2015-2016
Northampton Community College
Student Health Insurance Plan
Dear Student, Parent, or Guardian:
We are pleased to provide you with this overview of the Northampton
Community College Student Health Insurance Plan (SHIP). This SHIP
is underwritten by Companion Life Insurance Company as Policy Form
No. BSHP- POL et al and administered by Consolidated Health Plans,
Inc. CHP has contracted with Cigna for the plan’s provider network of
hospitals, physicians, and other health care providers.
Your ACA-compliant plan includes:

Worldwide coverage 24/7 – (Note: Outside U.S. is paid at 50%
of billed charges)

Comprehensive coverage both for emergency and nonemergency situations

Access to the Cigna PPO network
BENEFIT SUMMARY*
Aggregate Benefit
Maximum
Coinsurance – unless
stated otherwise
Out-of-Pocket
Maximum
Annual Deductible
Per Covered Person
Preventive Care
www.healthcare.gov
Inpatient Hospital
Expense
Physician’s Office
Visit
Mental Health Office
Visit
Unlimited
IN-NETWORK
OUT-OF- NETWORK
70% of PA
50% of R&C
$6,350 Individual
$12,700 Family
n/a
$600
$1,200
100% of PA
(deductible and
copay does not
apply)
70% of PA after a
$300 per
admission copay
100% of PA after
$25 per visit
copay
Paid the same as
any other
sickness
100% of U&C
50% of U&C after a
$300 per admission
copay
100% of U&C after
$40 per visit copay
Paid the same as any
other sickness
80% of PA after a
$100 copay
Ambulance Services
100% of PA after
$100 per trip
copay
100% of U&C after
$100 per trip copay
Outpatient Laboratory
Expenses
70% of PA
50% of U&C
Prescription Drug
Benefits
$30 copay for generics
$60 copay for brand name
$75 for non-formulary brand
$0 copay for generic contraceptives
80% of U&C after a
$100 copay
Waiver forms must be completed online at:
www.northampton.edu/studentinsurance/2015-16. Select the WAIVER
link, and proceed as directed. Have your current health insurance ID
card ready; you will need this information in order to waive the Student
Health Insurance Plan.
This plan waives the In- and Out-of-Network Annual Deductible for Covered
Medical Expenses for the following services: Physician Office Visit Expense,
Outpatient Mental Health & Substance Abuse Office Visit Expenses, Consultant
Expense, Walk-In Clinic Expense, Urgent Care Expense, Emergency Room
Expense, Pediatric Preventative Care Expense, Pap Smear Screening Expense,
and Mammogram Expense.
Visit:
Waive off the NCC
Student Health
Insurance Plan:
www.northampton.edu/studentinsurance/2015-16
Enroll my dependent in
the NCC Student
Health Insurance Plan:
Consolidated Health Plans
Learn about:

Plan Benefits

Preferred
Providers

Claims Processing

ID card
Consolidated Health Plans
(800) 633-7867 www.chpstudent.com
www.chpstudent.com
Cigna PPO
www.cigna.com
(800) 633-7867
Find a Provider:
Cigna Pharmacy Network
www.cigna.com (800) 633-7867
Find a Prescription
Drug Provider:
Cost and Period of Coverage
Annual
8/15/158/14/16
Fall
8/15/1512/31/15
Spring
1/1/168/14/16
New Spring
1/1/16-8/14/16
$2,500
$4,555
$1,097
$1,904
$1,403
$2,651
$1,493
$2,651
Per Child
$3,423
$1,431
$1,992
*Student Rates include an administrative fee.
$1,992
U&C = Usual and Customary
*This summary is provided for informational purposes as a courtesy and is not meant
to replace or override the terms or conditions detailed in the policy. It contains only a
partial, general description of plan benefits and does not constitute a contract. Please
refer to the policy for a full description of medical coverage, eligibility, exclusions,
limitations and provisions.
15-I5A83 (Flyer)
2015/2016 Waiver Deadlines
If you have comparable coverage, you may waive the Northampton
Community College Student Health Insurance Plan. The deadline to
waive the annual plan is August 31, 2015. If you do not complete the
online waiver by the deadline, the health insurance premium will
remain on your account and you will be covered by the College’s
Student Health Insurance Plan. The waiver deadline for newly enrolled
students in the Spring is January 31, 2016.
I need to:
Emergency Room
Expense
Co-pay waived if
admitted
PA= Preferred Allowance
Northampton Community College Insurance Requirements
Northampton Community College requires that all residential students,
international and allied health students purchase the health plan unless
proof of comparable coverage is provided. Students are automatically
enrolled in the college’s insurance plan unless they WAIVE coverage
by the waiver deadline. Coverage for eligible dependents is available.
Go to www.chpstudent.com for more information. The final enrollment
deadline for fall is August 31, 2015, and for new spring students is
February 5, 2016.
Student
Spouse
Your plan also offers the following value-added services:

Vision Discount Program

Medical Travel Assistance