Pln ummry - Relation Collegiate Solutions · Pln ummry 2019E4A21 C Underwritten by: National Guardian Life Insurance Company, Madison, WI National Guardian Life Insurance Company

Plan Summary

2019E4A21 – C

Underwritten by:National Guardian Life Insurance Company, Madison, WI

National Guardian Life Insurance Company is not affiliated with Guardian Life Insurance Company of Americaaka The Guardian or Guardian Life.

Policy Number:2019E4A21Revised 08/01/2019 4:37 PM

Student Health Insurance Plan (SHIP)www.4studenthealth.com/menlo

2019–2020

Important Contact Information and Resources

Insurance CompanyNational Guardian Life Insurance Company, Madison, WI

Policy Number2019E4A21

PPO NetworkTo locate PPO Physicians and facilities, visit the website, or call the number listed.

First Health Network(800) 226-5116www.myfirsthealth.com

Pharmacy Benefits ManagerThe Pharmacy Benefits Manager for this plan is Express Scripts.

Express Scripts(800) 447-9638www.express-scripts.com

Benefits and Claims AdministratorFor questions regarding benefits or claims status, contact the claims and benefits administrator.

Relation Insurance Administrators(800) 468-4343Monday–Friday, 8:00 a.m. to 5:00 p.m. (4:00 p.m. on Fridays) Pacific Time

Claims SubmissionFor submitting claims by mail, make a copy of your insurance ID card and the bill(s) and mail to this address within 90 days.

Relation Insurance AdministratorsP.O. Box 6040Agoura Hills, CA 91376-6040

Travel Assistance ServicesContact this company when you are traveling away from home and you need assistance with things such as transfer of medical records, legal referrals, transfer of funds, and information on travel conditions.

Scholastic Emergency Services(877) 488-9833 (in the U.S.)Call collect +1 (609) 452-8570 (outside U.S.)Email: [email protected] Number: 01-SES-SUM-08123Available 24/7/365

Plan AdministratorFor questions about eligibility, enrollment, and waivers.

Relation Insurance Services(800) 537-1777Monday–Friday, 8:00 a.m. to 5:00 p.m. Pacific Time

This Plan is Underwritten by National Guardian Life Insurance Company, 2 East Gilman Street, Madison, WI 53703 As Policy Form No.: NBH-280 (2019) CA PPO et al.

For a copy of the Company’s Privacy Notice, you may go to: www.studentplanscenter.com/privacy/NGLIC, or request one from the Health Office at your school, or from the Plan Administrator, or by writing to the address below:

National Guardian Life Insurance Company, c/o Privacy Officer, Student Insurance Division, Commercial Travelers Building, 70 Genesee Street, Utica, NY 13502

(Please indicate the school you attend with your written request.)Representations of this Plan must be approved by the Company.

Menlo College / 2019–2020 Plan Summary / 3 /

Notice

This is a brief description of the benefits provided by the plan. Please see the Certificate or Policy on file at your school for a description of benefits, limitations, and provisions of the plan. Subject to Insurance Department approval. Any provisions of the Policy, as described in this summary, that may be in conflict with the laws of the state where the school is located will be administered to conform with the requirements of that state’s laws, including those relating to mandated benefits.

The information contained in this summary is accurate at the time of publication, but may change in accordance with state and federal insurance regulations during the course of the Policy year. The most current version of this document will be posted online at the website listed on the cover. In the case of a discrepancy between two versions of the summary, the most recent will apply.

Eligibility and Enrollment

Any full-time undergraduate student who is registered and attending classes at Menlo College is required to have adequate health insurance coverage. You will be automatically enrolled in SHIP, unless you provide comparable coverage and submit a waiver by the Waiver Deadline Date (see Waiver FAQ for more information). If you have other health insurance, such as coverage under your parent’s or employer’s insurance plan, and you do not wish to enroll in SHIP, you may submit a waiver application. (Note: International students are not allowed to waive coverage.)

Students must actively attend classes for at least the first 31 days after the date for which coverage is purchased. Home study, correspondence, and television (TV) courses do not fulfill the Eligibility requirements that the student actively attend classes. The Company maintains its right to investigate student status and attendance records to verify that the Policy Eligibility requirements have been met. If and whenever the Company discovers that the Policy Eligibility requirements have not been met, its only obligation is refund of premium.

Coverage for dependents is not available under this plan.

For questions about enrollment, contact Relation Insurance Services at (800) 537-1777 (Monday–Friday, 8:00 a.m. to 5:00 p.m. Pacific Time).

Rates and Important Dates

The cost of coverage includes the cost of managing the plan. Coverage starts and ends at 12:01 a.m. local time at the Policyholder’s address.

Student Rate

Annual08/01/2019 to 08/01/2020

$1,950.00

Waiver Deadline

Annual08/01/2019 to 08/01/2020

09/09/2019

Fall08/01/2019 to 01/08/2020

09/09/2019

Spring01/08/2020 to 08/01/2020

01/15/2020

ID Card

Permanent insurance ID cards will be mailed to students after the start of the term. However, all students can download their insurance ID cards at www.4studenthealth.com/menlo at any time.

Carry your ID card with you at all times! You will need your card when you visit the doctor’s office, urgent care, or hospital.

Seeking Medical Care

If you experience an Injury or Sickness:

1. If you need to seek medical treatment, using PPO providers that are part of the First Health Network could decrease your costs. For a complete listing of PPO physicians, hospitals, and other facilities, visit www.myfirsthealth.com.

2. In case of an Emergency, go to the nearest hospital or call 911. Follow-up care at the ER is not covered; you will need to seek follow-up care with a PPO provider.

3. If it is not an Emergency but you need to seek medical treatment right away, using an Urgent Care Center instead of a Hospital ER may decrease your out-of-pocket expenses. To locate a local Urgent Care Center, visit www.myfirsthealth.com.

4. After you receive treatment at a PPO provider, your provider will usually submit a claim to the insurance company. You will receive an Explanation of Benefits from Relation, detailing what the insurance paid and what is your responsibility to pay. If you have questions about your Explanation of Benefits or what is your responsibility to pay, please call (800) 468-4343. Do not ignore any medical bills you receive.

5. If your provider bills you directly or asks you to pay up front, you will need to submit a claim.

Please visit www.4studenthealth.com/menlo and see Claims under the USE YOUR INSURANCE section for information about how to submit a claim.

Preferred Provider Organization

This plan includes a network of medical professionals, including doctors and hospitals, known as the

Preferred Provider Organization (PPO). This PPO is available through First Health Network. If you need to see a provider, you should utilize a PPO provider. While you are allowed to visit any provider of your choosing, if you use a PPO doctor or facility, you will pay less money out-of-pocket.

Network access provides benefits nationwide for Eligible Expenses incurred at 90% of the Preferred Allowance (PA) when treated by network providers (PPO). Benefits are provided worldwide for Eligible Expenses incurred at 70% of Usual and Reasonable Charge (U&R) when treated by non-network providers (non-PPO). Note: Charge in excess of U&R are still the responsibility of the Plan Participant.

(CONTINUED)

Menlo College / 2019–2020 Plan Summary/ 4 /

Preferred Providers have contracted to provide specific medical care at negotiated prices. The availability of specific providers is subject to change without notice. The Plan Participant should always confirm that a Preferred Provider is participating at the time services are required by checking the Preferred Provider Network website or calling the Preferred Provider Network and by asking the provider when he or she makes an appointment for services. Non-network providers have not agreed to any prearranged fee schedules. You may incur significant out-of-pocket expenses with these providers. Charges in excess of the insurance payment are your responsibility.

Please be aware that if you are treated at a PPO Hospital, it does not mean that all providers at that Hospital are PPO providers. If you are referred by a PPO provider to another provider or facility, it does not necessarily mean that the provider or facility to which you are referred is also a PPO provider. For example, when a network provider refers you to a lab for tests, be sure it is a network lab. This information can be found on the network website.

To find a PPO provider, visit www.myfirsthealth.com or call (800) 226-5116. Contact the provider prior to your visit to confirm their membership in the network.

Filing a Claim andGetting Your Medical Bills Paid

In most cases, the provider will submit the claim for you.

If you are required to pay for services up front, you will need to complete a claim form in order to be reimbursed by the insurance company.

Visit www.4studenthealth.com/menlo to download a claim form under Claims in the USE YOUR INSURANCE section. Fill out the form completely so your claim will be processed promptly. Send your claim form and all itemized bills pertaining to this claim to Relation Insurance Services at the address below. Attach all bills to the same claim form.

Relation Insurance AdministratorsP.O. Box 6040Agoura Hills, CA 91376-6040

Keep copies of all the documents you submit for claims.

If you have questions about claims, contact Relation Insurance Administrators at (800) 468-4343.

Preferred Provider Organization (continued)

Benefit Highlights

Actuarial Value: 89.48%Equivalent or next lowest coverage level: Platinum

IN-NETWORK NON-NETWORK

Policy Year Aggregate Maximum Benefit Unlimited

Policy Year Deductible

The Covered Person is responsible for paying the deductible amount listed before the company will begin paying benefits, except as indicated below.

$100 per Policy Year $300 per Policy Year

Coinsurance 90% of the PPO Allowance (PA) 70% of the Usual & Reasonable Charge (U&R)

Office Visit Copay $20 per visit None (coinsurance applies)

Urgent Care Copay $20 per visit None (coinsurance applies)

Emergency Services Expenses 90% PPO Allowance 90% PPO Allowance

Out-of-Pocket Maximum $6,350 per Policy Year No maximum

(CONTINUED)

Menlo College / 2019–2020 Plan Summary / 5 /

Benefits listed here have been truncated. See the Certificate or Policy for full information on each benefit, including limitations and included services. Definitions for terms used throughout this summary are included in the Certificate or Policy.

BENEFIT IN-NETWORK NON-NETWORK

Preventive ServicesNetwork Provider: The Deductible, Coinsurance, and any Copay are not applicable to Preventive Services.Non-Network Provider: The Deductible, Coinsurance, and any Copayment are applicable to Preventive Services provided through a Non-Network Provider.

100% of PA 70% of U&R

Primary Care Visits 100% of PA $20 Copay per visit 70% of U&R

Surgical Services (Inpatient and Outpatient) 90% of PA 70% of U&R

Maternity and Newborn Care See Certificate for a complete list of Covered Services, including applicable limitations and exclusions

Mental Health Disorder and Substance Use Disorder ServicesOutpatient Office Visits 100% of PA 70% of U&R

Mental Health Disorder and Substance Use Disorder Services All Other Outpatient Services 90% of PA 70% of U&R

Mental Health Disorder and Substance Use DisorderInpatient Hospital Room & Board Expense

90% of PA,$250 Copay per visit

70% of U&R,$250 Copay

Urgent Care $20 Copay per visit 70% of U&R

Emergency Service Expense 90% of PA 90% of PA

Ambulance 90% of PA

Rehabilitation Therapy and Habilitative Service (Outpatient) $20 Copay per visit 70% of U&R

Pediatric Dental Care Benefit Refer to the pediatric vision services and pediatric dental services in the Certificate for a complete list of covered services, including applicable limitations and exclusions. Pediatric Vision Care Benefit

Prescription Drugs

100% of U&R Charge after Copay (deductible waived)

$15 Generic Copay$30 Preferred Brand Copay

$50 Non-Preferred Brand Copay

See Prescription Card

70% of U&R

Benefit Highlights (continued)

Menlo College / 2019–2020 Plan Summary/ 6 /

1. Medical services rendered by provider employed for or contracted with the School, including team physicians or trainers, except as specifically provided in the Schedule of Benefits.

2. Dental treatment including orthodontic braces and orthodontic appliances, except as specified for accidental Injury to the Insured Person’s Sound, Natural Teeth or as specifically covered in the Policy under Laboratory Services, Hospitalization – Inpatient Services, Dental Services in Preparation for Radiation Therapy, or Pediatric Dental.

3. Professional services rendered by an Immediate Family Member or any who lives with the Insured Person.

4. Services or supplies hearing aids, except those resulting from a covered accidental Injury or as specifically covered under the Policy.

5. Weak, strained or flat feet, corns, calluses or ingrown toenails.

6. Treatment or removal of nonmalignant moles warts, boils, acne, actinic or seborrheic keratosis, dermatofibrosis or nevus of any description or form, hallus valgus repair, varicosity, or sleep disorders including the testing for same.

7. Charges of an institution, health service or infirmary for whose services payment is not required in the absence of insurance or services provided by Student Health Fees.

8. Any expenses in excess of Usual and Reasonable charges.

9. Treatment, services, supplies or facilities in a Hospital owned or operated by the Veterans Administration or a national government or any of its agencies, except when a charge is made which the Insured Person is required to pay.

10. Services that are duplicated when provided by both a certified nurse-midwife and a Physician.

11. Expenses incurred during a Hospital emergency room visit which is not of an emergency nature.

12. Expenses incurred after:

a) The date insurance terminates as to the Insured Person; and

b) The Maximum Benefit for each Covered Injury or Covered Sickness has been attained.

13. Elective Surgery or Treatment unless such coverage is otherwise specifically covered under the Policy.

14. Charges incurred for massage, in any form, except to the extent provided in the Schedule of Benefits.

15. Expenses for weight increase or reduction except Medically Necessary bariatric surgery, and hair growth or removal unless otherwise specifically covered under the Policy.

16. Expenses for radial keratotomy and services in connection with eye examination, eye glasses or contact lenses or hearing aids, except as required for repair caused by a Covered Injury or as specifically covered under the Policy.

17. Expenses incurred for Plastic or Cosmetic Surgery, unless needed to repair conditions resulting from an accidental injury or for the improvement of the physiological functioning of a malformed body member, except for services related to orthognathic surgery, osteotomy or any other form of oral surgery, dentistry, or dental processed to the teeth and surrounding tissue.

a) For the purposes of this provision, Plastic or Cosmetic Surgery means surgery that is performed to alter or reshape normal structures of the body in order to improve the patient’s appearance) In no event will any care and services for breast reconstruction or implantation or removal of breast prostheses be covered unless such care and services are performed solely and directly as a result of a Medically Necessary mastectomy.

18. Treatment to the teeth, including surgical extractions of teeth and any treatment of Temporomandibular Joint Dysfunction (TMJ) other than a surgical procedure for those covered conditions affecting the upper or lower jawbone or associated bone joints. Such a procedure must be considered Medically Necessary based on the Policy definition of the same. This exclusion does not apply to the repair of Injuries caused by a Covered Injury to the limits shown in the Schedule of Benefits or to services specifically covered under the Policy.

19. An Insured Person’s:

a) Committing or attempting to commit a felony, or

b) Being engaged in an illegal occupation.

20. Custodial care service and supplies.

21. Expenses that are not recommended and approved by a Physician.

22. Respite care, day care, recreational care, residential treatment, social services, custodial care or education services of any kind do not qualify as habilitative services.

General Exclusions and Limitations

Exclusion Disclaimer: Exclusion Disclaimer: Any exclusion in conflict with the Patient Protection and Affordable Care Act will be administered to comply with the requirements of the Act.

The Policy does not cover loss nor provide benefits for any of the following, except as otherwise provided by the benefits of the Policy and as shown in the Schedule of Benefits.

Menlo College / 2019–2020 Plan Summary / 7 /

Key Services • Medical consultation, evaluation and referral

• Hospital admission assistance

• Emergency medical evacuation

• Medical monitoring

• Emergency medical evacuation and repatriation of remains

• Prescription assistance

• Compassionate visit

• Care of minor children

• Emergency trauma counseling

• Lost luggage assistance

• Interpreter and legal referrals

• Pre-trip information

• Return of vehicle

• And much more...

All services must be arranged and provided by SES. No claims for reimbursement will be accepted.

How to Access ServicesIf you require medical assistance and are more than 100 miles from your permanent residence or campus or are in another country, call the SES Operations Center at (877) 488-9833 (inside USA), +1 (609) 452-8570 (outside USA), or email [email protected]. Please download an ID card from www.4studenthealth.com/menlo and carry it with you at all times.

Please provide the following information when you call:

• Your name, telephone number, and relationship to the patient

• Patient’s name, age, gender, reference number, and school

• Name, location, and telephone number of hospital or treating doctor if applicable

• Reference Number 01-SES-SUM-08123

Global Emergency Services

The following services are not part of the Plan Underwritten by National Guardian Life Insurance Company. These value added options are provided by Relation Insurance Services, in partnership with Scholastic Emergency Services.

National Guardian Life complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

(Arabic) 1بالمجان. تصل برقم +إذا آنت تتحدث اذآر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك

)800 (468-4343. (Chinese-S)

如果您说中文，您可以免费费得语言援助服务。请致电 +1 (800) 468-4343.

(Chinese-T)

如果您使用繁體中文，您可以免費獲得語言援助服務。請致電

+1 (800) 468-4343. (French)

Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le +1 (800) 468-4343.

(French Creole-Haitian)

Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele +1 (800) 468-4343.

(German) Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer +1 (800) 468-4343.

(Italian)

In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero +1 (800) 468-4343.

(Japanese)

日本語を話される場合、無料の言語支援をご利用いただけます。

+1 (800) 468-4343 まで、お電話にてご連絡ください.

(Korean) 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실

수 있습니다. +1 (800) 468-4343 번으로 전화해 주십시오.

(Persian-Farsi) اگر به زبان فارسی گفتگو می کنيد، تسهيالت زبانی بصورت رايگان برای شما فراهم می باشد. با

تماس بگيريد. 468-4343 (800) 1+ (Polish)

Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer +1 (800) 468-4343.

(Portuguese)

Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para +1 (800) 468-4343.

(Russian)

Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните +1 (800) 468-4343.

(Spanish)

Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al +1 (800) 468-4343.

(Tagalog)

Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa +1 (800) 468-4343.

(Vietnamese)

Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số +1 (800) 468-4343.

Plan Administered By Relation Insurance ServicesCA License No. 0G55426

EDUCATION SOLUTIONS

Certificate of Creditable Coverage

If you are no longer eligible to be insured under the plan and need to obtain proof of insurance, you may request a Certificate of Creditable Coverage from the plan administrator (Relation Insurance Services). This request can be made by phone or in writing, and it must include the name of the school and the name of each person who is no longer eligible to be insured under the plan.

Authorized Representation

In accordance with state and federal rules and regulations, we will not disclose individual information without authorization. This includes disclosures to family members for insured individuals who have reached the age of majority. If you would like to authorize an additional party to act as a personal representative for matters pertaining to this insurance plan, we must have an Authorization Form on file. To request a form, please contact Relation at the address below or download a form at www.4studenthealth.com/privacy-policy and mail it to the address below.

Summary of Privacy Policy

If you are covered under one of our insurance plans, we are committed to protecting your privacy. We strongly believe in maintaining the confidentiality of the personal information we obtain and/or receive about you. We do not disclose any nonpublic information about you to anyone, except as permitted or required by law. We do not sell or otherwise disclose your personal information to anyone for purposes unrelated to our products and services. We maintain physical, electronic, and procedural safeguards that comply with federal and state regulations to protect information about you from unauthorized disclosure. We may disclose any information we believe necessary to conduct our business as is legally required. You have the right to access, review, and correct all personal information collected. You may review this Privacy Policy in its entirety, or the Privacy Policies of other entities servicing the Policy, by writing to the address or visiting the website below. You may also submit a request to review your information, in writing, to the address below.

Marcos Rolon, Privacy Officer Relation Insurance AdministratorsP.O. Box 6040Agoura Hills, CA 91376-6040www.4studenthealth.com