PLAN YEAR 2020/2021 STUDENT INSURANCE PLAN 2021 Student Insurance Brochure.pdfeligibility section of this brochure for enrollment procedures. The Plan coordinates with the student’s

STUDENT INSURANCE PLANSUPPLEMENTAL COVERAGE FOR STUDENTS

PLAN YEAR 2020/2021

1 •Introduction

2 •YourPrivacyRights •Eligibility

3 •CoverageEffectiveDates •Cost •Part-timeEligibility •SummerCoverage

4 •StudentInsuranceWaiver

5 •Reinstatement •TerminationofMedicalCoverage

6 •HowtoSubmitaClaim •ClaimDenialandAppealsProcedure

7 •Definitions

8-11 •DescriptionofBenefits

12 •CoordinationofBenefits

13-16 •Exclusions

16 •Subrogation

Medical ID Card Inside Back Cover

TA B L E O F C O N T E N T S

The Student Insurance Plan or costs associated with the plan may change periodically. Please contact Student Insurance for current plan and rates. This is a limited policy. Read the contents carefully.

To the Parents and Students of Eastern Illinois University

EasternIllinoisUniversityprovidesasupplementalplanofmedicalcover-ageforinjuryandillnessforwhichthefeeisautomaticallyassessedalongwithtuitionandfeesforalleligiblestudentsenrolledinanon-campusprogramtaking9ormorehours.Studentsenrolledpart-time(anyprogramformat)with5ormorehoursareeligibletopurchasecoverage.Refertotheeligibilitysectionofthisbrochureforenrollmentprocedures.

ThePlancoordinateswiththestudent’sprimarycarrierandprovidesthestudentworldwideprotection,24hoursaday.StudentInsuranceisan economicalwaytoreduceoreliminateout-of-pocketexpenseswhen familyhealthplansdonotcover100%ofmedicalcostsbecauseofdeductibles,co-paymentamounts,limitationsonspecificbenefits,andout-of-networkpenalties.

ThePlanhasa$100deductibleperdiagnosis,perPlanyear,andpaysupto70%ofeligibleexpensesforphysicianandhospitalexpenses,labandx-ray,surgery,ambulancetransport,physicaltherapy,maternityexpenses,mentalhealthandsubstanceabusetreatment.

Intheeventofanon-emergencyinjuryorillness,theCoveredStudentisencouragedtoreporttotheHealth&CounselingServicesMedicalClinicforpropermedicaltreatmentorreferral.IfawayfromtheUniversity,consultaphysician.EmergencyRoomvisitstoSarahBushLincolnHealthCenterfornon-emergencytreatmentmaynotbeconsideredwithoutareferralfromaphysician.

ThePlanissecondaryifthestudentisentitledtobenefitsbyanyotherpolicy.PleaseseetheCoordinationofBenefitssectionofthisbrochureforfurtherinformation.

ThisbrochurecontainsspecificPlanbenefitinformation.Studentsshouldfamiliarizethemselveswiththeproperprocedurestoutilizethebenefitsavailable.

ConsulttheStudentInsuranceOfficeforinformationregardingenrollment,eligibility,benefits,limitationsorexclusions.

Angela R. Campbell, MSHI,RHIA,MedicalInsuranceManagerEric S. Davidson,Interim Director,Health&CounselingServicesDr. Anne Flaherty,VicePresidentforStudentAffairs

www.eiu.edu/studentinsurancePhone (217) 581-5290 • Fax (217) 581-7507

YOUR PRIVACY RIGHTS

EasternIllinoisUniversityknowsthattheprivacyofprotectedhealthinforma-tion(PHI)isanimportantissueforyou.TheHealthInsurancePortabilityandAccountabilityActof1996(HIPAA)hasbeenrevisedtoprotectyourPHIevenmore.TheseruleswillensurestrongerprotectionofyourPHIwithoutinterfer-ingwithyouraccesstoqualityhealthcare.ThenewlawallowsustoshareyourPHIwithotherhealthcareproviders,healthplans,hospitals,orotherhealthcareentities(“coveredentities”)fortreatment,payment,andotherhealthcareopera-tions.Tomanageyourhealthinsurancebenefits,theStudentInsuranceOfficemayneedtoaccessyourPHI.Weoftenusethisdatatofacilitatetreatment,coordinatecare,measurequalityimprovement,andpayclaimscorrectly. Under the revised HIPAA privacy law • Coveredentitiesmustprovidepatientswithwrittennoticeoftheir privacypracticesandpatient’sprivacyrights.Thenoticewillcontain informationthatdescribesyourrights,includingyourrighttoaccessorto restrictusesanddisclosuresofyourPHI. • YouwillgenerallyhaveaccesstoyourPHIandcanrequestamendments ofyourPHItocorrecterrors.Youcanalsorequestanaccountingofnon- routineusesanddisclosuresofyourPHI.

FormoredetailedinformationaboutourHIPAAprivacypoliciesseeourNoticeofPrivacyPracticesavailableonourwebsiteorinouroffice.

STUDENT ELIGIBILITY

EnrollmentinthePlanisautomaticforstudentsinthefollowingcategories: • Enrolledinanon-campusprogram,taking9ormorehoursonCountDay(firsttenclassdaysFall/Spring,firstfiveclassdaysSummer)oftheacademicterm; • GraduateAssistantsundercontracttotheUniversity; • Internationalstudentsenrolledinanon-campusprogram,taking3ormorehours.

TheStudentInsuranceFeewillbeincludedinallsucheligiblestudents’tuitionandfeebill.StudentsarerequiredtomeettheirtuitionandfeeobligationstotheUniversity,otherwisesubmittedclaimswillbedenied.

Studentsenrolledin5ormorehours(anyprogramformat)areeligibletopur-chasecoverageaspart-timestudentsandqualifyforreinstatement.RefertothesespecificsectionsinthebrochureorcontacttheStudentInsuranceOfficeformoreinformation.

EFFECTIVE DATE OF STUDENT MEDICAL COVERAGECoverageforeachTermisbasedonprogramformatandenrolledhoursasofCountDay(firsttenclassdaysFall/Spring,firstfiveclassdaysSummer)aspertheUniversityAcademicCalendar.

Studentsenrolledinanon-campusprogramwhopre-registerforatleast9hoursandcontinuetobeenrolledinatleastninehoursasofCountDayareassessedthefeeforcoverage.ThePlanprotectstheseeligibleCoveredStudents24hoursadayfrom12:01a.m.thedaytheCoveredStudentcompletesregistrationorthecoverageeffectivedateofeachTerm,whicheverislater,andcontinuesuntil12:00midnightonthedaybeforethecoverageeffectivedateofthenextsucceedingTermoftheUniversityAcademicCalendar.

Studentsenrolledinanon-campusprogramwhopre-registerforatleast9hoursbutdroptolessthan9hoursasofCountDaywillhavethefeerefundedandnocoverageisineffectthatTerm.Studentsinthiscategorymaybeeligibletopurchasecoverage.Refertothesection“Part-TimeEnrollment”foreligibilityrequirementsandapplicationdeadlines.

StudentsrequiredandnotifiedbytheUniversitytoarrivepriortothecoverageeffectivedateoftheTermwillbeallowedcoverage.DepartmentsmustnotifytheStudentInsuranceOfficeinadvanceandthefeeswillbeadjustedaccordingly.

EffectiveDateofStudentMedicalCoverage Cost CoveragePeriod CountDayFall2020 $109.95 8/18/20-12/31/20 9/04/20Spring2021 $109.95 1/1/21-5/16/21 1/25/21Summer2021 $87.45 5/17/21-8/15/21 5/24/21

PART-TIME ENROLLMENT Studentsregisteredfor5ormorehours(anyprogramformat),areeligibleforcoveragebutarenotautomaticallyenrolledinthePlan.ThesestudentsmustcompleteanonlineEnrollmentFormpriortoCountDay(firsttenclassdaysFall/Spring,firstfiveclassdaysSummer)ofeachTerm.EligibilityisbasedonprogramformatandenrolledhoursasofCountDay.Coverageisnotcontinuous;studentsmustre-applyeachsemester.

SUMMER COVERAGESummercoverageisavailableforstudentsinthefollowingcategories:• AllstudentscoveredduringtheSpringTerm(anyprogramformat)• StudentsnotcoveredintheSpringTermbutenrolled(anyprogramformat) inaminimumof5hoursforSummerTerm.

EligiblestudentsnotenrolledintheSummerTermhaveuntilMay16,2021tocompletetheonlineEnrollmentFormandmakepayment.EligiblestudentsenrolledintheSummerTermhaveuntilCountDay(fifthclassday),May24,2021tocompletetheonlineEnrollmentFormandmakepayment.CoverageunderthisextensioniseffectiveMay17,2021(ordateofpayment,whicheverislater)andterminatesatmidnightonAugust15,2021.Costis$87.45

STUDENT INSURANCE WAIVERStudentsmayapplyforawaiveroftheStudentInsuranceFee.WeurgethatthisactionbeconsideredonlyaftercarefulstudyofthePlanbenefitsandconsulta-tionwiththeStudentInsuranceOfficestaff.StudentsmustcompleteanInsuranceWaiverFormbyCountDay(firsttenclassdaysFall/Spring,firstfiveclassdaysSummer).ThewaiverformisavailableintheStudentInsuranceOffice,canbemaileduponrequest,orcanbedownloadedfromourwebsitewww.eiu.edu/stu-dentinsurance.

ThecompletedwaiverformmustbereturnedtoourofficePOSTMARKED NO LATER THAN THE WAIVER DEADLINE OF THE SEMESTER THE STUDENT IS REQUESTING A WAIVER FOR. Please note that students participating in the Intercollegiate Athletic Programs or Cheer Teams are ineligible for the medical coverage cancellation.

Waiver DeadlineFallTerm2020isSeptember4,2020SpringTerm2021isJanuary25,2021SummerTerm2021isMay24,2021

REINSTATEMENTReinstatementinthePlanwillonlybegrantedtostudentswhobecomeinvolun-tarilyineligibleforcoverageunderagroupinsuranceplan(e.g.,marriage,lossofemployment,etc.).ArequestforreinstatementinthePlanmustbesubmitted,withevidenceofinvoluntarylossofcoverage,totheStudentInsuranceOfficewithin31daysofthelossofcoverageunderthegroupinsuranceplan.Thisoptionisonlyavailabletostudentswhoareenrolledinandhavepaidtuitionandfeesfor5ormorehours.

PremiumrateswillnotbeproratedandtheeffectivedateofthecoveragewillbethedatethattheapplicationforreinstatementandpremiumaresubmittedtotheStudentInsuranceOfficeordateofterminationoftheotherinsurance,which-everislater.AdditionalinformationisavailableintheStudentInsuranceOfficeorbycalling581-5290.

TERMINATION OF MEDICAL COVERAGEThemedicalcoverageoftheCoveredStudentshallterminateat12:01a.m.,ontheearliestofthefollowingdates: 1.OnthedatethePlanends; 2.At12:01a.m.onthedayofthecoverageeffectivedateforthe nextsucceedingTermoftheUniversityyear; 3.OnthedateofentryoftheCoveredStudentintomilitaryservice, exceptfortemporarydutyof30daysorless.

IntheeventtheCoveredStudentceasestobeastudentattheUniversityandnorefundhasbeenmade,coverageshallendonthesamedatesasshownintheparagraphabove,fortheTerminwhichthecoveragewaseffective,asifthestudenthadnotlefttheUniversity.

Studentswhoreceivealate/retroactivewithdrawalfromtheUniversity,effectiveonorbeforeCountDay,witharefundoftuitionandfeesinaccordancewiththeUniversityStudentWithdrawalPolicy,willalsoreceivearefundoftheinsurancefeeandnocoverageisineffectthatTerm.

ThediscontinuanceofthePlanshallimmediatelyterminateallcoverageunderthePlanDocument.Suchterminationshallbewithoutprejudicetoanyclaimexpenseoriginatingpriorthereto.ThediscontinuanceofanycoverageprovidedhereundershallimmediatelyterminatethecoverageofallCoveredStudentsex-ceptwhentheCoveredStudentisconfinedintheHospitalonthedatecoveragewouldotherwiseterminate,coveragewillcontinueasdescribedhereinuntildateofdischarge,butnotmorethanthirty(30)days.

HOW TO SUBMIT A CLAIM1. ContacttheStudentInsuranceOfficeforverificationofcoverage.2. CompletetheStudentInsuranceClaimFormandsubmittoouroffice.Ifthe

formisnotcompleted,theclaimwillbedenied.Theclaimformandcompletefilinginstructionsareavailableonourwebsite eiu.edu/studentinsurance

3. ItistheCoveredStudent’sresponsibilitytoprovideprimaryandsecondary(ifapplicable)insuranceinformationtoallmedicalproviders.WhenHospitalchargesareincurred,theHospitalmustsubmitthestandardform(UB04anditemizedcharges).ForPhysicianchargesandotherexpenses,thestandardform,(CMS1500)mustbesubmittedfromeachprovider.Claimscannotbepaidfrom“statements”.

4. IftheCoveredStudentisentitledtobenefitsunderanyotherinsurancepol-icy,thatpolicyisprimary.RequirementsoftheprimarycarriermustbemetandanExplanationofBenefits(EOB)documentingpayment/denialfromtheprimarycarrierisrequiredbeforebenefitsarepayablebythisPlan.

5. Thecompletedclaimformandallrequireddocumentationreferencedabove;anyadditionalinformationrequestedbytheStudentInsuranceOffice;andpaymentoftuitionandfeeobligationstotheUniversityfortheTerm/Termsinwhichthemedicalexpenseoccurred;mustbemadewithin52weeksfromthedateofthefirstmedicalexpenseforanyonediagno-sis,orclaimswillbedenied.Ifinformationisreceivedand/orpaymentoftuitionandfeesismadewithinthespecifiedtimeperiod,theclaimwillbereopenedandclaimsreprocessed.Innoeventwillaclaimbeprocessedforpaymentbeyondthe52-weekperiod.TheUniversityisnotresponsibleforlost,stolen,ormis-directedmail.

CLAIM DENIALInmostcases,theStudentInsuranceOfficewillfurnishawrittennoticeofdenialofaclaimwithinninety(90)daysaftertheclaimisfiled.Ifadditionaltimeisneeded,anoticewillbesenttotheCoveredStudentexplainingtheneedforad-ditionaltimewhichmayextendupto180days.In the event the claim is denied, the notice will state: 1)Thespecificreasonorreasonsforthedenial. 2)ThespecificreferencetothepertinentPlanprovisionswhich promptedthedenial. 3)Whenappropriate,adescriptionofanyadditionalmaterialorinfor- mationthatisneeded,andanexplanationofwhyitisnecessary. 4)InformationonhowtocontacttheStudentInsuranceOfficeif theCoveredStudenthasanyquestionsregardingtheclaim.

CLAIMS APPEALSIfaclaimhasbeenpartiallyorfullydenied,theclaimantisentitledtoafurtherreview.TheCoveredStudentortheCoveredStudent’sdulyauthorizedrepre-sentativemayrequestareviewofpertinentdocuments,andsubmitissuesandcommentsinwritingtosupporttheCoveredStudent’sposition.Allappealsmustbesubmittedinwritingnomorethansixty(60)daysafterthedenialto:StudentInsurance,600LincolnAvenue,Charleston,IL61920.

TheStudentInsuranceOfficewillacknowledgereceiptoftheappeal,conductthereviewandnotifytheCoveredStudentofthedecisionwithinsixty(60)days.Intheeventthatadditionaltimetoreviewtheclaimisnecessary,theStudentInsuranceOfficewillnotifytheCoveredStudentthatanadditionalsixty(60)daysisnecessarytocompletethereviewoftheappeal.

DEFINITIONS(a)ACCIDENTAL BODILY INJURY/INJURY,referstoasuddenphysicalInjurycausedbyanexternalforcewhichisindependentofsickness,disease,andallothercauses,sustainedwhilecoveredunderthisPlan.

(b)COUNT DAY,referstotheFirstCensusDateofeachTermaspertheUniver-sityAcademicCalendar.10thclassdayFall/SpringTerm,5thclassdaySummerTerm.

(c)COVERED STUDENT,meansastudentofEasternIllinoisUniversitywhoisenrolledandassessedtheStudentInsurancefeeoriseligibletopurchasecoverage.

(d)DEDUCTIBLE,meanstheamountofexpensewhichmustbeincurredbeforeanybenefitsarepayablehereunder.ThePlanhasadisappearingdeductiblemeaningpaymentsbyanotherinsurancecarriercanbeusedtoreduceorsatisfytheplandeductible.

(e)ELIGIBLE EXPENSES,meanschargesfortreatment,services,orsupplieswhichare:(a)notinexcessoftheUsualandCustomaryCharges;(b)notinex-cessofthechargesthatwouldhavebeenmadeintheabsenceofthiscoverage;(c)incurredwhilethePlanisinforceastotheCoveredStudent.

(f)HOSPITAL,meansadulylicensedinstitutionforthecareofthesickwhichprovidesserviceunderthecareofaPhysicianincludingtheregularprovisionofbedsidenursingbyregisterednurses.Itdoesnotmeanhealthresorts,resthomes,nursinghomes,skillednursingfacilities,convalescenthomes,custodialhomesoftheagedorsimilarinstitutions.

(g)ILLNESS,meansabodilydisorder,disease,physicalillness,mentalinfirmity,orfunctionalnervousdisorder.

(h)MEDICALLY NECESSARY,meansaspecificserviceorsupplyprovidedtoaCoveredStudentwhichisprescribedororderedbyaPhysicianconsistentwiththeCoveredStudent’sIllness,Injuryorcondition,andrequiredfordefinitivemedicaldiagnosisandtreatment.

(i)PHYSICIAN/PROVIDER,meansanindividuallicensedtopracticemedicineunderthe“IllinoisMedicalPracticeAct”orundersimilarlawsofIllinoisorotherstatesorcountries.

(j)PLAN YEAR,shallbethesameastheacademicyear.

(k)SUBROGATION,meanstherightofthePlantoenforceaclaimagainstathirdpartyforreimbursementwhenThirdPartyLiabilityhasbeenestablishedforeligibleexpensespaidunderthisPlan.Therecoverywillnotexceedtheamountoftheaward.

(l)TERM,shallbeconsideredtheacademicperiod,semesterorsummerses-sioninwhichtheStudentisenrolled.

(m)USUAL AND CUSTOMARY,isbasedontheusualchargeforthesameserviceorsupplywithintherangeofotherPhysiciansorhealthcareprovidersofsimilartrainingandexperienceinthesamegeographicareaundersimilarorcomparablecircumstances.

BENEFIT SECTIONWhenaCoveredStudentreceivesbenefitsforthecoveredserviceslistedintheScheduleofBenefits,theyaresubjecttotheconditions,limitationsandexclusionsinthisbrochureandthedeductible,maximumbenefitamountandotherlimitationsspecified.BenefitsareprovidedonlywhentheCoveredStu-dentreceivessuchservicesonoraftertheCoveredStudent’seffectivedateofcoverage.Ifinpatientservicesareprovidedbyahealthcarefacility,theCoveredStudent’sadmissiontosuchfacilitymustoccuronoraftertheeffectivedateofcoverage.Inaddition,benefitsareprovidedonlyifrequiredinthereasonablejudgmentofthisPlanandareprovidedbyaPhysician(unlessotherwisespecified).

Schedule of BenefitsAnnualmaximumbenefit $15,000.00

OnlyoneDeductiblewillbetakenperInjuryorIllness.Allrelatedconditionsandrecurrentsymptomsofthesameorasimilarcondition,orinjuriesasaresultofthesameaccident,willbeconsideredoneillnessoroneinjury.

A. HOSPITAL OUTPATIENT/INPATIENT COVERED MEDICAL EXPENSES$100Deductiblethen70%ofreasonablechargeforHospitalRoomandBoard,(semi-privateorintensivecareaccommodations),andthefollowingitemsofMiscellaneousExpenseprovidedbyorunderthedirectionofaPhysician,Physi-cian’sAssistant,orNursePractitioner:

(a)x-rays*,includingx-ray,radiumtherapyandmammograms,routineatage35andover;(b)laboratorytests;(c)anestheticsandadministrationthereof;(d)useofoperatingroom;(e)temporarysurgicalappliances;(f)hospitalprovidedmedicines,drugsandtheadministrationthereof;(g)bloodtransfusionsandtheadministrationthereof;(h)bloodplasma;(i)oxygenandtherentalofequipmentfortheadministrationthereof;(j)anyotherneces-saryandprescribedmiscellaneoushospitalexpenses;and(k)medicalandsurgicalsupplies.

NOTE:Itemsa-jmaybecoveredoneitheraninpatientoroutpatientbasis.Itemk(medicalsupplies)maybecoveredoneitheraninpatientoroutpatientbasis;however,temporarysurgicalappliancesandsurgicalsuppliesmaybecoveredonlyconcurrentwithasurgicalprocedure.

Free-standing,licensedradiologycentersarepayablesameascategoryA.

*Specific Diagnostic procedures are limited to the following Schedule of Benefits.

A1. PHYSICIAN INPATIENT/OUTPATIENT DIAGNOSTIC PROCEDURE EXPENSE BENEFITIncludesradiology,cardiology,pathology,oncologyandlaboratorycharges.ChargesarepayablesameascategoryA.CT/MRIandnuclearorboneimagingarepaidat50%.

B. ANESTHESIA EXPENSE BENEFIT$100Deductiblethen70%ofananesthesiologist’s(licensedphysicianorCerti-fiedRegisteredNurseAnesthetist)reasonablecharge.

C. SURGICAL EXPENSE BENEFITIfaCoveredStudent,whileinsuredundertheseprovisions,undergoesacov-eredsurgicalprocedurewhichresultsfromIllness,AccidentalBodilyInjuryorpregnancy,thePlanwillpay70%oftheActualChargeor70%oftheUsualandCustomaryCharge,whicheverisless,nottoexceedtheactualchargeforsuchprocedure.Pre-andpost-operativecareisexcluded.IfasurgicalprocedureisperformedbytheemergencyroomPhysicianandonefollow-upvisitisrequiredbyanoutsidePhysician,thePlanwillpayaccordingtothePhysician’sExpenseBenefit.

AsurgicalprocedureperformedbytheEmergencyRoomPhysicianandbilledbythehospitalwillbepaidaccordingtotheSurgicalExpenseBenefit.

Ifduringasinglesurgicalsessiontwoormoreoperationsareperformedinsepa-rateoperativefieldsandthroughseparateincisions,thelimitofpaymentwillbe70%ofthelargestUsualandCustomaryChargeforanyoneoftheoperationssoperformed,plus40%oftheUsualandCustomaryChargeforeachlesserprocedure.

Ifduringasinglesurgicalsessiontwoormoreoperationsareperformedeitherinthesameoperativefieldorthroughthesameincision,thelimitofpaymentwillbe70%ofthelargestUsualandCustomaryChargeforanyoneoftheopera-tionssoperformed.

OralSurgerybenefitsprovidedonlyforthefollowingservices:a)excisionoftumor/cyst;b)tocorrectinjurieswhentheinjuryoccursonorafterthecoveragedate;orc)treatmentoffractures/dislocations;incisionanddrainageofcellulitis;orabscess,unlesscausedbyanoffendingtooth.

D. IN-HOSPITAL PHYSICIAN’S EXPENSE BENEFIT$100Deductiblethen50%foreachdayofconfinement,includingadmittingchargesforhistoryandphysical,withamaximumofonevisitperday.

Nobenefitsshallbepayableforexpensesincurredbyreasonofasurgicalprocedure.VisitsbyaspecializedPhysicianorconsultingPhysicianwillbeconsideredforadditionalpaymentbasedonareportbytheattendingPhysician.Maximumbenefitpaymentshallbe50%ofthespecializedPhysician’sreason-ablechargewithalimitofonevisitperhospitalconfinement.

IntheeventofconfinementinanIntensiveCareUnitorCriticalCareUnit,Physician’s(Specialist/Consultant)chargesforvisitswhilesoconfinedshallbepayableat50%ofthePhysician’sreasonablefee.MaximumofoneSpecialist/Consultantvisitperdayofconfinementallowed.

E. OUTPATIENT PHYSICIAN’S EXPENSE BENEFIT$100Deductiblethen70%ofanyreasonablechargepervisitwithalimitofonevisitperdayforchargesbyaPhysician,Physician’sAssistant,NursePracti-tioner,Podiatrist,Dentistand/oralicensedClinicalPsychologist,(includingLicensedClinicalSocialWorkers,underthesupervisionofaPhysician),otherthanduringaperiodofconfinement.

IftheexaminingPhysicianrefersthecoveredstudenttoaspecializedPhysician,andtreatmentisrenderedonthesameday,benefitswillbepaidat50%ofthespecializedPhysician’sreasonablecharge.Maximumofonevisitperdiagnosisisallowed.Benefitsalsoinclude,whennecessaryinthetreatmentofanInjuryorIllness,Physicianbilledorprescribedmedicaland/orsurgicalsuppliesanddressingsthatarerenderedinconnectionwithacoveredsurgicalprocedure.

The Emergency Room is not to be used as a doctor’s office.EmergencyRoomvisitstofornon-emergencytreatmentwillnotbeconsideredwithoutareferralfromaphysician.

F. AMBULANCE EXPENSE BENEFITTheexpenseofacommunity,hospital,orprivateambulanceservicewhenrequiredtotransportaCoveredStudenttoahospitalshallbe70%uptoamaxi-mumof$300perinjuryorillness.Iftransferredtoadifferenthospital,thePlanwillprovideforoneadditionaltransportat70%uptoa$300maximum.

G. DENTAL EXPENSE BENEFITAfter$100Deductible,upto$100perinjuredtoothwhentheCoveredStudentshallrequiretheservicesofalegallyqualifieddentalPhysicianorsurgeonastheresultofacoveredAccidentalBodilyInjurytosoundnaturalteethoccurringwhileinsured.

H. MATERNITY EXPENSE BENEFIT Maternityexpenses(routineand/orcomplicationsofpregnancy)willbecoveredthesameasanyothercondition.BenefitsareprovidedunderHospital,Surgical,andAnesthesiabenefitsaccordingtotheScheduleofBenefits.SurgicalBenefitincludeschargesfortotalobstetricalcare.TheUsualandCustomarysurgicalbenefitwillreflectanypriorpaymentspaidtotheProvider.

I. PSYCHIATRIC AND/OR SUBSTANCE ABUSE TREATMENT EXPENSE BENEFITInpatient–willbepaidthesameasanyothercondition,subjectto$100Deductible.

Outpatient–$100Deductible,then70%.Psychiatricevaluationandtestingpaidat70%ofthereasonablechargeupto$100perPlanYear.

Thetreatmentcentermustbelicensedorapprovedbytheregulatoryagencyhavingresponsibilityforsuchlicensingorapprovalunderthelawsinthejuris-dictioninwhichitislocated.

Please Note:Court-orderedtreatmentofAlcohol/SubstanceAbuseand/orDUIevaluation/remedialservicesisnotcovered.

J. PHYSIOTHERAPY EXPENSE BENEFITInpatient–$100Deductiblethen70%ofthereasonablecharge.

Outpatient–Expensesincurredforphysiotherapy,diathermy,heattreatment,manipulationormassageonanoutpatientbasisinanyformforanyoneInjuryorIllnessispayableat70%ofreasonablechargeafter$100deductibleuptoamaximumof$500perPlanyear.Outpatientphysiotherapy,renderedbyalicensedphysicaltherapistoraDoctorofChiropractic,mustfollowasurgicalprocedure(whilecovered)andbeprescribedbythesurgeon.Physiotherapymustoccurwithin52weeksfromdateofsurgery.IftheattendingphysicianisalsotheproviderofPhysicalTherapy,thentheCombinedMaximumPayablewillbe$500perdiagnosis,perPlanyear.

K. HEALTH & COUNSELING SERVICES ON-CAMPUS PHARMACY BENEFIT

Medication Cost without Coverage

Student Insurance Savings Final Cost

Tier I $15 $10 $5Tier II $25 $15 $10Tier III $50 $30 $20

Contraceptives $25 $25 $0No Deductible on Campus

COORDINATION OF BENEFITS (Reduction)ThePlanprovidesbenefitsinaccordancewithallofitsprovisionsonlytotheextentthatbenefitsarenotprovidedbyanyothervalidandcollectibleinsurance.IftheCoveredStudentisentitledtobenefitsbyothervalidandcollectibleinsurance,allbenefitspayablebysuchinsurancewillbedeterminedbeforebenefitswillbepaidbythePlan.ThePlanisthesecondpayortoanyotherinsurance(s)havingprimarystatusornocoordinationofbenefitsprovision.

IftheCoveredStudentiscoveredundergrouporblanketinsurancewhichisalsoexcesstoothercoverageandacopyoftheircoordinationofbenefitsisonfile,thisPlanpaysamaximumof50%ofthebenefitsotherwisepayable.

BenefitspaidbythisPlanwillnotexceed:(1)anyapplicablePlanmaximums;and(2)100%ofthecompensableexpensesincurredwhencombinedwithbenefitspaidbyanyothervalidandcollectibleinsurance.

“Othervalidcoverage”shallbedeemedascoverageprovidedbyanyorganizationsubjecttotheregulationsofinsurancelaworinsuranceauthoritiesofanystateoftheUnitedStatesoranyprovinceofCanada,oranyothercountry,andbyanyHospitalormedicalserviceorganization,andbyanygroupinsurance,automobilemedicalpaymentsinsur-ance,orcoverageprovidedbyaunionwelfareplanoremployer,oranyemployeebenefitorganization.ForthepurposeofapplyingtheforegoingPlanprovisionwithrespecttoanyCoveredStudent,anyamountofbenefitprovidedforsuchCoveredStudentpursuanttoanycompulsorystatute(includingemployer’sliabilitystatute)whetherprovidedbyagov-ernmentalagencyorotherwiseshallinallcasesbedeemedtobe“othervalidcoverage.”

Ifbenefitsareoverpaid,wehavetherighttorecovertheamountoverpaidbyeitherofthefollowingmethods:(1)Arequestforlumpsumpaymentoftheoverpaidamount;(2)Areductionofanyamountspayableundertheplan.

EXCLUSIONSNobenefitswillbeprovidedunderthisPlanfor:1.ServicesandsuppliesnotspecificallyprovidedforinthisPlan,andcomplicationsthereof;

2.ServicesandsupplieswhicharenotrequiredinthereasonablejudgmentofthePlan;

3.ServicesorsuppliesthatarefurnishedtotheCoveredStudentbythelocal,stateorfederalgovernmentandforanyservicesorsuppliestotheextentpaymentorbenefitsareprovidedoravailablefromthelocal,stateorfederalgovernment(forexample,Medicare)whetherornotthatpaymentorbenefitsarereceived,exceptasotherwiseprovidedbylaw;

4.ServicesandsuppliesforanyIllnesscontractedorInjurysustainedafterthecoveragedateasaresultofwar,declaredorundeclared,oranyactofwar,orbyparticipatinginariot,orastheresultofattemptingorcommittingacriminalact,orconditionscausedbyatomicexplosionsorradiation;

5.Servicesandsuppliesreceivedfromadentalormedicaldepartmentmaintainedbyoronbehalfofanemployer,amutualbenefitassociation,laborunion,trusteeorsimilarpersonorgroup;

6.Servicesandsupplieswhichdonotmeetacceptedstandardsofmedicalordentalpracticeincluding,butnotlimitedto,investigationalservicesandsupplies,andservicesandsuppliesrelatedthereto;

7.ServicesandsuppliesforwhichtheCoveredStudentisnotrequiredtomakepaymentorforwhichtheCoveredStudentwouldhavenolegalobligationtopayintheabsenceofthisoranysimilarcoverage;

8.Chargesforfailuretokeepascheduledvisit,chargesforcompletionofaclaimform,chargesformedicalrecords,x-raycopies,telephoneconsultations,andanyhandlingfees;

9.Servicesandsuppliesrenderedduringaninpatientadmissionwhichisprimarilyforcustodialcare,(i.e.,theprovisionofinpatientservicesandsuppliestoaCoveredStudentwhoisnotreceivingskillednursingservices);

10.Servicesandsuppliesusedtotreatconditionsrelatedtoautism,hyperkineticsyn-dromes,learningdisabilities,behavioralproblems,mentalretardation,orseniledeteriora-tion,beyondtheperiodnecessarytodiagnosethecondition,subjectto$100.00maximumbenefitfortesting;

11.Routinephysicalexaminations,includingroutinepapsmears,screeningexams,ortestingintheabsenceofInjuryorSickness;

12.Personalhygiene,comfortandconvenienceitemssuchasairconditioners,humidi-fiers,physicalfitnessequipment,correctiveshoesoradmissionkits;

13.Procurementoruseofprostheticdevices,specialappliances,specialbraces,ambula-toryapparatus,durablemedicalequipment,specializedequipmentandsurgicalimplants,exceptasspecificallyprovidedinthisPlan;however,nobenefitsareprovidedforrentalofanyoftheabovelistedsupplies;

14.Cosmeticsurgery(includingrhinoplasty)andrelatedservicesandsupplies,nasalandsinussurgery,exceptforthecorrectionofconditionsresultingfromAccidentalInjurieswhichoccurwhileinsured;

15.Servicesandsupplies,includingsurgery,forthetreatmentofobesityand/orweightcontrol;nutritionaleducationandotherpatienteducation;

16.Servicesandsuppliesrelatedtobiofeedback;

17.Maintenanceoccupationaltherapyandmaintenancephysicaltherapy;

18.Speechtherapy;

19.Visiontherapy,radialkeratotomy,eyeglassesorcontactlenses(exceptcataractlensesasspecificallyprovidedinthisplan)andtheexaminationforprescribingorfittingeyeglassesorcontactlensesorfordeterminingtherefractivestateofeyes;

20.Expensesincurredforacupuncture;alternative,holisticmedicine,and/ortherapy;includingbutnotlimitedtoyogaandhypnotherapy.

21.Hearingaidsorexaminationsfortheprescriptionorfittingofhearingaids;

22.Careofflatfeet,supportivedevicesforthefoot(orthotics),careofcorns;orcalluses,careoftoenailsandfallenarches,weakfeetorchronicfootstrainexceptifmedicallynecessaryduetodiabetesorcirculatoryproblems;

23.Immunizationinjections,includingallergyshotsandserum;therapeuticanddiagnosticinjections;injectionsforpainmanagementandrelatedservicesandsupplies;

24.ExpensesincurredforchargesmadebyaPhysicianorphysiotherapistifsuchpersonisrelatedtoorordinarilyresideswiththeCoveredStudent;

25.Dentaltreatmentordentalsurgery,exceptasspecificallyprovidedinthisPlan;

26.Injurysustainedwhile(a)participatinginanyintercollegiateorprofessionalsport,contestorcompetition;(b)travelingtoorfromsuchsport,contestorcompetitionasapar-ticipant;or(c)whileparticipatinginanypracticeorconditioningprogramforsuchsport,contestorcompetition;

27.Servicesrelatedtothediagnosisandtreatmentoftemporomandibularjoint(TMJ)disordersorsyndromesorothermyofunctionaldisorders;

28.Expensesresultingfromvoluntaryterminationofpregnancy,sterilizationprocedureorreversal,infertilitytreatment(maleorfemale)includinganyservices,testingorsuppliesrenderedforthepurposeorwiththeintentofinducingconception;

29.Outpatientprescriptiondrugs;

30.Servicesforassistantsurgery;

31.Electivesurgeryandelectivetreatment;

32.Losscausedbyskydiving,parachuting,hanggliding,gliderflying,parasailing,sailplaning,bungeejumping,orflightinanykindofaircraft,exceptwhileridingasapassen-geronaregularlyscheduledflightofacommercialairline;

33.Expensesincurredforcare,treatment,services,testing,orsuppliesfordiagnosisoforrelatedtoobstructivesleepapneaandsleepdisorders;

34.HumanOrganTransplantsotherthancornea,kidney,bonemarrow,heartvalve,muscular-skeletal,andparathyroidhumanorganortissuetransplants;

35.DiagnosticServiceaspartofroutinephysicalexaminationsorcheck-ups,pre-maritalexaminations,determinationoftherefractiveerrorsoftheeyes,auditoryproblems,sur-veys,casefinding,researchstudies,screeningorsimilarproceduresandstudies,ortestswhichareInvestigational;

36.AmedicalfacilityownedandoperatedbyaPhysicianwhichdoesnotmeetthedefini-tionofahospital;

37.Genderreassignmentsurgeryandrelatedservicesandsupplies;

38.ExpensesfortreatmentofMentalIllnessorSubstanceAbuseprovidedbyanEasternIllinoisUniversityStaffMember/orindividualundercontracttotheUniversity,inprivatepractice;

39.ExpensesfortreatmentofanInjurywhichistheresultofanautomobileaccidentwillnotbecoveredtotheextentofminimumcoveragerequiredbyanyapplicablestate“no-fault”lawforinjuriessufferedbyaCoveredStudentiftheCoveredStudentistheownerofthevehicleandisoperatingorridinginthevehicle,andthevehicleisnotcoveredbyno-faultinsuranceasrequiredbylaw;

40.ChargesincurredforservicesintheEmergencyRoom,ObservationorInpatientCarewhenthestudentleavesagainstmedicaladvice;

41.ChargesincurredintheEmergencyRoomwhichwereforadiagnosiswhichwasnotanEmergency.

42.ServicesandsuppliesforanyInjuryorIllnessarisingoutofandinthecourseofem-ploymentforwhichbenefitsand/orcompensationareavailableinwholeorinpartundertheprovisionsofanyWorker’sCompensationLaw,OccupationalDiseasesLaworsimilarLegislationoftheUnitedStatesofAmericaorofanyforeigncountryorofanyagencyorpoliticalsubdivisionofanyoftheforegoing,whetherornottheCoveredStudentclaimssuchcompensationorreceivessuchbenefitsandwhetherornotanyrecoveryishadbytheCoveredStudentagainstsuchthirdpartyfordamagesresultingfromsuchInjuryorIllness;

SUBROGATIONItisunderstoodandagreedthatthePlantowhichthisprovisionisattachedincludesthefollowing:

Thisprovisionapplieswhenaperson,otherthantheCoveredStudentforwhomaclaimismade,isconsideredresponsibleforanInjuryorIllness.TotheextentpaymentfortheInjuryorIllnessismade,ormaybemadeinthefuture,byorforthatresponsibleperson

(asasettlementjudgmentorinanyotherway)charges,arisingfromthatInjuryorIllnessarenotcovered.

IfaclaimisreceivedbyEasternIllinoisUniversitybenefitswouldbepayableif:

1.Paymentbyorfortheresponsiblepersonhasnotyetbeenmade;and

2.TheCoveredStudentinvolved,orifincapable,thatCoveredStudent’slegalrepresenta-tive,agreesinwritingtopaybackpromptlythebenefitspaidasaresultofInjuryorIllnesstotheextentofanyfuturepaymentsmadebyorfortheresponsiblepersonfortheInjuryorIllness.Theagreementistoapplywhetherornot:

(a)liabilityforthepaymentsisadmittedbytheresponsibleperson;and

(b)suchpaymentsareitemized.

3.TheCoveredStudentsubmitsasignedEIUsubrogationformtotheStudentInsuranceOffice.

AreasonableshareoffeesandcostsincurredtoobtainsuchpaymentsmaybedeductedfromamountstoberepaidtoEIUStudentInsurance.

AmountsdueEasternIllinoisUniversitytorepaybenefits,agreedtoasdescribedabove,maybedeductedfromotherbenefitspayablebyEasternIllinoisUniversityafterpaymentsbyorfortheresponsiblepersonaremade.

ThisprovisiontakeseffectandexpiresconcurrentlywiththePlantowhichitisattached.Thisprovisionissubjecttoalltheterms,limitationsandprovisionsofthisPlan.

ThisbrochurecontainstheprincipalprovisionsofthePlan.AcopyofthegoverningPlanDocumentisavailableattheStudentInsuranceOffice.IntheeventofaconflictbetweenthePlanandthisbrochure,thePlanDocumentwillprevail.

E-NUMBER

STUDENTNAME(PLEASEPRINT)

This card is for identification only. it is not a guarantee of coverage.

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Claims address:StudentInsurance,600LincolnAve,Charleston,IL61920

Claim may be faxed:217-581-7507

Forclaiminquires,verificationofeligibilityofbenefits,notificationofemergencyservicesreceivedorotherquestionspleasecall:Student Insurance 217-581-5290

Any other insurance coverage is used in determining the amount of benefits payable under this Plan.

STUDENT INSURANCE PLAN 82198600LINCOLNAVENUECHARLESTON,IL61920-3099PHONE:(217)581-5290