2012-2101-31 preliminary association benefit summary v4_benefit summary

Student Injury and Sickness
Insurance Plan for
ACSA - Budget Plan - New York Residents
2012-2013
ACSA is pleased to offer an Injury and Sickness Insurance Plan underwritten by UnitedHealthcare Insurance Company of New York to its members. All registered domestic undergraduate students taking 6 or more hours (3 hours during summer sessions); all graduate students taking 3 or morehours and/or registered for thesis or dissertation (maximum for one year if not taking credit hours); all registered students taking classes via the internet are eligible to enroll in the plan on a voluntary basis.
The student would have to be registered for and taking classes on campus in order for internet classes to qualify toward meeting the eligibility requirements. Eligible Dependents and Domestic Partners of students enrolled in the plan may participate in the plan on a voluntary basis. All students enrolled in a college, university, community college or technical school may purchase this plan as longas the eligibility requirements are met. International students, scholars, exchange program participants, participating in Optional Practical Training, internships, research and teaching, with a valid passport and all types of visas that allow for study who have not applied for permanent residency in the U.S. are eligible to enroll in the plan on a voluntary basis. Eligible dependents, as defined in the policy, who accompany the student and have a similar visa or passport, are eligible to enroll in the Highlights of the Coverage and Services
offered by UnitedHealthcare StudentResources are:
Up to $1,250,000 Per Insured Person, Per Policy Year Maximum Benefit for Covered Medical $5,000 Deductible Per Insured Person Per Policy Year. Covered Medical Expenses for Preferred Providers are payable at 80% of Preferred Allowance and Out of Network benefits are payable at 50% of Usual and Customary charges, up to $1,000 before the Insured Person is responsible for the Policy Deductible. Once the Policy Deductible of $5,000 Per Insured Person, Per Policy Year has been satisfied, the covered Medical Expenses are again payable at 80% of Preferred Allowance for Preferred Providers and Out of Network benefits are payable at 50% of Usual and Customary charges (all benefits are subject to satisfaction ofthe Deductible, specific benefit limitations, maximums and copays as described in the Prescription Drug Benefits: $25 Copay for Tier 1 / $45 Copay for Tier 2 / $60 Copay forTier 3 up to a 31-day supply per prescription filled at a UnitedHealthcare NetworkPharmacy (UHPS). Prescriptions must be filled at a UHPS network pharmacy.
Coverage available for eligible Dependents.
The Preferred Provider Network for this plan is: UnitedHealthcare Options PPO. Preferred Providers can be found using the following link,http://www.uhcsr.com/lookupredirect.aspx?delsys=01 Preventive Care Services which include, but are not limited to, annual physicals, GYN exams,routine screenings and immunizations are covered at 100% with no copay or deductible onlywhen the services are received from a Preferred Provider. Please see www.healthcare.govfor complete details of the services provided for specific age and risk groups.
Student - Under Age 24
Student - Age 24 to 29
Student - Age 30 and older
Each Child
*This plan is effective from 8/1/12 - 10/31/13 and the Annual enrollment is for 12 months during this time.
UnitedHealthcare StudentResources
Pre-Existing Condition: means any condition for which medical advice,
16. Outpatient Physiotherapy; except for a condition that required diagnosis, care or treatment was recommended or received within the surgery or Hospital Confinement: 1) within the 30 days immediately 6 months immediately prior to the Insured’s Effective date under the policy.
preceding such Physiotherapy; or 2) within the 30 days immediately “Pre-existing condition” does not include pregnancy.
following the attending Physician's release for rehabilitation; Exclusions and Limitations
No benefits will be paid for: a) loss or expense caused by, 18. Participation in a felony, riot or insurrection; contributed to, or resulting from; or b) treatment, services or supplies 19. Pre-existing Conditions, except for individuals who have been continuously insured under the school’s student insurance policy for Chemical Dependence (Alcoholism/Drug Abuse), except as at least 12 consecutive months. The Pre-existing Condition specifically provided in Benefits for Chemical Dependence exclusionary period will be reduced by the total number of months that the Insured was covered under Creditable Coverage which was Cosmetic procedures, except that cosmetic procedures does not continuous to a date not more than 63 days prior to the Insured’s include reconstructive surgery when such surgery is incidental to or follows surgery resulting from trauma, infection or other disease of 20. Prescription Drugs, services or supplies as follows, except as the involved part and reconstructive surgery because of a congenital disease or anomaly of a covered Dependent child which has resulted a. Therapeutic devices or appliances, including: hypodermic in a functional defect. It also does not include breast reconstructive needles, syringes, support garments and other non-medical substances, regardless of intended use, except as specifically Custodial Care; care provided in: rest homes, health resorts, homes provided in the Benefits for Diabetes Expense; for the aged, halfway houses, college infirmaries or places mainly for b. Drugs labeled, “Caution - limited by federal law to investigational domiciliary or custodial care; extended care in treatment or substance abuse facilities for domiciliary or custodial care; c. Fertility agents or sexual enhancement drugs, such as Parlodel, Dental treatment, except for accidental Injury to Sound, Natural Teeth Pergonal, Clomid, Profasi, Metrodin, Serophene, or Viagra, d. Refills in excess of the number specified or dispensed after one (1) year of date of the prescription.
Eye examinations, eyeglasses, contact lenses, prescriptions or fitting 21. Preventive medicines, serums, vaccines or immunizations; except as of eyeglasses or contact lenses. Vision correction, or other treatment for visual defects and problems; except when due to a disease 22. Routine Newborn Infant Care, well-baby nursery and related Physician charges, except as specifically provided in the Benefits for Foot care in connection with corns, calluses, flat feet, fallen arches, weak feet, chronic foot strain or symptomatic complaints of the feet; 23. Routine physical examinations and routine testing; preventive testing Hearing examinations or hearing aids; or other treatment for hearing or treatment; screening exams or testing in the absence of Injury or defects and problems. "Hearing defects" means any physical defect Sickness; except as specifically provided in the policy; of the ear which does or can impair normal hearing, apart from the 24. Services provided normally without charge by the Student Health Center of the Policyholder; or services covered or provided by the 10. The Insured’s being intoxicated or under the influence of any narcotic unless administered on the advice of a Physician; 25. Flight in any kind of aircraft, except while riding as a passenger on a 11. Injury or Sickness for which benefits are paid or payable under any regularly scheduled flight of a commercial airline; Workers' Compensation or Occupational Disease Law or Act, or 26. Suicide or attempted suicide or intentionally self-inflicted Injury; 27. Supplies, except as specifically provided in the policy; 12. Injury or Sickness outside the United States and its possessions, 28. Treatment in a Government hospital, unless there is a legal obligation Canada or Mexico, except for a Medical Emergency when traveling for the Insured Person to pay for such treatment; for academic study abroad programs business or pleasure; 29. Treatment, service or supply which is not a Medical Necessity, 13. Injury sustained by reason of a motor vehicle accident to the extent subject to Article 49 of N.Y. Insurance Law; and that benefits are paid or payable by mandatory automobile no-fault 30. War or any act of war, declared or undeclared; or while in the armed forces of any country (a pro-rata premium will be refunded upon 14. Injury sustained while (a) participating in any interscholastic sport, request for such period not covered).
contest or competition; (b) traveling to or from such sport, contest orcompetition as a participant; or (c) while participating in any practiceor conditioning program for such sport, contest or competition; 15. Investigational services or experimental treatment, except for experimental or investigational treatment approved by an ExternalAppeal Agent in accordance with Insured Persons Right to anExternal Appeal. If the External Appeal Agent approves benefits ofan experimental or investigational treatment that is part of a clinicaltrial, this policy will only cover the costs of services required toprovide treatment to the Insured according to the design of the trial.
The Company shall not be responsible for the cost of investigationaldrugs or devices, the costs of non-health cares services, the cost ofmanaging research, or costs which would not be covered under thispolicy for non-experimental or non-investigational treatmentsprovided in such clinical trial;

Source: http://www.frontier.edu/webdocs/fnu_healthplan_ny_budget-2012-2101-31.pdf