7/29/2019 865 Plan Summary Booklet 2012-13 http://slidepdf.com/reader/full/865-plan-summary-booklet-2012-13 1/22 STUDENT ACCIDENT AND SICKNESS PLAN 2012-2013 Policy Number PUH201986 Underwritten By ACE Property and Casualty Insurance Company Office of Student and Residence Life 120 Claremont Avenue New York, New York 10027-4698 “Your student health insurance coverage, offered by ACE Property and Casualty Insurance Company, 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: $100,000 on “Essential Benefits” described in this brochure. If you have any questions or concerns about this notice, contact ACE Property and Casualty Insurance Company at 1-800-352-4462. 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.”
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Office of Student and Residence Life120 Claremont Avenue
New York, New York 10027-4698
“Your student health insurance coverage,offered by ACE Property and Casualty
Insurance Company, may not meet theminimum standards required by the healthcare reform law for the restrictions onannual dollar limits. The annual dollar limitsensure that consumers have sufficientaccess to medical benefits throughout theannual term of the policy. Restrictions for annual dollar limits for group and individualhealth insurance coverage are $1.25 million
for policy years before September 23, 2012;and $2 million for policy years beginning onor after September 23, 2012 but beforeJanuary 1, 2014. Restrictions for annualdollar limits for student health insurancecoverage are $100,000 for policy yearsbefore September 23, 2012, and $500,000 for policy years beginning on or after September 23, 2012, but before January 1,2014. Your student health insurancecoverage put an annual limit of: $100,000 on“Essential Benefits” described in thisbrochure. If you have any questions or concerns about this notice, contact ACEProperty and Casualty Insurance Companyat 1-800-352-4462. Be advised that you maybe eligible for coverage under a grouphealth plan of a parent’s employer or under a parent’s individual health insurance policyif you are under the age of 26. Contact theplan administrator of the parent’s employer plan or the parent’s individual healthinsurance issuer for more information.”
Coordination of Benefits ........................................39
Reimbursement and Subrogation ............................39
Important Notice......................................................40Important Numbers..................................................41
Limited Benefits Health Insurance - The insuranceevidenced in this brochure provides limited benefitshealth insurance only. It does NOT provide basichospital, basic medical, major medical insurance,Medicare supplement, long term care insurance,nursing home insurance only, home care insuranceonly, or nursing home and home care insurance asdefined by the New York State Insurance
Voluntary enrollment is available to part-time students.To enroll on a voluntary basis, go online towww.cirstudenthealth.com/msmnyc. Annual coverageis effective on August 18, 2012 or January 1, 2013for new incoming students for Spring Semester.The last date to enroll for Fall Semester isJuly 25, 2012 and for Spring Semester for newlyenrolled students is December 2, 2012.
POLICY TERM
Accident and Sickness Medical Expense BenefitThe insurance coverage under the Base Plan becomeseffective at 12:01 a.m. on August 18, 2012 andcontinues until 12:01 a.m. on August 18, 2013 for eligible students.
REFERRAL REQUIREMENT
When at school, in the absence of a MedicalEmergency, and during regular office hours, thestudent's first visit must be with University MedicalPractice Associates, which is affiliated with St. Luke's-Roosevelt Hospital Center, in order to avoid adeductible per policy year. Insured students will berequired to pay a $5 per visit copayment at the time of the University Medical Practice Associates office visit.See page 39 for physician's address, office hours, andthe number to call for appointments.
If you are referred by University Medical PracticeAssociates to a PHCS Network provider, no deductiblewill be required. If you are referred by UniversityMedical Practice Associates to a provider who isoutside of the PHCS Network, a $100 deductible per policy year will be required.
In the case of an emergency, there are no extra charges
for treatment performed outside the PHCS Provider Network of doctors.
Non-Emergency Medical conditions treated without
referral from St. Luke’s-Roosevelt Hospital Center are
subject to a $200 deductible per policy year, whether
INTRODUCTION
This brochure is a brief description of the Student
Accident and Sickness Insurance Plan for students at
Manhattan School of Music. The exact provisionsgoverning this insurance are contained in the Master
Policy issued to the School. The Master Policy shall
control in the event of any conflict between the Policy
and this brochure.
We suggest that you retain this brochure so you will
have a ready reference to the benefits of the Plan. Any
provision of the Policy or the brochure which is in
conflict with the statutes of the state in which the
Policy is issued will be administered to conform with
the requirements of such state statutes.
Under HIPAA's Privacy Rule We are required to
provide you with notice of our legal duties and privacy practices with respect to personal health information.
You should receive a copy of this notice with your
insurance ID card. If, at anytime, you wish to request a
Network Providers, the Insured is entitled to a secondmedical opinion from a non-participating specialist, atno additional cost beyond that which the Insured wouldhave paid for services from a participating specialist, provided the Insured's attending Doctor provides awritten referral. A second medical opinion provided bya non-participating specialist absent a written referralwill be covered subject to the payment of additionalcoinsurance. We treat such charges the same way Wetreat Covered Charges for any other Sickness.
Chemical Abuse and Chemical Dependence
Inpatient Expense Benefit: If on account of Chemical Dependence or Chemical Abuse, an InsuredPerson requires inpatient treatment, We will pay for such treatment as follows: (a) when the Insured Personis confined as an inpatient in a Hospital or aDetoxification Facility, We will pay benefits for detoxification on the same basis as any other Sickness.But, We will not cover more than seven (7) days of active treatment in any one calendar year; (b) when theInsured Person is confined in a Hospital or ChemicalAbuse Treatment Facility, We will pay benefits for rehabilitation services on the same basis as any other Sickness. But, We will not cover more than thirty (30)days of inpatient care for such services in any onecalendar year.
As used in this provision, the term "Chemical AbuseTreatment Facility" means a facility: (a) in New York State, which is certified by the Office of Alcoholism
and Substance Abuse Services; or (b) in other states,which is accredited by the Joint Commission onAccreditation of Hospitals as alcoholism, substanceabuse, or chemical dependence treatment programs.
Chemical Abuse and Chemical Dependence
Outpatient Expense Benefit: If on account of Chemical Abuse or Chemical Dependence, an InsuredPerson requires outpatient treatment, We will pay for diagnosis and treatment of Chemical Abuse andChemical Dependence on the same basis as any other Sickness. But, We will not cover more than 60 visitsduring any one calendar year, for the diagnosisand treatment of Chemical Abuse and Chemical
Dependence. Coverage will be limited to facilities in New York State, which are certified by the Officeof Alcoholism and Substance Abuse Services asoutpatient clinics or medically supervised ambulatorysubstance programs. In other states, coverage is
COVERED MEDICAL EXPENSES
Covered Medical Expenses consist of the followingsubject to the benefit limits described in this brochure.
Autism Spectrum Disorder Expense Benefit: Wewill pay the Covered Percentage of the CoveredCharges incurred by an Insured Person for diagnosis or treatment of Autism Spectrum Disorder. Diagnosis or treatment for medical services, drugs and supplies must be Medically Necessary and prescribed by a Doctor.We cover such charges the same way We treat coveredcharges for any other sickness.
Bone Mineral Density Measurements and Tests
Expense Benefit: We will pay the Covered Percentageof the Covered Charges incurred for Bone MineralDensity Measurements or Tests for the prevention,diagnosis, and treatment of osteoporosis when
requested by a health care provider for a QualifiedIndividual. A Qualified Individual means an InsuredPerson who meets the following criteria: (1) previouslydiagnosed as having osteoporosis or having a familyhistory of osteoporosis; (2) symptoms or conditionsindicative of the presence, or the significant risk, of osteoporosis; (3) on a prescribed drug regimen posinga significant risk of osteoporosis; (4) with lifestylefactors to such a degree as posing a significant risk of osteoporosis; and (5) with age, gender, and/or other physiological characteristics which pose a significantrisk for osteoporosis. Coverage includes bone mineraldensity measurements or tests as covered under the
Federal Medicare program as well as those inaccordance with the criteria of the National Institute of Health, including dual-energy x-ray absorptiometry.If this Policy includes coverage for outpatient prescription drugs, then We also will cover drugs anddevices for bone mineral density that have beenapproved by the United States Food and DrugAdministration or generic equivalents as approvedsubstitutes in accordance with the above criteria. Wecover such charges the same way We treat CoveredCharges for any other Sickness.
Cancer-Second Opinion Expense Benefit: We cover charges for a second medical opinion by an
appropriate specialist, including but not limited to aspecialist affiliated with a specialty care center, in theevent of a positive or negative diagnosis of cancer or arecurrence of cancer or a recommendation of a courseof treatment for cancer. If this Plan requires the use of
limited to those facilities, which are accredited by theJoint Commission on Accreditation of Hospitals asalcoholism, substance abuse, or chemical dependencetreatment programs. Outpatient Services consisting of consultant or treatment sessions will not be payableunless these services are furnished by a Doctor or Psychotherapist who: (a) is licensed by the state or territory where the person practices; and (b) devotes asubstantial part of his or her time treating intoxicated persons, substance abusers, alcohol abusers, or alcoholics. Outpatient coverage includes up to 20outpatient visits during any one calendar year, for covered family members, even if the Insured Person inneed of treatment has not received, or is not receivingtreatment for Chemical Abuse and ChemicalDependence provided that the total number of suchvisits, when combined with those of the Insured
Person in need of treatment, do not exceed 60outpatient visits in any one calendar year, and providedfurther that the 60 visits shall be reduced only by thenumber of visits actually utilized by the coveredfamily members. We treat such charges the same wayWe treat Covered Charges for any other Sickness.
"Chemical Abuse and Chemical Dependence" meansan illness characterized by a physiological or psychological dependency, or both, on a controlledsubstance and/or alcoholic beverages. It is further characterized by a frequent or intense pattern of pathological use to the extent the user exhibits a lossof self-control over the amount and circumstances of
use; develops symptoms of tolerance or physiologicaland/or psychological withdrawal if the use of thecontrolled substance or alcoholic beverage is reducedor discontinued; and the user's health is substantiallyimpaired or endangered or his or her social or economic function is substantially disrupted.
Chiropractic Care Expense: We will pay for anInsured Person's Covered Charges for non-surgicaltreatment to remove nerve interference and its effects,which is caused by or related to Body Distortion. BodyDistortion means structural imbalance, distortion, or incomplete or partial dislocation in the human body which: (a) is due to or related to distortion,
misalignment, or incomplete or partial dislocation of or in the vertebral column; and (b) interferes with thehuman nerves. We treat such charges the same way Wetreat Covered Charges for any other Sickness.
Contraceptive Services Expense Benefit: We will
pay the Covered Percentage of the Covered Chargesfor Contraceptive Drugs and Devices. Such Drugs andDevices must be approved by the United States Foodand Drug Administration and prescribed legally by anauthorized health care provider. Covered services aresubject to applicable co-payments under thePrescription Drug Benefit Plan.
Diabetes Treatment Expense Benefit: We cover charges for the following Medically Necessary diabetesequipment services and supplies for the treatment of diabetes, when recommended by a Doctor or other licensed health care provider. We treat such charges thesame way We treat any other Covered Charges for aSickness. Such supplies include: blood glucosemonitors, blood glucose monitors for the legally blind,data management systems, test strips for glucosemonitors and visual reading, urine test strips, insulin,injection aids, cartridges for the legally blind, syringes,insulin pumps and appurtenances thereto, insulininfusion devices or oral agents for controlling bloodsugar. We also cover charges for expenses incurred for diabetes self-management education. Coverage for self-management education and education relating todiet shall be limited to medically necessary visits uponthe diagnosis of diabetes, where a Doctor diagnoses asignificant change in the Insured Person's symptomsor conditions which necessitates changes in a patient's self-management or upon determination thatreeducation or refresher education is necessary.Diabetes self-management education may be provided
by a Doctor or other licensed healthcare provider; theDoctor's office staff, as part of an office visit; or by acertified diabetes nurse educator, certified nutritionist,certified dietician, or registered dietician. Educationmay be limited to group settings wherever practicable.Coverage for self-management education andeducation relating to diet includes Medically Necessary home visits.
Diagnostic Screening for Prostate Cancer Expense
Benefit: We cover charges for Diagnostic Screeningfor Prostate Cancer as follows: (a) standard diagnostictesting including, but not limited to, a digital rectalexamination and a prostate-specific antigen test at any
age for men having a prior history of prostatecancer; and (b) an annual standard diagnosticexamination including, but not limited to, a digitalrectal examination prostate-specific antigen test for men: (1) age fifty and over who are asymptomatic; and
We will continue to provide coverage for care providedin the facility. The decision of the external appeal agentwill be binding on both Us and the Insured Person."Advanced Cancer" means a diagnosis of cancer by theInsured Person's attending health care practitioner certifying that there is no hope of reversal of primarydisease and that the person has fewer than sixty days tolive. We cover such charges the same way We treatCovered Charges for any other Sickness.
Miscellaneous Hospital Expense: If an InsuredPerson incurs Expense during a hospital confinement,or day surgery on an outpatient basis, We will paythe Covered Charges incurred. Such Expenses include:(a) anesthesia, anesthesia supplies and services; (b)operating, delivery, and treatment rooms andequipment; (c) diagnostic x-ray and laboratorytests; (d) lab studies; (e) oxygen tent; (f) blood and blood services; (g) inpatient prescribed drugs andmedicines; (h) medical and surgical dressings, supplies,casts, and splints; (i) radiation therapy, intravenouschemotherapy, kidney dialysis, and inhalationtherapy; (j) chemotherapy treatment with radioactivesubstances; (k) intravenous injections and solutions,and their administration; (l) physical and occupationaltherapy; and (m) other necessary and prescribedhospital expenses.
Accidental Dental Expense: When an Insured Personincurs expenses for dental treatment for Injury to soundnatural teeth, We will pay for the Covered Percentage
of the Covered Charges incurred on the same basis asany other injury.
Durable Medical Equipment Expense Benefit: If, byreason of Injury or Sickness, an Insured Person requiresthe use of Durable Medical Equipment, We will paythe Covered Percentage of the Covered Chargesincurred by the Insured Person for such DurableMedical Equipment, subject to the Deductible shown inthe Plan of Insurance. We pay the Covered Percentageof the Covered Charges incurred by the Insured Personfor the purchase of such Durable Medical Equipmentwhen the purchase price is expected to be less costlythan rental.
Temporomandibular Joint Dysfunction ExpenseBenefit: We will pay the Covered Percentage of theCovered Charges incurred for any diagnostic or surgical procedure involving bones or joints of the jawand facial region, if, under accepted medical standards,such procedure or surgery is Medically Necessary to
(2) age forty and over with a family history of prostatecancer or other prostate cancer risk factors. We treatsuch charges the same way We treat Covered Chargesfor any other Sickness.
Doctor Office Expense: If an Insured Person, requirescare and treatment by a Doctor, both in and out of thehospital, for non-surgical services, We will pay theCovered Charges incurred, limited to one visit per day.
Early Intervention Services: We cover charges for Medically Necessary Early Intervention Services. Wewill cover 70% of Reasonable and Customary incurredup to $100 per visit, limited to $1,000 per policy year for the prevention of repetitive stress disorders.Visits used for Early Intervention Services shall notreduce the number of visits otherwise available under the policy.
Eating Disorders: If an Insured Person requirestreatment for an Eating Disorder Condition such as: binge eating disorder including anorexia nervosa, and bulimia nervosa, and treatment has been provided by astate identified Eating Disorder Center or aComprehensive Health Care Center, We will pay theCovered Percentage of the Covered Chargesincurred by the Insured Person for such treatment.Covered treatment includes psychological services, andinpatient medical and surgical treatment. We cover such charges the same way We treat covered Chargesfor any other Sickness.
Emergency Room Expense: Treatment of a MedicalEmergency. If an Insured Person goes to theEmergency Room at a Non-Network Provider in thecase of a Medical Emergency as defined in this Policy,We will waive the $100 Out-of-Network deductible.Covered Expenses will be payable at 100% of theUsual and Customary Expense incurred.
End of Life Care Expense Benefit: If an InsuredPerson is diagnosed with Advanced Cancer, We willcover services provided by a facility or programspecializing in the treatment of terminally ill patients if the Insured Person's attending health care practitioner,in consultation with the medical director of the facilityor program determines that the Insured Person's carewould appropriately be provided by such a facility or program. If We disagree with the admission of theInsured Person into the facility, or the provision or continuation of care by the facility, We will initiate anexpedited external appeal. Until a decision is rendered,
one payment for the delivery and postnatal care provided. We also cover charges for parent education,assistance, and training in breast or bottle feeding andthe performance of any necessary maternal andnewborn clinical assessments. Covered services may be provided by a certified nurse-midwife under qualified medical direction if he or she is affiliated withor practicing in conjunction with a licensed facility. Wecover such charges the same way We treat CoveredCharges for any other Sickness.
Newborn Infant Care: Newborn infant care iscovered when the infant is confined in the Hospital andhas received continuous Hospital care from themoment of birth. This includes: (a) nursery charges; (b)charges for routine Doctor's examinations andtests; and (c) charges for routine procedures, exceptcircumcision. This benefit also includes the necessarycare and treatment of medically diagnosed congenitaldefects and birth abnormalities of newborn childrencovered from birth.
Mental Illness, Biologically Based and Serious
Emotional Disturbances of Children Expense
Benefit: If an Insured Person requires treatment for Biologically Based Mental Illness, We will pay for such treatment of a person of any age and for SeriousEmotional Disturbances of a Child under the sameterms and conditions applied to other medicalconditions. The benefits shall include the following: (a)inpatient Hospital services; (b) outpatient services; (c)
prescription drugs, if this Policy includes thePrescription Drug Expense Benefit. We cover suchcharges the same way We treat Covered Charges for any other Sickness.
Mental, Nervous, or Emotional Inpatient Hospital
Confinement Expense Benefit: If an Insured Personrequires treatment for a Mental, Nervous or EmotionalDisorders, We will pay for such treatment as follows:When the Insured Person requires HospitalConfinement for treatment of a Mental, Nervous or Emotional Disorder, We will pay the CoveredPercentage of the Covered Charges incurred for suchHospital Confinement on the same basis as any other
Sickness, Hospital Room and Board Expense of theHospital Expense Benefit. However, We will not cover more than thirty (30) days of inpatient care for suchservices in any one calendar year. Such confinementmust be in a licensed or certified facility, includingHospitals. What We pay is shown in the Plan of Insurance.
treat conditions caused by congenital or developmentaldeformity, Injury, disease or Sickness.
Benefits are not provided for the care or treatment of
the teeth or gums, for intraoral prosthetic devices, or for surgical procedures for cosmetic purposes.
We cover such charges the same way We treat CoveredCharges for any other Sickness.
Hospital Room and Board Expense: If an InsuredPerson requires confinement in a hospital, We will pay the Covered Charges incurred up to the dailysemi-private room rate.
Mammographic Examination Expense Benefit: Wewill pay the Covered Percentage of the CoveredCharges incurred for a Mammographic exam. Thecharges must be incurred while the Insured Person is
insured for these benefits. Benefits will be paid for thefollowing: (a) one Mammogram at any age for anInsured Person who has a prior history of breast cancer or who has a first degree relative with a prior history of breast cancer, upon recommendation of a Doctor; (b)one baseline Mammogram for an Insured Personage thirty-five through thirty-nine; and (c) oneMammogram annually for an Insured Person age fortyyears or older. We cover such charges the same wayWe treat Covered Charges for any other Sickness.
Maternity Expense Benefit: We will pay benefits for an Insured Person's Covered Charges for maternitycare, including hospital, surgical, and medical care. We
treat such charges the same way We treat CoveredCharges for any other Sickness.
We cover charges for a minimum of 48 hours of inpatient care following an uncomplicated vaginaldelivery and a minimum of 96 hours of inpatient carefollowing an uncomplicated cesarean section for anInsured Person and her newborn child in a health carefacility, unless the attending Doctor in consultationwith the mother, makes a decision for an earlier discharge from the Hospital. If so, We will cover charges for one home health care visit. The visit must be requested within 48 hours of the delivery (96 hoursin the case of a cesarean section) and the services must
be delivered within 24 hours: (a) after discharge; or (b)of the time of the mother's request, whichever islater. Charges for the home health care visit arenot subject to any Deductible, Coinsurance, or Copayments. Covered Charges include at least two payments, at reasonable intervals, for prenatal care and
Benefit: When an Insured Person is not so Hospitalconfined, We will pay the Covered Percentage of theCovered Charges incurred for at least 30 days of activetreatment in any calendar year, as shown in the Plan of Insurance, for covered outpatient services for thetreatment of Mental, Nervous, or Emotional Disorders.
The Mental, Nervous, or Emotional Disorder must, inthe professional judgment of health care providers, betreatable, and the treatment must be Medically Necessary.
Outpatient Treatment and Doctor services includecharges made in a facility operated by the Office of Mental Health, or by a psychiatrist or psychologistlicensed to practice in this state or a professionalcorporation or university faculty practice corporation.
We cover such charges the same way We treat CoveredCharges for any other Sickness. What We pay is shownin the Plan of Insurance.
Miscellaneous Outpatient Expense: If an InsuredPerson incurs expenses for the cost of diagnostic x-raysand laboratory tests, and other reasonable expenses for services or supplies, necessary for treatment of theInjury or Sickness as required by the attendingDoctor for which no other policy benefits are payable,We will pay the Covered Charges incurred.
Multiple Surgical Procedures Expense Benefit:
When Injury or Sickness requires multiple SurgicalProcedures through the same incision, We will payan amount not less than that for the most expensive procedure being performed. Multiple SurgicalProcedures performed during the same operativesession but through different incisions shall bereimbursed in an amount not less than the CoveredPercentage of the Covered Charge of the mostexpensive Surgical Procedure then being performed,and with regard to the less expensive SurgicalProcedure in an amount equal to 50 percent of theCovered Percentage of the Covered Charge for these procedures.
Licensed Nurse Expense Benefit: If by reason of Injury or Sickness, an Insured Person requires theservice of a licensed nurse or licensed practical nurseduring a Hospital Confinement, We will pay theCovered Charges incurred.
Pre-Hospital Medical Emergency Services: When,
by reason of Injury or Sickness, an Insured Personrequires the use of a community or Hospital ambulancein a Medical Emergency, We will pay benefits for theCovered Percentage of the Covered Charges incurredin excess of the deductible shown in the Plan of Insurance. Covered Charges include Pre-HospitalMedical Emergency Services provided by a licensedambulance service. As used in this provision, Pre-Hospital Medical Emergency Services means the prompt evaluation and treatment of a MedicalEmergency condition, and/or non-airbornetransportation of an Insured Person to a HospitalReimbursement for non-airborne transportation will be based on whether a prudent layperson, possessing anaverage knowledge of medicine and health, couldreasonably expect the absence of such transportationto result in: (1) placing the health of the person affected
with such condition in serious jeopardy, or in the caseof a behavioral condition placing the health of such person or others in serious jeopardy; (2) seriousimpairment to such person's bodily functions; (3)serious dysfunction of any bodily organ or part of such person; or (4) serious disfigurement of such person.Ambulance Service is transportation by a vehicledesigned, equipped, and used only to transport the sick and injured from home, scene of accident, or MedicalEmergency to a Hospital or between Hospitals. Surfacetrips must be to the closest local facility that can provide the covered service appropriate to thecondition. If there is no such facility available,
coverage is for trips to the closest facility outside thelocal area. Air transportation is covered whenMedically Necessary because of a life threateningInjury or Sickness. Air ambulance is air transportation by a vehicle designed, equipped and used only totransport the sick and injured to and from a Hospitalfor inpatient care.
Enteral Food Formula Expense Benefit: We will pay
for an Insured Person’s Covered Charges for enteral
formulas when prescribed by a Doctor or licensed
health care provider. The prescribing Doctor or health
care provider must issue a written order stating that the
enteral formula is Medically Necessary and has been
proven as a disease-specific treatment for thoseindividuals who are or will become malnourished or
suffer from disorders, which if left untreated will cause
chronic physical disability, mental retardation or death.
counseling and screening for adolescents at higher risk
(26) Tuberculin testing for children at higher risk of
tuberculosis (27) Vision screening for all childrenProsthetic Appliance And Orthotic Device Expense
Benefit: If, by reason of Injury or Sickness, an Insured
Person requires the use of a Prosthetic Appliance or
Orthotic Device, We will pay the Covered Percentage
of the Covered Charges incurred by the Insured Person
for the purchase, initial fitting, and needed adjustment
of such appliances or devices, as shown in the Plan of
Insurance.
Skilled Nursing Facility Expense Benefit: If an
Insured Person requires continuing treatment in a
Skilled Nursing Facility following hospitalization, We
will pay the Covered Percentage of the Covered
Charges incurred by the Insured Person for treatment in
such Skilled Nursing Facility. The services must be
Medically Necessary as a continuation of treatment for
the condition for which the Insured Person was
previously hospitalized. The Insured Person must be
admitted to the Skilled Nursing Facility within twenty–
four (24) hours following a Medically Necessary
Hospital stay. We cover such charges the same way Wetreat Covered Charges for any Hospital Confinement.Reconstructive Breast Surgery Expense Benefit: Wecover charges for inpatient hospital care for an InsuredPerson undergoing: (a) a lumpectomy or a lymph nodedissection for the treatment of breast cancer; or (b) amastectomy which is covered under this Plan.Coverage is limited to a time frame determined by theInsured Person's Doctor to be medically appropriate.We also cover charges for breast reconstructionsurgery after a mastectomy including: (a) all stagesof reconstruction of the breast on which themastectomy has been performed; and (b) surgery andreconstruction of the other breast to produce symmetry.Surgery and reconstruction will be provided in amanner determined by the attending Doctor and theInsured Person to be appropriate. We treat such chargesthe same way We treat Covered Charges for any other Sickness.
Surgical Expense: We will pay the Covered Chargesincurred for surgery performed by a licensed Doctor (in or out of the Hospital) and expenses in connectionwith a surgery and the Insured Person requires theservices of an anesthetist or assistant surgeon. Benefitswill be paid in accordance with the MDR Schedule(Medical Data Research) survey of surgical fees,
valued at the 80th percentile for Reasonable andCustomary Expense.
Second Surgical Opinion Expense Benefit: We will pay the Covered Percentage of the Covered Charges
Two Hands or Two Feet or Sight of Two Eyes..$ 10,000
One Hand and One Foot ................................$ 10,000
One Hand and Sight of One Eye....................$ 10,000
One Foot and Sight of One Eye.....................$ 10,000One Hand or One Foot or Sight of One Eye..$ 5,000
Loss of hands and feet means the loss at or above
the wrist or ankle joints. Loss of eyes means total
irrecoverable loss of the entire sight.
This provision does not cover the loss if it in any way
results from or is caused or contributed by: (1)
physical or mental illness; medical or surgical
treatment except treatment that results directly from a
surgical operation made necessary solely by an Injury
covered by this Plan; (2) an infection, unless it is
caused solely and independently by a covered accident;
(3) or participation in felony.
EXCLUSIONS AND LIMITATIONS
The Policy does not cover nor provide benefits for:
1. Expense incurred as the result of dental treatment,except as provided in the Sickness Dental ExpenseBenefit, if included in this Policy, or the DentalCare Expense Benefit Rider. This exclusion doesnot apply to treatment resulting from Injury tosound, natural teeth;
2. Services normally provided without charge by the
Policyholder health service, infirmary, or Hospital,or by Health Care Providers employed by thePolicyholder;
incurred for a Second Surgical Opinion consultation by a board certified specialist on the need for non-emergency surgery, which has been recommended by the Insured Person’s Doctor. The specialist must be board certified in the medical field relating to thesurgical procedure being proposed.
ACE TRAVEL ASSISTANCE SERVICES
Your Student Insurance Plan provides access to ACE’sTravel Assistance Services. These services areavailable on a 24-hour basis worldwide. To accessthese services students simply contact ACE’sAssistance Provider’s multilingual call center at thenumbers below. The following emergency services areincluded in this Plan:
• Medical Assistance including referral to a doctor or medical specialist, medical monitoring whenyou are hospitalized, emergency medicalevacuation to an adequate facility, medicallynecessary repatriation and return of mortalremains.
• Personal Assistance including pre-trip medicalreferral information and while you are on a trip:emergency medication, embassy and consular information, lost document assistance, emergencymessage transmission, emergency cash advance,emergency referral to a lawyer, translator or interpreter access, medical benefits verification
and medical claims assistance.
• Travel Assistance including emergency travelarrangements, arrangements for the return of your traveling companion or dependents and vehiclereturn.
To access ACE’s Travel Assistance Portal go towww.acetravelassistance.com and register your nameusing the Group ID and Activation code: listed below.
Group ID: aceah
Activation Code: security
In the event of an emergency call:1-800-243-6124 toll
free in the USA or Canada; or 1-202-659-7803 collectoutside of the USA.
3. Eyeglasses, contact lenses, hearing aids, or prescriptions or examinations therefor, except as provided in the Vision Care Expense Benefit
Rider;
4. Injury due to participation in a riot;
5. Injury or Sickness resulting from declared or undeclared war; or any act thereof;
6. Injury or Sickness for which benefits are paidunder any Workers Compensation or OccupationalDisease Law;
7. Injury sustained or Sickness contracted while inservice of the Armed Forces of any country, exceptas specifically provided. Upon the Insured Personentering the Armed Forces of any country, We will
refund the unearned pro-rata premium to suchInsured Person;
8. Treatment provided in a government hospitalunless there is a legal obligation to pay suchcharges in the absence of insurance;
9. Elective Treatment or elective surgery, except asspecifically provided;
10. Cosmetic surgery, except as the result of an Injuryoccurring while this Policy is in force as to theInsured Person. This exclusion shall also notapply to cosmetic surgery, which is reconstructivesurgery when such service is incidental to or follows surgery resulting from trauma, infectionor other disease of the involved body part; andreconstructive surgery because of congenitaldisease or anomaly of a covered Dependent childwhich has resulted in a functional defect;
11. Injuries sustained as the result of a motor vehicleaccident to the extent that benefits are recoveredor recoverable under mandatory no-fault benefitsinsurance;
12. Expense incurred after the date insuranceterminates for an Insured Person except as may bespecifically provided in the Extension of BenefitsProvision, when applicable;
13. For expenses as a result of participation in afelony;
14. Mental health benefits or services for individualswho are presently incarcerated, confined or committed to a local correctional facility or a
prison, or a custodial facility for youth operated bythe Office of Children and Family Services;
15. Mental health benefits or services solely becausesuch services are ordered by a court;
16. Benefits or services deemed cosmetic in nature onthe grounds that changing or improving anindividual’s appearance is justified by theindividual’s mental health needs.
This insurance does not apply to the extent that trade or
economic sanctions or other laws or regulations
prohibit Us from providing insurance, including, but
not limited to, the payment of claims.
APPEAL PROCEDURE
Internal Appeal
If Your claim is denied You will be notified of the
reason with a description of any additional information
necessary to appeal the denial.
If You or Your provider would like additional
information or have a complaint concerning the
denial, please contact the Insurer's Third Party
Administrator, Administrative Concepts, Inc. (ACI) at
1-888-293-9229. ACI will address concerns and
attempt to resolve the complaint. If ACI is unable to
resolve the complaint over the phone, You may file awritten internal appeal by writing to ACI. Please
include Your name, social security number, home
address, policy number, and any other information or
documentation to support the appeal.
The appeal must be submitted within 60 days of the
event that resulted in the complaint. ACI will
acknowledge Your appeal within 10 working days of
receipt or within 72 hours if the appeal involves a
life-threatening situation. A decision will be sent to You
within 30 days. If there are extraordinary circumstances
involved, ACI may take up to an additional 60 days
before rendering a decision.External Appeal
Under New York State Law, You have the right to an
External Appeal ONLY when a claim is denied because
services are not Medically Necessary or the services
Insured students will be required to pay a $5copayment per visit at the time of the office visit.All students must make an appointment with:University Medical Practice Associates............................................................877-420-42091090 Amsterdam Avenue, 4th Floor 114th Street at Amsterdam AvenueHours: Monday through Friday.........9 a.m. - 5 p.m.Please call for an appointment.
TRAVEL ASSISTANCE page 34
Toll Free from U.S. and Canada.......1-800-243-6124Call Collect Worldwide..................1-202-659-7803Assistance Portal......www.acetravelassistance.com
For claim and benefit questions:ADMINISTRATIVE CONCEPTS, INC.994 Old Eagle School Road, Suite 1005
Wayne, PA 19087-1802 Payor ID # 22384Toll Free.............................................888-293-9229Website........................................www.visit-aci.com