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Healthservices.boisestate.edu

2013–2014 BOISE STATE UNIVERSITY — SHIP SUMMARY
This student injury and sickness insurance plan is underwritten by UnitedHealthcare Insurance Company and is based on policy 2013-286-1. The Policy is a Non-Renewable One-Year Term Policy. This is a summary of the plan. Please read the certificate of coverage to determine whether this plan is right for you before you enroll. The certificate of coverage provides details of coverage, including costs, benefits, exclusions, any reductions or limitations, and the terms under which the coverage may be continued in force. Copies of the certificate are available from the University or may be viewed and downloaded at www.4studenthealth.com/boisestate.
Welcome!
Boise State University is pleased to offer an Injury and Sickness Insurance Plan underwritten by UnitedHealthcare Insurance Company. All full-time, full-fee paying domestic undergraduate students enrolled in at least 12 credit hours, all domestic full-fee paying graduate students enrolled in at least 9 credit hours, all graduate assistants and graduate fellows enrolled in at least 9 credit hours, all intercollegiate graduate assistants and all international students attending school at Boise State University are automatically enrolled in this insurance plan, unless proof of comparable coverage is furnished. All intercollegiate athletes are required to enroll in this insurance plan and cannot waive the health insurance. Also, all full-time non-full fee paying domestic students and part-time students (9–11 credit hours for undergraduate and 6–8 credit hours for graduate) are eligible to enroll on a voluntary basis.
Eligible students who do enroll may also insure their Dependents. Eligible Dependents are the student’s dependent children under 26 years of age.
Rates and Term Dates
MANDATORY
VOLUNTARY
Dates of Coverage
8/1/13–12/31/13
1/1/14–7/31/14
Dates of Coverage
8/1/13–12/31/13
1/1/14–7/31/14
Waiver/Enrollment
Enrollment
Deadline
Deadline
All Children
All Children
Preferred Provider Information
For a complete listing of Preferred Provider doctors and facilities within Idaho, call the Idaho Physicians Network (IPN) at 1-866-476-1076 or visit
www.ipnmd.com. For Preferred Providers outside Idaho, call the First Health Network at 1-800-226-5116 or visit www.myfirsthealth.com.
Prescription Drugs
If you fill your prescriptions at an Express Scripts pharmacy (Preferred Provider), simply present your ID card to the pharmacist and pay the applicable Copay at time of pickup. There are no claims to file. To locate an Express Scripts pharmacy near you, call 1-800-447-9638 or visit www.express-scripts.com.
Some local Express Scripts pharmacies include Albertson’s, Rite Aid, and Walmart.
If you fill your prescription at a pharmacy that is NOT in the Express Scripts network (out-of-network Provider), you must pay for it in full at the time of pickup. You may then submit a claim to AmeriBen for reimbursement for the portion the Company is responsible for paying.
Insurance ID Card
Your permanent ID card will be mailed to your address on your myBoiseState account after the start of Fall Semester. Permanent ID cards are mailed to you only once each school year (not each semester). If you need a replacement card, or haven’t received your card by mid-October, please contact AmeriBen at 1-877-955-1556. If you need to access medical care prior to receiving your permanent ID card in the mail, you may download and use a temporary card
from www.4studenthealth.com/boisestate.
On Campus Health Insurance & Billing Office:
Benefits, Claims, and ID Cards:
Waiver, Enrollment, and Plan Materials:
Hours: Monday–Friday, 8:00 a.m. to 5:00 p.m. Hours: Monday–Friday, 8:00 a.m. to 5:00 p.m. NOTICE REGARDING YOUR STUDENT HEALTH INSURANCE COVERAGE
Your student health insurance coverage, offered by UnitedHealthcare Insurance Company, may
not meet the minimum standards required by the Healthcare Reform Law for restrictions on an-
nual dollar limits. The annual dollar limits ensure that consumers have sufficient access to medi-
cal benefits throughout the annual term of the policy. The restriction for annual dollar limits for
group and individual health insurance coverage is $2 million for policy years beginning on or
after September 23, 2012, but before January 1, 2014. The restriction on annual dollar limits for
student health insurance coverage is $500,000 for policy years beginning on or after Septem-
ber 23, 2012, but before January 1, 2014. Your student health insurance coverage puts a policy
year limit of $500,000 that applies to the essential benefits provided in the Schedule of Ben-
efits unless otherwise specified. If you have any questions or concerns about this notice, contact
Customer Service at 1-877-955-1556. Be advised that you may be eligible for coverage under a
group health plan of a parent’s employer or under a parent’s individual health insurance policy
if you are under 26 years of age. Contact the plan administrator of the parent’s employer plan or
the parent’s individual health insurance issuer for more information.
Page 1 of 4
Schedule of Medical Expense Benefits
Injury and Sickness
Maximum Benefit:
$500,000 (Per Insured Person) (Per Policy Year) Paid as Specified Below
Deductible: Preferred Provider: $1,000 (Per Insured Person) (Per Policy Year) Out-of-Network: $2,000 (Per Insured Person) (Per Policy Year)
Coinsurance: Preferred Provider: 80% of Preferred Allowance, except as noted below Out-of-Network: 60% of Usual & Customary Charges, except as
noted below
Out-of-Pocket Maximum: Preferred Provider: None; Out of Network: None
The Policy provides benefits for the Covered Medical Expenses incurred by an Insured Person for loss due to a covered Injury or Sickness up to the
Maximum Benefit of $500,000.
The Preferred Provider for this plan is Idaho Physicians Network (IPN) in Idaho and First Health Network outside Idaho.
If care is received from a Preferred Provider, any Covered Medical Expenses will be paid at the Preferred Provider level of benefits. If a Preferred Provider is not available in the Network Area, benefits will be paid at the level of benefits shown as Preferred Provider benefits. If the Covered Medical Expense is incurred due to a Medical Emergency, 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.
Health Services Benefits: The Deductible will be waived when treatment is rendered at the Health Center. The following benefits will be paid at
100% of Covered Medical Expenses at the Health Center:
• Doctor’s Visits• Preventive Care Services• Immunizations• Injections (includes allergy injections)• Acne Treatment (when Medically Necessary)• Lab tests (Health Services sends certain lab tests off-site for processing. These fees are payable at 80% and are subject to the Deductible.)• Mental Illness Treatment• Medical Massage therapy (20 visits maximum)• Durable Medical Equipment (when available) For additional services available at the Health Center, go to the Website http://healthservices.boisestate.edu/
Treatment received by Dependents at the Health Center will be paid the same as a Preferred Provider.
Usual & Customary Charges are based on data provided by FAIR Health, Inc., using the 90th percentile based on location of provider.
Benefits are subject to the policy Maximum Benefit unless otherwise specifically stated. Benefits will be paid up to the Maximum Benefit for each service as scheduled below. All benefit maximums are combined Preferred Provider and Out-of-Network unless otherwise specifically stated. Covered Medical PA = Preferred Allowance U&C = Usual & Customary Charges
INPATIENT
Preferred Providers
Out-of-Network Providers
Room and Board Expense, daily semi-private room rate when confined as an Inpatient; 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.
Intensive Care
Routine Newborn Care, while Hospital Confined; and routine nursery care provided immedi-
ately after birth for an Inpatient stay of at least 48 hours following a vaginal delivery or 96 hours following a cesarean delivery. If the mother agrees, the attending Physician may discharge the newborn earlier.
Physiotherapy
Surgeon’s Fees, If two or more procedures are performed through the same incision or in im-
mediate succession at the same operative session, the maximum amount paid will not exceed 50% of the second procedure and 50% of all subsequent procedures.
Assistant Surgeon
Anesthetist, professional services administered in connection with Inpatient surgery.
Registered Nurse’s Services, private-duty nursing care.
Physician’s Visits, non-surgical services when confined as an Inpatient.
Pre-Admission Testing, payable within 7 working days prior to admission.
OUTPATIENT
Preferred Providers
Out-of-Network Providers
Surgeon’s Fees, if two or more procedures are performed through the same incision or in im-
mediate succession at the same operative session, the maximum amount paid will not exceed 50% of the second procedure and 50% of all subsequent procedures.
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.
Assistant Surgeon
Anesthetist, professional services administered in connection with outpatient surgery.
Physician’s Visits
Physiotherapy, includes but is not limited to the following: 1) physical therapy; 2) occupational
therapy; 3) cardiac rehabilitation therapy; 4) manipulative treatment; and 5) speech therapy. Speech therapy will be paid only for the treatment of speech, language, voice, communication, and auditory processing when the disorder results from Injury, trauma, stroke, surgery, cancer, or vocal nodules. (20 visits maximum Per Policy Year each for physical therapy, occupational therapy, and speech therapy.) (36 visits maximum Per Policy Year for cardiac therapy.) (Re- view of Medical Necessity will be performed after 12 visits per Injury or Sickness.)
Diagnostic X-ray Services
Page 2 of 4
OUTPATIENT (continued)
Preferred Providers
Out-of-Network Providers
Medical Emergency Expenses, facility charge for use of the emergency room and supplies.
Treatment must be rendered within 72 hours from time of Injury or first onset of Sickness. (The Copay/per visit Deductible will be waived if admitted to the Hospital.) Radiation Therapy
Chemotherapy
Laboratory Services
Tests & Procedures, diagnostic services and medical procedures performed by a Physician,
other than Physician’s Visits, Physiotherapy, X-Rays, and Lab Procedures. The following thera- pies will be paid under this benefit: inhalation, infusion, pulmonary, and respiratory.
Injections, when administered in the Physician’s office and charged on the Physician’s statement.
Prescription Drugs (up to a 30-day supply per prescription when filled at an Express Scripts
participating pharmacy.) (Copays waived for generic and single-source brand name contracep- tives.) (Diabetic prescriptions are covered as any other prescription.) If you fill your prescriptions at an Express Scripts pharmacy (Preferred Provider), simply pres- ent your ID card to the pharmacist and pay the applicable Copay at time of pickup. There are no claims to file. To locate an Express Scripts pharmacy near you, call 1-800-447-9638 or visit
www.express-scripts.com. Some local Express Scripts pharmacies include Albertson’s, Rite
Aid, and Walmart. If you fill your prescription at a pharmacy that is not in the Express Scripts network (out-of- network Provider), you must pay for it in full at the time of pickup. You may then submit a claim to AmeriBen for reimbursement for the portion the Company is responsible for paying.
OTHER
Preferred Providers
Out-of-Network Providers
Ambulance Services
Durable Medical Equipment, a written prescription must accompany the claim when submit-
ted. Benefits are limited to the initial purchase or one replacement purchase per Policy Year. Durable Medical Equipment includes external prosthetic devices that replace a limb or body part but does not include any device that is fully implanted into the body. (Prosthetic devices are limited to $100,000 maximum Per Policy Year.) (Durable Medical Equipment benefits paid under the $100,000 maximum are not included in the $500,000 Maximum Benefit.)
Consultant Physician Fees, when requested and approved by attending Physician.
Dental Treatment, made necessary by Injury to Sound, Natural Teeth only. (Benefits are not
subject to the $500,000 Maximum Benefit.)
Dental Treatment, benefits paid for removal of abscessed teeth or impacted wisdom teeth only.
Maternity, benefits will be paid for an Inpatient stay of at least 48 hours following a vaginal de-
livery or 96 hours following a cesarean delivery. If the mother agrees, the attending Physician may discharge the mother earlier.
Complications of Pregnancy
Mental Illness Treatment, services received on an Inpatient and outpatient basis.
Substance Use Disorder Treatment, services received on an Inpatient and outpatient basis.
Allergy Testing/Treatment (Includes allergy immunotherapy)
Skilled Nursing Facility, services received while confined as a full-time Inpatient in a licensed
Skilled Nursing Facility in lieu of or within 24 hours following a Hospital Confinement. (60 days maximum Per Policy Year)
Home Health Care, services received from a licensed home health agency that are ordered by
a Physician, provided or supervised by a Registered Nurse in the Insured Person’s home, and pursuant to a home health plan. (60 visits maximum Per Policy Year)
Hospice Care, services received from a licensed hospice agency and when recommended by
a Physician for an Insured Person that is terminally ill with a life expectancy of six months or less. (Hospice Care benefits are not subject to the $500,000 Maximum Benefit.)
Medically Necessary Treatment of Acne
Reconstructive Breast Surgery Following Mastectomy, in connection with a covered Mas-
tectomy. (as mandated by state of Idaho for Reconstructive Surgery Following Mastectomy)
Diabetes Services, in connection with the treatment of diabetes for Medically Necessary:
1) outpatient self-management training, education, and medical nutrition therapy service when ordered by a Physician and provided by appropriately licensed or registered healthcare profes- sionals; and 2) Prescription Drugs, equipment, and supplies including insulin pumps and sup- plies, blood glucose monitors, insulin syringes with needles, blood glucose and urine test strips, ketone test strips and tablets, and lancets and lancet devices.
Urgent Care Center, facility or clinic fee billed by the Urgent Care Center. All other services
rendered during the visit will be paid as specified in the Schedule of Benefits.
Sleep Apnea
Preventive Care Services, medical services that have been demonstrated by clinical evidence to
be safe and effective in either the early detection of disease or in the prevention of disease, have No Deductible,
been proven to have a beneficial effect on health outcomes, and are limited to the following as Copays, or Coinsur-
required under applicable law: 1) Evidence-based items or services that have in effect a rating of ance will be applied
“A” or “B” in the current recommendations of the United States Preventive Services Task Force; when the services are
2) immunizations that have in effect a recommendation from the Advisory Committee on Immuniza- received from a Pre-
tion Practices of the Centers for Disease Control and Prevention; 3) with respect to infants, children, ferred Provider
and adolescents, evidence-informed preventive care and screenings provided for in the compre- hensive guidelines supported by the Health Resources and Services Administration; and 4) with respect to women, such additional preventive care and screenings provided for in comprehensive guidelines supported by the Health Resources and Services Administration.
Accident coverage for Intercollegiate sports injuries is provided under a separate policy #2013-286-81. Additional coverage for intercollegiate sports injuries is also available under policy 2013-286-8 for an additional premium. Please see the ICS SHIP Summary for more information. Page 3 of 4
Pre-Existing Condition
Pre-Existing Condition means a condition, whether physical or mental, regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received during the six (6) months immediately preceding the Insured’s Effective Date under the policy. Exclusions and Limitations
No benefits will be paid for: a) loss or expense caused by, contributed to, or resulting from; or b) treatment, services, or supplies for, at, or related to any of the following:1. Acupuncture;2. Addiction, such as nicotine addiction, except as specifically provided in the policy; nonchemical addiction, such as gambling, sexual, spending, 3. Biofeedback;4. Cosmetic procedures, except cosmetic surgery required to correct an Injury for which benefits are otherwise payable under this policy or for 5. Custodial Care; care provided in rest homes, health resorts, homes for the aged, halfway houses, college infirmaries or places mainly for domiciliary or Custodial Care; extended care in treatment or substance abuse facilities for domiciliary or Custodial Care; 6. Dental treatment, except as specifically provided in the Schedule of Benefits;7. Elective Surgery or Elective Treatment;8. Elective abortion, except to preserve the life of the female upon whom the abortion is performed;9. Eye examinations, eye refractions, eyeglasses, contact lenses, prescriptions or fitting of eyeglasses or contact lenses, vision correction surgery, or other treatment for visual defects and problems; except when due to a covered Injury or disease process; 10. Flat foot conditions; supportive devices for the foot; subluxations of the foot; fallen arches; weak feet; chronic foot strain; symptomatic complaints of the feet; and routine foot care including the care, cutting, and removal of corns, calluses, toenails, and bunions (except capsular or bone 11. Hearing examinations; hearing aids; or other treatment for hearing defects and problems, except as a result of an infection or trauma. “Hearing defects” means any physical defect of the ear that does or can impair normal hearing, apart from the disease process; 12. Hirsutism; alopecia;13. Hypnosis;14. Injury or Sickness for which benefits are paid or payable under any Workers’ Compensation or Occupational Disease Law or Act, or similar 15. Injury sustained while (a) participating in any intercollegiate or professional sport, contest, or competition; (b) traveling to or from such sport, contest, or competition as a participant; or (c) while participating in any practice or conditioning program for such sport, contest, or competition; 16. Investigational services;17. Lipectomy;18. Pre-existing Conditions, except for individuals who have been continuously insured under the school’s student insurance policy for at least 12 consecutive months. The Pre-existing Condition exclusionary period will be reduced by the total number of months that the Insured provides documentation of continuous coverage under Qualifying Previous Coverage that was in force within 63 days prior to the Insured’s Effective Date under this policy. This exclusion will not be applied to an Insured Person who is under age 19; 19. Prescription Drugs, services, or supplies as follows: a) Therapeutic devices or appliances, including: hypodermic needles, syringes, support garments, and other non-medical substances, regardless of intended use, except as specifically provided in the policy; b) Biological sera, blood, or blood products administered on an outpatient basis; c) Drugs labeled “Caution - limited by federal law to investigational use” or experimental drugs; d) Products used for cosmetic purposes; e) Drugs used to treat or cure baldness; anabolic steroids used for bodybuilding;f) Anorectics - drugs used for the purpose of weight control;g) Fertility agents, such as Parlodel, Pergonal, Clomid, Profasi, Metrodin, or Serophene; orh) Refills in excess of the number specified or dispensed after one (1) year of date of the prescription; 20. Reproductive/Infertility services including but not limited to: fertility tests; infertility (male or female), including any services or supplies rendered for the purpose or with the intent of inducing conception; premarital examinations; impotence, organic or otherwise; female sterilization procedures except as specifically provided in the policy; vasectomy; sexual reassignment surgery; reversal of sterilization procedures; 21. Routine Newborn Infant Care, well-baby nursery, and related Physician charges; except as specifically provided in the policy;22. Services provided normally without charge by the Health Service of the Policyholder; or services covered or provided by the student health fee;23. Temporomandibular joint dysfunction;24. Sleep disorders, except as specifically provided in the policy;25. Surgical breast reduction, breast augmentation, breast implants, or breast prosthetic devices; or gynecomastia; except as specifically provided 26. Treatment in a Government hospital, unless there is a legal obligation for the Insured Person to pay for such treatment; and27. 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 request Page 4 of 4

Source: http://healthservices.boisestate.edu/services/files/13-14_BoiseState_Summary.pdf

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