Plan year: August 18, 2007–August 17, 2008
Student Gold Health Insurance Plan
Benefits outside of Wardenburg Health Center
Referrals
Is there a requirement of
written referrals?
All services outside of Wardenburg Health Center require a written
referral (See Exceptions to the requirement of a written
referral).
Benefits provided outside of Wardenburg Health Center are underwritten
by
the Chickering Group/Aetna.
What do I need to know about
Written Referrals?
A written referral for outside care is required from Wardenburg Health
Center to see providers in-network and out-of-network
when treatment is rendered within a 50-mile radius of Wardenburg
Health Center.
Exceptions to the requirement
of a written referral
- You need care due to an accident(s).
- You
are seeking medical care for dependents
- You are seeking treatment
when Wardenburg Health Center is closed.
- You have a medical emergency, which means the occurrence of a
sudden, serious, and unexpected sickness or injury. In the absence
of immediate medical attention, a reasonable person could believe
this condition would result in:
- Death*
- Placement of the insured's health in jeopardy*
- Serious impairment of bodily functions*
- Serious dysfunction of any body organ or part *
- In the case of a pregnant woman, serious jeopardy to the
health of the fetus*
*Expenses incurred for medical emergency will be paid only
for sickness or injury that fulfills the above conditions.
These expenses will not be paid for minor injuries or minor
illnesses.
- You need care and are outside the 50-mile radius of Wardenburg
Health Center. (Benefits will apply for in-network and out-of-network
visits.)
Providers
What is a preferred provider,
in-network, and out-of-network providers?
-
Preferred providers
are the physicians, hospitals, and other health care providers
who have contracted to provide specific medical care at negotiated
prices. A preferred provider is also called an in-network provider.
-
Providers
that have not been contracted to provide specific medical care at negotiated
prices are called out-of-network providers. You may incur significant
out-of-pocket expenses with these providers. Charges for services
rendered in excess of the insurance payment are your responsibility.
What is my In-Network Provider
Benefit?
When using an in-network health care provider other than Wardenburg
Health Center, the plan pays 80 percent of preferred allowance for outpatient
and inpatient care and professional services (once your deductible
is satisfied). (See table for the Schedule
of Medical Expense Benefits)
What is my Out-of-Network
Provider benefit?
When using an Out-of-Network health care provider, inpatient or
outpatient, the plan pays 50 percent of reasonable charges* for
most services once the deductible is met. (See table for Schedule
of Medical Expense Benefits)
*Based on the Medical Data Research (MDR) Index.
How do I find a preferred
provider to receive services outside of Wardenburg Health Center?
(Note: You will need to obtain a referral from a Wardenburg Health
Care provider. For appointment and information go to www.colorado.edu/healthcenter.)
For a list of in-network providers and
services outside of Wardenburg Health Center,
call Chickering at 888-834-4708 or go to www.chickering.com, select "Find Your School," enter "University of Colorado," and click "DocFind."
The availability of specific providers
is subject to change without notice. You
should always confirm that a preferred provider
is participating at the time services are
required by calling Chickering at 888-834-4708, by checking www.chickering.com, and/or by asking the provider
when you make an appointment for services.
Regardless of the provider, you are responsible for the payment
of your deductible. You must satisfy your deductible before benefits
are paid. Benefits will be paid according to the benefit limits
in the Schedule of Medical Expense Benefits.
Who are preferred providers?
Preferred providers are specialists, hospitals, urgent care centers, and medical facilities that are part of the Aetna Network. Go to www.chickering.com for more details.
Deductibles
What is my deductible?
Your deductible is $200 per person per plan year for the Student Gold Health Insurance Plan for services outside Wardenburg Health
Center. Benefits are payable after you have satisfied a deductible
each plan year and the Wardenburg Health Center referral system
has been properly used.
You are responsible for your deductible whenever you are seen outside
Wardenburg Health Center, even if you are referred by a Wardenburg
Health Center provider and/or Wardenburg Health Center is closed.
The deductible does not apply to eligible expenses incurred at Wardenburg
Health Center.
Co-Insurance
What percentage of my health
care costs (co-insurance percentage) is covered by the Student Gold Health Insurance Plan?
After your $200 deductible is met and you use an in-network
provider (preferred provider), the plan covers:
- 80 percent of the preferred allowance for most outpatient care and
professional services
- 80 percent of the preferred allowance for most inpatient hospitalization
care services
After your $200 deductible is met and you use an out-of-network
provider, the plan covers:
- 50 percent of reasonable charges* for most outpatient care and professional
services
- 50 percent of reasonable charges* for most inpatient hospitalization
care services
*Based on the Medical Data Research (MDR) Index.
What are the General Services
and Coverage Benefits Outside of Wardenburg Health Center?
The following outlines the basic features of the services and benefits
provided outside of Wardenburg Health Center. For more detailed information,
please refer to the Chickering Group/Aetna booklet
(which is sent to you when you enroll in the plan), or call 888-834-4708.
Benefits provided outside of Wardenburg Health Center are underwritten
by the Chickering Group/Aetna and require a referral
from Wardenburg Health Center.
- There is a $200 deductible per person for services outside
of Wardenburg Health Center.
- There is an aggregate maximum benefit of $250,000 per insured, per lifetime.
- If Wardenburg Health Center is closed and you seek medical attention,
you are required to meet the $200 deductible per person per
plan year.
- Your benefits for care outside of Wardenburg Health Center are
determined by the use of in-network or out-of-network providers
and services received, meeting your deductible, and complying
with the referral requirement.
- There is a $50 charge per emergency room visit in addition
to your deductible; then benefits will apply for in-network and
out-of-network services. (The $50 emergency room visit charge
is waived if you are hospitalized.) Go to What are
my hospitalization benefits and notification requirements for more information.
- There is a $200 charge for hospitalization in addition to
your deductible; then benefits will apply for in-network and out-of-network
services. Go to What are my hospitalization benefits
and notification requirements for more information.
- One mammogram per plan year will be covered at 100 percent with no deductible. See policy for age restrictions.
- One cytologic screening (pap smear) for women
18 years of age and older.
- One prostate cancer screening per plan year for any male insured,
50 years and up.
- Medically appropriate and necessary equipment for diabetes.
- Psychotherapy (Outpatient and Inpatient)
- Biologically based mental illness will be paid as any other sickness.
- Travel emergency medical assistance
- Prescription benefit provides 50 percent of reasonable charges* up to $3,000 dollars per plan year
- Spouse/Domestic Partner and Dependent Coverage is available.
*Based on the Medical Data Research (MDR) Index.
What is the mammography
benefit?
Benefits will be paid as for any other sickness for low-dose* screening
mammography for the presence of occult breast cancer for the actual
cost as listed for mammography on the Schedule of Medical Expense
Benefits; benefits will not be subject to any policy deductibles.
Coverage shall be provided according to the following guidelines:
- A single baseline mammogram for women thirty-five to thirty-nine
years of age.
- A mammogram not less than once every two years for women forty
to forty-nine years of age, or more often for women with higher
than average risk factors for breast cancer if recommended by
her physician.
- A mammogram every year for women fifty to sixty-five years of
age.
- A single baseline mammogram for women at high risk when referred.
*Low-dose mammography” means the X-ray examination of the
breast, using equipment dedicated specifically for mammography, including
but not limited to the X-ray tube, filter, compression device, screens,
films, and cassettes, with an average radiation exposure delivery
of less than one rad mid-breast, with two views for each breast.
What is the female cytologic
screening (pap smear and pelvic exam) benefits?
Benefits will be paid as any other sickness for cytologic screening
for women 18 years of age and older. One cytologic screening will
be payable every year (excluding females who have had a hysterectomy).
Benefits payable will be subject to the policy deductible and coinsurance,
if any.
“Cytologic screening” means a Papanicolaou Test (PAP
smear) and a pelvic exam. (An annual Pap smear and pelvic exam is
also covered at Wardenburg Health Center.)
What are the prostate cancer
screening benefits?
Benefits will be paid for actual billed charges, up to $65, for
an annual screening for the early detection of prostate cancer when
performed by a physician. Benefits will be payable for one screening
per year for any male insured, 50 years of age or older.
One screening per year shall be covered for any male insured 40
to 50 years of age who is at higher than average risk of developing
prostate cancer, as determined by the insured's physician.
The screening shall consist of the following tests:
- A prostate-specific antigen (PSA) blood test
- Digital rectal examination
Such benefit shall not reduce any diagnostic benefits otherwise
allowable under the policy. No deductible will apply for such screening.
What are the diabetes benefits?
Benefits will be provided for all medically appropriate and necessary
equipment, supplies, and diabetes self-management training and
educational services used to treat diabetes, if your treating
physician or a physician who specializes in the treatment of diabetes
certifies that such services are medically necessary. Diabetes
self-management training, educational services, and nutrition
counseling must be provided under the direct supervision of a
physician.
“Diabetes self-management training” means instruction
in an inpatient or outpatient setting -- including medical nutrition
therapy relating to diet, caloric intake, and diabetes management
(excluding programs of which the primary purposes are weight reduction)—that enables diabetic patients to understand the diabetic management
process and daily management of diabetic therapy as a method of avoiding
frequent hospitalizations and complications. The instruction must
be provided in accordance with a program in compliance with the National
Standards for Diabetes Self-Management Education Programs as developed
by the American Diabetes Association.
These benefits shall be provided to the same extent as for any other
sickness under the policy and are subject to all deductible, coinsurance,
limitations, and provisions of the policy.
What are the psychotherapy benefits?
- Nonbiological-based mental illnesses
Benefits for psychotherapy on an outpatient basis are as shown
in the Schedule of Medical Expense Benefits. When hospital
confined, benefits will be paid as shown in the Schedule
of Medical Expense Benefits, not to exceed 45 days inpatient confinement
and 90 days partial confinement per policy year.
All Covered Medical Expenses incurred as a result of psychotherapy
treatment or services are subject to the stated maximums (Please
see the table for the Schedule of Medical
Expense Benefits; if
otherwise provided under the policy, this includes items such
as prescription drugs and diagnostic testing.
- Biologically based mental illnesses?
Benefits are subject to any deductible, coinsurance, provisions
or other limitations of the policy. A referral is needed for
services outside of Wardenburg Health Center.
Benefits will be paid as any other sickness for the treatment
of biologically based mental illness. The benefit provided will
not duplicate any other benefits provided in this policy.
"Biologically based mental illness" means schizophrenia, schizo-affective
disorder, bipolar affective disorder, major depressive disorder, specific obsessive-compulsive
disorder, and panic disorder.
What is the travel emergency
medical assistance benefit?
You are eligible for global emergency medical assistance services
when you travel abroad or 100 miles or more from your permanent home
or campus address. Services are accessible 24 hours a day, 365 days
a year, and are provided by Assist America, Inc.
Key services include:
- Care for minor children
- Critical care monitoring
- Emergency medical evacuation
- Emergency message transmission
- Emergency trauma counseling
- Hospital admission guarantee
- Interpreter and legal referrals
- Lost luggage or document assistance
- Medical consultation, evaluation and referrals
- Medically supervised repatriation
- Prescription assistance
- Return of mortal remains
- Transportation to join patient
Please see www.AssistAmerica.com for
service descriptions.
To access Assist America services, please call:
800-872-1414 toll-free within the United States
301-656-4152 collect outside the United States
E-mail: medservices@AssistAmerica.com
Assist America is not travel or medical insurance; it provides emergency
medical assistance services. All medical costs incurred should be
submitted to your health plan and are subject to the policy limits
of your health coverage. All assistance services must be arranged
and provided by Assist America. Claims for reimbursement for services
not provided by Assist America will not be accepted.
Your spouse/domestic partner and dependent children may also be
eligible for services.
What is the prescription
benefit?
Your prescription benefits provide 50 percent of reasonable charges*
up to $3,000 maximum per policy year (allergy antigens, birth control
pills, Depo Provera, diaphragms, and cervical caps are
included in benefit).
*Based on the Medical Data Research (MDR) Index.
The prescription benefit is managed by Aetna Pharmacy Management.
You may fill your prescription at any pharmacy that accepts Aetna prescription cards.
What are my hospitalization
benefits and notification requirements?
Chickering must be notified of all hospital confinements prior to
admission. Chickering is open for pre-admission notification calls
from 8:30 a.m. to 6:30 p.m., MST, Monday through Friday. Calls may
be left on the customer service department's voice mail after hours
by calling 888-834-4708.
Pre-notification of medical non-emergency hospitalizations. The
patient, physician, or hospital should telephone 888-834-4708 at
least five working days prior to the planned admission.
Notification of medical emergency admissions. The patient, patient's
representative, physician, or hospital should telephone 888-834-4708
within two working days of the admission to provide the notification
of any admission due to medical emergency.
Important: Pre-notification is not a guarantee that benefits will
be paid.
All benefits provided outside of Wardenburg Health Center are underwritten
by the Chickering Group/Aetna and the benefits payable
are as defined in and subject to all provisions of the Policy. (www.chickering.com) |
