Louisiana State University
SHREVEPORT, LOUISIANA
(the “Policyholder”)
2013-2014 Academic Year
Student Insurance Health Plan
Administrator Policy # CHH9027024
Underwriter Reference # CAS9495330
LSU
Health Sciences Center
SHREVEPORT
IMPORTANT: ALL STUDENTS MUST EITHER ENROLL OR
COMPLETE AN INSURANCE WAIVER ONLINE AT WWW.STUDENTINSURANCE.COM/SCHOOLS/LA/ LSUHSC
This is only a brief description of the coverage available under policy series S30749NUFIC-PPO-LA. The Policy may contain definitions, reductions, limitations, exclusions and termination provisions. Full details of the coverage are contained in the Policy on file at the University. If there is any conflict between the contents of this document and the Policy, the Policy will govern in all cases. Travel Assistance services provided by Travel Guard. Insurance and services provided by member companies of American International Group, Inc. Coverage may not be available in all jurisdictions and is subject to actual policy language. For additional information, please visit our website at www.AIG.com.
Insurance Underwritten By:
National Union Fire Insurance Company of Pittsburgh, Pa.
NOTICE:
Your student health insurance coverage, offered by National Union Fire Insurance
Company of Pittsburgh, Pa., may not meet the minimum standards required by the
health care reform law for the restrictions on annual dollar limits. The annual dollar
limits ensure that consumers have sufficient access to medical benefits throughout the
annual term of the policy. Restrictions for annual dollar limits for group and individual
health insurance coverage are $1.25 million for policy years before September 23,
2012; and $2 million for policy years beginning on or after September 23, 2012
but before January 1, 2014. Restrictions for annual dollar limits for student health
insurance coverage are $100,000 for policy years before September 23, 2012, and
$500,000 for policy years beginning on or after September 23, 2012, but before
January 1, 2014. Your student health insurance coverage put an annual limit of:
$500,000 on Essential Health Benefits. If you have any questions or concerns about
this notice, contact AIG, Educational Markets at 1-888-622-6001. Be advised that
you may be eligible for coverage under a group health plan of a parent’s employer
or under a parent’s individual health insurance policy if you are under the age of
26. Contact the plan administrator of the parent’s employer plan or the parent’s
individual health insurance issuer for more information.
You can use your Smart Phone
QR Code Application to scan and
store Student Health Insurance Plan
Information.
IMPORTANT CONTACT INFORMATION
CLAIMS & ENROLLMENT INFORMATION
Toll Free Number: 888-622-6001 Website:
www.studentinsurance.com/Schools/LA/LSUHSC • Benefit /Enrollment Information
• Enrollment & Waivers • ID Cards
• Claim Form Submission
• Preferred Provider (PPO) Look-up & Map • My Account (Claim & Enrollment Status) • Helpful Links
PREFERRED PROVIDER INFORMATION
On-Campus: LSUHSC Shreveport
Verity HealthNet 225-819-1135 or www.verityhealth.com MultiPlan 888-342-7427 or www.multiplan.com TABLE OF CONTENTS
Certificate of Creditable Coverage page 5 Deadline For Purchasing Coverage page 5
Definitions pages 8-9
Effective & Termination Dates page 4
Enrollment/Eligibility page 4
Exclusions/Limitations pages 9-10
Frequently Asked Questions pages 11-12
How to File A Claim page 3
Optional Dental Coverage page 13
Rates page 11
Refund Policy page 5
Schedule of Benefits pages 6-7
“Semester Stop Out” page 5
Termination of Insurance & Extension of
Benefits After Termination of Coverage page 4 & 5
Travel Guard pages 12-13
Where To Go For Medical Care page 5
HOW TO FILE A CLAIM
1. Written notice of a Claim must be submitted within 90 days of the Injury or first treatment of a Sickness, or as soon as possible.
2. Complete and submit Claim Notification Form (front page only). Interactive forms are available at www. studentinsurance.com/Schools/LA/LSUHSC and paper forms are available at each college’s respective Student Affairs Office. ONE CLAIM NOTIFICATION FORM IS REQUIRED PER INJURY OR SICKNESS.
3. Itemized bills must be submitted to the claims office within 90 days after the occurrence or as soon as reasonably possible. Medical providers generally submit itemized bills; however, it is the Covered Person’s responsibility to verify submission.
4. Retain one copy of claims information submitted for your records.
PLEASE NOTE: The Claim Notification Form is designed to obtain all information required to process your claim. If this Claim Notification Form (front page only) is not completed, a delay in processing may occur due to lack of information.
ALL INSUREDS ARE REQUIRED TO COMPLETE AND SUBMIT ONE CLAIM NOTIFICATION FORM PER ACCIDENT/SICKNESS.
ENDORSED STUDENT HEALTH INSURANCE PLAN ENROLLMENT/ELIGIBILITY
As part of the acceptance criteria at Louisiana State University Health Sciences Center—Shreveport, all full and part-time students are required to have and maintain medical insurance for the duration of their studies.
During registration for EACH semester, students must either enroll in the Louisiana State University endorsed Student Health Plan (the “Plan”) or complete a waiver and provide proof of acceptable alternate insurance coverage by the waiver deadline. Full time and part time University students are eligible to enroll in the Plan. Home study, correspondence, television and on-line courses do not fulfill the eligibility requirements.
ALL STUDENTS ARE REQUIRED TO VISIT WWW. STUDENTINSURANCE.COM/SCHOOLS/LA/LSUHSC AND COMPLETE AN ENROLLMENT FORM OR PROVIDE ACCEPTABLE WAIVER INFORMATION.
Dependent coverage must be purchased directly from the Company (or its authorized representative) via check, money order, MasterCard or Visa.
IT IS THE STUDENT’S RESPONSIBILITY TO MAKE CERTAIN THAT THE PREMIUM IS RECEIVED BY THE COMPANY. MS IV Interim Residents are also eligible to purchase continuation coverage. Details are located on page 5.
Covered students may purchase coverage for eligible Dependents. Online enrollment is available to eligible Dependents and printable forms are available at www. studentinsurance.com/Schools/LA/LSUHSC. Part-time students may purchase coverage for themselves and their eligible Dependents. Dependent enrollment information and premium must be submitted directly to the Company (or its authorized representative). If the Covered Student’s coverage ceases due to his or her death, the surviving spouse who is 50 years old or older may continue coverage under this Plan, provided written request is made 90 days after the date of the Covered Student’s death. The coverage to be continued will be identical in scope to that provided for the spouse prior to the Covered Student’s death. If this continued coverage option is exercised by the spouse, coverage will continue uninterrupted unless one of the following occurs: (a) the spouse fails to make timely payment of the required premium; (b) the spouse becomes eligible for Medicare; (c) the spouse becomes insured under another accident and health plan; or (d) the spouse remarries. Newborn children are covered for Injury or Sickness from birth until 31 days old or until such time as the infant is well enough to be discharged from a Hospital or neonatal special care unit to his home, whichever period is longer. To continue coverage for a newborn, written notice and premium must be received by the Company within 31 days of birth date. Benefits are subject to the Maximum Policy benefit and Plan provisions.
Incoming first year and transferring students enrolling in the Student Health Insurance Plan for the first time may apply for insurance portability by completing a H.I.P.P.A. questionnaire. The completed questionnaire and a copy of the student’s “Certificate of Creditable Coverage” from their prior insurance company must be returned to National Union Fire Insurance
Company of Pittsburgh, Pa., P.O. Box 71331, Philadelphia, PA 19176-1321 for processing. Blank questionnaires are available by contacting AIG Educaitonal Markets at 1-888-622-6001/claimsinfo@studentinsurance.com. Questions regarding portability or the 12-month Pre-existing Condition limitation may be directed to AIG, Educational Markets at 1-888/622/6001/ claimsinfo@studentinsurance.com.
The Company maintains the right to investigate student status and attendance records to verify that Policy eligibility requirements have been met. If the Company discovers that the Policy eligibility requirements have not been met, the Company’s only obligation is refund of premium.
EFFECTIVE AND TERMINATION DATES
The Effective dates and Termination dates below are set to correspond with the 2013-2014 LSUHSC-S Academic Calendar. Continuous coverage means a person has been continuously insured under the Policy and the prior Student Health Insurance policies issued to the Policyholder. A listing of the prior Policy (2012-2013) Effective & Termination dates is located on page 11.
PERIOD OF COVERAGE
COLLEGE/PROGRAM (Payment 1)FALL SPRING/SUMMER(Payment 2) School of Allied Health 8/15/13 -1/1/14 1/2/14 - 8/14/14 Graduate Studies 8/1/13 -1/1/14 1/2/14 -7/31/14 School of Medicine I 7/15/13 -1/1/14 1/2/14 -7/14/14 School of Medicine II 7/15/13 -1/1/14 1/2/14 -7/14/14 School of Medicine III 6/18/13 - 1/1/14 1/2/14 -
6/17/14 School of Medicine IV 6/18/13 - 1/1/14 1/2/14 - 6/17/14
ALL PROGRAMS SPRING/NEW SUMMER NEW SUMMER ONLY MSIV INTERIM RESIDENTS All Colleges/ Programs 1/02/14 -8/14/14 5/14/14 -8/14/14 6/15/14 - 8/14/14 Subject to certain exclusions and limitations, this Insurance Plan covers insured students and Dependents 24 hours-a-day at home, at school, or while traveling during the term for which premium is paid. The coverage of an eligible student who enrolls for coverage under the Policy shall take effect at 12:01 a.m. on the latest of the following dates: (1) the Policy Effective Date (6/18/13); (2) the date for which the first premium for the Covered Student’s coverage is received by the Company; or (3) the date shown for the Covered Student’s college/ program; or (4) the date the Student becomes a member of an eligible class of persons.
Insurance for a Covered Student will end at 11:59 p.m. on the first of these to occur: (1) the date the Policy terminates (8/14/14); (2) the last day for which any required premium has been paid; (3) the date on which the Covered Student withdraws from the school because of: (a) entering the armed forces of any country (Premiums will be refunded on a
pro-rata basis (less any claims paid) when written request is made.); or (b) departure from the Policyholder’s school for his or her home country. Premiums will be refunded on a pro-rata basis (less any claims paid) only upon written proof from the Policyholder that the Covered Student is no longer an eligible person.
If withdrawal from the Policyholder’s school is for other than (a) or (b) above, no premium refund will be made. Students will be covered for the Policy term for which they are enrolled and for which premium has been paid.
Dependent coverage cannot commence earlier or extend beyond the Covered Student’s coverage, except as specifically provided in the Policy. Eligibility requirements must be met each time premium is paid to continue coverage. The Company maintains the right to investigate student status and attendance records to verify that the Policy eligibility requirements have been met. If it is discovered that the Policy eligibility requirements have not been met, the Company’s only obligation is to refund premium less any claims paid. It is the Covered Person’s responsibility to inquire about coverage dates for each new school year.
Benefits are payable only for those Eligible Expenses incurred while the coverage is in effect as to the Covered Person. Eligible Expenses incurred after the Covered Person’s Termination Date of insurance are not covered except as may be provided under the Extension of Benefits. Covered Students graduating in May will be covered until the end of the premium period purchased; however, Student Health Program benefits are separate from the Student Health Insurance Plan and do not apply after graduation.
WAIVER ENROLLMENT DEADLINES
The deadline to complete a waiver and provide proof of acceptable alternate insurance coverage or enroll in the endorsed Student Health Insurance Plan is 30 days from the effective date for your particular college program shown on page 11. A Dependent may become eligible for coverage under this Plan only when the student becomes eligible; or within 31 days of marriage, birth or adoption.
“SEMESTER STOP OUT”
If you need to take a semester off, you are eligible to extend your student insurance for one more semester by completing a “Semester Stop Out” form located at the University’s Student Affairs Office. The completed “Semester Stop Out” form, a completed enrollment form and full premium must be received on or before the Effective Date shown on the enrollment form for the semester you will not be attending.
This option is available only one time during your attendance at LSUHSC-S.
EXTENSION OF BENEFITS
If a Covered Person is confined to a Hospital on the date his or her coverage terminates, benefits will be payable for the Eligible Expenses incurred during the continuation of that Hospital Confinement. Such benefits will be payable until the earliest of: (1) the date the Hospital confinement ends; (2) the end of the 90 day period following the date his or her coverage terminated; or (3) the date the applicable Maximum
Amount is reached.
The Extension of Benefits will apply only to the extent the Covered Person will not be covered under the Policy or any other health insurance policy in the ensuing term of coverage.
CONTINUATION OF COVERAGE
A Covered Student, who is no longer eligible because he or she has graduated, may be eligible to continue coverage under the Policy. The Covered Student has the option to continue coverage for up to the earlier of: (1) end of the Policy Year in which he or she graduates with the payment of any required premium; or (2) end of period for which premium has been paid. Continuation of Coverage must be approved by the Company. Continuation of coverage will be subject to all the terms of the Policy.
CERTIFICATE OF CREDITABLE COVERAGE
Your coverage under the Policy is Creditable Coverage under Federal law. When your coverage terminates, you can request a Certificate of Creditable Coverage, which is evidence of your coverage under the Policy. You may need such a certificate if you become covered under a group health plan or other health plan within 63 days after your coverage under the Policy terminates. If the subsequent health plan excludes or limits coverage for medical conditions you have before you enroll, the Certificate may be used to reduce or eliminate those exclusions or limitations. In order to obtain a Certificate of Creditable Coverage, please contact AIG, Educational Markets Mail Center, P.O. Box 26050, Overland Park, KS 66225.
ALTERNATE COVERAGE
If you do not meet the eligibility requirements of this Plan, please call 1-800-285-8133 for information on alternative insurance plans.
WHERE TO GO FOR MEDICAL CARE
To receive maximum benefits under this Plan, the Company recommends that you utilize LSUHSC-S Healthcare Providers. Benefit examples for covered treatment include:
VERITY HEALTHNET/ MULTIPLAN PREFERRED PROVIDER ORGANIZATIONS (PPO)
If treatment or care is received in a Non- PPO facility because of an Emergency Medical Condition, benefits for Eligible Expense are payable at the PPO level.
Medical
Providers DeductibleStudent Dependent Deductible PercentageCovered
LSUHSC-S $0 $300 100%
Verity Healthnet
Multiplan PPO $300 $500 80%
Non-PPO
Providers $300 $500 60%
Health Care Services may be provided to you at a Network Health Care Facility by facility-based Doctors who are not in your health plan. You may be responsible for payment of all or part of the fees for those out-of-network services, in addition to applicable amounts due for co-payments, coinsurance, deductibles, and non-covered services.
Specific information about in-network and out-of-network facility based Doctors can be found at: www.studentinsurance. com/Schools/LA/LSUHSC or by calling the Customer Service telephone number at 1-888-622-6001.
Preferred Providers are the Doctors, Hospitals and other health care providers who have been contracted to provide specific medical care at negotiated prices. Preferred Providers are: Verity HealthNet and MultiPlan Hospitals and Doctors. Under a special agreement with Verity HealthNet PPO: LSUHSC coinsurance obligations are waived on eligible expenses. This waiver does not include deductibles or copayments except for eligible services performed at LSUHSC for Covered Students only. A complete listing of PPO participants is linked to the AIG, Educational Markets website at www.studentinsurance.com/ Schools/LA/LSUHSC. Providers may be periodically added or deleted as participants in the Preferred Provider Organization. It is the Covered Person’s responsibility to verify that a provider is a participating provider prior to services being rendered. Out-of-Network providers have not agreed to any prearranged fee schedules. Covered Persons may incur significant out-of-pocket expenses with these providers. Charges in excess of the insurance payment are the Covered Person’s responsibility.
OUTPATIENT PRESCRIPTION DRUG MANAGERS - CATAMARAN RX
The Student Health Insurance Plan provides pharmacy coverage through a prescription card program administered by Catamaran Rx. You may purchase prescription drugs at over 45,000 network pharmacies nationwide. You may check the latest listing of participating pharmacies through the Catalyst Rx website link at www.studentinsurance.com/Schools/LA/ LSUHSC (User Name: college; Password: college101) or by calling the Catamaran Rx help desk at 1-888-869-4600. Prescription Benefits are based on a Mandatory Generic Catamaran Rx Formulary, which means that Catamaran Rx participating pharmacies will fill generic prescriptions on all covered formulary medications if there is a generic drug on the market. If a generic is not available the brand-name co-pay will apply. If you or your Doctor chooses a brand-name drug, you will pay the difference between the brand-name and the generic, plus the brand-name co-pay. If your Doctor prescribes a non-formulary drug, you will be responsible for a $40 co-pay per prescription.
In order for you to take full advantage of your prescription benefit program, always have your prescriptions filled at a network pharmacy.
Please refer to the Schedule of Benefits for your coinsurance and maximum benefit information below.
SCHEDULE OF BENEFITS
Students:$500,000 Maximum per Injury/Sickness
Dependents: $500,000 Maximum per Injury/Sickness
Primary Benefit Amount: the first $100 of Eligible Expenses provided by the Policy.
Covered Percentage: Eligible Expenses are paid at 100% of the Allowable Charges if treatment is rendered by an LSUHSC-Shreveport provider, 80% of the Allowable Charges if treatment is rendered by a Verity HealthCare or MultiPlan Provider, and 60% of Reasonable & Customary if treatment is rendered by an out-of-network provider. If treatment or care is received in a Non- PPO facility because of an Emergency Medical Condition, benefits for Eligible Expense are payable at the PPO level.
DEDUCTIBLE PER POLICY YEAR: STUDENTS: $0 for covered services received from LSUHSC- Shreveport.
$300 for covered services received from all other medical providers.
DEPENDENTS: $300 for covered services received from LSUHSC-Shreveport. $500 for covered services received from all other medical providers.
INPATIENT BENEFITS
Hospital Room and Board—Daily semiprivate room rate and general nursing care Subject to the applicable Covered Percentage
Intensive Care Services Subject to the applicable Covered
Percentage
Hospital Miscellaneous— includes expenses incurred for anesthesia and operating room; laboratory tests and X-rays, (including professional fees); oxygen tent; drugs, medicines (excluding take-home drugs), dressings; and other Medically Necessary and prescribed Hospital expenses.
Subject to the applicable Covered Percentage
Surgeon’s Fees— When Injury or Sickness requires two or more surgical procedures which are performed through the same incision, and at the same operative session or immediate succession, the Company will pay only for the most expensive procedure performed.
Subject to the applicable Covered Percentage
Assistant Surgeon’s Fees Maximum 25% of surgical expense
Anesthesia Subject to the applicable Covered Percentage
SCHEDULE OF BENEFITS, Continued
INPATIENT BENEFITS, Continued
Doctor’s Visits are limited to one visit per day and are not applicable when related
to surgery. Subject to the applicable Covered Percentage
Private Duty Nursing rendered by a Registered Nurse (RN) or Licensed Practical
Nurse (LPN) Subject to the applicable Covered Percentage
Physiotherapy—limited to one visit per day. Subject to the applicable Covered Percentage
Psychiatric Conditions Paid as any other Sickness
Alcoholism and Substance Abuse Paid as any other Sickness
Maternity—Normal pregnancy and childbirth and complications of pregnancy -
Student & Spouse ONLY Paid as any covered Sickness (Student and Spouse ONLY)
OUTPATIENT BENEFITS
Surgeon’s Fees— When Injury or Sickness requires two or more surgical procedures which are performed through the same incision, and at the same operative session or immediate succession, the Company will pay only for the most expensive procedure performed.
Subject to the applicable Covered Percentage
Day Surgery Facility/Miscellaneous - When scheduled surgery is performed in a Hospital or outpatient facility, including: use of the operating room; laboratory tests and x-ray examinations (including professional fees); anesthesia; infusion therapy; drugs or medicines and supplies; therapeutic services (excluding physiotherapy or take home drugs and medicines).
Subject to the applicable Covered Percentage
Anesthesia Maximum 30% of Surgeon’s Allowance
Doctor’s Visits (other than a Doctor who performed surgery or administered
anesthesia) limited to one visit per day. Subject to the applicable Covered Percentage
Medical Emergency Expenses— for use of Hospital emergency room (only Medically Necessary and prescribed expenses) including operating room, laboratory and x-ray examinations, supplies.
Subject to the applicable Covered Percentage
Laboratory and Diagnostic X-ray Services; Radiation Therapy/ Chemotherapy; Tests and Procedures—when ordered by a Doctor for diagnosis and treatment of a Sickness or Injury.
Subject to the applicable Covered Percentage
Physiotherapy/Occupational & Speech Therapy Subject to the applicable Covered Percentage
Psychiatric Conditions Paid as any other Sickness
Alcoholism and Substance Abuse Paid as any other Sickness
Outpatient Prescription Drugs— limited to a maximum of $500,000 per Policy Year (Refer to Catamaran Rx information on page 6). However obtained, all Outpatient Prescription Drugs are Subject to the Outpatient Prescription Drug maximum. This benefit applies to all prescribed FDA-approved birth control methods. The co-pays will be waived for prescribed FDA-approved birth control.
$15 generic, $25 formulary & $40 non-formulary co-pay
Ambulance — when a Covered Person requires the use of a professional
ambulance in an emergency. Subject to the applicable Covered Percentage
Consultant Doctor’s Fee—when requested and approved by attending Doctor $1,000/Policy Year Max
Durable Medical Equipment Subject to the applicable Covered Percentage
Injury to sound natural teeth or removal of wisdom teeth $200/tooth (includes office visit, X-rays, etc.) Medical Evacuation/ Repatriation– since some items are not covered, the
Company should be contacted prior to incurring any expenses. To contact the Company call 1-800-626-2427.
$1,000,000 Combined Maximum Benefit
Home Country Benefit—International Students & Eligible Dependents $1,000
Preventive Services as specified by Patient Protection and Affordable Care Act (PPACA)
100% of Reasonable & Customary not subject to deductibles,
copayments, or coinsurance (Benefits not provided when rendered at a non-PPO provider)
Needlestick and Splatter—preventive care 100% of Reasonable & Customary
Louisiana mandates coverage for the following benefits: Treatment and correction of cleft lip and cleft palate; services performed by a qualified interpreter/transliterator when such services are used in connection with medical or diagnostic consultations performed by a Doctor; annual pap test, not subject to the Deductible, if any; mammograms; routine prostate preventive care; immunizations for Dependent children from birth to age 6; diagnosis and treatment of attention deficit/ hyperactivity disorder; treatment of osteoporosis; diabetes equipment, supplies and outpatient self-management training and education, including medical nutrition therapy; anesthesia and Hospital charges for dental treatment under certain circumstances; patient costs incurred with a clinical trial for cancer; and treatment of Severe Mental Illness, colorectal cancer screening, breast reconstruction following mastectomy, and any other applicable mandated benefits, subject to plan provisions.
DEFINITIONS
“Accident” means an occurrence which (a) is unforeseen; (b) is not due to or contributed to by Sickness or disease of any kind; and (c) causes Injury.
“Allowable Charges” means the charges agreed to by the Preferred Provider Organization for specified covered medical treatment, services and supplies.
“Covered Percentage” means the percentage of the
Eligible Expense that is payable as a benefit under the Policy.
“Covered Person” means a Covered Student while
coverage under the Policy is in effect and those Dependents with respect to whom a Covered Student is insured.
“Covered Student” means a student of this Policyholder who is insured under the Policy.
“Dependent” means: (a) the Covered Student’s spouse residing with the Covered Student; and (b) the Covered Student’s or spouse’s child until the date such child attains age 26.
The term “child” includes: (a)a legally adopted child; (b) a child who has been placed in the Covered Student’s or spouse’s home pending adoption procedures; (c) a step-child if such step-child depends on the Covered Student or spouse for full support; and (d) a Covered Student’s grandchild if such grandchild: (i) is in the Covered Student’s legal custody; (ii) resides with the Covered Student; and (iii) depends on the Covered Student for full support.
“Doctor” means: (a) legally qualified physician licensed by the state in which he or she practices; and (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 such practitioner; and (c) certified nurse midwives and licensed midwives while acting within the scope of that certification. The term “Doctor” does not include a Covered Person’s immediate family member.
“Eligible Expense” means a charge for any treatment, service or supply which is performed or given under the direction of a Doctor for the Medically Necessary treatment of a Sickness or Injury: (a) not in excess of the Reasonable and Customary charges; or (b) not in excess of the charges that would have been made in the absence of this coverage; (c) with respect to the Preferred Provider, is the Allowable Charge; (d) is the negotiated rate, if any; and (e) incurred while the Policy is in force as to the Covered Person except with respect to any expenses payable under the Extension of Benefits provision.
“Emergency Medical Condition” means a medical
condition of recent onset and severity, including severe pain, that would lead a prudent lay-person, acting reasonably and possessing an average knowledge of medicine and health, to believe that the absence of immediate medical attention could reasonably be expected to result in: (a) placing the health of the person, or with respect to a pregnant woman, the health of the woman or her unborn child in serious jeopardy, (b) serious impairment to such person’s bodily functions; (c) serious impairment or dysfunction of any bodily organ or part of such person; or (d) serious disfigurement of such person.
“Emergency Services” means, with respect to an
Emergency Medical Condition: (a) a medical screening examination (as required under section 1867 of the Social Security Act, 42, U.S.C. 1395dd) that is within the capability of the emergency department of a Hospital, including ancillary services routinely available to the emergency department to evaluate such Emergency Medical Condition; and (b) such further medical examination and treatment, to the extent they are within the capabilities of the staff and facilities available at the Hospital, as are required under section 1867 of the Social Security Act (42 U.S.C. 1395dd(e)(3)).
Emergency does not include the recurring symptoms of a chronic illness or condition unless the onset of such symptoms could reasonably be expected to result in the complications listed above.
“Essential Health Benefits” has the meaning found in section 1302(b) of the Patient Protection and Affordable Care Act and as further defined by the Secretary of the United States Department of Health and Human Services and includes ambulatory patient services; Emergency Services; Hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services,; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.
“Hospital” means a facility which meets all of these tests: (a) it provides in-patient 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 the jurisdiction in which it is located; and (f) it is accredited by the Joint Commission on Accreditation of Healthcare Organizations.
Hospital does not include a place run mainly: (a) as a convalescent home; or (b) as a nursing or rest home; (c) as a place for custodial or educational care; or as an institution mainly rendering treatment or services for: mental or nervous disorders; or substance abuse. The term “Hospital” includes: (a) an ambulatory surgical center or ambulatory medical center; and (b) a birthing facility certified and licensed as such under the laws where located. It shall also include rehabilitative facilities if such is specifically for treatment of physical disability.
Hospital also includes tax-supported institutions, which are not required to maintain surgical facilities.
“Injury” means bodily injury due to an Accident which: (a) results solely, directly and inDependently of disease, bodily infirmity or any other causes; (b) occurs after the Covered Person’s effective date of coverage; and (c) occurs while coverage is in force. All injuries sustained in any one Accident, including all related conditions and recurrent symptoms of these injuries, are considered one Injury.
“Medical Necessity/Medically Necessary” means that a drug, device, procedure, service or supply is necessary and appropriate for the diagnosis or treatment of a Sickness or Injury based on generally accepted current medical practice in the United States at the time it is provided.
A service or supply will not be considered as Medically Necessary if: (a) it is provided only as a convenience to the Covered Person or provider; or (b) it is not the appropriate treatment for the Covered Person’s diagnosis or symptoms; or (c) it exceeds (in scope, duration or intensity) that level of care which is needed to provide safe, adequate and appropriate diagnosis or treatment; or (d) it is experimental/investigational or for research purposes; or (e) could have been omitted without adversely affecting the patient’s condition or the quality of medical care; or (f) involves treatment of or the use of a medical device, drug or substance not formally approved by the U.S. Food and Drug Administration (FDA); or (g) involves a service, supply or drug not considered reasonable and necessary by the Center for Medicare and Medicaid Services Issues Manual; or (h) it can be safely provided to the patient on a more cost-effective basis such as outpatient, by a different medical professional or pursuant to a more conservative form of treatment.
The fact that any particular Doctor may prescribe, order, recommend, or approve a service or supply does not, of itself, make the service or supply Medically Necessary.
“Pre-existing Condition” means a Sickness or Injury for which medical care, treatment, diagnosis or advice was received or recommended within the 6 months prior to the Covered Person’s effective date of coverage under the Policy or a pregnancy existing on the Covered Person’s effective date of Coverage under the Policy. Genetic information shall not be treated as a preexisting condition in the absence of a diagnosis of the condition related to such information.
“Preventive Services” mandated by the Patient Protection and Affordable Care Act and, in addition to any other preventive benefits described in the Policy or Certificate, means the following services and without the imposition of any cost-sharing requirements, such as deductibles, copayment amounts or coinsurance amounts to any Covered Person receiving any of the following:
1. Evidence-based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force, except that the current recommendations of the United States Preventive Service Task Force regarding breast cancer screening, mammography, and prevention of breast cancer shall be considered the most current other than those issued in or around November 2009;
2. Immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the Covered Person involved;
3. With respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; and
4. With respect to women, such additional preventive care and screenings, not described in paragraph 1 above, as provided for in comprehensive guidelines supported by the Health Resources and Services Administration. The Company shall update new recommendations to the preventive benefits listed above at the schedule established by the Secretary of Health and Human Services.
“Reasonable and Customary” means the charge, fee
or expense which is the smallest of: (a) the actual charge; (b) the charge usually made for a covered service by the provider who furnishes it; (c) the negotiated rate, if any; and (d) the prevailing charge made for a covered service in the geographic area by those of similar professional standing.
“Geographic area” means the three digit zip code in which the services, procedure, devices, drugs, treatment or supplies are provided or a greater area, if necessary, to obtain a representative cross-section of charge for a like treatment, service, procedure, device, drug or supply.
“Sickness” means disease or illness including related conditions and recurrent symptoms of the Sickness which begins after the effective date of a Covered Person’s coverage. Sickness also includes pregnancy and complications of pregnancy. All Sicknesses due to the same or a related cause are considered one Sickness.
EXCLUSIONS
The Policy does not cover nor provide benefits for loss or expenses incurred:
1. as a result of dental treatment, or dental x-rays except as provided elsewhere in the Policy. This exclusion does not apply to Preventive Services mandated by the Patient Protection and Affordable Care Act.
2. for services normally provided without charge by this Policyholder’s Health Service, Infirmary or Hospital, or by health care providers employed by this Policyholder or services covered by the Student Health fee.
3. for eye examinations, eyeglasses, contact lenses, or prescription for such; hearing aids except as otherwise provided; orthodontic braces and orthodontic appliances or prescriptions or examinations for such. This exclusion does not apply to Preventive Services mandated by the Patient Protection and Affordable Care Act.
4. as a result of an Accident occurring in consequence of riding as a passenger or otherwise in any vehicle or device for aerial navigation, except as a fare-paying passenger in an aircraft operated by a commercial scheduled airline.
5. for Injury or Sickness resulting from war or act of war, declared or undeclared.
6. as a result of an Injury or Sickness for which the Covered Person is entitled to benefits under any Workers’ Compensation or Occupational Disease Law.
7. as a result of Injury sustained or Sickness contracted while in the service of the Armed Forces of any country. Upon the Covered Person entering the Armed Forces of any country, the Company will refund any unearned pro-rata premium. This does not include Reserve or National Guard Duty for training unless it exceeds 31 days. 8. for treatment provided in a government Hospital unless
there is a legal obligation to pay such charges in the absence of insurance.
9. for cosmetic surgery other than reconstructive surgery needed to repair conditions resulting from an Injury which occurs while covered under the Policy, provided treatment begins within 3 months from the date of the Injury. “Cosmetic surgery does not include breast reconstructive surgery after a mastectomy, except as specifically provided in the Policy.
10. for Injuries sustained as the result of a motor vehicle Accident to the extent provided for any loss or any portion thereof for which mandatory automobile no-fault benefits are recovered or recoverable.
11. for preventive treatment, testing, immunizations, injections, medicines, serums, vaccines, vitamins anti-toxins or oral contraceptives except as specifically provided in the Policy. This exclusion does not apply to Preventive Services mandated by the Patient Protection and Affordable Care Act.
12. as a result of committing or attempting to commit an assault or felony or participation in a riot or insurrection. 13. after the date insurance terminates for a Covered Person
except as may be specifically provided in the Extension of Benefits Provision.
14. for any services rendered by a Covered Person’s immediate family member.
15. for any treatment, service or supply which is not Medically Necessary.
16. as a result of suicide or any attempt at suicide or intentionally self-inflicted Injury or any attempt at intentionally self-inflicted Injury. This exclusion does not apply to Repatriation of Remains coverage or Emergency Evacuation coverage.
17. for treatment of temporomandibular joint dysfunction. 18. for treatment of mental and nervous conditions except as
specifically provided in the Policy.
19. for the treatment of alcoholism or drug addiction except as specifically provided in the Policy.
20. for loss sustained or contracted in consequence of the Covered Person’s being intoxicated or under the influence of narcotics unless administered on the advice of a Doctor.
21. for surgery and/or treatment of: acne; allergy, including allergy testing and anti-toxins; biofeedback-type services; circumcision; corns, calluses and bunions; deviated nasal septum, including submucuous resection and/or other surgical correction thereof except for purulent sinusitis or unless due to Injury occurring while coverage is in force; family planning except as specifically provided; impotence, organic or otherwise; learning disabilities; and vasectomy. This exclusion does not apply to Preventive Services mandated by the Patient Protection and Affordable Care Act.
22. for routine physical examinations, health examinations or preschool physical examinations, including routine care of a newborn infant, well-baby care and related Doctor charges, except as specifically provided for in the Policy. This exclusion does not apply to Preventive Services mandated by the Patient Protection and Affordable Care Act.
23. for Injury resulting from travel in, sitting in or on, getting in or off, or working on or around any motorcycle or recreational vehicle or upon a snowmobile, ATV (all terrain or similar type two or three-wheeled vehicle; bobsledding or bungee jumping.
24. for Injury resulting from: the practicing for, participating in, or traveling as a team member to and from intercollegiate sports activity, including travel to and from the activity and practice; hang gliding; sky diving. 25. for rest cures or custodial care.
26. for treatment in the Hospital emergency room which is not due to an Emergency Medical Condition.
27. for Injury resulting from fighting, except in self-defense.
28. for care or treatment of the pregnancy of a Dependent child. This exclusion does not apply to complications of pregnancy.
29. for treatment, services, drugs, device, procedures or supplies that are experimental or investigational.
30. within the Covered Person’s home country of domicile for benefits in excess of $1,000 with respect to an international Covered Person.
31. for treatment, service or supply for which a charge would not have been made in the absence of insurance.
LIMITATIONS AND REDUCTIONS
1. Pre-existing Conditions –Pre-existing Conditions are not covered for the first 12 months following a Covered Person’s effective date of coverage under the Policy. This limitation will not apply if: (a) the Covered Person has been covered under the Policyholder’s prior Policy for 12 consecutive months; or (b) the individual seeking coverage under the Policy has an aggregate of 18 months of creditable coverage and becomes eligible and applies for coverage under the Policy within 63 days of termination of prior creditable coverage. Credit will be given for the time the individual was covered under the prior creditable coverage; and (1) the individual’s most recent prior creditable coverage was under an employer group plan; and (2) the individual accepted and used up COBRA continuation of coverage or similar state coverage if it was offered to him or her; and (3) the individual is not eligible for coverage Medicare or Medicaid; and (4) the individual does not have other health insurance.
The Pre-existing Conditions limitation does not apply to: (a) a newborn Dependent child; or (b) a child adopted by the Covered Person or placed with the Covered Person for adoption, if adoption orplacement for adoption occurs while covered under the Policy, and the child has not attained 18 years of age; (c)a Covered Person under age nineteen (19).
Proof of prior creditable coverage may be directed to the AIG, Educational Markets Mail Center, PO Box 26050, Overland Park, KS 66225.
2. Non-Duplication of Coverage – If the benefits in the Student Health Insurance Plan are payable under more than one provision, then benefits will be provided only under the provision providing the greater benefit.
PRIMARY/COORDINATION OF BENEFITS MEDICAL EXPENSE
The Company will pay the Eligible Expenses incurred for Injury or Sickness up to the Primary Benefit Amount of $100 as shown on the Schedule of Benefits. Such Eligible Expenses will be payable in accordance with the terms of the Policy. Subsequent submissions of claims for Eligible Expenses for the same Injury or Sickness which are in excess of the Primary Benefit Amount will be coordinated with any other valid and collectible insurance as described in the Policy.
SUBROGATION
When benefits are paid to or for a Covered Person under the terms of the Policy, the Company shall be subrogated, unless otherwise prohibited by law, to the rights of recovery of such Covered Person against any person who might be acknowledgedly liable or found legally liable by a Court of of competent jurisdiction for the Injury that necessitated the Hospitalization or the medical or surgical treatment for which
RATES
InsuredClassification (Payment 1)Fall (Payment 2)Spring Spring/SummerNew SummerNew Interim ResidentsMSIV
Please refer to the table below for specific dates for your specific college/program.
Student Only $1,209 $1,209 $1,439 $ 626 $ 391
Add the following rates to the student only rate abpve.
Spouse Only $2,546 $2,546 $3,005 $1,304 $ 833 Child(ren) Only $2,823 $2,823 $3,330 $1,444 $ 922 Spouse & Child(ren) $5,369 $5,369 $6,335 $2,758 $1,755
EFFECTIVE AND TERMINATIONS DATES
COLLEGE/PROGRAM * FALL (Payment 1) * SPRING/SUMMER (Payment 2)
• School of Allied Health 8/15/13 - 1/1/14 1/2/14 - 8/14/14 • Graduate Studies 8/1/13 - 1/1/14 1/2/14 - 7/31/14 • School of Medicine I 7/15/13 - 1/1/14 1/2/14 - 7/14/14 • School of Medicine II 7/15/13 - 1/1/14 1/2/14 - 7/14/14 • School of Medicine III 6/18/13 - 1/1/14 1/2/14 - 6/17/14 • School of Medicine IV 6/18/13 - 1/1/14 1/2/14 - 6/17/14
ALL PROGRAMS NEW SPRING/SUMMER NEW SUMMER ONLY MSIV INTERIM RESIDENTS
All Colleges/Programs 1/2/14 - 8/14/14 5/14/14 - 8/14/14 6/15/14 - 8/14/14
* Eligible insureds maintaining continuous coverage from the prior Policy year will maintain their original effective and termination dates, provided eligibility requirements are met and premium(s) are received on or before the 30-day grace period.
The 2010/11, 2011/12 and 2012/13 Policy Effective & Termination dates are as follows:
COLLEGE/ PROGRAM 2012/13 2011/12 2010/11
School of Allied Health 8/15/12-8/14/13 8/15/11-8/14/12 8/15/10-8/14/11
Graduate Studies 8/1/12-7/31/13 8/1/11-7/31/12 8/1/10-7/31/11
School of Medicine I 7/15/12-7/14/13 7/15/11-7/14/12 7/15/10-7/14/11
School of Medicine II 7/15/12-7/14/13 7/15/11-7/14/12 7/15/10-7/14/11 School of Medicine III 6/18/12-6/17/13 6/18/11-6/17/12 6/18/10-6/17/11 School of Medicine IV 6/18/12-6/17/13 6/18/11-6/17/12 6/18/10-6/17/11 benefits were paid. Such subrogation rights shall extend only
to the Company’s recovery of the benefits the Company has paid for such Hospitalization and treatment and the Company shall pay fees and costs associated with such recovery. The Company’s right of subrogation will not be enforced until the Covered Person has been made whole, as determined by a court of law, as a result of Injury or Sickness.
FREQUENTLY ASKED QUESTIONS
1. What is my policy number? 9495330
2. Am I required to enroll in this insurance plan?
LSUHSC-S requires all students either to purchase this insurance Plan or provide proof of alternate coverage at registration.
3. How do I waive the insurance? To waive coverage under the Plan, you must complete a waiver form and provide proof of other insurance coverage at registration. Students are required to complete an enrollment form or waiver at www.studentinsurance.com/Schools/LA/
LSUHSC.
4. What is the deadline to waive the insurance? The waiver form and proof of other insurance must be submitted prior the date of registration for each semester.
5. How/Where do I pay for the insurance? Student only insurance premium will be added to your LSUHSC-S account and charged against financial aid allowance, as applicable or paid by check. Students are required to complete an enrollment form or insurance waiver at www.studentinsurance.com/Schools/LA/LSUHSC.
6. How do I enroll my Dependents? Complete the enrollment form and follow the payment instructions listed on the form. Students may enroll their eligible Dependents online at www.studentinsurance.com/ Schools/LA/LSUHSC using credit card, or obtain printable enrollment forms at www.studentinsurance.com/Schools/ LA/LSUHSC. For additional questions, contact AIG, Educational Markets at 1-888-622-6001.
7. What is the deadline to purchase the insurance?
LSUHSC-S requires all students to enroll in this Plan or waive coverage and provide proof of other insurance at each registration. (Details and Dependent information are located on page 5.)
8. What if I get married or have a child after the enrollment deadline and want to add my Dependent?
A spouse may be added within 31 days of marriage and a child may be added within 31 days of birth/adoption. A copy of the marriage certificate or birth/adoption certificate must be submitted with the enrollment form and payment.
9. If I enroll in this Plan, do I also need to purchase Needlestick Coverage? No. The Needlestick Coverage is included in this Plan.
10. If I enroll in this Plan, do I also need to purchase Medical Evacuation and Repatriation Coverage? No. The Medical Evacuation and Repatriation Coverage is included in this Plan.
11. What is my deductible? The per Policy Year Student deductible is $0 for covered services received from LSUHSC-S; $300 for covered services received from outside LSUHSC-S providers. The per Policy Year Dependent deductible is $300 for covered services received from LSUHSC-S and $500 for covered services received from outside LSUHSC-S providers.
12. What does “In-Network” mean? In-Network providers are the preferred providers available to you through the Verity HealthNet and MultiPlan PPO Network. Preferred Providers are the Doctors, Hospitals and other health care providers who have contracted to provide specific medical care at negotiated prices. Preferred Providers are: Verity HealthNet Hospitals and Doctors and MultiPlan. Under a special agreement with Verity HealthNet PPO: LSUHSC coinsurance obligations are waived on eligible expenses. This waiver does not include deductibles or copayments, except for eligible services performed at LSUHSC. To locate an In-Network provider, visit the AIG, Educational
Markets website at www.studentinsurance.com/Schools/ LA/LSUHSC and click on the “Locate a PPO Doctor/ Hospital”. Participation of individual providers is subject to change without notice. It is the responsibility of the Insured to confirm participation at the time services are rendered. A provider nomination form is also available.
13. What does “Out-of-Network” provider mean? Out-of-Network providers are providers that do not participate in the LSUHSC-S, Verity HealthNet or MultiPlan PPO Networks. Out-of-Network benefits are reduced to 60% of Reasonable and Customary as shown on the Schedule of Benefits. Participation of individual providers is subject to change without notice. It is the responsibility of the Covered Person to confirm participation at the time services are rendered. PPO directories may be accessed through AIG, Educational Markets’ website at www. studentinsurance.com/Schools/ LA/LSUHSC.
14. How do I submit a claim? Claim Notification Forms are available at the respective Student Affairs Offices or by contacting AIG, Educational Markets at www. studentinsurance.com or 1-888-622-6001. Online claim submission is also available at www.studentinsurance. com/Schools/LA/LSUHSC. The completed claim form and itemized medical bills should be forwarded to AIG, Educational Markets Mail Center, PO Box 26050, Overland Park, KS 66225.
15. Who do I call to check the status of a claim? AIG,
Educational Markets, 1-888-622-6001, or visit www. studentinsurance.com/Schools/LA/LSUHSC.
16. What is my policy’s maximum benefit? The Policy Maximum is $500,000 per covered Injury/Sickness.
17. What if I am out of state when I get sick or injured?
This Plan covers you anywhere in the world up to the policy limits. Benefits for loss or expenses incurred in an international Covered Person’s home country is subject to a policy limit of $1,000.Please follow the procedure in the brochure for filing a Claim Notification Form.
18. Do I need to call in to pre-certify before going to a Hospital?No, pre-certification is not required. However, please feel free to contact us at 1-888-622-6001 or www.studentinsurance.com/Schools/LA/LSUHSC for benefit assistance.
19. Do I need a referral to see a Doctor? You are not required to obtain a referral. However, students are encouraged to use the LSUHSC-S Clinics/ Hospital. Covered services received from the LSUHSC-S Clinics/ Hospital are subject to a reduced deductible and higher benefits (see brochure, pages 5 and 6).
TRAVEL GUARD
Procedures on How to Access Travel Guard 24-Hour Assistance Call Center How to Contact Travel Guard:
• Inside the US and Canada, dial 1-877-249-5362 toll-free. • Outside the US and Canada:
• Request an international operator.
• Request the operator to place a collect call to the USA at 1-715-295-9625.
• Our fax number is 1-262-364-2203.
When to Contact Travel Guard:
• Call Travel Guard when you require medical assistance or have a medical emergency.
• Call Travel Guard for all non-medical situations (lost luggage, lost documents, legal help, etc.)
• Call Travel Guard whenever there is a question.
Travel Guard is available
24-hours-a-day/7-days-a-week/365-days-a-year
Our multi-lingual/multicultural Travel Assistance Coordinators (TACs) are trained professionals ready to help you should the need arise while you are traveling or away from home.
The Travel Guard Services Medical Staff consists of full-time, on-site Registered Nurses and Emergency Physicians who work as a team to provide the best outcome for our clients. This team is directed by a dedicated Medical Director (MD) and Manager of Medical Services (RN). Nursing staff is on-site 24-hours; a physician has daily responsibility for a 24-hour period and is on-site during daytime hours.
What information will you need to provide Travel Guard when you call:
• Advise Travel Guard TPA is AIG, Educational Markets • Provide your Policy Number or School Name
• Advise Travel Guard regarding the nature of your call and/ or emergency. Be sure to provide your contact information at your current location in the event Travel Guard needs to call you back.
Description of Services
General Information: These services include advice and information regarding travel documentation, immunization requirements, political/environmental warnings, and information on global weather conditions. Travel Guard can also provide information on available currency exchange rates, local Bank/Government holidays, and by implementing our databases with the information, provide ATM and Customer Service locations to clients. Travel Guard also provides emergency message storage & relay and translation services.
• Visa & Immunization
• Weather & Exchange Rates • Environmental & Political Warnings
Technical: These services provide assistance to members in the event of lost or stolen luggage, personal effects, documents and tickets. Travel Guard can arrange cash transfers & vehicle return in the event of illness or accident, provide legal referrals, and help with arrangements for members who encounter enroute emergencies that force them to interrupt their trips. • Legal Referral
• Embassy/Consulate Information • Lost/Stolen Luggage
• Claims-related Assistance & Personal Effects Assistance • Telephone Interpretation
• Lost Document Assistance
• Enroute Travel Assistance & Cash Transfer Assistance
Medical: These services are the most complicated of those offered and can last up to several weeks. They involve Travel Guard’s Medical Staff in addition to other network providers and often include post-case payment/billing coordination on the traveler’s behalf. These services include physician/dental/ Hospital referral, medical case monitoring, shipment of medical records and prescription medications, medical evacuation, repatriation of remains and insurance/claims coordination.
Medical Assistance:
• Medical Referral
• Out-patient Assistance • In-patient Assistance
Medical Transport: as shown below.
• Evacuation • Repatriation of Remains
REPATRIATION/MEDICAL EVACUATION
(Benefits for Repatriation of Remains and Medical Evacuation are underwritten by National Union Fire
Insurance Company of Pittsburgh, Pa.)
Combined Maximum Limit of $1,000,000 REPATRIATION OF REMAINS
In the event an Injury or Emergency Sickness causes your death while you are outside your home country, the Plan will reimburse Eligible Expenses reasonably incurred for preparation and transportation of the body remains.
MEDICAL EVACUATION
The Plan will pay for evacuation to the nearest adequate medical facility following a covered Injury or Emergency Sickness if you are outside your home country and a Doctor determines that adequate medical treatment is not locally available.
Travel Guard must make all arrangements
and must authorize all expenses in advance for these benefits to be payable. If it was not reasonably possible to contact Travel Guard in advance, the Company reserves the right to determine the benefits payable, including any reductions.
STUDENT ASSIST SERVICES
• Concierge Services: You receive the comfort, care, and attention of Travel Guard’s Personal Assistance Coordinators available 24/7 to respond to virtually any request – large or small.
• Personal Security Assistance: You can feel safe and secure with Travel Guard’s Personal Security Assistance at home or while traveling. To activate personal security services, please log on to: http://aig.com/ travelguardassistance. To register:
Click “Sign In” in the upper right corner. Click ‘Register Here’.
Complete required fields: First Name, Last Name, Email Address, Policy #9495330, then click “Submit”.
For more details visit the AIG, Educational Markets’ website at www.studentinsurance.com. You will be able to access the information under LSUHSC—Shreveport Student Health Insurance Plan’s personalized webpage.
OPTIONAL DENTAL COVERAGE
The following Optional Dental Coverage is available subject to payment of additional premium at initial enrollment: This limited dental coverage provides benefits for both diagnostic/ preventive and primary services and is available to students and Dependents on an optional basis. The optional dental coverage is only available to students and Dependents upon initial enrollment in the 2013-2014 Student Health Insurance Plan. The dental coverage provides the benefits shown below subject to a Policy Year Maximum benefit of $500 per person and an Optional Dental Coverage Policy Year deductible of $50 per person. Eligibility, Termination, and Effective Dates of coverage under this optional dental coverage are the same as the medical plan.
A. DIAGNOSTIC AND PREVENTIVE SERVICES – After
the Optional Dental Coverage Policy Year deductible has been satisfied, the Plan will pay 100% of Reasonable and Customary charges for the following services:
• Oral Exams • Prophylaxis • Space Maintainers • X-Rays
• Emergency Treatment • Biopsy of Oral Tissue • Pulp Vital Tests
B. PRIMARY SERVICES– After the Policy Year deductible has been satisfied, the Plan will pay for 100% of Reasonable and Customary charges for the following services:
• Fillings • Oral Surgery • Endodontics
• Anesthesia • Re-cement Crowns, In-Lays and Bridges • Periodontics • Repair of Dentures Orthodontic services for which treatment began prior to the policy are excluded; and any gold foil restoration, gold fillings, inlays, crowns, bridges, cosmetic procedures and dentures are excluded.
No benefits will be paid for expenses incurred for broken appointments or for care or treatment of a condition for which you are entitled to or eligible for benefits under any Worker’s Compensation Act or similar act.
DENTAL LIMITATIONS
Two (2) of each of the following per Policy year: Oral Exams One (1) of each of the following per Policy year: Bitewing X-rays, Topical Fluoride applications, Pulp Vitality test.
One (1) full mouth X-ray every 36 months.
Benefits for fluoride applications and space maintainers are available only to participants under the age of 19.
“At AIG, we value the trust our customers have placed in us. That is why protecting the privacy of your personal information is of paramount importance to us. For more privacy information, please go to www.studentinsurance.com”
AMERICAN HEALTH HOLDING, INC. 24-Hour Student Emergency Care Hotline
(American Health Holding, Inc. is not affiliated with National Union Fire Insurance Company of Pittsburgh, Pa.)
For confidential health care advice and information, 24 hours a day, 365 days a year,
CALL TOLL-FREE 866-315-8756
Comprehensive Resources and Advice from Registered Nurses
• Direct access to an extensive Health Information Library, covering issues ranging from women’s health to pediatrics. Detailed directories with topic codes and instructions for access to health-related topics.
• Choose to talk directly with a nurse. Discuss a current illness or health issue, or receive counseling on chronic conditions. Nurses can also educate callers about treatments, lifestyle choices and self-care strategies. • Integrated phone access to specially trained personnel,
trained to provide referral services for a number of health related concerns including mental health and/or substance abuse.
CLAIMS SHOULD BE MAILED TO:
AIG, Educational Markets Mail CenterPO Box 26050 Overland Park, KS 66225
AGENCY:
AIG, Educational Markets
Web address: www.studentinsurance.com Email: educationalmarkets@studentinsurance.com
1-888-622-6001
FOR PROVIDERS INQUIRING ABOUT CLAIMS/BENEFITS: TOLL- FREE: 1-888-622-6001
A copy of the Certificate of Insurance is available at your respective Student Affairs Office.
Insured Student: _____________________________________________
Identification Number: __________________________D.O.B._________
Group Name: Louisiana State University Health Sciences Center
Policy Number: CHH9027024
PREFERRED PROVIDER INFORMATION:
On Campus: LSUHSC-Shreveport
Verity HealthNet MultiPlan
225-819-1135 Toll Free: 1-888-342-7427
www.verityhealth.com www.multiplan.com See Reverse Side for Important Information
CLIP & CARRY
LSUHSC - SHREVEPORT TEMPORARY ID CARD
Note: The information shown below reads exactly the same as your Permanent I.D. card and may be utilized as both a Temporary card and/or Replacement for lost cards.
Customer Service/Claims: 1-888-622-6001 Pre-Notification: 1-877-266-7778
INSTRUCTIONS FOR FILING CLAIMS:
PPO Providers mail claims to: AIG, Educational Markets Mail Center P.O. Box 26050
Overland Park, KS 66225
STUDENTS FILE ONLINE AT: WWW.STUDENTINSURANCE.COM/ SCHOOLS/LA/LSUHSC
QUESTIONS: www.studentinsurance.com
PRESCRIPTION DRUGS: CATAMARAN RX TOLL FREE: 888-869-4600 Caramaran Rx co-pays: $15/$25/$40 www.catamaranrx.com BIN: 610011
GROUP: PNP1 PCN: IRX
Insurance Underwritten by National Union Fire Insurance Company of Pittsburgh, Pa. This card does not guarantee benefits.
LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER-SHREVEPORT
2013-2014 Student Health Insurance Plan
Underwritten by: National Union Fire Insurance Company of Pittsburgh, Pa. Administrator Policy Number: CHH9027024 Underwriter Reference Number: CAS9495330
All students
COMPLETE AN ENROLLMENT OR WAIVER FORM AT WWW.STUDENTINSURANCE.COM/SCHOOLS/LA/LSUHSC
must either enroll in the LSUHSC-S endorsed plan (the “Plan”) or submit proof of acceptable alternative coverage by another plan. If proof of acceptable alternate coverage by another plan is submitted, the requirement to purchase insurance under the Plan may be waived. All students are required to either enroll in the Plan or waive coverage under the Plan online at www.studentinsurance.com/Schools/LA/LSUHSC
IMPORTANT: Dependent premium and enrollment must be remitted directly to AIG, Educational Markets or an authorized
representative at registration.
.
Complete Enrollment Form to enroll in the Student Health Insurance Plan.
STUDENTS SHOULD:
ENROLLMENT FORM
Student Name:
Last First Name Middle Name
Address: Telephone #:
Street City State Zip
E-mail Address: Student ID#: Date of Birth:
College Enrolled in: School of Allied Health Graduate Studies MS I MS II MS III MS IV MS
Check the coverage period for which you are enrolling:
INSURED CLASSIFICATION FALL (Payment 1) SPRING (Payment 2) SPRING/SUMMER (New Insureds) SUMMER (New Insureds) MSIV INTERIM RESIDENTS Coverage Dates: P lea se r efer t o p age 2 of the br oc hur e f or sp ecifi c d ate s for your spe cifi c c olle ge/ pr ogr a m.
Student Only $1209 $1209 $ 1,439 $ 626 $ 391
Add the following r ates to the student only rate above
Spouse Only $2,546 $2,546 $3,005 $1,304 $ 833 Child(ren) Only $2,823 $2,823 $3,330 $1,444 $ 922 Spouse and Child(ren) $5,369 $5,369 $6,335 $2,758 $1,755 Optional Dental enrollment must be elected at initial policy year enrollment and premium must be added to the Plan rates above:
Student Only
Spouse (add to student rate) Each Child (add to student rate)
$284 $288 $206 N/A N/A N/A $284 $288 $206 N/A N/A N/A N/A N/A N/A
If you elect to pay dependent premium by Visa or MasterCard, please complete the credit card authorization below by contacting AIG, Educational Markets at 1-888-622-6001 or www.studentinsurance.com/Schools/LA/LSUHSC. Payment by check (payable to National Union Fire Insurance Company of Pittsburgh, Pa.) or credit card for dependents may be remitted to an authorized representative at registration or mailed to: National Union Fire Insurance Company of Pittsburgh, Pa., PO Box 71331, Philadelphia, PA 19176-1321.
Complete section if paying by Visa/MasterCard & mail to above address: Charge Card Authorization: Visa MasterCard
Card No.: _________ ________ Charge this amount: $ Expiration Date:
Signature of Cardholder (Print) Name of Cardholder
Deadline to purchase coverage for eligible dependents is 30 days from the effective date of coverage for your particular college/program shown on page 4 of the Student Health Insurance Plan brochure or under conditions shown on page 5 of the Student Health Insurance Plan brochure.
It is the Covered Person’s responsibility to inquire about the premium and coverage dates for each new school year.
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
“I have read the Student Health Insurance Plan brochure and elect to enroll myself and (if applicable)my eligible dependents as shown below.”
Signature of Student: _______________________________________ Date: ________________________________________________
Complete this section if you are electing dependent coverage: (List names on separate sheet of paper, if necessary).
DEPENDENT NAMES RELATIONSHIP DATE OF BIRTH
____________________________________________ ______________________________ __________________________
