STUDENT GOLD HEALTH INSURANCE
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Boulder, Colorado 80309
“the Policyholder”
2013-2014
STUDENT GOLD HEALTH INSURANCE
PLAN GUIDE
Designed for University of Colorado Boulder
Students & their Dependents
Administrator Policy Number: CHH8017734
Underwriter Reference Number: CAS9493060
Insurance Underwritten by
National Union Fire Insurance Company of Pittsburgh, Pa.
with its principal place of business in New York, NY
the “Company”
1
AT A GLANCE
24-Hour Emergency Hotline................................................... page 22
Accidental Death & Dismemberment........................................ page 15
Basic Plan Dates and Cost......................................................... page 5
Bone Density Testing............................................................... page 12
Claims Procedures.................................................................. page 21
Continuation of Coverage......................................................... page 5
Coordination of Benefits.......................................................... page 17
Definitions....................................................................... pages 17-18
Eligibility................................................................................... page 3
Enrollment Deadlines................................................................ page 5
Exclusions........................................................................ pages 16-17
How To Select or Waive Coverage.............................................. page 4
Inpatient Pre-Admission Notification Requirement.........................page 22
Maternity Expense............................................................pages 13, 15
Prescription Drugs............................................................pages 14, 17
Optional Dental Benefits......................................................... page 20
Optional Vision Benefits.......................................................... page 19
Preferred Provider Organization (PPO)....................................... page 6
WHC Referral Requirement........................................................ page 7
Repatriation & Medical Evacuation Benefits.............................. page 23
Routine Services for Dependent Children.................................. page 13
Schedule of Benefits........................................................... pages 9-14
Temporary Student Gold Health Insurance Plan ID Card........... page 21
This is only a brief description of the coverage available under policy S30749NUFIC-CO-UCB. The Policy may
contain definitions, reductions, limitations, exclusions and termination provisions. Full details of the coverage
are contained in the Policy. If there is any conflict between the contents of this document and the Policy, or
if any point is not covered in this document, the terms and conditions of the Policy will govern in all cases.
Travel assistance services provided by Travel Guard. Insurance and services provided by member companies
of American International Group, Inc. Coverage may not be available in all jurisdictions and is subject to actual
policy language. For additional information, please visit our website at www.AIG.com.
2
Who Needs Medical Coverage and Why?
In the United States, health insurance coverage isn’t just a good idea — it is considered a necessity by most people. Medical
care can be extremely expensive. A medical emergency, sudden illness, or serious accident could end the educational dreams
of an uninsured person and cause financial devastation for the student and his or her family.
Unless you have coverage through an employer’s group health plan, one of the best ways to obtain health insurance coverage
is to enroll in the “Student Gold Health Insurance Plan” (Plan) which is the University of Colorado Boulder’s endorsed Health
Plan described in this Guide.
The Plan covers certain routine medical care, lab work, prescription drugs, and care for a sickness, injury, surgery, or a
hospital stay. In addition to coverage for eligible medical care at the on-campus Wardenburg Health Center (Wardenburg),
Covered Persons can be referred to other healthcare providers when care is needed that is not available at Wardenburg.
CU-Boulder’s mandatory health insurance policy
CU-Boulder’s goal is to provide students with the best educational experience possible. Because health and wellness can
directly affect the quality of this experience, CU-Boulder requires all students to be covered by a health insurance plan and
makes optional coverage available for eligible dependents.
Please keep in mind that most degree-seeking CU-Boulder students will be automatically enrolled and billed each semester for
the Student Gold Health Insurance Basic Plan, unless a waiver of Plan Coverage is completed and approved (See “Eligibility”,
“ How to Select or Waive Coverage” and “Enrollment Deadlines” on page 4).
Eligibility
Students
Eligible students must actively attend classes for at least the first 31 days after the date for
which coverage is purchased.
• Degree-seeking undergraduate students enrolled in six or more credit hours and
graduate students enrolled in one credit hour are eligible and are automatically enrolled
in the Plan.
• Continuing Education, ACCESS and Study Abroad students enrolled in six or more credit
hours, and paying the base student and Wardenburg Health Center fees, are eligible to
enroll in the Plan and must do so by visiting Wardenburg Health Clinic.
• Students approved for the Time Off or Stay Connected programs for medical reasons
are eligible to enroll in the Plan and must do so by visiting Wardenburg Health Center.
NOTE: Home study, correspondence and television (TV) courses do not fulfill the eligibility
requirements that the student actively attend classes. The Company maintains its right
to investigate student status and attendance records to verify that the policy eligibility
requirements have been met. If the Company discovers the eligibility requirements have not
been met, its only obligation is to refund premium.
Dependents
• The Covered Student’s legally married spouse or registered domestic partner; and
children under age 26 are eligible.
• Newborn children are covered for Injury or Sickness from birth until 31 days old (includes
Eligible Expenses for inpatient or outpatient care). Coverage may be continued for that
child when the Company is notified in writing within 31 days from the date of birth and
the required premium is received.
• Covered Students may purchase dependent coverage at the time of student’s enrollment
in the plan; or within 31 days of date of marriage, birth or adoption only. Dependent
eligibility expires concurrently with that of the Covered Student, except as specifically
provided under the Extension of Benefits.
• Covered Students desiring to enroll eligible dependents may do so by completing the
enrollment process and remitting full applicable premium payment to the University. See
page 5 for Plan Cost and Enrollment Deadlines.
NOTE: Dependent Children are not able to seek treatment at Wardenburg Health Center (WHC).
3
Enrollment How to Enroll in Optional Club
Automatic enrollment Sports Coverage
Due to the University’s mandatory policy for health insurance,
all undergraduate students enrolled for 6 or more credit hours
(1 hour for graduate students) are automatically enrolled
Optional Club Sports Coverage
in the Student Gold Health Insurance Plan and billed each Injuries arising out of
semester (see page 3 for Exceptions to automatic and online participation in club sports
enrollment). In order to opt out of the insurance please are specifically excluded from
follow the directions below: coverage under the Student
Refer to: www.colorado.edu/studentinsurance Gold Health Insurance Plan. If
Voluntary enrollment: Continuing Education, ACCESS you wish to receive coverage
and Study Abroad students enrolled in six (6) or more and benefits for an injury
credit hours, and paying the base student and WHC fees; resulting from membership
and students approved for the Time Off or Stay Connected and participation in club
programs for medical reasons may enroll for coverage sports, the optional club sports
only under the following conditions: (a) during an initial or coverage must be selected
subsequent open enrollment period; or (b) within 31 days during open enrollment and
of a marriage, birth or adoption; or (c) within 31 days of
the appropriate premium
ineligibility under another creditable plan.
must be paid. Optional
coverage may be purchased
How to Select or Waive by visiting www.colorado.edu/
studentinsurance.
Coverage Only those students enrolled
in the Basic Plan are eligible and
Students must select or waive the University insurance may select the additional sports
through the online student portal at https://portal. coverage.
prod.cu.edu/FedAuthLogin.html
Students Continuing from Fall into Spring How to Enroll in the
If you enrolled in the plan for Fall 2013, you will automatically
be enrolled in Spring 2014 unless you actively waive coverage. Optional Dental Coverage
If you waived the plan in the Fall, you may still enroll for
Spring/Summer 2014 within the enrollment period. All main and/or Optional Vision
campus students must make an insurance choice every year.
Coverage
New Spring 2014 Students
If you are a new student starting in Spring 2014 the final
deadline for selecting the plan or waiving coverage for Spring The Optional Dental Coverage and Optional Vision
semester is January 19, 2014. If you are a Spring 2014 Coverage enrollment are available to Covered Persons at
student, the insurance plan you choose for that semester initial enrollment under the Basic Plan each Policy Year by
continues into the summer, whether you are taking classes completing the online enrollment and payment process at:
or not. Students must select or waive the University insurance www.colorado.edu/studentinsurance
through the online student portal at https://portal.prod.
cu.edu/FedAuthLogin.html Plan details on pages 19 and 20.
DID YOU KNOW? The Policy is a non-renewable one-year term
You can use your insurance policy. Similar coverage may be
Smart Phone purchased for the following academic year. It is
QRCode Application the Covered Student’s responsibility to maintain
to scan and store continuity of coverage by inquiring about such
Student Gold coverage if he or she has not received the
Health Insurance
Plan Information. information for the new policy year.
4
Late Enrollment—what do you do if
BASIC PLAN DATES & COST you miss the enrollment deadline or
SPRING/ SUMMER lose coverage after the deadline?
FALL ONLY
SUMMER
Semester Semester (New A student who initially waived coverage under the University’s
(billed Fall (billed Spring Partici- Student Gold Health Insurance Plan but subsequently experi-
Semester) pants)
Semester) ences ineligibility under another coverage may elect to enroll
COVERAGE 8/18/13 - 1/1/14 - 6/1/14 - for coverage under the University’s policy within 31 days of
ineligibility under another Creditable Coverage plan.
PERIOD 12/31/13 8/17/14 8/17/14
Student A student eligible to enroll on a voluntary basis who does not
$1,515 $1,515 $758 enroll himself or herself during an open enrollment period
Spouse/domestic may not apply for coverage until the next subsequent open
$3,598 $3,598 $1,800 enrollment period unless application for coverage is made
partner
within 31 days of a marriage, birth or adoption; or (c) within
Each Child $2,092 $2,092 $1,046 31 days of ineligibility under another creditable plan.
Plan Costs include an administrative fee.
What to do if you miss the waiver
OPTIONAL CLUB SPORTS COST deadline?
FALL SPRING/SUMMER If you meet the criteria to drop the Student Gold Health
Insurance Plan after the fall or spring semester deadlines,
Student Only $126 $126 you may petition to waive the health plan, for one month past
the deadline. A $25 processing fee will be charged.
ENROLLMENT DEADLINE DATES FOR
BASIC PLAN AND Information for teaching, research,
OPTIONAL COVERAGE: or graduate assistants, or graduate
Fall 2013 - September 5, 2013 part-time instructors
Spring 2014 - January 23, 2014 If you are a teaching, research, or graduate assistant or a
Summer 2014 - June 5, 2014 graduate part-time instructor and hold at least a 20 percent
The Master Policy on file at the University becomes appointment, the University will contribute a portion of the
effective at 12:01 a.m. August 18, 2013. The coverage cost toward the Student Gold Health Insurance Plan. Call the
of an eligible student who enrolls for coverage under Graduate School for details and eligibility.
the Policy shall take effect at 12:01 a.m. on the latest
of the following dates: (1) the Policy Effective Date; (2) Continuation of Coverage
the date for which the first premium for the Covered
Student’s coverage is received by the Company; or (3) Covered Persons enrolled in the Continuation Plan are not
the date the Policyholder’s term of coverage begins; (4) eligible to receive services at Wardenburg Health Center. A
the date the student becomes a member of an eligible referral is not required for outside providers.
class of persons as described in the Description of Class
section of the Schedule of Benefits in the Policy on file If a Covered Student is no longer an eligible person under
with the Policyholder. The Master Policy terminates at the Policy, he or she has the right to exercise the option to
11:59 p.m. August 17, 2014. Insurance for a Covered continue coverage up to 3 months beginning on the date
Student will end at 11:59 p.m. on the first of these to coverage would otherwise terminate. When a Covered Student
occur: (a) the date the Policy terminates; (b) the last chooses to exercise this right, his or her written request and
day for which any required premium has been paid; (c)
the date on which the Covered Student withdraws from the appropriate premium must be received by the Company
the school because of: (1) entering the armed forces within 31 days following the date coverage under the Policy
of any country (Premiums will be refunded on a pro- terminates. In no event will this option to continue coverage
rata basis (less any claims paid) when written request be extended beyond the number of months initially requested.
is made; or (2) withdrawal from school during the first Continuation of coverage will be subject to the terms and
31 days of the period for which enrollment was made.
If withdrawal from the Policyholder’s school is for other conditions of the Policy in effect on the date the Covered
than (1) or (2) above, no premium refund will be made. Student becomes eligible under this option. Call 1-888-
Students will be covered for the Policy term for which 622-6001 to obtain information regarding enrollment in the
they are enrolled and for which premium has been paid. Continuation Plan. Enroll by visiting www.studentinsurance.
Coverage for dependents will not be effective prior to com/Schools/CO/CUB.
that of the Covered Student or extend beyond that of the
Covered Student. Refunds of pro-rated premiums are
allowed only upon entry into the armed forces.
5
Extension of Benefits house Doctor-ordered lab and/or X-ray, mental health
visits are available at WHC (see the following pages
If the Covered Person is confined to a Hospital on the date
for details). Eligible Expenses incurred at WHC are not
his or her coverage terminates as a result of a Sickness or
subject to deductibles, pre-existing or co-pays (other
Injury for which benefits were payable prior to the date his
than pharmacy). Benefits for covered hospitalization,
or her coverage terminated, benefits will be payable for
emergency room charges, obstetrical care, specialized
Eligible Expenses incurred until the earliest of: (1) the date the
care and testing outside Wardenburg Health Center are
Hospital confinement ends; (2) the end of the 90 day period
outlined in the Schedule of Benefits.
following the date his or her coverage terminated; or (3) the
date the applicable Maximum Amount is reached. 2. Preferred Provider Organization (PPO): Cofinity
The Extension of Benefits will apply only to the extent the (inside Colorado) and First Health (outside Colorado)
Covered Person will not be covered under the Policy or any provide 24-hour helplines and web support at www.
other health insurance policy in the ensuing term of coverage. myameriben.com. These organizations are groups of
Doctors, Hospitals and medical care providers who have
agreed to provide medical services at reduced costs
Overview of the Student for CU-Boulder insured students and their dependents
requiring care outside of Wardenburg. PPO discounts
Gold Health Insurance Plan can significantly reduce out-of-pocket expenses by
reducing the cost of the Covered Person’s deductible
for Students & Dependents and co-insurance payments.
3. Pharmacy Benefit Manager: Express Scripts is
The Student Gold Health Insurance Plan has been developed a nationwide pharmacy benefit manager providing
for CU-Boulder students and their eligible dependent spouse/ a 24-hour helpline staffed by qualified customer
domestic partner and children. The Plan provides certain service staff and pharmacy technicians. Express Scripts
benefits for medical, orthopedic, women’s health, pharmacy, provides prescription drug support services and discount
psychological health and psychiatry coverage at Wardenburg pharmacy benefits to insured CU-Boulder students and
Health Center and from preferred providers for Eligible covered dependent/domestic partner.
Expenses not available at Wardenburg. 4. Dental and Vision: Covered Persons are also entitled
The Plan includes special design features in an effort to keep to enroll in the optional dental coverage and an optional
coverage and medical services affordable. Examples include: vision coverage. Details and enrollment are available
1. Primary Medical Provider: Wardenburg Health at: www.studentinsurance.com.
Center (WHC) is the primary medical provider for 5. Optional Club Sports Coverage: Covered
covered students and spouses/domestic partners (not Persons are also entitled to enroll in the Optional Club
children) for services such as acute care visits. Sports Coverage. Enrollment is available at www.
Chronic illness management, routine healthcare, in- studentinsurance.com.
6
Wardenburg Health Center (WHC) Referral
You must receive the referral from WHC before you receive Covered Medical
Care. If you need urgent care when WHC is closed or you need emergency
care, you must return to WHC for necessary follow-up care, except as stated
below.
Wardenburg Health Center (WHC) Referral Requirement
The student and spouse/domestic partner must first utilize 4. Medical care obtained when the Covered Student
the resources of Wardenburg Health Center where treatment or spouse/domestic partner is no longer able to use
will be administered or a referral issued. No benefits will be the WHC; due to a change in student status;
paid for expenses incurred for medical treatment rendered 5. Services provided for Dermatology, Maternity, OB/
outside WHC for which no prior approval or referral is GYN Care, Home Health Care, Dental Treatment
obtained. A referral from WHC must accompany the claim or Eye Care;
when submitted. Exceptions to the Referral Requirement are 6. No services are available for dependent children at
as follows: WHC and therefore, are exempt from the Referral
1. Medical Emergency. The Covered Student or spouse/ Requirements; or
domestic partner must return to WHC for necessary 7. Preventive Services not covered at Wardenburg
follow-up care, except when referred to a specialist Health Center.
as a result of an emergency room visit. See definition Call Student Insurance at 303-492-5107 to determine
of Emergency Medical Condition on page 18; whether a preventive care service is available at WHC.
2. When Wardenburg Health Center is closed.
Wardenburg is not a 24-hour facility; Visit website at www.colorado.edu/studentinsurance to find a
3. Medical care received more than 15 miles from provider in the Cofinity PPO Network if being treated within
campus; the State of Colorado or First Health.
Services and Benefits Inside Wardenburg Health Center
Wardenburg Health Center is the Primary Care Provider Psychological Health and Psychiatry
for Students and spouse/domestic partners enrolled in the • Initial assessment/urgent care
Student Gold Health Insurance Plan. The benefits provided at • Individual, couples, and group therapy
Wardenburg Health Center are not part of the Student Gold • Substance abuse evaluation and treatment
Health Insurance Plan. • Eating disorders evaluation and treatment
No co-insurance, co-pay or deductible. • Medical evaluation and medication management
Medical Clinic • Stress management services
• Primary care for Sickness and Injuries that do not Sports Medicine
require the services of a specialist • 25 physical therapy visits per policy year
• Routine immunizations • 10 chiropractic visits per policy year at WHC with
• Travel Clinic services (excluding specialty travel a valid referral from an appropriate health care
immunizations) provider
• Men’s health services including one annual exam per • Orthopedic surgeon consultations
policy year; including HPV (Human Papilloma virus) Women’s Health Services
vaccines • One annual exam per policy year
• Sexually Transmitted Infection testing and education • Gynecology services and consultations that do not
• Allergy injections require the services of a specialist outside of WHC
• Nutrition services • Birth control consultations
• Preventive Services • Human Papillomavirus (HPV) vaccination
Laboratory and X-Ray • Sexually Transmitted Infection testing and education
• Coverage for x-ray services Eye Exam
• Coverage for laboratory services when ordered by • One routine eye exam per plan year through WHC’s
WHC provider only contracted optical provider. Glasses, contacts and
contact lens fittings are not covered.
7
Services and Benefits Inside Wardenburg Health Center, (Continued)
Outpatient mental health and
substance abuse services
The Department of Psychological Health and Psychiatry
(PHP) will provide assessment and treatment services. The
type of treatment offered, the frequency of treatment, and
the duration of treatment will be determined by the health
care provider’s assessment, the needs of the Covered Person,
and the availability of services. PHP utilizes brief, focused
individual and couples therapy, along with a wide range of
longer-term group therapy options.
Specialists at Wardenburg Health Wardenburg Health Center
Center (WHC) services provided at WHC, but
Wardenburg Health Center contracts for the services of
specialty Doctors from the Boulder community and the not covered by Student Gold
Anschutz Medical Campus of the University of Colorado Health Insurance Plan include,
Denver. Specialty clinic visits at Wardenburg are subject to
appointment availability, and may be limited during the but are not limited to:
summer session and breaks. • Acupuncture
Orthopedic Services in Sports Medicine • ADHD/ADD testing
• 100 percent coverage for orthopedic visits at WHC • Bike fits
with a valid referral from an appropriate health care • Copies of X-rays and medical records
provider. • Custom knee braces
• All relevant records are shared with the specialist, who • Immunizations for Japanese encephalitis, rabies,
reports back to WHC with results, thereby setting up yellow fever, and typhoid
a system for continuity of care between WHC and the • Loaned equipment
specialist. • Massage therapy
Chiropractic Services in Sports Medicine • Missed appointments
• Patient-requested lab tests (not Medically Necessary)
• 100 percent as shown on page 7.
• Replacement of medical supplies
Gynecology Services in Women’s Health
Services
• 100 percent coverage for gynecologist consults and
specialty procedures including but not limited to:
If you are no longer a CU-Boulder
colposcopy, L.E.E.P., biopsy, and cryosurgery at WHC. student, you may not receive any
IMPORTANT: Your deductible, coinsurance, and copay services at WHC unless you:
WILL apply to the following:
• If you require specialist care outside of Wardenburg • Completed the spring semester but
Health Center, even if a Wardenburg Health Center are not enrolled for the summer or
health care provider refers you.
• If you require specialist care, and no appointments are • Withdrew after the 31st day of the
available at Wardenburg Health Center, and you are
referred outside of Wardenburg Health Center.
semester in which case you will be
• You are always responsible for the deductible, eligible for treatment at WHC until
coinsurance, and copay for services you receive outside the end of the semester.
of Wardenburg Health Center, even if a WHC referral
is issued.
8Basic Plan Schedule of Benefits
(Refer to Wardenburg Health Center Referral Requirement, page 7.)
Plan Feature
Policy Year Maximum Benefit Unlimited
Deductible per Covered Person
per Policy Year $250 PPO / $500 Non-PPO
(PPO and Non-PPO are applied
separately)
Pharmacy Deductible per Covered $50
Person per Policy Year
Once the Out-of-Pocket Limit has been
satisfied, Eligible Expenses will be payable
at 100% for the remainder of the Policy
Year, not to exceed any benefit maximum
that may apply. The Policy Year Deductible
$5,000 PPO / $10,000 Non-PPO and coinsurance apply toward meeting
Out-of-Pocket Limit
applied separately the Out-of-Pocket maximum. Per service
copays, non-covered charges, charges
above the Reasonable and Customary
Charge, and any charges above the
service limit will not apply toward the Out-
of-Pocket Limit.
OUT-OF-
PREFERRED
INPATIENT NETWORK
PROVIDERS
PROVIDERS
PPO = Allowable Charges R&C = Reasonable and Customary Charges
Anesthetist—Professional Services 80% of PPO 80% of R&C
Assistant Surgeon 80% of PPO 50% of R&C
Biologically Based Mental Illness Paid as any other Sickness See page 15 for more details.
Doctor Visits (non-surgical) 80% of PPO 50% of R&C
The per admission copay is in addition
to the per Policy Year Deductible. Eligible
Expenses include Hospital room and
board charges (limited to average semi-
private room rate except if ICU or CCU)
and general nursing care provided by the
$200 copay per $200 copay per Hospital; and Miscellaneous expenses
Hospital Expense admission admission such as the cost of the operating room,
80% of PPO 50% of R&C laboratory tests, X-ray examinations,
anesthesia, drugs (excluding take home
drugs) or medicines, therapeutic services,
and supplies. In computing the days
payable under this benefit, the date of
admission will be counted, but not the date
of discharge.
Intensive Care 80% of PPO 50% of R&C See Hospital Expense above.
See Benefits for Mental Disorders on page
Mental Disorders Paid as any other Sickness
15.
Physiotherapy/Occupational
80% of PPO 50% of R&C
Therapy
9Basic Plan Schedule of Benefits (Continued)
(Refer to Wardenburg Health Center Referral Requirement, page 7.)
OUT-OF-
PREFERRED
INPATIENT, Continued NETWORK
PROVIDERS
PROVIDERS
PPO = Allowable Charges R&C = Reasonable and Customary Charges
Payable within 14 Days prior to
Pre-Admission Testing 80% of PPO 50% of R&C
admission.
Private Duty Nursing 80% of PPO 50% of R&C
48 hours vaginal delivery / 96 hours
for cesarean. While Hospital Confined;
Routine Newborn Care Paid as any other Sickness
and routine nursery care provided
immediately after birth.
If two or more procedures are performed
through the same incision or in immediate
succession at the same operative session,
Surgeon’s Fees 80% of PPO 50% of R&C the maximum amount paid will not exceed
the applicable coinsurance levels for the first
procedure and second procedures and 25%
of the third and subsequent procedures.
OUT-OF-
PREFERRED
OUTPATIENT NETWORK
PROVIDERS
PROVIDERS
Anesthetist 80% of PPO 80% of R&C
Assistant Surgeon 80% of PPO 50% of R&C
Chemotherapy & Radiation Therapy 80% of PPO 50% of R&C
Related to scheduled surgery performed in
a Hospital, or an outpatient surgical facility
including the cost of the operating room;
Day Surgery Facility/Miscellaneous
80% of PPO 50% of R&C laboratory tests and X-ray examinations,
Procedures
including professional fees; anesthesia;
drugs or medicines (excluding take-home
drugs); and supplies
Diagnostic X-ray and Laboratory
80% of PPO 50% of R&C
Services
$40 copay per $40 copay per
visit visit
100% of PPO 50% of R&C
Doctor’s Visits (non surgical)
Policy Year Policy Year
deductible does deductible does
not apply. not apply.
For use of Hospital Emergency Room,
including attending Doctor’s charges,
$150 copay per $150 copay per operating room, laboratory and x-ray
examinations, supplies. 1) The $150
Emergency Room visit visit
copay is waived if admitted. Policy Year
100% of PPO 100% of R&C Deductible does not apply. 2) Treatment
must be rendered within 72 hours from
time of Injury or first onset of Sickness.
Administered in the Doctor’s office and
Injections 80% of PPO 50% of R&C
charged on the Doctor’s statement.
10Basic Plan Schedule of Benefits (Continued)
(Refer to Wardenburg Health Center Referral Requirement, page 7.)
OUT-OF-
PREFERRED
OUTPATIENT, Continued NETWORK
PROVIDERS
PROVIDERS
PPO = Allowable Charges R&C = Reasonable and Customary Charges
Mental Disorders Refer to Doctor Visit Benefit on page 10.
Paid as any other Paid as any other
Sickness Sickness Refer to page 15 - “Benefits for Mental
Biologically Based Mental Illness Disorders”
Physiotherapy/Occupational Therapy 80% of PPO 50% of R&C
• $15
copay per Benefit includes birth control with no
prescription copay.
for Generic Insulin covered at 100% and are not
• $15 copay per • $30 subject to the maximum per Policy Year.
Prescription Drugs prescription copay per Prescribed pre-natal vitamins are
for Generic prescription covered.
$50 deductible per Policy Year, • $30 copay per for Brand Mail order Prescription Drugs through
Limited to a 31-day supply per prescription Name Express Scripts at 2.5 times the copay.
prescription for Formulary Out-of-Network
Brand Name Pharmacy, the See page 14 for details.
Express Scripts Pharmacy Benefit If a Covered Person’s Doctor chooses
Manager— Maximum per Policy Year. • $60 copay per Covered Person
prescription must pay for the a brand or non-formulary drug and
for Non- Prescription Drug a generic is available, the Covered
formulary at the pharmacy Person will pay the difference between
Brand Name and submit receipt the brand/non-formulary drug and the
with a Prescription generic (low tier) cost and the applicable
Claim Form for copay.
reimbursement. The Basic Plan Deductible Amount per
Policy Year will be waived.
If two or more procedures are
performed through the same incision
or in immediate succession at the same
operative session, the maximum amount
Surgeon 80% of PPO 50% of R&C
paid will not exceed the applicable
coinsurance levels for the first procedure
and second procedures and 25% of the
third and subsequent procedures.
Diagnostic services and medical
procedures by a Doctor, other than
Tests & Procedures 80% of PPO 50% of R&C
Doctor Visits, Physiotherapy, X-Rays
and Lab Procedures.
$75 copay per $75 copay per
visit visit
100% of PPO 50% of R&C
Urgent Care
Policy Year Policy Year
deductible does deductible does
not apply. not apply.
OUT-OF-
PREFERRED
OTHER NETWORK
PROVIDERS
PROVIDERS
Alcoholism Expense Paid as any other Sickness
Ambulance Services 80% of PPO 80% of PPO
11Basic Plan Schedule of Benefits (Continued)
(Refer to Wardenburg Health Center Referral Requirement, page 7.)
OUT-OF-
PREFERRED
OTHER NETWORK
PROVIDERS
PROVIDERS
PPO = Allowable Charges R&C = Reasonable and Customary Charges
Biofeedback Coverage 80% of PPO 80% of PPO
Not otherwise covered by Preventive
Bone Density Testing 100% of PPO 100% of PPO
Benefits.
CAT Scan/MRI 80% of PPO 50% of R&C
Additional Premium/Enrollment
Club Sports Paid as any other Injury
Required
Made necessary due to Injury to sound,
Dental Treatment (Accidental Injury) 80% of PPO 50% of R&C natural teeth only. $2,000 maximum
per Policy Year.
For diabetic needles/syringes and
testing supplies, insulin pump supplies
Diabetic Expense 80% of PPO 50% of R&C and glucose monitor or sensors, the
benefit will be payable at 100%; and is
not subject to the Deductible.
Diagnostic: paid as any other
Colorectal Cancer Screening Sickness/deductible applies Not otherwise covered by Preventive
(Diagnostic & Routine Colonoscopy) Routine: paid as any other Sickness/ Services
deductible waived
Benefits are limited to one visit per day
Dialysis Treatment 80% of PPO 50% of R&C and do not apply when related to a
Doctor’s visit.
A written prescription must accompany
Durable Medical Equipment and
the claim when submitted. Replacement
Braces & Appliances 80% of PPO 80% of R&C
equipment is not covered. Benefits
include Prosthetic Devices.
Fertility Testing 80% of PPO 50% of R&C Benefits payable for testing only.
Home Health Care 80% of PPO 50% of R&C In lieu of hospitalization.
Not otherwise covered by Preventive
Services. Benefits include charges
100% of R&C incurred for cervical cancer
HPV Vaccine 100% of PPO Policy Year immunization for covered females
Policy Year deductible does under age 26. If the initial shot in the
deductible does not apply. series is received prior to the Covered
not apply. Person turning age 26, subsequent
immunizations are covered according
to standard protocol.(Doctor’s visit
copay will apply.)
Intramural Sports Paid as any other Injury
100% of PPO 100% of R&C
Policy Year Policy Year
Mammography
deductible does deductible does
not apply. not apply.
12Basic Plan Schedule of Benefits (Continued)
(Refer to Wardenburg Health Center Referral Requirement, page 7.)
OUT-OF-
PREFERRED
OTHER, Continued NETWORK
PROVIDERS
PROVIDERS
PPO = Allowable Charges R&C = Reasonable and Customary Charges
Maternity & Complications of
Paid as any other Sickness
Pregnancy
Nutritional Counseling 100% of PPO 100% of PPO
100% of PPO 100% of R&C
As specified by the Patient Protection and
not subject to not subject to
Affordable Care Act (PPACA). (To view a
Preventive Services Benefit deductible, deductible,
list of covered preventive services, log
copayment, or copayment, or
onto www.healthcare.gov)
coinsurance coinsurance.
100% of PPO 100% of R&C
Policy Year Policy Year
Prostate Cancer Screening
deductible does deductible does
not apply. not apply.
Benefits are payable for Eligible
Expenses for Breast Reconstructive
Surgery after a mastectomy. This
includes coverage for: 1) All stages of
the reconstruction of the breast on which
Reconstructive Breast Surgery Paid as any other Sickness the mastectomy has been performed;
2) surgery and reconstruction of the
other breast to produce symmetrical
appearance; and 3) prostheses and
physical complications at all stages of
mastectomy, including lymphedemas.
Repatriation and Medical Evacuation - Refer to page 23 - Travel Assist/Student Assist
1 visit per day and does not apply
Respiratory Therapy 80% of PPO 50% of R&C
when related to Doctor Visits.
$40 maximum per exam. Benefit
100% of PPO 100% of R&C
includes one annual eye exam that
Policy Year Policy Year
Routine Eye Exam includes refraction. A routine eye exam
deductible does deductible does
does not include charges for contact
not apply. not apply.
lens exam.
Routine Hearing Exam 80% of PPO 50% of R&C
Not otherwise covered by Preventive
Services Benefit (See page 13). Includes
Preventive Health Services 100% of PPO 100% of R&C
routine tests and immunizations per
CDC guidelines.
100% of PPO 100% of PPO Not otherwise covered by Preventive
Routine Services for Dependent Policy Year Policy Year Services Benefit (See page 13).
Children deductible does deductible does Includes immunizations per CDC
not apply. not apply. guidelines.
1 visit per day and does not apply
Speech Therapy 80% of PPO 50% of R&C
when related to Doctor Visits.
13Basic Plan Schedule of Benefits (Continued)
(Refer to Wardenburg Health Center Referral Requirement, page 7.)
OUT-OF-
PREFERRED
OTHER, Continued NETWORK
PROVIDERS
PROVIDERS
PPO = Allowable Charges R&C = Reasonable and Customary Charges
Eligible Expenses include:
(a) mental health counseling (subject to
the limitations applicable to inpatient
and outpatient treatment of Mental
and Nervous Disorders);
(b) hormone replacement therapy
(subject to the limitations applicable
to Prescription Drugs);
(c) sexual reassignment surgery, limited
Transsexualism/Gender Identity to $10,000 per Policy Year.
Paid as any other Sickness
Disorders (1) for female to male:
mastectomy, hysterectomy,
salpingo-oophorectomy,
vaginectomy,metoidioplasty,
scrotoplasty, urethroplasty,
placement of testicular prosthesis,
phalloplasty; or
(2) male to female: orchiectomy,
penectomy, vaginoplasty,
clitoroplasty, labiaplasty.
Treatment of Temporomandibular Joint
80% of PPO 80% of R&C
Dysfunction
Prescription Drugs
The Student Gold Health Insurance Plan provides pharmacy other medical substances, regardless of intended use;
coverage through a prescription card program administered except as provided under Benefits for Diabetes;
by Express Scripts. A Covered Person may purchase (b) Biological sera, blood or blood products administered on
prescription drugs at over 60,000 network pharmacies an outpatient basis;
nationwide. The latest listing of participating pharmacies is
available at: www.colorado.edu/studentinsurance (c) Drugs labeled, “Caution—limited by federal law to
investigational use” or experimental drugs;
Prescription Benefits are based on a Mandatory Generic
Formulary, which means that participating pharmacies will fill (d) Products used for cosmetic purposes;
generic prescriptions on all covered formulary medications if (e) Drugs used to treat or cure baldness; anabolic steroids
there is a generic drug on the market. If a Covered Person’s used for body building;
Doctor chooses a brand or non-formulary drug and a generic
(f) Anorectics—drugs used for the purpose of weight
is available, the Covered Person will pay the difference
control;
between the brand/non-formulary drug and the generic (low
tier) cost and the applicable copay. (g) Fertility agents or sexual enhancement drugs, such
as Parlodel, Pergonal, Clomid, Profasi, Metrodin,
Prescription benefits are subject to all Plan provisions.
Serophene, or Viagra;
Please refer to the Schedule of Benefits for your deductible,
coinsurance and maximum benefit information (pages 8-12). (h) Growth hormones; or
The following Prescription Drugs, services or supplies are not (i) Refills in excess of the number specified or dispensed
covered: after one (1) year of date of the prescription.
(a) Therapeutic devices or appliances, including:
hypodermic needles, syringes, support garments and
14Accidental Death and *
Dismemberment Benefit
Loss of Life, Limb or Sight
If such Injury shall independently of all other causes and
within 180 days from the date of Injury solely result in any
one of the following specific losses, the Covered Person or
beneficiary may request the Company to pay the applicable
amount below. Payment under this benefit will not exceed the
policy Maximum Benefit.
For Loss of:
Life....................................................... $10,000
Both Hands or Both Feet........................ $10,000
Sight of Both Eyes.................................. $10,000
One Hand and One Foot....................... $10,000
One Hand and Sight of One Eye............ $10,000
Maternity Testing One Foot and Sight of One Eye ............. $10,000
One Hand or One Foot............................ $5,000
The Sight of One Eye .............................. $5,000
The Policy does not cover routine, preventive or screening Thumb or Index Finger............................. $2,500
examinations unless Medical Necessity is established based “Loss” of a hand or foot means complete severance through
on medical records. The following maternity routine tests or above the wrist or ankle joint. “Loss” of sight of an eye
and screening exams will be considered if all other policy means the total, irrevocable loss of the entire sight in that eye.
provisions have been met: Initial screening at first visit - “Loss” of thumb and index finger means complete severance
Pregnancy test: Urine human chorionic gonadotropic (HCG) through or above the metacarpophalangeal joint of both
(first trimester only), Asymptomatic bacteriuria; Urine culture, digits. “Severance” means the complete separation and
Blood type and Rh antibody, Toxoplasmosis; Blood Typing dismemberment of the part from the body.
ABO; Microbial Nucleic Acid Probe; Rubella, Pregnancy-
associated plasma proteie-A (PAPPA)(first trimester only),
Free beta human chorionic gonadotropin (HCG), Hepatitis MANDATED BENEFITS
B; HBsAg, Pap smear, Gonorrhea, Gc culture, Chlamydia; Benefits for Prosthetic Devices *
Clamydia culture, Syphilis; RPR, and HIV-ab; Each visit Benefits will be paid for the Reasonable and Customary
- Urine analysis, Once every trimester - Hematocrit and Charges for the purchase of Prosthetic Devices.
Hemoglobin; Once during first trimester - Ultrasound; Once Prosthetic device means an artificial device to replace, in
during second trimester - Ultrasound (anatomy scan); Triple whole or in part, an arm or leg.
Alpha-fetroprotein (AFP), Estriol, hCG or Quad screen test Benefits are limited to the most appropriate model that
Alpha fetroprotein (AFP), Estriol, hCG, inhibin-a; Once adequately meets the medical needs of the Covered
during second trimester if age 35 or over - Amniocentesis or Person as determined by the attending Doctor. Repairs and
Chorionic cillus sampling (CVS); Once during second or third replacements of Prosthetic Devices are also covered unless
trimester - 50g Glucola (blood glucose 1 hour post prandial); necessitated by misuse or loss.
and Once during third trimester - Group B Strep Culture. For Benefits for Biologically Based Mental Illness *
additional information regarding Maternity Testing, please Benefits will be paid the same as any other Sickness for the
call AmeriBen at 1-855-639-8676. treatment of Biologically Based Mental Illness and Mental
Disorders as defined below. The benefit provided will not
duplicate any other benefits provided in this policy.
“Biologically Based Mental Illness” means schizophrenia,
schizoaffective disorder, bipolar affective disorder, major
depressive disorder, specific obsessive-compulsive disorder,
To receive the network discount and panic disorder.
at a participating pharmacy, “Mental Disorder” means post-traumatic stress disorder,
present your Student Health drug and alcoholism disorders, dysthymia, cyclothymia,
social phobia, agoraphobia with panic disorder and general
Insurance ID card when anxiety disorder. The term includes anorexia nervosa and
you purchase the prescription. bulimia nervosa to the extent those diagnoses are treated on
For a list of participating pharmacies, an outpatient, day treatment, and inpatient basis, exclusive of
access the Express Scripts link at residential treatment. For purposes of this coverage, Mental
Disorder does not include autism.
www.colorado.edu/studentinsurance
* Benefits shall be subject to all Policy Year Deductible,
copayment, coinsurance, limitations, and any other
provisions of the policy.
15Benefits for Therapies for Congenital Defects and Birth or with the intent of inducing conception; hair growth
Abnormalities * or removal; impotence, organic or otherwise; learning
Benefits will be paid the same as any other Sickness for disabilities; premarital examinations; vasectomy; alopecia.
physical, occupational and speech therapy for congenital This exclusion does not apply to Preventive Services
mandated by the Patient Protection and Affordable Care
defects and birth abnormalities for covered dependent
Act.
children beginning after the first 31 days of life to the child’s 2. For elective abortions.
sixth birthday. 3. For addiction and co-dependency services and supplies
Benefits will be paid for the greater of the number of such related to: nicotine addiction; caffeine; and non-chemical
visits provided under the policy or twenty visits per year for addictions, such as gambling, sex, spending, shopping,
each therapy. Benefits will be provided without regard to working and religion; and treatment for co-dependency.
whether the condition is acute or chronic and without regard 4. As a result of injury sustained or Sickness contracted
to whether the purpose of the therapy is to maintain or to while in the service of the Armed Forces of any country.
improve functional capacity. Upon the Covered Person entering the Armed Forces of
any country, the Company will refund any unearned pro-
Benefits for Hearing Aids for Minor Children * rata premium. This does not include Reserve or National
Benefits will be paid the same as any other Sickness for Guard Duty for training unless it exceeds 31 days.
Eligible Expenses for Hearing Aids for a minor dependent 5. As a result of committing or attempting to commit an
child who has a hearing loss that has been verified by a assault or felony or participation in a felony, riot or civil
licensed Doctor and a licensed Audiologist. The Hearing Aid commotion.
shall be medically appropriate to meet the needs of the minor 6. For breast reconstruction and implantation or removal
dependent child and according to accepted professional of breast prostheses unless such care and services are
performed solely and directly as a result of a Medically
standards.
Necessary mastectomy.
Benefits shall include the purchase of the following: 7. For any period of care designed to help a Covered Person
1. Initial Hearing Aids and replacement Hearing Aids not in the activities of daily living not requiring continuous
more frequently than every five years; attention by trained medical or paramedical personnel.
Such care may involve: preparation of special diet;
2. A new Hearing Aid when alterations to the existing supervision over medication that can be self-administered;
Hearing Aid cannot adequately meet the needs of the and assisting the person getting in or out of bed, walking,
minor dependent child; and bathing, dressing, eating and using the toilet.
3. Services and supplies including, but not limited to the 8. For cosmetic surgery except that “cosmetic surgery” shall
initial assessment, fitting, adjustments, and auditory not include reconstructive surgery when such surgery is
training that is provided according to professional incidental to or follows surgery resulting from trauma,
infection or other disease of the involved part and
standards.
reconstructive surgery because of a congenital disease
Additional Mandated Benefits or anomaly of a covered dependent newborn child which
Benefits are provided for the items listed below as mandated has resulted in a functional defect. It also shall not
by the State of Colorado. A detail of these benefits may be include breast reconstructive surgery after a mastectomy.
found in the Master Policy on file at the University’s Student 9. For rest cures or custodial care.
Insurance Office. These benefits include Benefits for Cleft 10. As a result of dental treatment, except for treatment
Lip or Cleft Palate, Benefits for Hospitalization and General resulting from Injury to sound, natural teeth. This exclusion
Anesthesia for Dental Procedures for Dependent Children, does not apply to Preventive Services mandated by the
Benefits for Treatment of Autism Spectrum Disorders, Benefits Patient Protection and Affordable Care Act.
for Medical Foods, Benefits for Mammography, Diabetes, 11. For donor expenses in relation to organ transplants.
Child Health Supervision Services, Cervical Cancer Vaccine, 12. For elective treatment or elective surgery.
Colorectal Cancer Screening, Prostate Cancer Screening, 13. For treatment, services, drugs, device, procedures or
and any other applicable mandated benefits. supplies that are experimental or investigational.
14. For eye examinations (except as specifically provided),
* Benefits shall be subject to all Policy Year Deductible, eyeglasses, contact lenses, or prescription for such,
copayment, coinsurance, limitations, and any other or treatment for visual defects and problems. “Visual
defects” means any physical defect of the eye which
provisions of the policy.
does or can impair normal vision apart from the disease
process. Vision examinations not related to prescription
or fitting of lenses will be covered only when performed
in connection with the diagnosis or treatment of Sickness
EXCLUSIONS or Injury. Eye refraction is not covered. This exclusion
does not apply to Preventive Services mandated by the
Patient Protection and Affordable Care Act.
The Policy does not cover nor provide benefits for loss or 15. For eye surgery such as radial keratotomy when the
expenses incurred: primary purpose is to correct myopia (nearsightedness),
1. For surgery and/or treatment of: acupuncture; hyperopia (farsightedness) or astigmatism (blurring).
gynecomastia; family planning; infertility (male or female), 16. For treatment provided in a government Hospital unless
including any services or supplies rendered for the purpose there is a legal obligation to pay such charges in the
16absence of insurance.
17. For any services rendered by a Covered Person’s
Immediate Family Member.
COORDINATION OF
18. For Injury resulting from: the practicing for, participating
in, or traveling as a team member to and from
BENEFITS
intercollegiate, or professional sports activity, including
travel to and from the activity and practice. If the Covered Person has other group type, governmental, or
19. For maintenance therapy which is defined as those automobile no fault medical benefits coverage, the benefits
therapy services rendered to a Covered Person who is no payable under the Policy will be coordinated with the other
longer making documentable progress to maintain the coverage so that the combined benefits paid or provided by
level of progress previously attained. all plans will not exceed 100% of the allowable expense. The
20. For a treatment, service or supply which is not Medically plan paying second takes the benefits of the primary plan into
Necessary, except as specifically provided. account when it determines benefits.
21. For mental or nervous disorders except as specifically
provided.
22. For outpatient prescription drugs except at specifically
provided.
DEFINITIONS
23. For personal items or services such as television,
telephone or transportation. “Accident” means an occurrence which (a) is unforeseen; (b)
24. For preventive treatment, testing, medicines, serums, or is not due to or contributed to by Sickness or disease of any
vaccines except as specifically provided. This exclusion kind; and (c) causes Injury.
does not apply to Preventive Services mandated by the “Act” means the Patient Protection and Affordable Care Act
Patient Protection and Affordable Care Act. of 2010 (Public Law 111-148) as amended by the Health
25. For routine physical examinations, health examinations Care and Education Reconciliation Act of 2010 (Public Law
or preschool physical examinations, including routine 111-152).
care of a newborn infant, well-baby care and related
“Allowable Charges” means the charges agreed to by the
Doctor charges, except as specifically provided for in the
Policy. This exclusion does not apply to Preventive Services Preferred Provider Organization for specified covered medical
mandated by the Patient Protection and Affordable Care treatment, services and supplies.
Act. “Covered Person” means a Covered Student and his or her
26. For elective sterilization or its reversal, unless otherwise dependent(s) insured under the Policy.
provided. “Covered Student” means a student of this Policyholder who
27. For services normally provided without charge by is insured under the Policy.
the Policyholder’s Health Service/Center, Infirmary or “Deductible/Deductible Amount” means the dollar amount
Hospital, or by health care providers employed by the of Eligible Expenses a Covered Person must pay before
Policyholder or services covered by the Student Health benefits become payable.
Service/Center fee. “Doctor” means: (a) legally qualified physician licensed by
28. After the date insurance terminates for a Covered Person
the state in which he or she practices; and (b) a practitioner
except as may be specifically provided in the Extension of
Benefits Provision. of the healing arts performing services within the scope of
29. For chiropractic care or treatment not related to the his or her license as specified by the laws of the state of such
treatment of Sickness or Injury. practitioner; and (c) certified nurse midwives and licensed
30. For Injury or Sickness resulting from war or act of war, midwives while acting within the scope of that certification.
declared or undeclared. The term “Doctor” does not include a Covered Person’s
31. Weight management, services and supplies related Immediate Family Member.
to weight reduction programs; weight management “Elective Treatment” means medical treatment, which is
programs, related nutritional supplies and treatment for not necessitated by a pathological change in the function
obesity, (except for surgery for morbid obesity). Treatment or structure in any body part, occurring after the Covered
of morbid obesity is covered. Morbid obesity is defined Person’s effective date of coverage.
as follows: Morbid obesity associated with serious and
Elective treatment includes, but is not limited to: tubal ligation;
life-threatening disorders such as diabetes mellitus and
hypertension. Morbid obesity means a body weight two vasectomy; breast reduction unless as a result of mastectomy;
times the normal weight or greater, or 100 pounds in submucous resection and/or other surgical correction of
excess of normal body weight based on normal body deviated nasal septum, other than necessary treatment of
weight using generally accepted height and weight tables acute purulent sinusitis; treatment for weight reduction;
for a person of the same age, sex, height and frame. learning disabilities; botox injections; treatment of infertility.
Benefits will be provided only upon written request for “Eligible Expense” means a charge for any treatment, service
treatment with a treatment plan written by a Doctor, and or supply which is performed or given under the direction of
services and treatment must meet the requirements of a Doctor for the Medically Necessary treatment of a Sickness
Medical Necessity. Surgery for removal of skin or fat, or Injury: (a) not in excess of the Reasonable and Customary
except as specifically provided in the Policy. charges; or (b) not in excess of the charges that would have
32. As a result of an Injury or Sickness for which benefits
been made in the absence of this coverage; (c) with respect
are paid under any Workers’ Compensation or
Occupational Disease Law. to the Preferred Provider, is the Allowable Charge; (d) is the
17negotiated rate, if any and (e) incurred while the Policy is in “Injury” means bodily injury due to an Accident which: (a)
force as to the Covered Person except with respect to any results solely, directly and independently of disease, bodily
expenses payable under the Extension of Benefits Provision. infirmity or any other causes; (b) occurs after the Covered
“Emergency Medical Condition” means the sudden, and at Person’s effective date of coverage; and (c) occurs while
the time, unexpected onset of a health condition that requires coverage is in force. All injuries sustained in any one Accident,
immediate medical attention, that a prudent lay person having including all related conditions and recurrent symptoms of
average knowledge of health services and medicine and these injuries, are considered one Injury.
acting reasonably would have believed that an emergency “Medical Necessity/Medically Necessary” means that a
medical condition or life or limb threatening emergency drug, device, procedure, service or supply is necessary and
existed and that failure to provide medical attention would appropriate for the diagnosis or treatment of a Sickness or
result in serious impairment to bodily functions or serious Injury based on generally accepted current medical practice
dysfunction of a bodily organ or part, or would place the in the United States at the time it is provided.
person’s health in serious jeopardy. A service shall not be considered as Medically Necessary if:
Emergency does not include the recurring symptoms of a chronic (a) it is provided only as a convenience to the Covered Person
illness or condition unless the onset of such symptoms could or provider; or (b) it is not the appropriate treatment for the
reasonably be expected to result in the complications listed above. Covered Person’s diagnosis or symptoms; or (c) it exceeds
“Emergency Services” means the following: (in scope, duration or intensity) that level of care which is
(a) a medical screening examination, as required by federal needed to provide safe, adequate and appropriate diagnosis
law, that is within the capability of the emergency or treatment; or (d) it is experimental/investigational or for
department of a Hospital, including ancillary services research purposes; or (e) could have been omitted without
routinely available to the emergency department, to adversely affecting the patient’s condition or the quality
evaluate an Emergency Medical Condition; of medical care; or (f) involves treatment of or the use of
(b) such further medical examination and treatment that are a medical device, drug or substance not formally approved
required by federal law to stabilize an Emergency Medical by the U.S. Food and Drug Administration (FDA); or (g)
Condition and are within the capabilities of the staff and involves a service, supply or drug not considered reasonable
facilities available at the Hospital, including any trauma and necessary by the Healthcare Financing Administration
and burn center of the Hospital. Medicare Coverage Issues Manual or Center for Medicare
“Essential Health Benefits” means the essential health and Medicaid Services Issues Manual; or (h) it can be safely
benefits defined in Section 1302(b) of the Act. This includes provided to the patient on a more cost-effective basis such as
at least the following general categories and the items and outpatient, by a different medical professional or pursuant to
services covered within the categories: (a) Ambulatory patient a more conservative form of treatment.
services; (b) Emergency services; (c) Hospitalization; (d) The fact that any particular Doctor may prescribe, order,
Maternity and newborn care;(e) Mental health and substance recommend or approve a service or supply does not, of itself,
use disorder services, including behavioral health treatment; make the service or supply Medically Necessary.
(f) Prescription drugs; (g) Rehabilitative and habilitative “Reasonable and Customary” means the charge, fee
services and devices; (h) Laboratory services; (i) Preventive or expense which is the smallest of: (a) the actual charge;
and wellness services and chronic disease management; (j) (b) the charge usually made for a covered service by the
Pediatric services, including oral and vision care. provider who furnishes it; (c) the negotiated rate, if any; and
“Hospital” means a facility which meets all of these tests: (d) the prevailing charge made for a covered service in the
(a) provides in-patient services for the care and treatment of geographic area by those of similar professional standing.
injured and sick people; and (b) it provides room and board “Geographic area” means the three digit zip code in which
services and nursing services 24 hours a day; and (c) it has the services, procedure, devices, drugs, treatment or supplies
established facilities for diagnosis and major surgery; and are provided or a greater area, if necessary, to obtain a
(d) it is supervised by a Doctor; and (e) it is run as a Hospital representative cross-section of charge for a like treatment,
under the laws of the jurisdiction which it is located; and (f) service, procedure, device, drug or supply.
it is accredited by the Joint Commission on Accreditation of “Sickness” means disease or illness including related
Healthcare Organizations. conditions and recurrent symptoms of the Sickness. Sickness
Hospital does not include a place run mainly: (a) as a also includes pregnancy and Complications of Pregnancy. All
convalescent home; or (b) as a nursing or rest home; (c) as Sicknesses due to the same or a related cause are considered
a place for custodial or educational care; or as an institution One Sickness.
mainly rendering treatment or services for: Mental or Nervous
Disorders; or substance abuse. The term “Hospital” includes:
(a) an ambulatory surgical center or ambulatory medical
center; and (b) a birthing facility certified and licensed as
such under the laws where located. It shall also include
rehabilitative facilities if such is specifically for treatment of
physical disability.
Hospital also includes tax-supported institutions, which are
not required to maintain surgical facilities.
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