause results in an Injury.
means the percentage of the Covered Expense for which the Insured Person is
responsible for a covered service. The Coinsurance is separate and not a part of the Deductible
means a specified dollar amount an Insured Person must pay for specified
charges. The Copayment is separate from and not a part of the Deductible or Coinsurance.
Covered Charge or Covered Expense
means reasonable charges which are: 1) not in excess
of Reasonable and Customary Expenses; 2) not in excess of the maximum benefit amount
payable per service as specified in the Schedule of Benefits; 3) made for services and supplies
not excluded under the policy; 4) made for services and supplies which are a Medical
Necessity; 5) made for services included in the Schedule of Benefits; and 6) in excess of the
amount stated as a Deductible, if any.
Covered Expenses will be deemed “incurred” only: 1) when the covered services areprovided; and 2) when a charge is made to the Insured Person for such services.
means the amount of Expenses for covered services and supplies which must be
incurred by the Insured Person before specified benefits become payable.
as used herein means: (a) a legally qualified physician licensed by the state in which
he or she practices; or (b) a practitioner of the healing arts performing services within the
scope of his or her license as specified by the laws of the state of residence of such
practitioner; or (c) a certified nurse midwife while acting within the scope of that certification;
other than a member of the person’s immediate family. The term “member of the immediate
family” means any person related to an Insured Person within the third degree by the laws of
consanguinity or affinity.
means the first date a student or a covered dependent becomes covered under
Elective Surgery or Elective Treatment
means those health care services or supplies that do
not meet the health care needs for a Sickness or Injury. Elective Surgery or Elective Treatment
includes any service, treatment or supplies that: 1) are deemed by the Company to be research
or experimental; or 2) are not recognized and generally accepted medical practices in the
Elective Surgery or Elective Treatment includes, but is not limited to: breast reduction; sexualreassignment surgery; submucous resection and/or other surgical correction for deviated nasalseptum, other than necessary treatment of covered chronic purulent sinusitis; treatment forweight reduction; learning disabilities, except for testing; immunizations, except for childhood immunizations; treatment of infertility and routine physical examinations.
Experimental or Investigational Care
means a service or supply: (a) that We, in Our
discretion, determine is not commonly and customarily recognized as being safe and effective
for the particular diagnosis or treatment; or (b) which requires approval by any governmental
authority and such approval has not been granted before the service or supply is furnished.
We may rely upon the advice of medical consultants and commonly recognized national
medical organizations in determining which services or supplies are experimental or
means a facility which meets all of these tests: (a) it provides inpatient services for
the care and treatment of injured and sick people; and (b) it provides room and board services
and nursing services 24 hours a day; and (c) it has established facilities for diagnosis and
major surgery; and (d) it is supervised by a Doctor; and (e) it is run as a Hospital under the
laws of jurisdiction in which it is located. Hospital does not include a place run mainly; (a) for
alcoholics or drug addicts; (b) as a convalescent home; (c) as a nursing or rest home; or (d) as
a hospice facility.
means a stay of 18 or more consecutive hours as a resident bed-
patient in a Hospital.
means bodily injury caused by an Accident which is the sole cause of the Loss. All
injuries due to the same or a related cause are considered one Injury.
means an Insured Student and their covered Dependent(s) while insured under
means a student of The Ohio State University who is eligible and insured for
coverage under this Plan.
Lifetime Aggregate Maximum
means the amount payable by the Company for incurred
Covered Charges for all Injuries or Sicknesses and will never exceed an amount determined by
subtracting from the sum of $500,000 the following: (i) all amounts paid under this policy for
all Injuries or Sicknesses; (ii) all amounts paid to or in respect of an Insured for all Injuries or
Sicknesses under any other policy issued to the Policyholder by this Company, regardless of the
policy period of such other policy.
The Maximum Benefit for all benefit coverage afforded under this policy is $500,000 for allInjuries or Sicknesses. Covered Charges shall not include amounts paid by the Insured forCoinsurance.
means medical expenses covered by this Plan as a result of Injury or Sickness as defined
in this Plan.
means a medical condition that manifests itself by such acute symptoms
of sufficient severity, including severe pain, that a prudent layperson with average knowledge of
health and medicine could reasonably expect the absence of immediate medical attention to
result in any of the following: 1) Placing the health of the Insured Person or, with respect to a
pregnant woman, the health of the woman or her unborn child, in serious jeopardy; 2) Serious
impairment to bodily functions; 3) Serious dysfunction of any bodily organ or part.
Medical Necessity or Medically Necessary
means that a service, drug or supply is needed for
the diagnosis or treatment of an Injury or Sickness in accordance with generally accepted
standards of medical practice in the United States at the time the service, drug or supply is
provided. A service, drug or supply shall be considered “needed” if it: (a) is ordered by a Doctor;
and (b) is commonly and customarily recognized through the medical profession as appropriate
for the particular Injury or Sickness for which it was ordered. A service, drug or supply shall not
be considered as medically necessary if it is investigational, experimental, or educational
This policy only provides payment for services, procedures and supplies which are a MedicalNecessity. No benefits will be paid for expenses which are determined not to be a MedicalNecessity including any or all days of Hospital Confinement.
are Doctors, Hospitals and other healthcare providers who have contracted
to provide specific medical care at negotiated prices.
have not agreed to any pre-arranged fee schedules.
means the dollar limit an Insured Person is responsible to pay during
a Policy Year, as shown in the Schedule of Benefits. After an Insured Person has reached the
Out-of-Pocket Maximum, We cover most benefits at 100% of the Reasonable and Customary
Expense for the remainder of the Policy Year. Some benefits, such as prescription coverage
however, will always remain payable at the percentage shown in the Schedule of Benefits. The
Out-of-Pocket Maximum is met by accumulated Deductible, Coinsurance and Copayments.
Amounts above the Reasonable and Customary Expense, non-covered services, or penalties for
non-precertification, do not count toward the Out-of-Pocket Maximum.
means the 12-month period beginning on the Policy Effective Date of the Plan.
means The Ohio State University.
means the amount a Network Provider will accept as payment in full
for Covered Charges.
Reasonable and Customary Expense
means fees and prices generally charged within the
locality where performed for Medically Necessary services and supplies required for
treatment of cases of comparable severity and nature. No payment will be made under this
policy for any expenses incurred which in the judgment of the Company are in excess of
Reasonable and Customary Expense.
means sickness or disease which is the sole cause of the Loss under this Policy.
Sickness includes both normal pregnancy and complications of pregnancy. All sicknesses due
to the same or a related cause are considered one Sickness.
means United HealthCare Insurance Company.
means the Insured Person.
Schedule of Benefits
This schedule includes benefits through Student Health Services, Counseling and Consultation
Service, and Health Insurance Benefits with providers in the OSU MHCS Network Providers,
BeechStreet Network and Non-Network Providers. Refer to the Covered Service Section for a
complete description of benefits.
PA = Preferred Allowance
Max = maximum
R&CE = Reasonable & Customary Expense
Student Health Network
Lifetime Aggregate Maximum Benefit
Annual Plan Maximum
Deductible (per Policy Year)
Out-of-Pocket Max (per Policy Year
• Individual (Non-Network Provider accrues
Student Health Network
Inpatient Hospital Expense Benefits
Surgical Expense Benefits
(Inpatient Or Outpatient)
Voluntary Termination of Pregnancy
Doctor’s Office Visits Expense Benefit
Emergency Room Expense Benefits
Student Health Network
Urgent Care Expense Benefit
Physical Therapy/Chiropractic Care
Expense Benefits 4
up to a combined max Charges
of $750 per Policy Year
Eye Exam Expense Benefits, limited to
One Exam per Policy year. Only applies
to Comprehensive Plan
Outpatient Expense Benefits
• Hospital Outpatient Department Expense 100% of
• Diagnostic X-ray and Laboratory Expense 100% of
• Allergy Testing and Allergy Extracts Expense 100% of
• Treatment for Transgender Medical Paid as any
Pre-admission Tests Expense Benefit
Maternity Expense Benefits
Child Health Supervision Services
includes both medical 100% of Billed 90% of PA
and behavioral services which are Charges
Student Health Network
Dental Expense Benefit,
Home Health Care
includes home infusion Not Applicable
therapy (limited to 40 home visits per Injury /Illness)
Mammography Examination Expense
Reconstructive Breast Surgery Expense
Pap Smear Examination Expense
Benefit (Covered once per Policy Year)
Prostate Cancer Screening Expense Benefits
Colorectal Health Screening
screening for Insureds over 50 years of age only)
Diabetes Treatment Expense Benefit
Prosthetic and Orthotic Device Expense
100% of Billed 90% of PA
Ambulance Expense Benefit ($1,000 per
Durable Medical Equipment Expense
100% of Billed 90% of R&CE
Prescription Drug Expense Benefit
(34 day supply per fill)
Student Health Network
Learning disabilities and ADHD Expense
Not Applicable 50% of PA
Benefit, limited to testing only,
up to a
combined maximum of $250 Per Policy Year.
For treatment, please refer to footnote #7.Biologically Based Mental Illness,
Mental & Nervous Condition Expense
•Inpatient, up to a combined maximum of Not Applicable 90% of PA
Alcohol and Drug Abuse Condition
1. This is combined Network Provider and Non-Network Provider Benefit Max. per Insured Person
2. Expense in excess of the $2,000 medical and $500 prescription Annual Max. may be eligible for
benefits at the Network Provider level.
3. PA means the negotiated amount a Network Provider will accept as payment for covered medical
expense. Insured Person’s Coinsurance is based on the Network fee schedule.
4. There is a $750 combined (Physical and Chiropractic Care) Network and Non-Network Benefit Max.
Per Policy Year. Benefits also can be provided through a licensed Athletic Trainer for approved
physical /medical and rehabilitative services.
5. Glass frames and lenses and contact lenses fittings only available at Student Health Services or OSU
6. The combined max. benefit outside of the Student Health Center for outpatient prescription drugs is
7. The benefits are limited to a combined max. of 25 visits per Policy Year outside of Counseling and
Consultation Service. Services must be Pre-Certified after the fourth visit for mental health services.
Includes treatment of learning disabilities/ADHD.
8. The Copayment for OSU students enrolled in classes is waived for the first 10 visits for Psychotherapy.
9. Benefits are limited to a combined max. of $2,000 per Policy Year outside of Counseling and
Consultation Service. Services must be Pre-Certified after the fourth visit.
Your health care services under this Plan are listed below. In order for these services andsupplies to be considered Covered Services, they must be:
2. Rendered and billed by a Doctor or Provider; and
3. Medically Necessary, except as specified.
Except for the following services, this Plan will provide coverage for services subject to thePre-Existing Condition Limitations, rendered and billed by the Wilce Student Health Centeronce the Insured Student has exhausted the annual maximum benefit, or the prescription drugmaximum benefit, under the Student Health Services portion of the Plan:
Refer to the section describing your Student Health Services benefits on page 10 for moredetail.
Please be advised that some services are subject to Pre-Certification Approval. Refer to thesection on Utilization Review Management on page 29 for details.
Inpatient Hospital Expense Benefits: The following inpatient Hospital services are covered:
• Hospital Room and Board Expense Benefit:
We will pay the Covered Percentage of the
Covered Charges incurred, as shown in the Schedule of Benefits, for a semi-private roomcontaining two or more beds, including meals, special diets and nursing services, otherthan private duty nursing services. Coverage includes a bed in a special care unit.
• Miscellaneous Hospital Expense Benefit:
We will pay the Covered Percentage of the
Covered Charges incurred, as shown in the Schedule of Benefits for the followingMiscellaneous Hospital Expenses:
(a) anesthesia, anesthesia supplies and services;
(b) operating, delivery and treatment rooms and equipment;
(c) diagnostic x-ray and laboratory tests;
(f) prescribed drugs and medicines (excluding take home drugs);
(g) medical and surgical dressings, supplies, casts and splints;
(h) radiation therapy, intravenous chemotherapy, kidney dialysis, and inhalation therapy;
(i) physical and occupational therapy; and
(j) other necessary and prescribed Hospital expenses.
• In Hospital Doctor’s Fees and Medical Expense Benefit:
When, by reason of Injury or
Sickness, an Insured Person who is confined as a resident bed-patient in a Hospital,requires the services of a Doctor, who may or may not have performed the surgery on theInsured Person, We will pay the Covered Percentage of the Covered Charge incurred forsuch services, as shown in the Schedule of Benefits. The following medical servicesperformed by a Doctor are covered on an inpatient basis: (a) limited to one Doctor visitper day (b) constant care and treatment while an Insured Person is confined in an intensivecare unit; (c) care by two or more Doctors during one Hospital stay when the InsuredPerson’s condition requires the skill of separate Doctors; (d) consultation by anotherDoctor when requested by the Insured Person’s Doctor. Coverage is limited to oneconsultation per admission. Staff consultations required by Hospital rules are not covered.
• Consultant Expense Benefit:
If, by reason of Injury or Sickness, an Insured Person
requires the service of a Consultant or a Specialist when they are deemed necessary andordered by an attending Doctor for the purpose of confirming and determining a diagnosis,We will pay the Covered Percentage of the Covered Charges incurred as shown in theSchedule of Benefits. Limited to one consultation per admission.
Surgical Expense Benefits:
The following Surgical Services performed by a Doctor are
covered on an inpatient or outpatient basis.
• Surgery Expense Benefit:
When, by reason of Injury or Sickness, an Insured Person
requires surgery on an inpatient or outpatient basis, We will pay the Covered Percentageof the Covered Charges incurred, as shown in the Schedule of Benefits, for the SurgicalExpense, in connection with any one surgical procedure. Surgical Expense means chargesby a Doctor for: (a) a surgical procedure; (b) necessary preoperative treatment during aHospital stay in connection with such procedure; and (c) usual post-operative treatment.
• Multiple Surgical Procedures Expense Benefit:
When an Injury or Sickness requires
multiple surgical procedures through the same incision, We will pay an amount not lessthan that for the most expensive procedure being performed. Multiple surgical proceduresperformed during the same operative session but through different incisions shall bereimbursed in an amount not less than the Covered Percentage of the Covered Charge ofthe most expensive surgical procedure then being performed, and with regard to the lessexpensive surgical procedure in an amount equal to 50 percent of the Covered Percentageof the Covered Charge for these procedures.
• Anesthesia Expense Benefit:
If, in connection with such operation, the Insured Person
requires the services of an anesthetist, We will pay the Expenses incurred; but We will notpay more than the Covered Percentage of the Covered Charges incurred as shown in theSchedule of Benefits.
• Assistant Surgeon Expense Benefit:
If, in connection with such operation, the Insured
Person requires the services of an Assistant Surgeon, We will pay the Expense incurred;but We will not pay more than the Covered Percentage of the Covered Charges incurredas shown in the Schedule of Benefits.
• Second Surgical Opinion Expense Benefit:
This Plan shall provide benefits to an
Insured Person for a second opinion consultation by a board certified specialist on the needfor non-emergency surgery which has been recommended by the Insured Person’s Doctor.
The Specialist must be board certified in the medical field relating to the surgicalprocedure being proposed. Benefits will also be provided for any required x-rays anddiagnostic tests done in connection with that consultation. We will pay the CoveredCharges incurred by the Insured Person as shown in the Schedule of Benefits. AnyDeductible is waived for Expenses incurred in connection with the Second SurgicalOpinion.
Voluntary Termination of Pregnancy Expense Benefit:
If, as a result of pregnancy, an
Insured Person has a voluntary termination of pregnancy, We will pay the Covered Percentage
of the Covered Charges incurred as shown in the Schedule of Benefits. Covered Expenses for
the voluntary termination of pregnancy must be incurred while this Plan is in force as to the
Insured Person. Due to Ohio state law, this benefit is not available to Graduate Associates
or Fellows who are receiving the University subsidy for the Student Health Insurance
Outpatient Expense Benefit:
If, by reason of Injury or Sickness, an Insured Person incurs
expenses in a Doctor’s office, Hospital outpatient department, emergency room, clinical lab,
radiological facility, or other similar facility licensed by the state, We will pay the Covered
Percentage of the Covered Charges incurred for Outpatient Services as shown in the Schedule
Covered Charges for Outpatient Services are charges for the following services:
(a) a Doctor’s office visit, while not Hospital Confined and limited to 1 per day;
(b) a Hospital outpatient department or emergency room;
(c) diagnostic x-ray and laboratory testing;
(d) allergy testing and allergy extracts;
(e) blood and blood services, if provided and billed by a Hospital or other facility;
(f) physical and occupational therapy, and chiropractic care, limited to 1 visit per day;
(g) radiation therapy, intravenous chemotherapy, kidney dialysis, inhalation therapy,
(h) radiological lab or other similar facility licensed by the state;
(j) home health care, including home infusion therapy;
(k) medically necessary non-surgical treatment for transgender medical treatment, limited
to office visits, lab tests, pharmacy and hormone treatment.
Pre-Admission Tests Expense Benefit:
This Plan shall provide for reimbursement of charges
made by a Hospital for use of its outpatient facilities for tests ordered by a Doctor. The tests
must be performed as a planned preliminary to the Insured Person’s admission as an inpatient
for surgery in that same Hospital. However: (a) the test must be necessary for, and consistent
with, the diagnosis and treatment of the condition for which surgery is to be performed; (b)
reservations for a Hospital bed and for an operating room must be made prior to the date the
tests are done; (c) the surgery actually takes place within seven days of pre-surgical tests; and
(d) the Insured Person is physically present at the Hospital for the tests. We will pay the
Covered Percentage of the Covered Charges as shown in the Schedule of Benefits.
Maternity Expense Benefit:
Benefits will be paid as specified in the Schedule of Benefits
for a minimum of forty-eight hours of inpatient care following a normal vaginal delivery and
a minimum of ninety-six hours of inpatient care following a cesarean delivery. Services
covered as inpatient care shall include medical, educational, and any other services that are
consistent with the inpatient are recommended in the protocols and guidelines developed by
national organizations that represent pediatric, obstetric, and nursing professionals. The policy
shall cover a physician-directed source of follow-up care. Services covered as follow-up care
shall include physical assessment of the mother and newborn, parent education, assistance and
training in breast or bottle feeding, assessment of the home support system, performance of
any medically necessary and appropriate clinical tests, and any other services that are
consistent with the follow-up care recommended in the protocols and guidelines developed by
national organizations that represent pediatric, obstetric, and nursing professionals. The
coverage shall apply to services provided in a medical setting or through home health care
visits. The coverage shall apply to a home health care visit only if the health care professional
who conducts the visit is knowledgeable and experienced in maternity and newborn care.
When a decision is made to discharge a mother or newborn prior to the expiration of the
applicable number of hours of inpatient care required to be covered, the coverage of follow-
up care shall apply to all follow-up care that is provided within seventy-two hours after
discharge. When a mother or newborn receives at least the number of hours of inpatient care
required to be covered, the coverage of follow-up care shall apply to follow-up care that is
determined to be medically necessary by the health care professionals responsible for
discharging the mother or newborn. Any decision to shorten the length of inpatient stay shall
be made by the physician attending the mother or newborn, except that if a nurse-midwife is
attending the mother in collaboration with a physician, the decision may be made by the
nurse/midwife. Decisions regarding early discharge shall be made only after conferring with
the mother or a person responsible for the mother or newborn. For the purposes of this benefit,
a person responsible for the mother or newborn may include a parent, guardian, or any other
person with authority to make medical decisions for the mother or newborn.
Child Health Supervision Services Benefit:
Benefits shall be provided as specified on the
Schedule of Benefits for an Insured for child health supervision services from the moment of
birth until age nine. Benefits for child health supervision services that are provided to a child
during the period from birth to age one shall include benefits for the hearing screening for
newborns or infants required by Ohio law. Covered Charges shall include those for: (a) all
visits for and costs of childhood and adolescent immunizations recommended by the Advisory
Committee on Immunization Practices of the Centers for Disease Control; (b) services
performed at birth, two months, four months, six months, nine months, twelve months, fifteen
months, eighteen months, two years and annually thereafter until age nine; (c) all visits for and
costs of age-appropriate screening tests for tuberculosis, anemia, Lead toxicity, hearing, and
vision as determined by the American Academy of Pediatrics; (d) a medical history, physical
examination, developmental assessment, and parental anticipatory guidance services at each
of the visits required under terms (a), (b), and (c) above; and (e) any laboratory tests
considered necessary by the Doctor as indicated by the services provided under items (a), (b),
(c), or (d) above. Coverage must be consistent with: (a) public policy; (b) professional
standards; and (c) scientific evidence of the effectiveness.
Benefits shall be provided as specified on the Schedule of Benefits
for an Insured for a screening mammography to detect the presence of breast cancer.
Screening mammography does not include diagnostic mammography. The maximum benefit
payable for screening mammographies is 130% of the Medicare reimbursement amount.
Benefits shall cover expenses in accordance with all of the following:
(1) If an Insured is at least 35 years of age but under 40 years of age, one screening
(2) If an Insured is 40 through 49 years of age inclusive, one screening mammography
every other year, or more frequently upon recommendation of a Doctor;
(3) If an Insured is at least 50 years of age but less than 65 years of age, one screening
(4) If a licensed Doctor has determined that the Insured has risk factors to breast cancer,
Benefits shall be provided only for screening mammographies that are performed in a facilityor mobile mammography screening unit that is accredited under the American College ofRadiology mammography accreditation program or in a hospital.
Screening mammography means a radiological examination utilized to detect unsuspectedbreast cancer at an early stage in asymptomatic people and includes the x-ray examination ofthe breasts using equipment that is dedicated specifically for mammography, including the x-ray tube, filter, compression device, screens, film, and cassettes, and that has an averageradiation exposure delivery of less than one rad mid-breast. Screening mammographyincludes 2 views of each breast. The term also includes the professional interpretation of thefilm. Insured is responsible only for deductible and copayment amounts.
Reconstructive Breast Surgery Expense Benefit:
We cover charges following a
mastectomy for the following services (a) reconstruction of the breast on which the
mastectomy has been performed; (b) surgery and reconstruction of the nondiseased breast to
produce a symmetrical appearance; and (c) prostheses and treatment of physical
complications for all stages of mastectomy, including lymphedemas (swelling associated with
the removal of lymph nodes). We will pay the Covered Percentages of the Covered Charges
incurred as shown in the Schedule of Benefits.
Pap Smear Examination Expense Benefit:
We cover charges for Covered Expenses
incurred, as shown in the Schedule of Benefits, for a Cytologic Screening (pap smear).
Benefits will be paid for a Cytologic Screening once a year, or more frequently if
recommended by a Doctor. Such benefits will include the examination, laboratory fee, and
the Doctor’s interpretation of the laboratory results. We will pay the Covered Percentages of
the Covered Charges incurred as shown in the Schedule of Benefits.
Prostate Cancer Screening Expense Benefit:
We will pay the Covered Percentage of the
Covered Charges incurred, as shown in the Schedule of Benefits, for Prostate Cancer
Screening for: (a) men age 40 and over who are symptomatic or in a high risk category; or (b)
an annual screening for men age 50 and over. The Prostate Cancer Screening must consist at
a minimum of a Prostate Specific Antigen (PSA) blood test and a digital rectal examination.
We will pay the Covered Percentages of the Covered Charges incurred as shown in the
Schedule of Benefits.
Accidental Dental Expense Benefit:
When an Insured Person incurs expenses for dental
treatment for Injury to sound natural teeth, We will pay the Covered Percentage of the
Covered Charges incurred as shown in the Schedule of Benefits.
Benefits for Biologically Based Mental Illness:
Benefits will be paid the same as any other
Sickness for the treatment of Biologically Based Mental Illness if both of the following apply:
1) The Biologically Based Mental Illness is clinically diagnosed by a Doctor authorized to
practice medicine and surgery or osteopathic medicine and surgery, a psychologist, aprofessional clinical counselor, professional counselor, independent social worker, or aclinical nurse specialist whose nursing specialty is mental health.
2) The prescribed treatment is not experimental or investigational, having proven its
clinical effectiveness in accordance with generally accepted medical standards.
“Biologically Based Mental Illness” means schizophrenia, schizoaffective disorder, majordepressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, and panic disorder, as these terms are defined in the most recent editionof the diagnostic and statistical manual of mental disorders published by the AmericanPsychiatric Association.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
Mental and Nervous Condition & Alcohol and Drug Abuse Condition Expense Benefit:
If an Insured Person requires treatment for a Mental or Nervous Condition or on account ofalcoholism, Alcohol Abuse, Drug Abuse or drug dependency, We will pay for such treatmentas follows:
Benefits for Inpatient Hospital Confinement
(a) When the Insured Person requires Hospital confinement for treatment of a Mental or
Nervous Condition, We will pay the Covered Percentages of the Covered Charges forsuch Hospital confinement incurred as shown in the Schedule of Benefits.
(b) When the Insured Person is confined as an inpatient in: (i) a Hospital; or (ii) a
Detoxification Facility for the treatment of alcoholism, Alcohol Abuse, Drug Abuse, ordrug dependency, We will pay the Covered Percentage of the Covered Charges for suchHospital Confinement incurred as shown in the Schedule of Benefits.
Such confinement must be in a licensed or certified facility, including Hospitals.
Benefits for Outpatient Services
(a) We will pay the Covered Percentage of the Covered Charges incurred as shown in the
Schedule of Benefits for covered outpatient services for the treatment of Mental andNervous Conditions. The Mental and Nervous Condition must, in the professionaljudgment of health care providers, be treatable and the treatment must be MedicallyNecessary. Outpatient treatment and Doctor services include charges made by anoutpatient treatment department of a Hospital or community mental health facility, orcharges for services rendered in a Doctor’s office. Treatment may be provided by anyproperly licensed Doctor, psychologist or other provider as required by law.
(b) We will pay the Covered Percentage of the Covered Charges incurred as shown in the
Schedule of Benefits for covered outpatient services for the treatment of alcoholism,Alcohol Abuse, Drug Abuse or drug dependency. Outpatient treatment and Doctorservices include charges for services rendered in a Doctor’s office or by an outpatienttreatment department of a Hospital, community mental health facility or alcoholismtreatment facility, so long as the Hospital, community mental health facility oralcoholism treatment facility is approved by the Joint Commission on the Accreditationof Hospitals or certified by the Department of Health. The services must be legallyperformed by, or under the clinical supervision of, a licensed Doctor or a licensedpsychologist who certifies every three months that the Insured Person needs tocontinue such treatment.
Covered Charges for Outpatient Mental & Nervous Condition Expenses are limited toa combined maximum of 25 visits per policy year outside of Counseling andConsultation Service and the copayment for the first 10 visits at the Counseling andConsultation Service is only waived for OSU students currently enrolled in classes.
Covered Charges for Outpatient Alcohol and Drug Abuse Condition Expense arelimited to a combined maximum of $2,000 per Policy Year outside of Counseling andConsultation Service. Services must be Pre-Certified after the 4th visit for eitherOutpatient Mental & Nervous Conditions or Outpatient Alcohol and Drug AbuseCondition Expense.
Mental or Nervous Conditions
means those conditions listed in the standard
nomenclature of the American Psychiatric Association.
means a condition that is characterized by a pattern of pathological use
of alcohol with repeated attempts to control its use, and with significant negative
consequences in at least one of the following areas of life: medical, legal, financial, or
means a condition which is characterized by a pattern of pathological use
of a drug with repeated attempts to control its use, and with significant negative
consequences in at least one of the following areas of life: medical, legal, financial or
means a facility that provides direct or indirect services to an
acutely intoxicated individual to fulfill the physical, social and emotional needs of the
individual by: (a) monitoring the amount of alcohol and other toxic agents in the body
of the individual; (b) managing withdrawal symptoms; and (c) motivating the
individual to participate in the appropriate addictions treatment programs for Alcohol
or Drug Abuse.
Diabetes Treatment Expense Benefit:
We cover charges for Medically Necessary diabetes
equipment, diabetes supplies, and diabetes outpatient self-management training and
educational services, including medical nutrition therapy, that the Insured Person’s treating
Doctor or other appropriately licensed health care provider or a Doctor who specializes in the
treatment of diabetes, certifies are necessary for the treatment of: (a) insulin-using diabetes;
(b) non-insulin-using diabetes; or (c) elevated blood glucose levels induced by pregnancy.
The diabetes outpatient self-management training and educational services, including medical
nutrition therapy shall be provided through programs supervised by an appropriately licensed,
registered, or certified health care provider whose scope of practice includes diabetes
education or management. We will pay the Covered Percentage of the Covered Charges
incurred as shown in the Schedule of Benefits.
Ambulance Expense Benefit:
When, by reason of Injury or Sickness, an Insured Person
requires the use of a community or Hospital ambulance in a Medical Emergency, We will pay
the Covered Percentage of the Covered Charges incurred as shown in the Schedule of
Benefits. Ambulance Service is transportation by a vehicle designed, equipped and used only
to transport the sick and injured from home, scene of accident or Medical Emergency to a
Hospital or between Hospitals. Surface trips must be to the closest local facility that can
provide the covered services appropriate to the condition. If there is no such facility available,
coverage is for trips to the closest facility outside the local area. Air transportation is covered
when Medically Necessary because of a life threatening Injury or Sickness. Air ambulance is
air transportation by a vehicle designed, equipped and used only to transport the sick and
injured to and from a Hospital for inpatient care.
Prosthetic and Orthotic Device and Durable Medical Equipment Benefit:
If, by reason of
Injury or Sickness, an Insured Person requires the use of a Prosthetic or Orthotic Device, or
Durable Medical Equipment, We will pay the Covered Percentage of the Covered Charges
incurred by the Insured Person for such devices and equipment as shown on the Schedule of
Benefits and, 1) when prescribed by a Physician, and 2) a written prescription accompanies
the claim submitted. Durable medical equipment includes equipment that is: 1) primarily and
customarily used to serve a medical purpose; 2) can withstand repeated use; and 3) generally
is not useful to a person in the absence of Injury or Sickness. No benefits will be paid for rental
charges in excess of purchase price. Replacement Durable Medical Equipment is not covered.
Prescription Drug Expense Benefit:
If by reason of Injury or Sickness, an Insured Person
requires prescription drugs, We will pay the Covered Percentage of the Covered Charges
incurred by the Insured Person for such drugs, subject to the Coinsurance, as shown in the
Schedule of Benefits. The maximum Pharmacy benefit is $1,250 per policy year for Insured
Persons (in addition to the $500 available to insured students at the Student Health Center).
Covered prescriptions are subject to a 10% generic coinsurance or a 20% brand coinsurance
with no generic equivalent or a 50% brand coinsurance with generic equivalent. There is a
minimum $10 coinsurance per prescription. Non-student dependents covered by an Insured
Student will have access to Outpatient Prescription Drugs and coverage through the Student
Health Services Pharmacy. Covered dependents can fill/refill their prescriptions subject to the
10% generic coinsurance, 20% brand coinsurance with no generic equivalent, or a 50% brand
coinsurance with generic equivalent. There is a $10 minimum coinsurance up to $1,250 per
The prescription drugs must be prescribed by a Doctor. We only cover prescription drugswhich are approved for the treatment of the Insured Person’s Injury or Sickness by the Foodand Drug Administration. We will also cover a drug prescribed for a treatment for which it hasnot been approved by the Food and Drug Administration if the drug is recognized as beingmedically appropriate for the specific treatment for which the drug has been prescribed in oneof the following established reference compendia: a) the American Medical Association DrugEvaluations; (b) the American Hospital Formulary Service Drug Information; (c) the UnitedStates Pharmacopoeia Drug Information; or (d) it is recommended by a clinical study orreview article in a major peer-reviewed professional journal. However, Covered Charges donot include Experimental or Investigational Drugs or any drug which the Food and DrugAdministration has determined to be contraindicated for the specific treatment for which thedrug has been prescribed.
Scholastic Emergency Services:
Global Emergency Medical Assistance
If you are a student insured with this insurance plan, you and your insured spouse or domesticpartner and minor child(ren) are eligible for Scholastic Emergency Services (SES). Therequirements to receive these services are as follows:
International Students, insured spouse or domestic partner and insured minor child(ren): Youare eligible to receive SES worldwide, except in your home country.
Domestic Students, insured spouse or domestic partner and insured minor child(ren): You areeligible for SES when 100 miles or more away from your campus address and 100 miles ormore away from your permanent home address or while participating in a Study Abroadprogram.
The Emergency Medical Evacuation and Return of Mortal Remains services provided by SESmeet U.S. visa requirements. The Emergency Medical Evacuation services are not meant tobe used in lieu of or replace local emergency services such as an ambulance requested throughemergency 911 telephone assistance. All SES services must be arranged and provided by SES,any services not arranged by SES will not be considered for payment.
Medical Consultation, Evaluation and Referrals
Care for Minor Children Left Unattended Due to a Medical Incident
Please log into your online account www.uhcsr.com for additional information on SES GlobalEmergency Assistance Services, including service descriptions and program exclusions andlimitations.
(877) 488-9833 Toll-free within the United States
(609) 452-8570 Collect outside the United States
Services are also accessible via e-mail at [email protected]
When calling the SES Operations Center, please be prepared to provide:
1. Caller's name, telephone and (if possible) fax number, and relationship to the patient
2. Patient's name, age, sex, and Reference Number (found on student’s ID card)
3. Description of the patient’s condition
4. Name, location, and telephone number of hospital, if applicable
5. Name and telephone number of the attending physician
6. Information of where the physician can be immediately reached
SES is not travel or medical insurance but a service provider for emergency medical assistanceservices. All medical costs incurred should be submitted to your health plan and are subject tothe policy limits of your health coverage. All assistance services must be arranged andprovided by SES. Claims for reimbursement of services not provided by SES will not beaccepted. Please refer to your SES brochure for Program Guidelines as well as limitations andexclusions pertaining to the SES program. Please refer to www.uhcsr.com.
Utilization Review Management
The Plan contracts with CareAllies to provide utilization management services. The goal ofthe program is to assure medical necessity appropriateness of setting and length of treatmentfor all proposed level of care. The review also monitors an Insured Person’s treatmentprogress and identifies when case management intervention is needed. Once an InsuredPerson contacts CareAllies, a notice of Pre-Certification and the approved treatment plan aretransferred to the Claims Administrator. Pre-Certification does not guarantee benefits.
Pre-Certification of Hospital Admissions
. Pre-Admission Certification must be obtained for
every Hospital Admission. Please refer to the subsequent sections on Pre-Admission
Certification provisions for Maternity and Medical Emergency admissions. These admissions
have separate certification requirements.
Insured Persons are responsible for obtaining Pre-Admission Certification and are responsiblefor informing the Hospital or other Doctor that their insurance plan requires Pre-AdmissionCertification.
To obtain Pre-Admission Certification:
• CareAllies must be provided with necessary information to make decisions regarding the
• CareAllies must be contacted no less than forty-eight (48) hours prior to Hospital
admissions. This does not apply to Medical Emergency admissions. Refer to thefollowing section for descriptions of the certification provisions for this type ofadmission. Notice may be given to CareAllies by the Hospital, admitting Doctors,Insured Person, or family members of Insured Person.
Notice may be given by calling CareAllies at 1-800-348-1313.
The following information is requested by CareAllies in order to evaluate planned Hospitaladmissions:
Name, social security number, and age of patient;
Student’s name, social security number, and name of the university;
Names and telephone numbers of admitting Doctors and Hospitals.
When Pre-Admission Certification is provided to Insured Persons, a certain number ofInpatient Hospital days for the stays are assigned. If CareAllies is not informed of admissionswithin the required period of time, payment of benefits for admitting Doctors and Hospitalscharges are reduced by 50% of Covered Expenses up to $5,000. This is referred to as a“penalty”. This penalty will not be applied toward any Deductibles, Coinsurance or Out-of-Pocket Maximum. It is not necessary to pre-certify Hospital admissions that occur outside ofthe United States.
Pre-Certification of Medical Emergency Admissions
. If an Insured Person is admitted to a
Hospital for Medical Emergency admission, notice of admission must be provided to
CareAllies no later than one (1) day following the date of admission. Notice may be given to
CareAllies by the Hospital, admitting Doctor, Insured Person, or family members of Insured
Notice may be given by calling CareAllies at 1-800-348-1313.
CareAllies reviews cases within one (1) working day of the date they are informed of theadmission. The reviews are performed with Insured Persons’ Doctors or designated staff todetermine if continued Hospital stays are Medically Necessary. If CareAllies is not informedof Medical Emergencies within the required period of time, payment of benefits for admittingDoctors and Hospitals charges are reduced by 50% of Covered Expenses up to $5,000. Thisis referred to as a “penalty”. This penalty will not be applied toward any Deductibles,Coinsurance or the Out-of-Pocket Maximum.
Medical Emergency admissions are defined as admissions to a Hospital through theemergency rooms of those facilities for treatment of a Medical Emergency. MedicalEmergency admissions are unplanned admissions scheduled less than forty-eight (48) hoursprior to the admission, for treatment of a Medical Emergency. It is not necessary to pre-certifyHospital admissions that occur outside the United States.
Pre-Certification of Maternity Admissions.
An anticipated maternity admission must be
reported to CareAllies during the first three (3) months of the pregnancy to ensure that a high
risk screening evaluation will be done. When an Insured Person is actually admitted to a
Hospital for the express purpose of giving birth, CareAllies should be notified of the
admission no later than one (1) day following the admission date. Notice may be given to
CareAllies by the Hospital, admitting Doctor, Insured Person, or family members of the
Notice may be given by calling CareAllies at 1-800-348-1313.
If the admission and discharge dates are the same or if the Insured Person is discharged on theday following the admission date, it is not necessary to notify CareAllies of the maternityadmission following the admission date.
Maternity admissions are admissions to Hospitals expressly for giving birth.
Additional Hospitalization Reviews.
Additional Hospitalization reviews include:
• During an Insured Person’s Hospital stay, CareAllies continues to review the Hospital
stay. This does not apply to maternity admissions except if the stay is greater than twodays. The purpose of continued reviews is to obtain updates as to an Insured Person’sprogress and, if necessary, to enable CareAllies to reevaluate the Medical Necessity of acontinued Hospital stay.
• All weekend (Friday and Saturday) Hospital admissions are reviewed. Coverage is
limited to Medically Necessary admissions.
• Review for discharge planning is also conducted. Discharge planning identifies patients
who require extended care following a discharge. Discharge planning also determinesthe most appropriate setting for continued care.
Pre-Certification for Home Infusion Therapy.
Pre-certification must be obtained for any
Home Infusion Therapy services. Insured Persons are responsible for obtaining Pre-
Certification and are responsible for informing their Doctor that their insurance plan requires
To obtain Pre-Certification for Home Infusion Therapy:
• CareAllies must be provided with necessary information to make decisions regarding the
Medical Necessity of Home Infusion Therapy services; and
• CareAllies must be contacted no less than forty-eight (48) hours prior to the receipt of
Notice may be given by calling CareAllies at 1-800-348-1313.
Pre-Certification for Outpatient Mental Health and Nervous Condition and Alcohol and DrugAbuse Condition Benefits. Pre-Certification must be obtained in order to receive themaximum benefit payable for Outpatient Mental Health and Nervous Condition and Alcoholand Drug Abuse Condition Benefits. A Pre-Certification is a pre-treatment review byCareAllies of the Medical Necessity of Outpatient Mental Health and Nervous Condition andAlcohol and Drug Abuse Condition Benefits Services. Pre-Certification must be obtainedafter the fourth outpatient visit for a mental illness, counseling, or substance abuse condition(alcoholism and drug addiction). Pre-Certification may be obtained by calling CareAllies at1-800-338-9059.
It is the Insured Person’s responsibility to obtain Pre-Certification and inform the Doctor thatthey are a participant in a program that has Pre-Certification requirements. Pre-Certificationdoes not guarantee benefits.
To obtain Pre-Certification:
1. CareAllies must be provided with information necessary to make a decision as to the
2. CareAllies must be informed no later than three days prior to the fifth visit. Notice can
be given by: (a) the Hospital; (b) the Doctor; or (c) the Insured Person.
When Pre-Certification is provided to the Insured Person, a certain length of treatment for theservice will be assigned. During the treatment a continued treatment review will be conductedand extensions to the initial treatment plan will be viewed for Medical Necessity. If servicesare not determined to be Medically Necessary during pretreatment review or continuedtreatment review, the Insured Person and the Doctor will be notified and no payment will bemade for services determined to be not Medically Necessary.
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