2013-300-1 combined benefit flyer 4-page v3_layout

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; except as specifically provided in the policy; Nicotine addiction, except as specifically provided in the policy; Cosmetic procedures, except cosmetic surgery required to correct an Injury for which benefits are otherwise payable under this policy or for newborn or adoptedchildren; 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; Designed Especially for the Students of
Dental treatment, except for accidental Injury to Sound, Natural Teeth or as specifically provided in the Benefits For Dental Expenses; Eye examinations, eye refractions, eyeglasses, contact lenses, prescriptions or fitting of eyeglasses or contact lenses, vision correction surgery, or other treatment forvisual defects and problems; except when due to a covered Injury or disease process; Flat foot conditions; supportive devices for the foot; fallen arches; weak feet; chronic foot strain; symptomatic complaints of the feet; and routine foot care including thecare, cutting and removal of corns, calluses, toenails, and bunions (except capsular or bone surgery); Health spa or similar facilities; strengthening programs; 10. Hearing examinations; hearing aids; cochlear implants; or other treatment for hearing defects and problems except as specifically provided in the Benefits for Hearing and Speech Disorders, except as a result of an infection or trauma. "Hearing defects" means any physical defect of the ear which does or can impair normal hearing,apart from the disease process; 11. Hirsutism; alopecia;12. Hypnosis;13. Immunizations, except as specifically provided in the policy; preventive medicines or vaccines, except where required for treatment of a covered Injury or as specifically 14. Injury caused by, contributed to, or resulting from the use of alcohol, intoxicants, hallucinogenics, illegal drugs, or any drugs or medicines that are not taken in the recommended dosage or for the purpose prescribed by the Insured Person's Physician; 15. Injury or Sickness for which benefits are paid or payable under any Workers' Compensation or Occupational Disease Law or Act, or similar legislation;16. Injury or Sickness outside the United States and its possessions, Canada or Mexico, except when traveling for academic study abroad programs, business or pleasure;17. Injury sustained by reason of a motor vehicle accident to the extent that benefits are paid or payable by any other valid and collectible insurance; Knoxville
18. 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; Chattanooga
20. Lipectomy;21. Participation in a riot or civil disorder; commission of or attempt to commit a felony; or fighting except when unprovoked and in self-defense; 22. 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 a priorhealth insurance policy which provided benefits similar to this policy provided the coverage was continuous to a date within 63 days prior to the Insured’s effective date Tullahoma
under this policy. This exclusion will not be applied to an Insured Person who is under age 19; 23. Prescription Drugs, services or supplies as follows: 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; Immunization agents, except as specifically provided in the policy; biological sera, blood or blood products administered on an outpatient basis; Drugs labeled, “Caution - limited by federal law to investigational use” or experimental drugs; Student Injury and Sickness Insurance Plan
Drugs used to treat or cure baldness; anabolic steroids used for body building; Anorectics - drugs used for the purpose of weight control; Fertility agents or sexual enhancement drugs, such as Parlodel, Pergonal, Clomid, Profasi, Metrodin, Serophene, or Viagra; Refills in excess of the number specified or dispensed after one (1) year of date of the prescription.
24. Reproductive/Infertility services including but not limited to: family planning; 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 2013-2014
provided in the policy; vasectomy; sexual reassignment surgery; reversal of sterilization procedures;; 25. Research or examinations relating to research studies, or any treatment for which the patient or the patient’s representative must sign an informed consent document identifying the treatment in which the patient is to participate as a research study or clinical research study; 26. Preventive care services; routine physical examinations and routine testing; preventive testing or treatment; screening exams or testing in the absence of Injury or Academic School Year
Sickness; except as specifically provided in the policy; 27. Services provided normally without charge by the Health Service of the Policyholder; or services covered or provided by the student health fee;28. Nasal and sinus surgery, except for treatment of a covered Injury or treatment of chronic purulent sinusitis;29. Flight in any kind of aircraft, except while riding as a passenger on a regularly scheduled flight of a commercial airline;30. Supplies, except as specifically provided in the policy;31. Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices, or gynecomastia; except as specifically provided in the policy;32. Treatment in a Government hospital, unless there is a legal obligation for the Insured Person to pay for such treatment; 33. 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 for such period not Your student health insurance coverage, offered by UnitedHealthcare Insurance Company may not
34. Weight management, weight reduction, nutrition programs, treatment for obesity, (except surgery for morbid obesity), surgery for removal of excess skin or fat.
meet the minimum standards required by the healthcare reform law for restrictions on annual
Pre-Existing Condition means 1) the existence of symptoms which would cause an ordinarily prudent person to seek diagnosis, care or treatment within the 12 months dollar limits. The annual dollar limits ensure that consumers have sufficient access to medical
immediately prior to the Insured's Effective Date under the policy; or, 2) any condition which originates, is diagnosed, treated or recommended for treatment within the 12months immediately prior to the Insured's Effective Date under the policy.
benefits throughout the annual term of the policy. Restrictions for annual dollar limits for group and
individual health insurance coverage are $1.25 million for policy years before September 23, 2012;
and $2 million for policy years beginning on or after September 23, 2012 but before January 1, 2014.
Restrictions on annual dollar limits for student health insurance coverage are $100,000 for policy
years before September 23, 2012 and $500,000 for policy years beginning on or after September
23, 2012, but before January 1, 2014. Your student health insurance coverage puts a policy year limit
of $500,000 for each Injury or Sickness that applies to the essential benefits provided in the
Schedule of Benefits unless otherwise specified. If you have any questions or concerns about this
notice, contact Customer Service at 1-800-767-0700. 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 the age of 26. Contact the plan administrator of the parent’s
The student injury and sickness insurance coverage is underwritten by UnitedHealthcare Insurance Company and is based on policy 2013-1268-1, employer plan or the parent’s individual health insurance issuer for more information.
2013-303-1, 2013-1336-1 and 2013-201885-1. Please read the plan brochure to determine whether this plan is right for you before you enroll. The plan brochure provides details of the coverage,including costs, benefits, exclusons, any reductions or limitations and the terms under which the coverage may remain in force. Copies of the brochureare available from the University or may be viewed and downloaded at www.uhcsr.com. If you have any questions, please contact Customer Service at 800-767-0700. The Policy is a Non-Renewable One-Year Term Policy.
SCHEDULE OF MEDICAL EXPENSE BENEFITS
Welcome to UnitedHealthcare StudentResources Up To $500,000 Maximum Benefit (For Each Injury or Sickness)
Good Health is vital to keeping your academic career on track, and health insurance plays a key role against unexpected illness or injury. Your institution is working with Deductible Preferred Provider ~ $350 (Per Insured Person, Per Policy Year) ~ Deductible Out-of-Network ~ $600 (Per Insured Person, Per Policy Year)
UnitedHealthcare StudentResources to provide you with straightforward health care benefit coverage.
Coinsurance Preferred Providers 80% except as noted below ~ Coinsurance Out-of-Network 60% except as noted below
* Receive coverage for most major services, including pharmacy, hospitalization and mental health services.
The Preferred Provider for this plan is UnitedHealthcare Choice Plus.
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 with the necessary expertise is not available in the Network Area, benefits will be paid at the * Obtain online health information and benefit plan management tools anytime and anywhere on www.uhcsr.com.
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 * Access a national network of physicians and specialists easily and directly, without a referral.
provided when an Out-of-Network provider is used. 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 for each Injury or Sickness.
Student Health Center (SHC) Referral Required - UT Knoxville Knoxville Student Health Center Benefits: All UT Knoxville students must use the resources of the Student Health Center (SHC) first where treatment will be administered or referral issued. The policy Deductible will be waived and
benefits will be paid at 100% of Covered Medical Expenses for all Services administered and processed through the SHC. If Laboratory or X-Ray Services are sent outside the SHC for processing, the Deductible will apply and benefits will be All international students are automatically enrolled in this plan on a hard waiver paid as specified in the Schedule of Medical Expense Benefits. Expenses rendered outside the Knoxville SHC for which no prior referral is obtained will be covered at the non-preferred level of coinsurance.
basis. Degree seeking students taking 6 or more undergraduate credit hours or The student must use the services of the Health Center first where treatment will The benefits payable are as defined in and subject to all provisions of the policy and any riders or endorsements thereto. Benefits are subject to the policy Maximum Benefit unless otherwise specifically stated. Benefits will be paid up to the 3 or more graduate credit hours and students participating in a co-op program are be administered or referral issued. Expenses incurred for medical treatment 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 Expenses include: eligible to purchase this plan on a voluntary basis.
rendered outside of the Student Health Center for which no prior approval or PA = Preferred Allowance
U&C = Usual & Customary Charges
Eligible students who do enroll may also insure their Dependents. Eligible referral is obtained will be paid at 60% of the benefits otherwise payable under INPATIENT
Preferred Providers
Out-of-Network Providers
Dependents are the student’s spouse (husband or wife) or Domestic Partner and the Schedule of Benefits. A referral issued by the SHC must accompany the claim Hospital Expenses, daily semi-private room rate when confined as an Inpatient; general nursing care provided by the Hospital. Hospital Miscellaneous Expenses, such as the cost
dependent children under 26 years of age. See the Definitions section of the when submitted. Only one referral is required for each Injury or Sickness per 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 Brochure for the specific requirements needed to meet Domestic Partner of days payable under this benefit, the date of admission will be counted, but not the date of discharge.
A SHC referral for outside care is not necessary only under any of the following Intensive Care
Routine Newborn Care, while Hospital Confined; and routine nursery care provided immediately after birth for an Inpatient stay of at least 48 hours following a vaginal delivery
1. Medical Emergency. The student must return to SHC for necessary follow-up or 96 hours following a cesarean delivery. If the mother agrees, the attending Physician may discharge the newborn earlier.
The Policy becomes effective at 12:01 a.m. August 1, 2013 and terminates at Physiotherapy
2. When the Student Health Center is closed.
Surgeon’s Fees, If two or more procedures are performed through the same incision or in immediate succession at the same operative session, the maximum amount paid will not
exceed 50% of the second procedure and 50% of all subsequent procedures.
3. When service is rendered at another facility during break or vacation periods.
Assistant Surgeon
4. Medical care received when the student is more than 50 miles from campus.
Anesthetist, professional services administered in connection with inpatient surgery.
5. Medical care obtained when a student is no longer able to use the SHC due Registered Nurse’s Services, private duty nursing care.
6. Maternity, obstetrical and gynecological care.
Physician’s Visits, non-surgical services when confined as an Inpatient. Benefits do not apply when related to surgery.
7. Mental Illness treatment and Substance Use Disorder treatment.
Pre-Admission Testing, payable within 3 working days prior to admission.
Dependents are not eligible to use the SHC; and therefore, are exempt from the OUTPATIENT
Preferred Providers
Out-of-Network Providers
Surgeon’s Fees, If two or more procedures are performed through the same incision or in immediate succession at the same operative session, the maximum amount paid will not
Each Child
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
All Children
professional fees; anesthesia; drugs or medicines; therapeutic services; and supplies. Usual and Customary Charges for Day Surgery Miscellaneous are based on the Outpatient Surgical
Facility Charge Index.
Assistant Surgeon
Note: the amounts stated above include certain fees charged by the school youare receiving coverage through. Such fees include amounts which are paid to Anesthetist, professional services administered in connection with outpatient surgery.
certain non-insurer vendors or consultants by, or at the direction of your school.
Physician’s Visits, benefits for Physician’s Visits do not apply when related to surgery.
FrontierMEDEX: Global Emergency Medical Assistance: Physiotherapy, 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 If you are a student insured with this insurance plan, you and your insured spouse and minor child(ren) are eligible for FrontierMEDEX. The requirements to receive these auditory processing when the disorder results from Injury, trauma, stroke, surgery, cancer or vocal nodules.
15 visits maximum per Injury or Sickness is combined for all services listed.
International Students, insured spouse, Domestic Parter and insured minor child(ren): You are eligible to receive FrontierMEDEX services worldwide, except in your 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.
Diagnostic X-Ray, Covered 100% at the Knoxville Student Health Center
Domestic Students, insured spouse, Domestic Partner and insured minor child(ren): You are eligible for FrontierMEDEX services when 100 miles or more away from Radiation Therapy
your campus address and 100 miles or more away from your permanent home address or while participating in a Study Abroad program.
Chemotherapy
FrontierMEDEX includes Emergency Medical Evacuation and Return of Mortal Remains that meet the US State Department requirements. The Emergency Medical Evacuation services are not meant to be used in lieu of or replace local emergency services such as an ambulance requested through emergency 911 telephone Laboratory Services, Covered 100% at the Knoxville Student Health Center
assistance. All services must be arranged and provided by FrontierMEDEX; any services not arranged by FrontierMEDEX will not be considered for payment.
Tests and Procedures, diagnostic services and medical procedures performed by a Physician, other than Physician Visits, Physiotherapy, x-rays and lab procedures. The
following therapies will be paid under this benefit: inhalation therapy, infusion therapy, pulmonary therapy and respiratory therapy.
*Transfer of Insurance Information to Medical Providers Injections, when administered in the Physician’s office and charged on the Physician’s statement.
*Continuous Updates to Family and Home Physician Prescription Drugs, Mail order through UHCP at 2.5 times the retail Copay up to a 90 day supply.
*Replacement of Corrective Lenses and Medical Devices *Transportation to Join a Hospitalized Participant *Replacement of Lost or Stolen Travel Documents *Facilitation of Hospital Admission Payments *Replacement of Lost or Stolen Travel Documents Preferred Providers
Out-of-Network Providers
Ambulance Services
Durable Medical Equipment, a written prescription must accompany the claim when submitted. Benefits are limited to the initial purchase or one replacement purchase per Policy
Please visit your school's insurance coverage page at www.uhcsr.com for the FrontierMEDEX brochure which includes service descriptions and program exclusions 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. $2,500 maximumPer Policy Year. Durable Medical Equipment benefits payable under the $2,500 maximum are not included in the $500,000 Maximum Benefit. Covered 100% at the Knoxville Student Health Center Consultant Physician Fees, when requested and approved by the attending Physician.
(800) 527-0218 Toll-free within the United States or (410) 453-6330 Collect outside the United States.
Services are also accessible via e-mail at [email protected].
Dental Treatment, made necessary by Injury to Sound, Natural Teeth only. $1,000 maximum Per Policy Year. Benefits are not subject to the $500,000 Maximum Benefit.
Maternity, benefits will be paid 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 mother earlier.
Complications of Pregnancy
UnitedHealthcare StudentResources Insureds have online
Insured Students have access to nurse advice, Elective Abortion, $1,000 maximum Per Policy Year. Elective Abortion benefits are not subject to the $500,000 Maximum Benefit.
goal is to provide you with access to the access to claims status, EOBs, ID Cards, network providers, health information, and counseling support 24 Reconstructive Breast Surgery Following Mastectomy, in connection with a covered Mastectomy. See Benefits for Reconstructive Surgery.
correspondence and coverage information by logging in to hours a day by dialing the number listed on the My Account at www.uhcsr.com/myaccount. Insured students permanent ID card. Collegiate Assistance Hospital Outpatient Facility or Clinic, facility or clinic fee billed by the Hospital. All other services rendered during the visit will be paid as specified in the Schedule of Benefits.
informed decisions regarding medications.
who don’t already have an online account may simply select the Program is staffed by Registered Nurses and Mental Illness Treatment, services received on an Inpatient and outpatient basis. Institutions specializing in or primarily treating Mental Illness and Substance Abuse Disorders are
Our national retail network includes more “create My Account Now” link. Follow the simple, onscreen Licensed Clinicians who can help students than 60,000 pharmacies, with national and directions to establish an online account in minutes using your 7- determine if they need to seek medical care, need Substance Use Disorder Treatment services received on an Inpatient and outpatient basis. Institutions specializing in or primarily treating Mental Illness and Substance Abuse
regional chains and many local independent digit Insurance ID number or the email address on file.
legal/financial advice or may need to talk to As part of UnitedHealthcare StudentResources’ environmental
someone about everyday issues that can be Diabetes Services, in connection with the treatment of diabetes. See Benefits for Daibetes Treatment.
commitment to reducing waste, we’ve introduced a number of TMJ Disorder, TMJ Disorder benefits are not subject to the $500,000 Maximum Benefit.
using a participating pharmacy, including the initiatives designed to preserve our precious resources while also Acupuncture in Lieu of Anesthesia
protecting the security of a student’s personal health information.
Urgent Care Center, facility or clinic fee billed by the Hospital. All other services rendered during the visit will be paid as specified in the Schedule of Benefits.
My Account has been enhanced to include Message Center - a One way we are becoming greener is to no longer To get prescription drug information go to automatically mail out ID Cards. Instead, we will Second Surgical Opinion
self-service tool that provides a quick and easy way to view any www.uhcsr.com or call 1-855-828-7716.
email notifications we may have sent. In Message Center, send an email notification when the digital ID cardis available to be downloaded from My Account.
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
notifications are securely sent directly to the Insured student’s of disease, have been proven to have a beneficial effect on health outcomes and are limited to the following as required under applicable law: 1) Evidence-based items or services email address. If the Insured student prefers to receive paper An Insured student may also use My Account to that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force; 2) immunizations that have in effect a recommendation copies, he or she may opt-out of electronic delivery by going into request delivery of a permanent ID card through from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; 3) with respect to infants, children, and adolescents, evidence-informed the mail. ID Cards may also be accessed via our preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; and 4) with respect to women, such My Email Preferences and making the change there.
additional preventive care and screenings provided for in comprehensive guidelines supported by the Health Resources and Services Administration.
No Deductible, Copays or Coinsurance will be applied when the services are received from a Preferred Provider.

Source: http://sga.utsi.edu/Insurance/QuickLinks/2013-2014_Student_Health_Flyer.pdf