Plan year: August 18, 2006 - August 17, 2007

Student Gold Health Insurance Plan

Spouse/Domestic Partner and Dependent Coverage

• Is there Spouse/Domestic Partner and Dependent Coverage?
• What is the deadline to enroll?
• Spouse/Domestic Partner coverage benefits
• Dependent coverage benefits
• Who is considered an eligible dependent?
• Are newborn children automatically covered by the plan?
• What benefits are available for periodic “healthy child” visits?
• What maternity benefits are available?

Is there Spouse/Domestic Partner and Dependent Coverage?
There is spouse/domestic partner and dependent coverage available . To enroll your spouse/domestic partner and/or dependent, go to the Student Health Plans Office (Wardenburg Health Center, room 251). Premium costs are not the same as for the student.

You and your spouse/domestic partner and/or dependents must choose the same plan and meet the same deadlines. (See Exceptions to Automatic Enrollment.

Spouse/domestic partners and dependents must be re-enrolled and premiums paid each semester during open enrollment for coverage.

Fall deadline September 6, 2006
See deadlines. Spring deadline January 24, 2007. Summer deadline June 11, 2007.

Spouse/Domestic Partner Coverage Benefits
Coverage for your spouse/domestic partner at Wardenburg Health Center and outside of the health center is identical to your student coverage and coverage conditions, including deductible, co-insurances for in-network and out-of-network (See Schedule of Benefits).

Dependent coverage benefits

• Wardenburg Health Center offers family practice and pediatric care by appointment. Eligible health care services are covered at 100 percent when your dependent is seen at Wardenburg Health Center. (No co-payment.)
• Preventive immunizations are covered at 100 percent for dependents when seen at Wardenburg Health Center. (No co-payment.)
• When you use Wardenburg Health Center for your dependents, complete the Health Plan Information Form from the Business Office at the health center, prior to seeing your dependent’s health care provider.
• Dependent children must be on the same plan as the insured.
• No referral is necessary for dependent care Outside Wardenburg Health Center, however:
  • The deductible applies
  • Co-insurance for in-network and/or out-of-network applies (See Schedule of Benefits).

Who is considered an eligible dependent?
Eligible dependents are your spouse (except in the event of divorce or annulment) or domestic partner and your unmarried children under 19 years of age, or 24 years if a full-time dependent student at an accredited institution of higher learning, who are not self-supporting. Stepchildren, foster children, and legally adopted children may be included the same as your natural children when you provide written evidence that they depend upon you for support and maintenance. Dependent eligibility expires concurrently with that of the insured student.

If a dependent, except a child covered at birth, is confined for medical care or treatment in any institution or at home when coverage would normally start, the dependent will not be covered until given a final release by the physician from all such confinement. No one will be eligible as a dependent while covered as a student or while in active military service.

A child who is physically or mentally incapable of self-support upon attaining age 19 may be continued under the health care insurance while remaining incapacitated and unmarried, subject to the continuation of your own coverage. You must furnish proof of incapacity to the MEGA Life and Health Insurance Company within 31 days of the child's attainment of the limiting age; thereafter, if a claim is denied under the policy because the child has attained limiting age, such proof of incapacity must be furnished to the company for reconsideration.

Are newborn children automatically covered by the plan?
In the event of the birth of a child to a covered student while the student's insurance is in force, that child will automatically become a covered person from the moment of birth. Coverage will continue without cost for 31 days. Written notice of birth and the required premium, if any, must be furnished to the company within 31 days of the date of birth, or the coverage will terminate for that child at the end of the 31-day period. Coverage for newborn infants is subject to all policy provisions, including the deductible.

What benefits are available for periodic “healthy child” visits?
Benefits shall be provided for Child health supervision services from birth up to the age of 13, the same as for any sickness, subject to the same coinsurance or co-payments as for any physician visit. No deductible or dollar limit provisions apply.

Child health supervision services rendered during a periodic review are covered only to the extent such services are provided during the course of one visit by, or under the supervision of a single physician, physician's assistant, or registered nurse.

“Child health supervision services” means the periodic review of a child's physical and emotional status by a physician or other provider as above. A review shall include, but not be limited to, a history, complete physical examination, developmental assessment, anticipatory guidance, appropriate immunizations, preventive services, and laboratory tests in keeping with prevailing medical standards. Benefits are payable on a per visit basis to one health care provider per visit.

What maternity benefits are available?
Pre-natal care is typically billed by a woman’s physician at the end of the maternity. The physician typically bills one global fee for the entire term, including services for delivery of the child. Payment is usually made at the end of the pregnancy, when the physician sends the final bill.

Other times, doctors will bill for each visit and submit the bills separately. When a bill for a visit is received, AmeriBen processes it, and records it as part of the global fee for maternity.

Other items are processed under their corresponding benefits, such as: anesthesia, X-ray, lab tests, and other procedures. All services rendered that pertain to the maternity are considered one condition.

What maternity tests are covered?
The following maternity routine tests and screening exams will be considered, if all other policy provisions have been met: pregnancy test, CBC, hepatitis B surface antigen, Rubella screen, syphilis screen, chlamydia, HIV, gonorrhea, toxoplasmosis, blood typing ABO, RH blood antibody screen, urinalysis, urine bacterial culture, microbial nucleic acid probe, Pap smear, and glucose challenge test (at 24-28 weeks gestation).

One ultrasound will be considered in every pregnancy, without additional diagnosis. Any subsequent ultrasounds can be considered if a claim is submitted with the Pregnancy Record and Ultrasound report that establishes medical necessity. Additionally, the following tests will be considered for women over 35 years of age: AFP blood screening; amniocentesis/AFP screening; and chromosome testing. Fetal stress/non-stress tests are covered. Pre-natal vitamins are not covered except at Wardenburg Health Center. For more information on maternity testing, please call AmeriBen at 800-626-5520.

All benefits provided outside of Wardenburg Health Center are underwritten by the MEGA Life and Health Insurance Company and the benefits payable are as defined in and subject to all provisions of the Policy. (AmeriBen 800-626-5520)

Note: Your spouse/domestic partner and dependents are subject to the same plan benefits, exclusions and limitations as the insured student.