ELMIRA COLLEGE
STUDENT ACCIDENT AND STUDENT HEALTH INSURANCE PLAN
BENEFIT HIGHLIGHTS 2015/2016
Aggregate Maximum Benefit per Policy Year: Unlimited
IN-NETWORK
Deductible Amount per Covered Person per Policy Year
Out-of-Pocket Maximum per Policy Year
OUTPATIENT SERVICES
Doctor’s Visits/Walk-in Care (limited to one visit per day and does
not apply when related to surgery)Includes injections and infusion
therapy when administered in the Doctor’s office.
Urgent Care
Hospital Emergency Room and Non-Scheduled Surgery,
including operating room laboratory and x-ray examination,
supplies. The co-pay is waived if admitted to the Hospital as an
$250
$5,000
IN-NETWORK
$25 co-pay per visit
100% of Allowable Charges
OUT-OF-NETWORK
$250
$5,000
OUT-OF-NETWORK
$25 co-pay per visit 60%
of R & C
$40 co-pay per visit
80% of Allowable Charges
$40 co-pay per visit
60% of R & C
$150 co-pay per visit
80% of Allowable Charges
$150 co-pay per visit
60% of R & C
$25 co-pay per visit
80% of Allowable Charges
$25 co-pay per visit
80% of Allowable Charges
$25 co-pay per visit
60% of R & C
$25 co-pay per visit
60% of R & C
$25 co-pay per visit
80% of Allowable Charges
$25 co-pay per visit
60% of R & C
$25 co-pay per visit
80% of Allowable Charges
$25 co-pay per visit
60% of R & C
100% of R & C
Not subject to deductible
and co-pays.
60% of R & C
inpatient.
X-Ray and Laboratory
CAT Scan/MRI/PET Scans/Nuclear Medicine
Diagnostic Services and Medical Procedures performed by
the Doctor (other than Doctor’s visits, physiotherapy, x-rays and
lab procedures).
Habilitation and Rehabilitation Services
Preventive Services Benefit (in accordance with the
comprehensive guidelines supported by USPSTF and
HRSA): Includes Preventive Services such as:
• Adult Annual Physical Examinations
• Adult Immunizations
• Routine Gynecological Services/Well Woman Exams
• Cervical Cytological Screening
• Family Planning & Reproductive Health Services
• Bone Mineral Density Measurements or Testing
• Mammography Screenings
• Well Baby and Well Child Care and Immunizations
• Screening for Prostate Cancer
All other Preventive Services required by USPSTF and HRSA.
Chiropractic Services
Allergy Testing & Treatment
Alcoholism/Drug Abuse (up to 60 visits per Policy Year for a Covered
Person / up to 20 visits per Policy Year for family members) (Total number of
visits combined shall not exceed 60 visits)
Psychiatric Conditions
Biologically Based Mental Illness
Mental or Nervous Disorders
Outpatient Prescription Benefit
Eligible Prescriptions are paid on a reimbursement basis and a
claim form will need to be filed per the standard claim
procedures. Benefits include medication management for
chronic conditions.
Outpatient Surgical Expense
Outpatient Anesthesia (professional services)
Day Surgery Facility/Miscellaneous
$25 co-pay per visit
80% of Allowable Charges
Paid the same as any other Sickness
Paid the same as any other Sickness
Paid the same as any other Sickness
Paid the same as any other Sickness but not less
than 20 days per Policy Year
Co-pay per prescription or refill: Generic: $15 copay Formulary: $25 co-pay Non-Formulary: $40 co-pay
Please Note: Co-pay does not apply for Generic
Prescription Contraceptives as specified by the Patient
Protection and Affordable Care Act (PPACA).
80% of Allowable Charges
60% of R & C
80% of Allowable Charges
60% of R & C
80% of Allowable Charges
60% of R & C
$25 co-pay per visit
80% of Allowable Charges
Second Surgical Opinion
80% of Allowable Charges
Radiation Therapy and Chemotherapy
INPATIENT SERVICES
Room and Board Expense (except if intensive care unit, limited
to average daily semi-private room rate)
Pre-Admission Testing
IN-NETWORK
$25 co-pay per visit 60%
of R & C
60% of R & C
OUT-OF-NETWORK
$150 copay per admission then
$150 copay per
80% of Allowable Charges
admission then 60% of R
&C
80% of Allowable Charges
60% of R & C
Hospital Miscellaneous
80% of Allowable Charges
60% of R & C
Habilitation and Rehabilitation Services
80% of Allowable Charges
60% of R & C
Surgical Expense (Doctor’s Charges)
80% of Allowable Charges
60% of R & C
Assistant Surgeon
80% of Allowable Charges
60% of R & C
Anesthesia (professional services)
80% of Allowable Charges
60% of R & C
Doctor’s Visits (limited to one visit per day)
80% of Allowable Charges
60% of R & C
Skilled Nursing Facility
80% of Allowable Charges
60% of R & C
Psychiatric Conditions
Biologically Based Mental Illness
Mental or Nervous Disorders
Paid the same as any other Sickness
Paid the same as any other Sickness
Alcoholism/Drug Abuse (Detox up to 7 days per Policy
Year/Rehab up to 30 days per Policy Year)
IN-NETWORK
OTHER SERVICES
Specialist’s, Consultant’s Fees Expense
Pediatric Services, including oral and vision care
Dental Treatment for Injury
Ambulance
Maternity, Complications of Pregnancy & Newborn Care
Durable Medical Equipment and Braces; Prosthetic Appliances
and Devices
Home Health Care: Up to 40 visits per Policy Year. Four hours of
home health aide service shall be considered as one home care visit.
OUT-OF-NETWORK
$25 co-pay per visit
$25 co-pay per visit
80% of Allowable Charges
60% of R & C
$25 co-pay per visit
$25 co-pay per visit
80% of Allowable Charges
60% of R & C
80% of Actual Charge
80% of R & C
Paid the same as any other Sickness
80% of Allowable Charges
60% of R & C
80% of Allowable Charges
60% of R & C
80% of Allowable Charges
60% of R & C
Hospice Care
$50,000 Maximum Benefit
Medical Evacuation
$50,000 Maximum Benefit
Repatriation of Remains
Additional Coverage Required by the State of New York: Pre-Hospital Medical Emergency Services; Diabetic
Equipment; Supplies and Self-Management Education; Autism Spectrum Disorders; Contraceptive Services; Breast
Reconstruction; Breast Cancer Treatment; Clinical Trials Expense; Cancer Second Opinion; Enteral Formulas up to $2,500 per
Policy Year; End of Life Care; Hearing Aids Expense; Off Label Cancer Drugs; and any other applicable coverage required by
the State of New York. Please see the Policy on file with the Policyholder for details.
*PREMIUM RATES:
Fall Term
Winter-Summer Term
8/1/15-12/31/15
1/1/16-7/31/16
$900
$ 900
*Rates include administrative fees.
This document provides only a brief description of the coverage available. The Policy contains reductions, limitations, exclusions
and termination provisions. Full details of the coverage are contained in each Policy. If there are any conflicts between this
document and the Policy, the Policy shall govern.