Student Health Insurance
Designed for the Students
of
TABLE OF CONTENTS
Where to find help? ............................................................................................ 3
Am I eligible?....................................................................................................... 3
Coverage for dependents ................................................................................... 3
How do I waive/enroll? ....................................................................................... 4
Late waiver/waiver appeal process .................................................................... 4
Effective dates and cost ...................................................................................... 4
Termination of benefits ...................................................................................... 5
2015-2016
Premium refund policy ....................................................................................... 5
Extension of benefits .......................................................................................... 5
Underwritten by:
Definitions ........................................................................................................6-8
Companion Life Insurance Company
Columbia, SC
As Policy form #BSHP-POL
Policy Number: 2015I5A83
Preferred provider information .......................................................................... 9
Pre-certification policy ........................................................................................ 9
Basic Accident and Sickness Benefits .............................................................9-12
Mandated Benefits ......................................................................................12-15
Group Number: S210614
Medical Evacuation Benefit .............................................................................. 16
Effective: August 15, 2015 to August 15, 2016
Repatriation of Remains Benefit ....................................................................... 16
Right of Reimbursement ................................................................................... 16
Exclusions.....................................................................................................16-18
Claim Procedures .............................................................................................. 19
IMPORTANT NOTICE
This brochure provides a brief description of the important features of the
Policy. It is not a Policy. Terms and conditions of the coverage are set forth in
the Policy. Please keep this material with your important papers.
Claim Appeal Process ....................................................................................... 20
Value Added Services ........................................................................................ 21
NONDISCRIMINATORY
Health care services and any other benefits to which a Covered Person is
entitled are provided on a nondiscriminatory basis, including benefits
mandated by state and federal law.
15-I5A83 (Bro.)
2
HOW DO I WAIVE/ENROLL?
WHERE TO FIND HELP
For questions about claims status, eligibility, enrollment and benefits please
contact:
CONSOLIDATED HEALTH PLANS
2077 Roosevelt Avenue
Springfield, MA 01104
(413) 733-4540
Toll Free (800) 633-7867
AM I ELIGIBLE?
Northampton Community College (NCC) requires students accepted into certain
programs of study or residing in on-campus housing to carry health insurance
while enrolled at NCC. International students studying on an F-1 Student Visa
are also required to carry health insurance. Students enrolled in the following
programs are enrolled in the college student group health insurance plan
unless they have their own insurance and WAIVE the college insurance plan:



Allied Health Majors
Residents in On-Campus Housing
International Students – F1 Visa Only
Students must actively attend class for at least the first 31 days after the date
for which coverage is purchased. Home study, correspondence, on-line classes,
and television (TV) courses, do not fulfill the eligibility requirement that the
student actively attend classes. If it is discovered the eligibility requirements
have not been met, our only obligation is to refund premium, less any claims
paid. This plan provides worldwide protection 24 hours per day during the term
of the policy for each student insured. This includes coverage on and off
campus, at home or while traveling between home and school during interim
vacation periods.
COVERAGE FOR DEPENDENTS
Insured Students who are enrolled in the Student Health Insurance Plan may
also enroll their eligible Dependents. An eligible Dependent is a spouse or a
child up to age 26. Dependent eligibility expires concurrently with that of the
Insured Student.
Students may also enroll their Dependents within sixty (60) days of an eligible
qualifying event. Eligible qualifying events for a Dependent are defined as birth
or marriage (to the Insured Student). Students interested in enrolling their
Dependents because of a qualifying event should contact Consolidated Health
Plans for an enrollment form and premium information. Coverage will be
effective as of the date of the qualifying event. Enrollment requests (including
payments) received after the sixty (60) days following the qualifying event will
not be accepted.
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If You are eligible to be covered under this Program, You are automatically
enrolled, unless You waive coverage. To document proof of comparable
coverage, students need to complete the online Waiver Form and submit it
prior to the start of the school year. To submit the online Waiver Form:
1.
2.
3.
Go to www.northampton.edu/studentinsurance/2015-16;
Click on the Waiver link; and
Complete all of the required information as directed.

WAIVER DEADLINES – Fall: August, 31, 2015; Spring: January 31, 2016

ENROLLMENT DEADLINES – Fall: September 5, 2015; Spring: January 31,
2016
If You are eligible for coverage and wish to enroll in the Plan outside of these
enrollment opportunities, You must present documentation from Your former
insurance company that it is no longer providing You with personal Accident and
Sickness insurance coverage. Your Effective Date of coverage under this Insurance
Program will be the date that Your former insurance expired, but only if You make
the request for coverage within sixty (60) days from the date that Your previous plan
expired. Otherwise, the Effective Date of coverage under this Insurance Program will
be the first (1st) of the month following Our receipt of Your written request for
coverage. The appropriate premium must accompany Your enrollment form for
coverage.
LATE WAIVER/WAIVER APPEAL PROCESS
After the deadline, the Student Health Insurance Plan may not be
waived/cancelled, except as provided by policy guidelines.
EFFECTIVE DATES AND COSTS
The Northampton Community College Student Health Insurance Plan provides
coverage to students for a twelve (12) month period – from 12:01 a.m. August
15, 2015, through 12:01 a.m. August 15, 2016.
Student*
Spouse
Each
Child
Annual
8/15/20158/15/2016
Fall
8/15/1512/31/15
$2,500
$4,555
$1,097
$1,904
$1,431
$3,423
*The above student rates include an administrative fee.
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Returning
Spring
1/1/168/15/16
$1,403
$2,651
$1,992
New Spring
1/1/168/15/16
$1,493
$2,651
$1,992
TERMINATION OF BENEFITS
An Insured's coverage will end on the earliest of the date:
1. The Policy terminates;
2. The Insured is no longer eligible; or
3. The period ends for which premium is paid.
A Dependent's coverage will end on the earliest of the date:
1. He or she is no longer a Dependent;
2. The Insured's coverage ends; or
3. The period ends for which premium is paid; or
4. the Policy terminates
PREMIUM REFUND POLICY
If you withdraw from school within the first 31 days of a coverage period, you
will not be covered under the Policy and the full premium will be refunded, less
any claims paid. After 31 days, you will be covered for the full period that you
have paid the premium for, and no refund will be allowed. (This refund policy
will not apply if you withdraw due to a covered Accident or Sickness.)
Exception: A Covered Person entering the armed forces of any country will not
be covered under the Policy as of the date of such entry. In this case, a pro-rata
refund of premium will be made for any such person and any covered
dependents upon written request received by Consolidated Health Plans within
90 days of withdrawal from school.
EXTENSION OF BENEFITS
If a Covered Person is confined in a Hospital for a medical condition on the date
his insurance ends, expenses Incurred during the continuation of that Hospital
stay will be considered a Covered Expense, but only while such expenses are
incurred during the 90 day period following the termination of insurance. We
will not continue to pay these Covered Expenses if:
1. The Covered Person's medical condition no longer continues;
2. The Covered Person reaches the Lifetime Aggregate Maximum per
covered Accident or covered Sickness;
3. The Covered Person obtains other coverage; or
4. The Covered Expenses are incurred more than 3 months following
termination of insurance.
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DEFINITIONS
Accident means an unexpected and unintended event which is the direct cause
of an Injury. The Accident must occur while the Covered Person is insured
under the Policy.
Copayment means a fixed dollar amount that the Covered Person must pay
before benefits are payable under the Policy.
Covered Accident means an Accident that occurs while coverage is in force for
a Covered Person and results in a loss or Injury covered by the Policy for which
benefits are payable.
Covered Expenses means expenses actually incurred by or on behalf of a
Covered Person for treatment, services and supplies not excluded or limited by
the Policy. Coverage under the Policy must remain continuously in force from
the date the Accident or Sickness occurs until the date treatment, services or
supplies are received for them to be a Covered Expense. A Covered Expense is
deemed to be incurred on the date such treatment, service or supply, that gave
rise to the expense or the charge, was rendered or obtained.
Covered Sickness means Sickness, disease or trauma related disorder due to
Injury which: 1.) Causes a loss while the Policy is in force; and 2.) which results
in Covered Medical Expenses. Covered Sickness includes Mental Health
Disorders and Substance Abuse Disorders.
Deductible means the dollar amount of Covered Expenses that must be
incurred as an out-of-pocket expense by each Covered Person on a Policy Term
basis before benefits are payable under the Policy.
Dependent means: 1) an Insured's lawful spouse; or 2) an Insured's natural,
adopted or foster child or child for whom the Member has legal custody or
legal guardianship who is under the age of 26. Coverage will continue for a child
who is 26 or more years old, chiefly supported by his or her parent or
dependent on other care providers and incapable of self-sustaining
employment by reason of a handicapped condition that occurred before the
attainment of the limiting age. Proof of the child's condition and dependence
will be requested by Us within 2 months prior to the date the child will cease to
qualify as a child as defined above. Such proof must be submitted to Us within
31 days from the date of the request. We may, at reasonable intervals
thereafter, require proof of the continuation of such condition and
dependence. If proof is not submitted within the 31 days following any such
request, coverage for the Dependent will terminate.
With respect to a handicapped child, “dependent on other care providers”
means such child requires a Community Integrated Living Arrangement, group
home, supervised apartment, or other residential services licensed or certified
by the Department of Human Services, the Department of Public Health, or the
Department of Public Aid.
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The term “spouse” also includes your domestic partner. You and your domestic
partner must submit a complete domestic partner affidavit and meet the
following criteria to qualify your domestic partner for insurance under this
group policy. For at least six consecutive months prior to the effective date of
your domestic partner insurance, you and your domestic partner:
1. are and have been each other's sole domestic partner, and have
maintained the same principal place of residence and intend to do so
indefinitely;
2. are both at least 18 years of age;
3. are not married or related by blood; and
4. are jointly responsible for each other's welfare and financial obligations.
The term also includes the child of your domestic partner.
Doctor means a Doctor licensed to practice medicine. It also means any other
practitioner of the healing arts who is licensed or certified by the state in which
his or her services are rendered and acting within the scope of that license or
certificate.
It will not include a Covered Person or member of the Covered Person’s
Immediate Family or household.
Elective Surgery or Elective Treatment means those health care services or
supplies that do not meet the health care need for a Sickness or Injury. Elective
surgery or elective treatment includes any service, treatment or supplies that:
1. Are deemed by the Insurer to be researched, investigative, or
experimental;
2. Are not generally recognized and accepted medical practices in the United
States.
Essential Health Benefits – mean benefits that are defined as such by the
Secretary of Labor in the following general categories, and the items and
service covered within the categories:
1. Ambulatory patient services;
2. Emergency services;
3. Hospitalization;
4. Maternity and newborn care;
5. Mental health and substance use disorder services, including behavioral
health treatment;
6. Prescription drugs;
7. Rehabilitative and habilitative services and devices;
8. Laboratory services;
9. Preventative and wellness services and chronic disease management; and
10. Pediatric services, including oral and vision care.
Experimental or Investigational means any procedure, treatment, facility,
supply, device, or drug that:
1. Is not generally accepted by the United States medical community as
effective for diagnosis, care or treatment; or
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2.
Is subject to research protocols indicating that the procedure, treatment,
facility, supply, device or drug is “experimental or investigational”; or
3. Requires the patient to sign a consent form which indicates that the
procedure, treatment, supply, device or drug is “experimental or
investigational” or is part of a research or study program; or Requires the
provider’s institutional review board to acknowledge that the procedure,
treatment, facility, supply, device or drug is “experimental or
investigational,” and subject to the board’s approval.
Injury means accidental bodily harm sustained by a Covered Person that results
directly and independently of disease and any bodily infirmity from a Covered
Accident. All injuries sustained by one person in any one Accident, including all
related conditions and recurrent symptoms of these injuries, are considered a
single Injury.
Insured means a person in a Class of Eligible Persons who enrolls for coverage
and for whom the required premium is paid making insurance in effect for that
person. An Insured is not a Dependent covered under the Policy.
Medically Necessary means a service, drug or supply which is necessary and
appropriate for the diagnosis and treatment of a Covered Injury and Covered
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 will not be considered as Medically Necessary if, it:
1. Is investigational, experimental or for research purposes;
2. Is provided solely for the convenience of the patient, the patient’s family
Doctor, Hospital or any other provider;
3. Exceeds in scope, duration or intensity the level of care that is needed to
provide safe, adequate and appropriate diagnosis or treatment;
4. Could have been omitted without adversely affecting the person’s
condition or the quality of medical care; or
5. Involves the use of a medical device, drug or substance not formally
approved by the United States Food and Drug Administration.
Out-of-Network means a provider who has not agreed to any prearranged fee
schedules. We will not pay charges in excess of the Usual and Customary
Charges.
Preferred Allowance means the amount a Preferred Provider will accept as
payment in full for covered medical expenses.
Preferred Provider means the Doctors, Hospitals and other health care
providers who have contracted to provide specific medical care at negotiated
prices.
Substance Abuse means abuse of or addiction to drugs or alcohol.
Usual and Customary Charge means the average amount charged by most
providers for treatment, service or supplies in the geographic area where the
treatment, service or supply is provided.
We, Our, Us means Companion Life Insurance Company, Inc., or its authorized
agent.
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PPO PLAN - PREFERRED PROVIDER INFORMATION
The Northampton Community College health insurance plan for the 2015-2016
Policy Year has a Preferred Provider Organization Network through Cigna. To
maximize Your savings and reduce Your out-of-pocket expense, select a Preferred
Provider. Preferred Providers are independent contractors and are neither
employees nor agents of Northampton Community College, Consolidated Health
Plans, or Companion Life Insurance Company. You can obtain information regarding
Preferred Providers through the Internet at: www.cigna.com. Choose PPO option.
PRE-CERTIFICATION POLICY
This plan does not require pre-certification of benefits. Please refer to the
schedule of benefits section of the policy for covered benefits.
ACCIDENT AND SICKNESS EXPENSE BENEFITS
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. Covered Expenses are considered
incurred on the date the treatment or service is rendered or the supply is
furnished. Covered Medical Expenses are:
Aggregate Maximum Benefit
Unlimited
Out-of-Network
PPO Provider
Provider
Deductible, per Insured or
$600 per Policy
$1,200 per Policy
Dependent
Year
Year
70% of Preferred 50% of Usual and
Coinsurance
Allowance (PA)
Customary (U&C)
Out-of-Pocket Maximum per Policy
$6,350 Individual
None
Year
$12,700 Family
Out of Country Coverage
50% of Billed Charges
Out-of-Network
INPATIENT EXPENSE BENEFIT
PPO Provider
Provider
Hospital Room and Board, limited to
50% of (U&C)
the Daily semi-private room rate 70% of PA after a
after a $300
including general nursing care $300 copay per
copay per
provided and charged for by the
admission
admission
Hospital.
Intensive Care We will make this 70% of PA after a
50% of U&C
payment in lieu of the semi-private
$300 per
after a $300 per
room expenses.
admission copay
admission copay
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Hospital Miscellaneous Expense,
incurred while Hospital Confined or
as a precondition for being Hospital
Confined, for services and supplies
such as the cost of operating room,
laboratory tests, X-ray examinations,
anesthesia, drugs (excluding take
home drugs) or medicines, physical
therapy, therapeutic services and
supplies. In computing the number
of days payable under this benefit,
the date of admission will be
counted but not the date of
discharge.
Surgery
Assistant Surgeon
Anesthetist
Doctor’s Visits, Limited to 1 visit per
day. Does not apply when related to
surgery.
Skilled Nursing Facility – up to a
maximum of 120 days per Policy
Year
70% of PA
50% of U&C
70% of PA
70% of PA
70% of PA
50% of U&C
50% of U&C
50% of U&C
70% of PA
50% of U&C
70% of PA after a
$300 per
admission copay
Same as any
Mental Health Disorders and
other covered
Substance Abuse
sickness
OUTPATIENT EXPENSE BENEFIT
Surgery
70% of PA
Day Surgery Miscellaneous
70% of PA
Assistant Surgeon
70% of PA
Anesthetist
70% of PA
Primary Care Visit to treat an Injury
or Sickness (includes syringes and
$25 copay per
needles dispensed during a visit),
Specialist Visit, Other Practitioner visit, then 100%
Office Visit, Consultant Physician
of PA
Services when requested by the
attending physician.
Preventive Care and Wellness
Services (no deductible, copay, or
coinsurance will apply to in-network
100% of PA
services)
https://www.healthcare.gov/what-are-mypreventive-care-benefits/#part=1
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50% of U&C after
a $300 per
admission copay
Same as any other
covered sickness
50% of U&C
50% of U&C
50% of U&C
50% of U&C
$40 copay per
visit, then 100% of
U&C
100% of U&C
Medical Emergency Expense
Inpatient deductible applies to out-ofnetwork
$100 copay
(waived if
admitted), then
80% of PA
$100 copay
(waived if
admitted), then
80% of U&C
Diagnostic X-ray Services
70% of PA
50% of U&C
Laboratory Procedures
70% of PA
50% of U&C
70% of PA
50% of U&C
70% of PA
50% of U&C
70% of PA
50% of U&C
70% of PA
$50 copay per
visit, then 70% of
PA
$25 copay per
visit, then 70% of
PA
Same as any
other covered
sickness
50% of U&C
$75 copay per
visit, then 50%
of U&C
$40 copay per
visit, then 50%
of U&C
Same as any
other covered
sickness
Rehabilitative/Habilitative therapies –
including Physical, Occupational,
Speech, and Chiropractic Care
Radiation and Chemotherapy
Hospice
Home Health Care
Urgent Care
Routine Eye Exam (Adult)
Mental Health Disorders and
Substance Abuse
Accidental Dental Expense, injury to
sound, natural teeth
Maternity
Durable Medical Equipment
Acupuncture in lieu of Anesthesia
Expense
Pediatric Dental – 1 check-up every 6
months
Pediatric Vision – 1 exam per Policy
Year – including one set of frames and
lenses
Intercollegiate, Club and Intramural
Sports Injuries
Abortion Expense (elective)
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Medical Evacuation
Repatriation
MANDATED BENEFITS
Additional Benefits
Ambulance Service
Prescription Drugs - must be filled at
participating Cigna pharmacy. Go to
www.cigna.com
$30 copay for a 30-day supply of a
generic drug ($0 copay for a 30-day
supply of a generic contraceptive)
or $60 copay for a 30-day supply of
a preferred brand name drug; $75
copay for a 30-day supply of a
brand name drug
100% of U&C
100% of U&C
100% of PA
after a $100
copay per trip
100% of U&C
after a $100
copay per trip
70% of PA
70% of U&C
100% of PA
70% of PA
100% of U&C
50% of U&C
70% of PA
50% of U&C
100%
50%
100%
50%
No Benefit
No Benefit
This plan will also pay any applicable benefits mandated by Pennsylvania State
Insurance Law, the same as for any other covered sickness unless stated otherwise.
All mandated benefits are subject to the terms and conditions generally applicable
to other benefits provided under the policy. If any Preventive Services Benefit is
subject to the mandated benefits required by state law, they will be
administered under the federal or state guideline, whichever is more favorable
to the student.
Mastectomy and Reconstructive Surgery Benefit: We will pay the Usual and
Reasonable expenses incurred for inpatient care following a Mastectomy for
the length of stay that the treating Physician determines is necessary to meet
generally accepted criteria for safe discharge. We will also provide coverage for
a home health care visit that the treating Physician determines is necessary
within forty-eight (48) hours after discharge when the discharge occurs within
forty-eight (48) hours following admission for the Mastectomy. We will also
provide coverage for Prosthetic Devices; physical complications including
lymphedemas; and Reconstructive Surgery incident to any Mastectomy in a
manner determined in consultation with the attending Physician and the
Insured Person.
Mastectomy means the removal of all or part of the breast for Medically
Necessary reasons, as determined by a Physician.
Prosthetic Devices means the use of initial and subsequent artificial devices
to replace the removed breast or portions thereof, pursuant to an order of
the Insured Person’s Physician.
Reconstructive Surgery means a surgical procedure performed on one breast
or both breasts following a mastectomy, as determined by the treating
Physician, to reestablish Symmetry Between Breasts or alleviate functional
impairment caused by the mastectomy. The term Reconstructive Surgery
shall include, but is not limited to, augmentation mammoplasty, reduction
mammoplasty and mastopexy.
Symmetry Between Breasts means approximate equality in size and shape of
the non-diseased breast with the diseased breast after definitive
Reconstructive Surgery on the diseased or non-diseased breast has been
performed.
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Treatment and Self-Management of Diabetes Benefit: We will pay the Usual
and Reasonable expenses incurred the equipment, supplies and outpatient selfmanagement training and education, including medical nutrition therapy for
the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational
diabetes and non-insulin-using diabetes if prescribed by a Physician.
Equipment and supplies shall include the following: blood glucose monitors,
monitor supplies, insulin, injection aids, syringes, insulin infusion devices,
pharmacological agents for controlling blood sugar and orthotics.
Diabetes outpatient self-management training and education shall be provided
under the supervision of a Physician with expertise in diabetes to ensure that
persons with diabetes are educated as to the proper self-management and
treatment of their diabetes, including information on proper diets. Coverage
for self-management education and education relating to diet and prescribed
by a Physician shall include:
1. visits medically necessary upon the diagnosis of diabetes;
2. visits under circumstances whereby a Physician identifies or diagnoses
a significant change in the patient's symptoms or conditions that
necessitates changes in a patient's self-management; and
3. where a new medication or therapeutic process relating to the
person's treatment and/or management of diabetes has been
identified as medically necessary by a licensed Physician.
Cancer Benefits: We will pay the Usual and Reasonable expenses incurred for
cancer chemotherapy and cancer hormone treatments, whether performed in
a Physician's office, in an outpatient department of a Hospital, in a Hospital as a
Hospital inpatient or in any other medically appropriate treatment setting on
the same basis as benefits for cancer chemotherapy and cancer hormone
treatments and services which have been approved by the United States Food
and Drug Administration for general use in treatment of cancer.
Coverage for Cost of Nutritional Supplements Benefits: We will pay the Usual
and Reasonable expenses incurred for the cost of nutritional supplements
(formulas) as Medically Necessary for the therapeutic treatment of
phenylketonuria, branched-chain ketonuria, galactosemia and homocystinuria
as administered under the direction of a Physician. There is no Deductible
imposed for this Benefit.
Dental Anesthesia for Children and Developmentally Disabled Insured
Persons: We will pay the Usual and Reasonable expenses incurred for General
Anesthesia and Associated Medical Costs provided to an Eligible Dental Patient
for Dental Care. This Benefit does not cover Dental Care for which general
anesthesia is provided nor does it cover general anesthesia for Dental Care
rendered for temporal mandibular joint disorders.
For purposes of this Benefit:
Associated Medical Costs means hospitalization and all related medical
expenses normally incurred as a result of the administration of General
Anesthesia.
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Dental Care means the diagnosis, treatment planning and implementation
of services directed at the prevention and treatment of diseases,
conditions and dysfunctions relating to the oral cavity and its associated
structures and their impact upon the human body or the implementation
of professional dental care provided to dental patients by a legally qualified
dentist or Physician operating within the scope of the dentist's or
Physician's training and licensure.
Eligible Dental Patient means an Insured Person who is seven (7) years of
age or younger or developmentally disabled for whom a successful result
cannot be expected for treatment under local anesthesia and for whom a
superior result can be expected for treatment under General Anesthesia.
General Anesthesia means a controlled state of unconsciousness, including
deep sedation, that is produced by a pharmacologic method, a
nonpharmacologic method or a combination of both and that is
accompanied by a complete or partial loss of protective reflexes that
include the Insured Person's inability to maintain an airway independently
and to respond purposefully to physical stimulation or verbal command.
Autism Spectrum Disorders Benefit: We will pay the Usual and Reasonable
expenses incurred for the diagnostic assessment and treatment of Autism
Spectrum Disorder and services for Insured children under the age of 21, up to
$36,000 per year. Treatment must be:
1. for an Autism Spectrum Disorder;
2. Medically necessary;
3. Identified in a treatment plan;
4. Be prescribed, ordered or provided by a licensed physician, licensed
physician assistant, licensed psychologist, licensed clinical social
worker or certified registered nurse practitioner; and
5. Be provided by an autism service provider or a person, entity or group
that works under the direction of an autism service provider.
Diagnostic assessment and treatment of Autism Spectrum Disorders include:
1. Prescription drugs and blood level tests;
2. Services of a psychiatrist and/or psychologist (direct or consultation);
3. Applied behavioral analysis; and
4. Other rehabilitative care and therapies, such as speech and language
pathologists, occupational and physical therapists.
Child Immunizations Benefit: When Dependent coverage is a part of this
policy, We will pay the expenses incurred for childhood immunizations and for
medically necessary booster doses of all immunizing agents used in child
immunizations.
As used in this benefit, child immunizations, including the immunizing agent,
reimbursement for which will not exceed 150% of the average wholesale price,
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which, as determined by the Pennsylvania Department of Health, conform with
the standards of the Advisory Committee on Immunization Practices of the
Center For Disease Control, the United States Department of Health and
Human Services. Benefits for such immunizations will be exempt from any
deductible requirements or specific benefit limitations, subject to any
Aggregate Lifetime Maximum Benefit or Policy Maximums.
Benefits for such immunizations will be exempt from any deductible
requirements or specific benefit limitations.
Medical Foods (Enteral Formulas) Benefit: We will pay the Usual and
Reasonable expenses incurred for the treatment of inherited metabolic
diseases on the same basis as any other Covered Sickness, except that any
deductible provisions will not apply to the enteral formulas portion of this
benefit. Inherited metabolic diseases include those characterized by deficient
metabolism or malabsorption originating from congenital defects or defects
arising shortly after birth, of amino acid, organic acid, carbohydrate or fat,
including phenylketonuria, branched-chain ketonuria, galactosemia and
homocystinuria. Such treatment will include the enteral formulas and special
food products that are part of a diet prescribed by a licensed Physician and
managed by a health care professional in consultation with a Physician who
specializes in the treatment of metabolic disease. Such diet must be deemed
Medically Necessary to avert the development of serious physical and mental
disabilities or to promote normal development or function as a consequence of
an inherited metabolic disease. We will provide coverage for this benefit only
to the extent that the cost of Medically Necessary formulas and special food
products exceeds the cost of a normal diet.
For the purposes of this benefit, the following definitions will apply:
Enteral formula means an enteral product or enteral products for use at home
that are prescribed by a Physician or nurse practitioner, or ordered by a
registered dietician upon referral by a health care provider authorized to
prescribe dietary treatments as being Medically Necessary for the treatment of
an inherited metabolic disease.
Special Food Product means a food product that is: a. Prescribed by a Physician
or nurse practitioner for the treatment of an inherited metabolic disease and is
consistent with the recommendations and best practices of qualified health
professionals with expertise germane to, and experience in the treatment and
care of such condition. It does not include a food that is naturally low in
protein, but may include a food product that is specially formulated to have
less than one gram of protein per serving; and b. Used in place of normal food
products, such as grocery store foods used by the general population.
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MEDICAL EVACUATION
When as a result of a Covered Accident or Sickness, You or Your covered
Dependent is hospitalized for five (5) days or more, The Company will pay,
upon the recommendation and approval of the attending Physician, for the
evacuation of You or Your covered Dependent to Your natural country, or to a
facility operated pursuant to the law for the care and treatment of injured or ill
persons, the actual U&C expense incurred not to exceed the unlimited
aggregate plan maximum. This benefit is payable in addition to any other
benefit of the Policy. Emergency Medical Evacuation must be approved in
advance by the Company. See Policy for full benefit description.
REPATRIATION OF REMAINS COVERAGE
If You or Your covered Dependent dies while insured under this policy, The
Company will pay the actual U&C expenses incurred for preparation, including
cremation and transportation to Your home country (in accordance with the
applicable international requirements) the remains of the deceased’s body, but
not to exceed the unlimited plan aggregate maximum. This benefit is payable in
addition to any other benefit of the Policy. Repatriation of Remains must be
approved in advance by the Company.
RIGHT OF REIMBURSEMENT
If a Covered Person incurs expenses for Sickness or Injury that occurred due to
the negligence of a third party: (a) We have the right to reimbursement for all
benefits We have paid from any and all damages collected from the third party
for those same expenses whether by action at law, settlement or compromise
by the Covered person, Covered Person's parents, if the Covered Person is a
minor, or Covered Person's legal representative as a result of that Sickness or
Injury, and (b) We are assigned the right to recover from the third party, or his
or her insurer, to the extent of the benefits paid for that Sickness or Injury.
EXCLUSIONS
Any exclusion in conflict with the Patient Protection and Affordable Care Act
will be administered to comply with the requirements of the Act. The plan
does not cover nor provide benefits for any of the following, except as
otherwise provided by the benefits of this Policy and as shown in the Schedule
of Benefits. The Policy does not provide coverage for loss caused by or resulting
from:
1. Charges that are not Medically Necessary or in excess of the Usual and
Customary charge;
2. Expenses in connection with services and prescriptions for eye
examinations, eye refractions, eye glasses or contact lenses, or the
fitting of eyeglasses or contact lenses, radial keratotomy or laser
surgery for vision correction or the treatment of visual defects or
problems, except as specifically provided;
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3.
Expenses in connection with cosmetic treatment or cosmetic surgery,
except as a result of:
a. a covered Injury that occurred while the Covered Person was
insured;
b. a covered child's congenital defect or anomaly; or
c. as specifically provided for in the Policy.
4. Injuries arising out of:
a. playing or participating in an interscholastic, intercollegiate,
or professional sport, contest or competition;
b. traveling to or from such sport, contest or competition as a
participant; or
c. participation in any practice or conditioning program for such
sport, contest, or competition.
5. Drugs and medications for the treatment of impotence and/or sexual
dysfunction;
6. Reproductive/Infertility procedures and fertility tests, including but
not limited to: family planning, fertility tests, infertility (male or
female), including any supplies rendered for the purpose or with the
intention of achieving conception; premarital examinations. Examples
of fertilization procedures are: ovulation induction; in vitro
fertilization; embryo transplant; or similar procedures that augment or
enhance the Covered Person's reproductive ability; impotence organic
or otherwise.
7. Expenses incurred in connection with voluntary sterilization or
sterilization reversal, vasectomy or vasectomy reversal and sexual
reassignment;
8. War, or any act of war, whether declared or undeclared; service in the
Armed Forces of any country. Loss which occurs during or as a result of
committing or attempting to commit an assault, felony, or
participation in a riot or insurrection, engaging in an illegal occupation;
9. Expenses incurred for Injury or Sickness for which benefits are paid or
payable under any Worker's Compensation or Occupational Disease
Law or Act, or similar legislation.
10. Treatment, services, supplies, in a Veteran's Administration or Hospital
owned or operated by a national government or its agencies unless
there is a legal obligation for the Covered Person to pay for the
treatment.
11. Expenses incurred for dental care or treatment of the teeth, gums or
structures directly supporting the teeth, including surgical extractions
of teeth. This exclusion does not apply to the repair of Injuries to
sound natural caused by a covered Injury, and except as specifically
provided in the Hospitalization and Anesthesia for Dental Procedures
expense benefit; or Pediatric Dental Care.
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12. Autistic disease of childhood, hyperkinetic syndromes, milieu therapy,
conceptual handicap, developmental delay or disorder, or mental
retardation;
13. Elective Surgery or Elective Treatment as defined by the Policy;
14. Foot care including: flat foot conditions, supportive devices for the
foot, subluxations, care of corns, bunions (except capsular or bone
surgery), calluses, toenails, fallen arches, week feet, foot strain, and
symptomatic complaints of the feet, except those related to diabetic
care;
15. Hearing examinations or hearing aids; or other treatment for hearing
defects or problems. "Hearing defects" means any physical defect of
the ear which does or can impair normal hearing, apart from the
disease process;
16. Immunizations, except as specifically provided in the Policy; preventive
medicines or vaccines, except when required for treatment of a
covered Injury or as specifically provided in the Policy;
17. Hirsutism, alopecia;
18. Weight management, weight reduction, treatment for obesity, surgery
for the removal of excess skin or fat, or nutrition programs, except as
related to treatment for diabetes.
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CLAIM PROCEDURES
1.
Itemized medical bills should be mailed promptly to Cigna at the address
listed.
SUBMIT ALL CLAIMS TO:
Cigna
PO Box 188061
Chattanooga, TN 37422-8061
Electronic Payor ID: 62308
2.
Direct all questions regarding benefits available under the Plan, claim
procedures, status of a submitted claim or payment of a claim to
Consolidated Health Plans.
CLAIMS ADMINISTRATOR:
Consolidated Health Plans
2077 Roosevelt Ave
Springfield, MA 01104
Local: (413) 733-4540 or Out of area: (800) 633-7867
www.chpstudent.com
Group: S210614
Medical bills must be submitted within ninety (90) days from the date of
treatment. We will pay benefits to You or a parent when a receipted bill is
submitted for a covered claim. When benefits are assigned, they will be paid
directly to the provider of hospital-medical care. Claim forms may be obtained
from the college, if at college, or from the above when away from college.
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CLAIMS APPEAL PROCESS
Once a claim is processed and upon receipt of an Explanation of Benefits (EOB),
an Insured Person who disagrees with how a claim was processed may appeal
that decision. The Insured Person must request an appeal in writing within 180
days of the date appearing on the EOB. The appeal request must include any
additional information to support the request for appeal, e.g. medical records,
physician records, etc. Please submit all requests to the Claims Administrator.
Claims Administrator:
CONSOLIDATED HEALTH PLANS
2077 Roosevelt Avenue
Springfield, MA 01104
(413) 733-4540
Toll Free (800) 633-7867
This plan is underwritten by:
COMPANION LIFE INSURANCE COMPANY
COLUMBIA, SC
As Policy Form No.: BSHP-POL
For a copy of the Company’s privacy notice you may go to:
www.consolidatedhealthplan.com/about/hipaa
or
Request one from the Health Office at your School
or
Request one from:
Companion Life Insurance Company
C/O Privacy Officer
70 Genesee Street
Utica, NY 13502
(Please indicate the school you attend with your written request)
Representations of the Plan must be approved by the Company.
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VALUE ADDED SERVICES
VISION DISCOUNT PROGRAM
For Vision Discount Benefits please go to:
www.chpstudent.com
EMERGENCY MEDICAL AND TRAVEL ASSISTANCE
FrontierMEDEX ACCESS services is a comprehensive program providing You
with 24/7 emergency medical and travel assistance services including
emergency security or political evacuation, repatriation services and other
travel assistance services when you are outside Your home country or 100 or
more miles away from your permanent residence. FrontierMEDEX is your key
to travel security.
For general inquiries regarding the travel access assistance services coverage,
please call Consolidated Health Plans at 1-800-633-7867.
If you have a medical, security, or travel problem, simply call FrontierMEDEX for
assistance and provide your name, school name, the group number shown on
your ID card, and a description of your situation. If you are in North America,
call the Assistance Center toll-free at: 1-800-527-0218 or if you are in a foreign
country, call collect at: 1-410-453-6330.
If the condition is an emergency, you should go immediately to the nearest
physician or hospital without delay and then contact the 24-hour Assistance
Center. FrontierMEDEX will then take the appropriate action to assist You and
monitor Your care until the situation is resolved.
Your out-of-pocket costs may be lower when you utilize Cigna PPO Providers. For a
listing of Cigna PPO Providers, go to www.cigna.com or contact Consolidated Health
Plans at (413) 773-4540, toll-free at (800) 633-7867, or www.chpstudent.com for
assistance.
THE SINGLE SOURCE FOR ALL OF YOUR INQUIRIES
GENERAL INSURANCE QUESTIONS
3070 Riverside Drive, Columbus, OH 43221
Website: www.cirstudenthealth.com/northampton
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