Plan year: August 18, 2006 - August 17, 2007
Student Gold Health Insurance Plan
Schedule of Medical Benefits of Care Outside Wardenburg Health Center
STUDENT HEALTH INSURANCE PLAN /
POLICY #2006-4005-2 SCHEDULE OF MEDICAL EXPENSE BENEFITS PAID AS
SPECIFIED BELOW FOR INJURY AND SICKNESS MAXIMUM BENEFIT $50,000
(FOR EACH INJURY OR SICKNESS) DEDUCTIBLE -- $200.00 (PER INSURED
PERSON) (PER POLICY YEAR)
- If two or more covered members of a family are injured in the
same accident, only one deductible will be charged each policy
year against
their combined eligible expenses due to the accident.
- Preferred Allowance means the MEGA Life and Health Insurance
Company’s
allowance for a specified covered medical expense or the provider’s
charge, whichever is less.
- After the deductible has been satisfied,
covered
medical expenses will be paid at the applicable percentage
specified below, up to $50,000 per plan year for each injury or
sickness.
- Prescription drug expenses will be covered at 50 percent up to $2,000
maximum (per policy
year).
- One eye exam per policy year up to $60 maximum, at
Wardenburg Health Center only.
- The following will be covered
the same
as any other sickness: Nasal Sinusitis, Sleep Disorders, Fertility
Testing and Attention Deficit Disorder (ADHD/ADD test not covered).
- Coverage for newborn infants is subject to ALL Policy
Provisions.
- The Policy provides benefits for the Usual and
Customary
Charges (UCC) incurred by an Insured Person for loss
due to a
covered
Injury or Sickness.
- If you receive care from
a Preferred Provider, any Covered
Medical Expenses will be paid at the Preferred
Provider level of benefits. See Preferred
Provider information.
- If
a Preferred
Provider is not available in your Network
Area (within 50 miles), benefits will be paid at the level
of benefits shown
as
Preferred Provider benefits.
- If the Covered
Medical Expenses are incurred
due to an emergency treatment, benefits
will be paid at the Preferred Provider level of Benefits. In
all other
situations,
reduced,
or
lower benefits will be provided when
an Out-of-Network
provider
is used.
- The Benefits payable are as
defined in
and subject to all provisions
of the Policy.
| Inpatient |
| |
In Network (preferred providers) |
Out of Network |
| Location |
Within 50 miles of WHC:
- Boulder Community Hospital
- University of Colorado Hospital/ University
Physicians
Outside 50 miles of WHC:
|
|
|
Hospitalization Fee
|
$200 per hospitalization in addition to deductible
|
$200 per hospitalization in addition to deductible
|
|
Room & Board/Hospital Miscellaneous, daily semi-private
room rate, and general nursing care provided by the hospital.
Hospital miscellaneous expenses such as the cost of the
operating room, laboratory tests, X-ray examinations, anesthesia,
drugs (excluding take-home drugs) or medicines, therapeutic
services, and supplies. In computing the number of days
payable under this benefit, the date of admission will be
counted, but not the date of discharge.
|
80 percent of Preferred Allowance
|
50 percent of usual and customary charges
|
|
Intensive Care
|
Paid under Hospital Miscellaneous
|
Paid under Hospital Miscellaneous
|
|
Physiotherapy
|
80 percent of Preferred Allowance
$2000 maximum per policy year |
50 percent of usual and customary charges
$2000 maximum per policy year |
|
Surgeon's Fees, if multiple procedures are performed,
the second procedure will be payable at 50 percent and the third
procedure will be payable at 25 percent. Four or more procedures
will be paid a composite fee based on the physician' s written
report.
|
80 percent of Preferred Allowance
|
50 percent of usual and customary charges
|
|
Anesthetist
|
80 percent of Preferred Allowance
|
80 percent of usual and customary charges
|
|
Registered Nurse's Services, private-duty nursing
care
|
80 percent of Preferred Allowance
|
50 percent of usual and customary charges
|
|
Physician's Visits, benefits are limited to one visit
per day and do not apply when related to surgery
|
80 percent of Preferred Allowance
|
50 percent of usual and customary charges
|
|
Pre-Admission Testing, benefits for
eligible charges incurred in connection with pre-admission
X-rays and laboratory tests when the resulting hospital
confinement starts within 10 days.
|
80 percent of Preferred Allowance
|
50 percent of usual and customary charges
|
|
Psychotherapy (Inpatient), $50,000 Aggregate Lifetime
Maximum for all psychotherapy treatment or services
|
80 percent of Preferred Allowance
45 days maximum (per policy year)
|
50 percent of usual and customary charges
45 days maximum (per policy year)
|
|
Biologically Based Mental Illness
|
Paid as any other sickness
|
Paid as any other sickness
|
|
Alcoholism/Drug Abuse
|
80 percent of Preferred Allowance
45 days maximum (per policy year)
|
50 percent of Usual & Customary Charges
45 days maximum (per policy year)
|
| Outpatient |
| |
In Network (preferred providers) |
Out of Network |
| Location |
Within 50 miles of WHC:
- Boulder Community Hospital
- University of Colorado Hospital/ University Physicians
Outside 50 miles of WHC:
|
50 miles
|
|
Surgeon's Fees, if multiple procedures are performed,
the second procedure will be payable at 50 percent and the third
procedure will be payable at 25 percent. Four or more procedures
will be paid a composite fee based on the physician's written
report.
|
80 percent of Preferred Allowance
|
50 percent of usual and customary charges
|
|
Day Surgery Miscellaneous related to scheduled surgery
performed in a hospital, including the cost of the operating
room; laboratory tests and X-ray examinations, including
professional fees; anesthesia; drugs or medicines; and supplies.
Usual and Customary charges for Day Surgery Miscellaneous
are based on the Outpatient Surgical Facility Charge Index.
|
80 percent of Preferred Allowance
|
50 percent of usual and customary charges
|
|
Anesthetist
|
80 percent of Preferred Allowance
|
80 percent of usual and customary charges
|
|
Physician's Visits benefits are limited to one visit
per day. Benefits for Physician's Visits do not apply when
related to surgery or physiotherapy.
|
80 percent of Preferred Allowance
|
50 percent of usual and customary charges
|
|
Physiotherapy, Dialysis Treatment, Speech and Respiratory
Therapy benefits are limited to one visit per day
and do not apply when related to physician's visits.
Benefits are payable only for a condition that required
surgery or hospital confinement: 1) within the 30 days
immediately preceding such physiotherapy, or 2) within
the 30 days immediately following the attending physician's
release for rehabilitation. In addition, physiotherapy
visits for other than surgery or hospitalization are
available at Wardenburg Health Center only; copay $10.
|
80 percent of Preferred Allowance
$2000 maximum per policy year
|
50 percent of usual and customary charges
$2000 maximum per policy year
|
|
Medical Emergency Expenses, use of the Emergency
Room and supplies
|
$200 per visit in addition. to deductible / waived if hospitalized
80 percent of Preferred Allowance
|
$200 per visit in addition to deductible / waived if hospitalized
50 percent of usual and customary charges
|
|
Diagnostic X-ray & Laboratory Services
|
80 percent of Preferred Allowance
|
50 percent of usual and customary charges
|
|
Radiation Therapy & Chemotherapy
|
80 percent of Preferred Allowance
|
50 percent of usual and customary charges
|
|
Prescription Drugs, benefits payable for generic
drugs (and brand drugs when no generic drugs are available).
The policy deductible does not apply to prescriptions. (Limited
to 30-day supply or 100 units, whichever is greater, at
time of purchase.)
|
50 percent of negotiated Express Scripps rate
$2,000 maximum (per policy year)
|
No Benefits
|
|
Tests & Procedures, diagnostic services and medical
procedures performed by a physician; other than physician's
visits; physiotherapy; X-rays and lab procedures.
|
80 percent of Preferred Allowance
|
50 percent of usual and customary charges
|
|
Injections, when administered in the physician's
office and charged on the physician's statement
|
80 percent of Preferred Allowance
|
50 percent of usual and customary charges
|
|
Psychotherapy $50,000 Aggregate Lifetime Maximum
for all psychotherapy treatment or services
|
80 percent of Preferred Allowance
$2,000 maximum (per Policy year)
|
50 percent of usual and customary charges
$2,000 maximum (per Policy year)
|
|
Biologically Based Mental Illness
|
Paid as any other sickness
|
Paid as any other sickness
|
|
Alcoholism/Drug Abuse
|
80 percent of Preferred Allowance
$2,000 maximum (per policy year)
|
50 percent of usual and customary charges
$2,000 maximum (per policy year)
|
| Other |
|
Ambulance Services
|
80 percent of Preferred Allowance
|
50 percent of Preferred Allowance
|
|
Braces and Appliances, a written prescription must
accompany the claim when submitted. Replacement braces and
appliances are covered if required because of a change in
the insured's physical condition. Benefits include prosthetic
devices.
|
80 percent of Usual and Customary Charges
|
50 percent of Usual and Customary Charges
|
|
Consultant Physician Fees, when requested and approved
by the attending physician
|
80 percent of Preferred Allowance
|
50 percent of usual and customary charges
|
|
Dental Treatment, made necessary by injury to sound,
natural teeth
|
80 percent of Preferred Allowance
$2,000 maximum (per policy year)
|
50 percent of usual and customary charges
$2,000 maximum (per policy year)
|
|
Maternity/Complications of Pregnancy
|
Paid as any other sickness
|
Paid as any other sickness
|
|
Repatriation/Medical Evaluation
|
Benefits provided by Assist America
|
Benefits provided by Assist America
|
|
Mammography
When referred. The policy deductible will not apply
|
100 percent Preferred Allowance
|
50 percent of usual and customary charges
|
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)
|
 |
