Aetna Student Health Plan Design and Benefits Summary
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Aetna Student Health Plan Design and Benefits Summary Preferred Provider Organization (PPO) University of Missouri Kansas City – International Students Policy Year: 2019 – 2020 Policy Number: 890439 www.aetnastudenthealth.com (877) 375-7905
Special Missouri Notice
An enrollee who is a member of a group health plan with coverage for elective abortions has the right to exclude and
not pay for coverage for elective abortions if such coverage is contrary to his or her moral, ethical or religious beliefs.
Your group contract holder has not purchased an optional rider for elective abortions pursuant to VAMS section
376.805.
This is a brief description of the Student Health Plan. The Plan is available for University of Missouri System students
and their eligible dependents. The Plan is underwritten by Aetna Life Insurance Company (Aetna). The exact provisions,
including definitions, governing this insurance are contained in the Certificate of Coverage issued to you and may be
viewed online at www.aetnastudenthealth.com. If there is a difference between this Benefit Summary and the
Certificate of Coverage, the Certificate will control.
Coverage Periods
Students: Coverage will become effective at 12:01 AM on the Coverage Start Date indicated below, and will terminate at
11:59 PM on the Coverage End Date indicated.
Coverage Period Coverage Start Date Coverage End Date Enrollment Deadline
Annual 08/01/2019 07/31/2020 09/06/2019
Fall 08/01/2019 12/31/2019 09/06/2019
Spring/Summer 01/01/2020 07/31/2020 02/07/2020
Summer 06/01/2020 07/31/2020 06/05/2020
Eligible Dependents: Coverage will become effective at 12:01 AM on the Coverage Start Date indicated below, and will
terminate at 11:59 PM on the Coverage End Date indicated. Coverage for insured dependents terminates in accordance
with the Termination Provisions described in the Master Policy.
Coverage Period Coverage Start Date Coverage End Date Enrollment Deadline
Annual 08/01/2019 07/31/2020 09/06/2019
Fall 08/01/2019 12/31/2019 09/06/2019
Spring/Summer 01/01/2020 07/31/2020 02/07/2020
Summer 06/01/2020 07/31/2020 06/05/2020
University of Missouri – Kansas City 2019-2020 Page 2Rates
The rates below include both premiums for the Plan underwritten by Aetna Life Insurance Company (Aetna) as well as
the University of Missouri – Kansas City administrative fee.
Premium Rates
Coverage Period Annual Fall Spring/Summer Summer
Student $2,053 $858 $1,195 $342
Student & Spouse $4,034 $1,686 $2,348 $672
Student & Child(ren) $4,034 $1,686 $2,348 $672
Student, Spouse & Child(ren) $6,015 $2,514 $3,501 $1,002
Student Coverage
Eligibility
All non-immigrant international students, scholars and Optional Practical Training/Academic Training (OPT) participants
holding F or J visas attending UMKC are eligible for this coverage. Enrollment in this Plan is mandatory and automatic for
all nonimmigrant international students upon academic enrollment each semester.
Distance learning students taking home study, correspondence or television courses are not eligible to enroll in the Plan.
If you withdraw from school within the first 31 days of a coverage period, you will not be covered under the Policy and
the full premium will be refunded. After 31 days, you will be covered for the full period that you have paid the premium
for, and no refund will be allowed. (This refund policy will not apply if you withdraw due to a covered Accident or
Sickness.)
Enrollment
Non-immigrant international students on F-1 and J-1 visas will be automatically enrolled unless waiver requirements are
met. Waiver application and proof of other coverage must be submitted to the International Student Affairs Office
within 31 days of the first day of class each semester. If the waiver information is not received or not approved by the
indicated deadline, the student will remain enrolled in the International Student/Scholar Health Insurance Plan.
Enrollment for Scholars and post-completion Optional Practical Training/Academic Training (OPT) participants is optional
and requires completion of an enrollment form each term. Visiting Scholars may obtain enrollment forms at the
International Student Affairs Office. OPT students may enroll online at www.aetnastudenthealth.com, choose the
University of Missouri – Kansas City, click on View Your School and click on the Enroll link on the left hand side of the
screen.
University of Missouri – Kansas City 2019-2020 Page 3Dependent Coverage
Eligibility
Covered students may also enroll their lawful spouse and/or dependent children up to the age of 26.
Enrollment
Students can also enroll eligible dependents online by visiting www.aetnastudenthealth.com, choose the University of
Missouri – Kansas City, click on View Your School and click on the Enroll link on the left hand side of the screen. Please
refer to the Coverage Periods section of this document for coverage dates and deadline dates. Dependent enrollment
applications will not be accepted after the enrollment deadline, unless there is a significant life change that directly
affects their insurance coverage. (An example of a significant life change would be loss of health coverage under another
health plan). The completed Enrollment Form and premium must be sent to Aetna Student Health. Please contact the
International Student Affairs Office or customer service at (877) 375-7905 to request an Enrollment Form.
Important note regarding coverage for a newborn infant or newly adopted child:
Your newborn child is covered on your health plan for the first 31 days from the moment of birth.
• To keep your newborn covered, you must notify us (or our agent) of the birth and pay any required premium
contribution during that 31 day period.
• You must still enroll the child within 31 days of birth even when coverage does not require payment of an
additional premium contribution for the newborn.
• If you miss this deadline, your newborn will not have health benefits after the first 31 days.
• When you tell us of the newborn’s birth, we will send you the forms and instructions to enroll your newborn.
We will also give you an additional ten (10) days from the date we provide these forms to enroll your newborn
child. Your newborn will be covered for treatment of injury or illness, including medically diagnosed congenital
defects and birth abnormalities.
• If your coverage ends during this 31 day period, then your newborn‘s coverage will end on the same date as
your coverage. This applies even if the 31 day period has not ended.
A child that you, or that you and your spouse, civil union partner or domestic partner adopts or is placed with you for
adoption, is covered on your plan for the first 31 days from the date of birth or the date of placement in your home, if a
petition for adoption is filed within 30 days of the date of birth, or within 30 days from the date of placement in your
home. The child will continue to be considered adopted unless she or he is removed from your home prior to issuance of
a legal decree of adoption. Placement means “in the physical custody of the adoptive parent.” Coverage includes the
necessary care and treatment of medical conditions existing prior to the date of placement.
• To keep your child covered, we must receive your completed enrollment information within 31 days from the
date of placement for adoption or the final decree of adoption, whichever is earliest.
• You must still enroll the child within 31 days of the adoption or placement for adoption even when coverage
does not require payment of an additional premium contribution for the child.
• If you miss this deadline, your adopted child or child placed with you for adoption will not have health benefits
after the first 31 days.
• If your coverage ends during this 31 day period, then coverage for your adopted child or child placed with you
for adoption will end on the same date as your coverage. This applies even if the 31 day period has not ended.
If you need information or have general questions on dependent enrollment, call Member Services at (877) 375-7905.
University of Missouri – Kansas City 2019-2020 Page 4Medicare Eligibility Notice You are not eligible for health coverage under this student policy if you have Medicare at the time of enrollment in this student plan. If you obtain Medicare after you enrolled in this student plan, your health coverage under this plan will not end. As used here, “have Medicare” means that you are entitled to benefits under Part A (receiving free Part A) or enrolled in Part B or Premium Part A. In-network Provider Network Aetna Student Health offers Aetna’s broad network of In-network Providers. You can save money by seeing In-network Providers because Aetna has negotiated special rates with them, and because the Plan’s benefits are better. If you need care that is covered under the Plan but not available from an In-network Provider, contact Member Services for assistance at the toll-free number on the back of your ID card. In this situation, Aetna may issue a pre-approval for you to receive the care from an Out-of-network Provider. When a pre-approval is issued by Aetna, the benefit level is the same as for In-network Providers. Precertification You need pre-approval from us for some eligible health services. Pre-approval is also called precertification. Precertification for medical services and supplies In-network care Your in-network physician is responsible for obtaining any necessary precertification before you get the care. If your in- network physician doesn't get a required precertification, we won't pay the provider who gives you the care. You won't have to pay either if your in-network physician fails to ask us for precertification. If your in-network physician requests precertification and we refuse it, you can still get the care but the plan won’t pay for it. You will find additional details on requirements in the Certificate of Coverage. Out-of-network care When you go to an out-of-network provider, it is your responsibility to obtain precertification from us for any services and supplies on the precertification list. If you do not precertify, your benefits may be reduced, or the plan may not pay any benefits. Refer to your schedule of benefits for this information. The list of services and supplies requiring precertification appears later in this section Aetna will not retroactively reduce or terminate a previously approved service or supply unless: • Such authorization is based on a material misrepresentation or omission about the treated or cause of the health condition or • The plan terminated before services are provided; or • Coverage terminated before the services were provided. University of Missouri – Kansas City 2019-2020 Page 5
Precertification call
Precertification should be secured within the timeframes specified below. To obtain precertification, call Member
Services at the toll-free number on your ID card. This call must be made:
Non-emergency admissions: You, your physician or the facility will need to call and request
precertification at least 14 days before the date you are scheduled to
be admitted.
An emergency admission: You, your physician or the facility must call within 48 hours or as soon
as reasonably possible after you have been admitted.
An urgent admission: You, your physician or the facility will need to call before you are
scheduled to be admitted. An urgent admission is a hospital admission
by a physician due to the onset of or change in an illness, the diagnosis
of an illness, or an injury.
Outpatient non-emergency services You or your physician must call at least 14 days before the outpatient
requiring precertification: care is provided, or the treatment or procedure is scheduled.
Access to Obstetrical and Gynecological (Ob/Gyn) Care
You do not need pre-certification from Aetna or from any other person (including a Primary Care Provider) in order to
obtain access or make an appointment to receive obstetrical or gynecological care from a health care professional in
Aetna’s Network who specializes in obstetrics or gynecology. The health care professional, however, may recommend
certain elective medical procedures that may require pre-certification. Preventive care services do not require pre-
certification.
Please see the “Pre-certification” provision in the Certificate of Coverage for a list of services under the Plan that require
pre-certification. Please see the Schedule of Benefits for any penalty or benefit reduction that may apply to your
coverage when pre-certification is not obtained for the listed services or supplies when received from a non-preferred
care provider.
We will provide a written notification to you and your physician of the precertification decision, where required by state
law. If your precertified services are approved, the approval is valid for 30 days as long as you remain enrolled in the
plan.
If you require an extension to the services that have been precertified, you, your physician, or the facility will need to
call us at the number on your ID card as soon as reasonably possible, but no later than the final authorized day.
If precertification determines that the stay or outpatient services and supplies are not covered benefits, the notification
will explain why and how you can appeal our decision. You or your provider may request a review of the precertification
decision. See the When you disagree - claim decisions and grievances procedures section of Certificate of Coverage.
What if you don’t obtain the required precertification?
If you don’t obtain the required precertification:
• Your benefits may be reduced, or the plan may not pay any benefits. See the schedule of benefits
Precertification penalty section.
• You will be responsible for the unpaid balance of the bills.
• Any additional out-of-pocket expenses incurred will not count toward your deductibles or maximum out-of-
pocket limits.
University of Missouri – Kansas City 2019-2020 Page 6What types of services and supplies require precertification?
Precertification is required for the following types of services and supplies:
Inpatient services and supplies Outpatient services and supplies
Stays in a hospice facility Applied behavior analysis
Stays in a hospital Certain prescription drugs and devices*
Stays in a rehabilitation facility Complex imaging
Stays in a residential treatment facility for treatment Cosmetic and reconstructive surgery
of mental disorders and substance abuse
Stays in a skilled nursing facility Emergency transportation by airplane
Home health care
Hospice services
Intensive outpatient program (IOP) – mental disorder and
substance abuse diagnoses
Kidney dialysis
Knee surgery
Medical injectable drugs, (immunoglobulins, growth
hormones, multiple sclerosis medications, osteoporosis
medications, botox, hepatitis C medications)*
Outpatient back surgery not performed in a physician’s
office
Partial hospitalization treatment – mental disorder and
substance abuse diagnoses
Private duty nursing services
Psychological testing/neuropsychological testing
Sleep studies
Transcranial magnetic stimulation (TMS)
Wrist surgery
*For a current listing of the prescription drugs and medical injectable drugs that require precertification, contact Member
Services by calling the toll-free number on your ID card, in the How to contact us for help section, or by logging onto the
Aetna website at www.aetnastudenthealth.com.
Coordination of Benefits (COB)
Some people have health coverage under more than one health plan. If you do, we will work together with your other
plan(s) to decide how much each plan pays. This is called coordination of benefits (COB).
Here’s how COB works
• When this is the primary plan, we will pay your medical claims first as if the other plan does not exist
• When this is the secondary plan, we will pay benefits after the primary plan and will reduce the payment based
on any amount the primary plan paid
• We will never pay an amount that, together with payments from your other coverage, add up to more than
100% of the allowable submitted expenses
For more information about the Coordination of Benefits provision, including determining which plan is primary and
which is secondary, you may call the Member Services telephone number shown on your ID card. A complete
description of the Coordination of Benefits provision is contained in the Policy issued to The University of Missouri
System and may be viewed online at www.aetnastudenthealth.com.
University of Missouri – Kansas City 2019-2020 Page 7University of Missouri – Kansas City Student Health and Wellness (SHW)
The student health insurance plan is designed to work with your campus student health center. Out-of-pocket costs are
generally lower at the student health center and the location is ideal for students to seek care.
The mission of Student Health and Wellness (SHW) is to provide quality health care, health promotion, and health
education that maximizes student learning potential. SHW provides healthcare on acute illnesses, stable chronic health
problems, and health promotion/prevention strategies. SHW personnel include nurse practitioners, registered nurses,
health educator, and support staff. There is no visit charge for currently enrolled UMKC students; additional services or
laboratory testing may involve a charge. These additional charges can be paid for with cash, check or charged to the
student's UMKC account.
Student Health and Wellness services include:
• well-woman exams, blood pressure measurement, birth control counseling;
• first aid (non-emergency);
• immunizations (including Hepatitis A and B, Meningitis, MMR, Tetanus [TDaP], Gardasil 9, and Seasonal Flu
shots);
• physical examinations;
• STD testing and treatment;
• travel consultation;
• allergy injections with student-furnished serum; and
• Tuberculosis screening.
Health promotion services include informational brochures, updated web information, health fairs, and classroom
presentations. Student Health reaches out to students with programming related to healthy sexual behaviors, alcohol
and drug awareness, safe driving, nutrition and a promotion of a well-rounded integration of mental and physical
health. A student desiring specific health information may contact Student Health and Wellness by phone (816-235-
6133) or e-mail studenthealth@umkc.edu.
Student Health is open Monday - Friday and offers late afternoon appointments two days per week. Students can make
an appointment by calling 816-235-6133 or an appointment can be made from the website. More information about
services and health information is available at http://info.umkc.edu/studenthealth.
Description of Benefits
The Plan excludes coverage for certain services (referred to as exceptions in the certificate of coverage) and has
limitations on the amounts it will pay. While this Plan Design and Benefit Summary document will tell you about some of
the important features of the Plan, other features may be important to you and some may further limit what the Plan
will pay. To look at the full Plan description, which is contained in the Certificate of Coverage issued to you, go to
www.aetnastudenthealth.com. If any discrepancy exists between this Benefit Summary and the Certificate of
Coverage, the Certificate will control.
This Plan will pay benefits in accordance with any applicable Missouri Insurance Law(s).
Metallic Level: Gold, tested at 81.90%
How your plan works while you are covered for in-network coverage
Your in-network coverage helps you:
• Get and pay for a lot of – but not all – health care services
• Pay less cost share when you use an in-network provider
University of Missouri – Kansas City 2019-2020 Page 8Policy year deductible In-network coverage Out-of-network coverage
You have to meet your policy year deductible before this plan pays for benefits.
Student $400 per policy year $800 per policy year
Spouse $400 per policy year $800 per policy year
Each child $400 per policy year $800 per policy year
Family None None
Policy year deductible waiver
The policy year deductible is waived for all of the following eligible health services:
• In-network care for Preventive care and wellness, Family planning services - female contraceptives, and Pediatric
Dental Services.
• In-network care and out-of-network care for immunizations for children under five years of age, Prescribed
Medicines Expense, and Pediatric Vision Services.
Maximum out-of-pocket limits
Maximum out-of-pocket limit per policy year
Student $6,350 per policy year None
Spouse $6,350 per policy year None
Each child $6,350 per policy year None
Family $12,700 per policy year None
Precertification covered benefit penalty
This only applies to out-of-network coverage: The certificate of coverage contains a complete description of the
precertification program. You will find details on precertification requirements in the Medical necessity and
precertification requirements section.
Failure to precertify your eligible health services when required will result in the following benefit penalties:
- A $500 benefit penalty will be applied separately to each type of eligible health services.
The additional percentage or dollar amount of the recognized charge which you may pay as a penalty for failure to
obtain precertification is not a covered benefit and will not be applied to the policy year deductible amount or the
maximum out-of-pocket limit, if any.
University of Missouri – Kansas City 2019-2020 Page 9The coinsurance listed in the schedule of benefits below reflects the plan coinsurance percentage.
This is the coinsurance amount that the plan pays. You are responsible for paying any remaining coinsurance.
Eligible health services In-network coverage Out-of-network coverage
Preventive care and wellness
Routine physical exams
Performed at a physician’s office 100% (of the negotiated charge) 70% (of the recognized charge)
per visit per visit
No copayment or policy year
deductible applies
Covered persons through age 21: Maximum Subject to any age and visit limits provided for in the comprehensive
age and visit limits per policy year guidelines supported by the American Academy of Pediatrics/Bright
Futures/Health Resources and Services Administration guidelines for
children and adolescents.
For details, contact your physician or Member Services by logging
onto your Aetna secure website at www.aetnastudenthealth.com or
calling the toll-free number on your ID card.
Covered persons age 22 and over: Maximum 1 visit
visits per policy year
Preventive care immunizations
Performed in a facility or at a physician's 100% (of the negotiated charge) 70% (of the recognized charge)
office per visit per visit
No copayment or policy year Covered 100% for children up to
deductible applies 5 years of age. Deductible &
coinsurance applies thereafter.
Maximums Subject to any age limits provided for in the comprehensive
guidelines supported by Advisory Committee on Immunization
Practices of the Centers for Disease Control and Prevention
For details, contact your physician or Member Services by logging
onto your Aetna secure website at www.aetnastudenthealth.com or
calling the toll-free number on your ID card.
Child health supervision services
Covered according to the type of Covered according to the type of
benefit incurred and the place benefit incurred and the place
where the service is received where the service is received
University of Missouri – Kansas City 2019-2020 Page 10Eligible health services In-network coverage Out-of-network coverage
Well baby/child exams
Limited to: Covered according to the type of Covered according to the type of
Covered persons through age 22 benefit incurred and the place benefit incurred and the place
where the service is received where the service is received
Maximum visits per policy year • Limited to 7 exams in the first 12 months
• Limited to 3 exams in the second 12 months
• Limited to 3 exams in the third 12 months Limited to 1 exam
thereafter per policy year benefit maximum
Early intervention for infants and toddlers (First Steps)
Early intervention services office visit for Covered according to the type of Covered according to the type of
children from birth to age 3 benefit incurred and the place benefit incurred and the place
where the service is received where the service is received
Well woman preventive visits
Routine gynecological exams (including Pap smears)
Performed at a physician’s, obstetrician (OB), 100% (of the negotiated charge) 70% (of the recognized charge)
gynecologist (GYN) or OB/GYN office per visit per visit
No copayment or policy year
deductible applies
Maximums Subject to any age limits provided for in the comprehensive
guidelines supported by the Health Resources and Services
Administration.
Maximum visits per policy year 1 visits
Preventive screening and counseling services
Obesity and/or healthy diet counseling office 100% (of the negotiated charge) 70% (of the recognized charge)
visits per visit per visit
No copayment or policy year
deductible applies
Maximum visits per policy year 26 visits. However, of these only 10 visits will be allowed under the
(This maximum applies only to covered plan for healthy diet counseling provided in connection with
persons age 22 and older.) Hyperlipidemia (high cholesterol) and other known risk factors for
cardiovascular and diet-related chronic disease.
Misuse of alcohol and/or drugs counseling 100% (of the negotiated charge) 70% (of the recognized charge)
office visits per visit per visit
No copayment or policy year
deductible applies
Maximum visits per policy year 5 visits
University of Missouri – Kansas City 2019-2020 Page 11Eligible health services In-network coverage Out-of-network coverage
Preventive screening and counseling services (continued)
Use of tobacco products counseling office 100% (of the negotiated charge) 70% (of the recognized charge)
visits per visit per visit
No copayment or policy year
deductible applies
Maximum visits per policy year 8 visits
Depression screening counseling office visits 100% (of the negotiated charge) 70% (of the recognized charge)
per visit per visit
No copayment or policy year
deductible applies
Maximum visits per policy year 1 visit
Sexually transmitted infection counseling 100% (of the negotiated charge) 70% (of the recognized charge)
office visits per visit per visit
No copayment or policy year
deductible applies
Maximum visits per policy year 2 visits
Genetic risk counseling for breast and ovarian 100% (of the negotiated charge) 70% (of the recognized charge)
cancer counseling office visits per visit per visit
No copayment or policy year
deductible applies
Age and frequency limitations Not subject to any age or frequency limitations
Lead poisoning screening Covered according to the type of Covered according to the type of
benefit incurred and the place benefit incurred and the place
where the service is received. where the service is received.
Refer to the specific cost-sharing Refer to the specific cost-sharing
in this schedule of benefits that in this schedule of benefits that
applies to the type of expense applies to the type of expense
that you incurred that you incurred
Routine cancer screenings performed at a physician’s office, specialist’s office or facility
Routine cancer screenings 100% (of the negotiated charge) 70% (of the recognized charge)
per visit per visit
No copayment or policy year
deductible applies
Maximums Subject to any age; family history; and frequency guidelines as set
forth in the most current:
• Evidence-based items that have in effect a rating of A or B in the
current recommendations of the United States Preventive Services
Task Force; and
• The comprehensive guidelines supported by the Health Resources
and Services Administration.
For details, contact your physician or Member Services by logging
onto your Aetna secure website at www.aetnastudenthealth.com or
calling the toll-free number on your ID card.
University of Missouri – Kansas City 2019-2020 Page 12Eligible health services In-network coverage Out-of-network coverage
Preventive screening and counseling services (continued)
Mammogram maximums Age 35 and older; subject to any family history; and frequency
guidelines as set forth in the most current:
• Evidence-based items that have in effect a rating of A or B in the
current recommendations of the United States Preventive Services
Task Force and
• The comprehensive guidelines supported by the Health Resources
and Services Administration; or
• State law (where stricter).
For details, contact your physician or Member Services by logging
onto your Aetna secure member website at
www.aetnastudenthealth.com or calling the toll-free number on
your ID card in the How to contact us for help section.
Lung cancer screening maximums 1 screening every 12 months*
*Important note: Any lung cancer screenings that exceed the lung cancer screening maximum above are covered
under the Outpatient diagnostic testing section.
Prenatal care services (provided by a physician, an obstetrician (OB), gynecologist (GYN),
and/or OB/GYN)
Preventive care services only 100% (of the negotiated charge) 70% (of the recognized charge)
per visit per visit
No copayment or policy year
deductible applies
Important note: You should review the Maternity care and Well newborn nursery care sections. They will give you
more information on coverage levels for maternity care under this plan.
Comprehensive lactation support and counseling services
Lactation counseling services - facility or 100% (of the negotiated charge) 70% (of the recognized charge)
office visits per visit per visit
No copayment or policy year
deductible applies
Lactation counseling services maximum visits 6 visits
per policy year either in a group or individual
setting
Important note: Any visits that exceed the lactation counseling services maximum are covered under the Physicians
and other health professionals section.
Breast pump supplies and accessories 100% (of the negotiated charge) 70% (of the recognized charge)
per item per item
No copayment or policy year
deductible applies
University of Missouri – Kansas City 2019-2020 Page 13Eligible health services In-network coverage Out-of-network coverage
Family planning services –contraceptives
Contraceptive counseling services office visit 100% (of the negotiated charge) 70% (of the recognized charge)
per visit per visit
No copayment or policy year
deductible applies
Contraceptive counseling services maximum 2 visits
visits per policy year either in a group or
individual setting
Contraceptives (prescription drugs and devices)
Contraceptive prescription drugs and devices 100% (of the negotiated charge) 70% (of the recognized charge)
provided, administered, or removed, by a per item per item
physician during an office visit
No copayment or policy year
deductible applies
Voluntary sterilization
Inpatient provider services 100% (of the negotiated charge) 70% (of the recognized charge)
No copayment or policy year
deductible applies
Outpatient provider services 100% (of the negotiated charge) 70% (of the recognized charge)
per visit per visit
No copayment or policy year
deductible applies
Physicians and other health professionals
Physician and specialist services
Office hours visits $20 copayment then the plan 50% (of the recognized charge)
(non-surgical and non-preventive care by a pays 80% (of the balance of the per visit
physician and specialist) negotiated charge) per visit
Includes telemedicine consultations thereafter
Allergy testing and treatment
Allergy testing performed at a physician’s or Covered according to the type of Covered according to the type of
specialist’s office benefit and the place where the benefit and the place where the
service is received. Refer to the service is received. Refer to the
specific cost-sharing in this specific cost-sharing in this
schedule of benefits that applies schedule of benefits that applies
to the type of expense that you to the type of expense that you
incurred incurred
Allergy injections treatment performed at a Covered according to the type of Covered according to the type of
physician’s, or specialist office benefit and the place where the benefit and the place where the
service is received. Refer to the service is received. Refer to the
specific cost-sharing in this specific cost-sharing in this
schedule of benefits that applies schedule of benefits that applies
to the type of expense that you to the type of expense that you
incurred incurred
University of Missouri – Kansas City 2019-2020 Page 14Eligible health services In-network coverage Out-of-network coverage
Allergy testing and treatment (continued)
Allergy sera and extracts administered via Covered according to the type of Covered according to the type of
injection at a physician’s or specialist’s office benefit and the place where the benefit and the place where the
service is received. Refer to the service is received. Refer to the
specific cost-sharing in this specific cost-sharing in this
schedule of benefits that applies schedule of benefits that applies
to the type of expense that you to the type of expense that you
incurred incurred
Physician and specialist - inpatient surgical services
Inpatient surgery performed during your stay 80% (of the negotiated charge) 50% (of the recognized charge)
in a hospital or birthing center by a surgeon
Anesthetist 80% (of the negotiated charge) 50% (of the recognized charge)
Surgical assistant 80% (of the negotiated charge) 50% (of the recognized charge)
Physician and specialist - outpatient surgical services
Outpatient surgery performed at a 80% (of the negotiated charge) 50% (of the recognized charge)
physician’s or specialist’s office or outpatient per visit per visit
department of a hospital or surgery center by
a surgeon
Anesthetist 80% (of the negotiated charge) 50% (of the recognized charge)
per visit per visit
Surgical assistant 80% (of the negotiated charge) 50% (of the recognized charge)
per visit per visit
In-hospital non-surgical physician services
In-hospital non-surgical physician services 80% (of the negotiated charge) 50% (of the recognized charge)
per visit per visit
Consultant services (non-surgical and non-preventive)
Office hours visits (non-surgical and non- $20 copayment then the plan 50% (of the recognized charge)
preventive care) pays 80% (of the balance of the per visit
(includes telemedicine consultations) negotiated charge) per visit
thereafter
Second surgical opinion Covered according to the type of Covered according to the type of
benefit incurred and the place benefit incurred and the place
where the service is received. where the service is received.
Refer to the specific cost-sharing Refer to the specific cost-sharing
in this schedule of benefits that in this schedule of benefits that
applies to the type of expense applies to the type of expense
that you incurred that you incurred
University of Missouri – Kansas City 2019-2020 Page 15Eligible health services In-network coverage Out-of-network coverage
Second opinion - cancer
Second opinion - cancer Covered according to the type of Covered according to the type of
benefit incurred and the place benefit incurred and the place
where the service is received. where the service is received.
Refer to the specific cost-sharing Refer to the specific cost-sharing
in this schedule of benefits that in this schedule of benefits that
applies to the type of expense applies to the type of expense
that you incurred that you incurred
Alternatives to physician office visits
Walk-in clinic visits (non-emergency visit) $20 copayment then the plan 50% (of the recognized charge)
pays 80% (of the balance of the per visit
negotiated charge) per visit
thereafter
Hospital and other facility care
Inpatient hospital $200 copayment then the plan 50% (of the recognized charge)
(room and board) and other miscellaneous pays 80% (of the balance of the per admission
services and supplies) negotiated charge) per
admission
Subject to semi-private room rate unless
intensive care unit required
Room and board includes intensive care
For physician charges, refer to the Physician
and specialist – inpatient surgical services
benefit
Preadmission testing Covered according to the type of Covered according to the type of
benefit incurred and the place benefit incurred and the place
where the service is received. where the service is received.
Refer to the specific cost-sharing Refer to the specific cost-sharing
in this schedule of benefits that in this schedule of benefits that
applies to the type of expense applies to the type of expense
that you incurred that you incurred
Alternatives to hospital stays
Outpatient surgery (facility charges)
Facility charges for surgery performed in the 80% (of the negotiated charge) 50% (of the recognized charge)
outpatient department of a hospital or
surgery center
For physician charges, refer to the Physician
and specialist - outpatient surgical services
benefit
University of Missouri – Kansas City 2019-2020 Page 16Eligible health services In-network coverage Out-of-network coverage
Home health care
Outpatient 80% (of the negotiated charge) 50% (of the recognized charge)
per visit per visit
Outpatient private duty nursing 80% (of the negotiated charge) 50% (of the recognized charge)
per visit per visit
Hospice care
Inpatient facility (room and board and other 80% (of the negotiated charge) 50% (of the recognized charge)
miscellaneous services and supplies) per admission per admission
Outpatient 80% (of the negotiated charge) 50% (of the recognized charge)
per visit per visit
Skilled nursing facility
Inpatient facility $200 copayment then the plan 50% (of the recognized charge)
(room and board and miscellaneous pays 80% (of the balance of the per admission
inpatient care services and supplies) negotiated charge) per
Subject to semi-private room rate unless admission
intensive care unit is required
Room and board includes intensive care
Emergency services and urgent care
Emergency services
Hospital emergency room $100 copayment then the plan Paid the same as in-network
pays 80% (of the balance of the coverage
negotiated charge) per visit
Non-emergency care in a hospital emergency Not covered Not covered
room
Important note:
• As out-of-network providers do not have a contract with us the provider may not accept payment of your cost
share, (copayment/coinsurance), as payment in full. You may receive a bill for the difference between the
amount billed by the provider and the amount paid by this plan. If the provider bills you for an amount above
your cost share, you are not responsible for paying that amount. You should send the bill to the address listed
on the back of your ID card, and we will resolve any payment dispute with the provider over that amount.
Make sure the ID card number is on the bill.
• A separate hospital emergency room copayment/coinsurance will apply for each visit to an emergency room.
If you are admitted to a hospital as an inpatient right after a visit to an emergency room, your emergency
room copayment/coinsurance will be waived and your inpatient copayment/coinsurance will apply.
• Covered benefits that are applied to the hospital emergency room copayment/coinsurance cannot be applied
to any other copayment/coinsurance under the plan. Likewise, a copayment/coinsurance that applies to
other covered benefits under the plan cannot be applied to the hospital emergency room
copayment/coinsurance.
• Separate copayment/coinsurance amounts may apply for certain services given to you in the hospital
emergency room that are not part of the hospital emergency room benefit. These copayment/coinsurance
amounts may be different from the hospital emergency room copayment/coinsurance. They are based on the
specific service given to you.
• Services given to you in the hospital emergency room that are not part of the hospital emergency room
benefit may be subject to copayment/coinsurance amounts that are different from the hospital emergency
room copayment/coinsurance amounts.
University of Missouri – Kansas City 2019-2020 Page 17Eligible health services In-network coverage Out-of-network coverage
Urgent care
Urgent medical care provided by an urgent 80% (of the negotiated charge) 50% (of the recognized charge)
care provider per visit per visit
Non-urgent use of urgent care provider Not covered Not covered
Pediatric dental care (Limited to covered persons through the end of the month in which
the person turns age 19)
Type A services 100% (of the negotiated charge) 70% (of the recognized charge)
per visit per visit
No copayment or deductible
applies
Type B services 70% (of the negotiated charge) 50% (of the recognized charge)
per visit per visit
No policy year deductible applies
Type C services 50% (of the negotiated charge) 50% (of the recognized charge)
per visit per visit
No policy year deductible applies
Orthodontic services 50% (of the negotiated charge) 50% (of the recognized charge)
per visit per visit
No policy year deductible applies
Dental emergency treatment Covered according to the type of Covered according to the type of
benefit incurred and the place benefit incurred and the place
where the service is received. where the service is received.
Refer to the specific cost-sharing Refer to the specific cost-sharing
in this schedule of benefits that in this schedule of benefits that
applies to the type of expense applies to the type of expense
that you incurred that you incurred
Specific conditions
Birthing center (facility charges)
Inpatient (room and board and other Paid at the same cost-sharing as Paid at the same cost-sharing as
miscellaneous services and supplies) hospital care. hospital care.
Diabetic services and supplies (including equipment and training)
Diabetic services and supplies (including Covered according to the type of Covered according to the type of
equipment and training) benefit and the place where the benefit and the place where the
service is received. Refer to the service is received. Refer to the
specific cost-sharing in this specific cost-sharing in this
schedule of benefits that applies schedule of benefits that applies
to the type of expense that you to the type of expense that you
incurred incurred
University of Missouri – Kansas City 2019-2020 Page 18Eligible health services In-network coverage Out-of-network coverage
Impacted wisdom teeth
Impacted wisdom teeth 80% (of the negotiated charge) 80% (of the recognized charge)
Accidental injury to sound natural teeth
Accidental injury to sound natural teeth 80% (of the negotiated charge) 80% (of the recognized charge)
Anesthesia and related facility charges fora dental procedure
Anesthesia and related facility charges for a Covered according to the type of Covered according to the type of
dental procedure benefit and the place where the benefit and the place where the
service is received. Refer to the service is received. Refer to the
specific cost-sharing in this specific cost-sharing in this
schedule of benefits that applies schedule of benefits that applies
to the type of expense that you to the type of expense that you
incurred incurred
Anesthesia and hospital charges for dental care
Anesthesia and hospital charges for dental Covered according to the type of Covered according to the type of
care benefit and the place where the benefit and the place where the
service is received. Refer to the service is received. Refer to the
specific cost-sharing in this specific cost-sharing in this
schedule of benefits that applies schedule of benefits that applies
to the type of expense that you to the type of expense that you
incurred incurred
Temporomandibular joint dysfunction (TMJ) and craniomandibular joint dysfunction (CMJ) treatment
TMJ and CMJ treatment Covered according to the type of Covered according to the type of
benefit and the place where the benefit and the place where the
service is received. Refer to the service is received. Refer to the
specific cost-sharing in this specific cost-sharing in this
schedule of benefits that applies schedule of benefits that applies
to the type of expense that you to the type of expense that you
incurred incurred
Dermatological treatment
Dermatological treatment Covered according to the type of Covered according to the type of
benefit and the place where the benefit and the place where the
service is received. Refer to the service is received. Refer to the
specific cost-sharing in this specific cost-sharing in this
schedule of benefits that applies schedule of benefits that applies
to the type of expense that you to the type of expense that you
incurred incurred
Maternity care
Maternity care (includes delivery and Covered according to the type of Covered according to the type of
postpartum care services in a hospital or benefit and the place where the benefit and the place where the
birthing center) service is received. Refer to the service is received. Refer to the
specific cost-sharing in this specific cost-sharing in this
schedule of benefits that applies schedule of benefits that applies
to the type of expense that you to the type of expense that you
incurred incurred
University of Missouri – Kansas City 2019-2020 Page 19Eligible health services In-network coverage Out-of-network coverage
Maternity care (continued)
Well newborn nursery care in a hospital or 80% (of the negotiated charge) 50% (of the recognized charge)
birthing center
No policy year deductible applies No policy year deductible applies
Note: The per admission copayment amount and/or policy year deductible for newborns will be waived for nursery charges for the
duration of the newborn’s initial routine facility stay. The nursery charges waiver will not apply for non-routine facility stays.
Pregnancy complications
Inpatient Covered according to the type of Covered according to the type of
(room and board and other miscellaneous benefit and the place where the benefit and the place where the
services and supplies) service is received. Refer to the service is received. Refer to the
specific cost-sharing in this specific cost-sharing in this
Subject to semi-private room rate unless schedule of benefits that applies schedule of benefits that applies
intensive careunit required to the type of expense that you to the type of expense that you
incurred incurred
Room and board includes intensive care
Family planning services – other
Voluntary sterilization for males 100% (of the negotiated charge) 70% (of the recognized charge)
Inpatient physician or specialist surgical
services No policy year deductible applies
Voluntary sterilization for males 100% (of the negotiated charge) 70% (of the recognized charge)
Outpatient physician or specialist surgical
services No policy year deductible applies
Gender Reassignment (Sex Change) Treatment
Surgical, hormone replacement therapy, and Covered according to the type of Covered according to the type of
counseling treatment benefit and the place where the benefit and the place where the
service is received. Refer to the service is received. Refer to the
specific cost-sharing in this specific cost-sharing in this
schedule of benefits that applies schedule of benefits that applies
to the type of expense that you to the type of expense that you
incurred incurred
Autism spectrum disorder
Autism spectrum disorder diagnosis and Covered according to the type of Covered according to the type of
testing benefit and the place where the benefit and the place where the
service is received. Refer to the service is received.
specific cost-sharing in this Refer to the specific cost-sharing
schedule of benefits that applies in this schedule of benefits that
to the type of expense that you applies to the type of expense
incurred that you incurred
Autism spectrum disorder treatment Covered according to the type of Covered according to the type of
(includes physician and specialist office visits, benefit and the place where the benefit and the place where the
diagnosis and testing) service is received. Refer to the service is received.
specific cost-sharing in this Refer to the specific cost-sharing
schedule of benefits that applies in this schedule of benefits that
to the type of expense that you applies to the type of expense
incurred that you incurred
University of Missouri – Kansas City 2019-2020 Page 20Eligible health services In-network coverage Out-of-network coverage
Autism spectrum disorder (continued)
Physical, occupational, and speech therapy Covered according to the type of Covered according to the type of
associated with diagnosis of autism spectrum benefit and the place where the benefit and the place where the
disorder service is received. Refer to the service is received. Refer to the
specific cost-sharing in this specific cost-sharing in this
The copayment or coinsurance for any schedule of benefits that applies schedule of benefits that applies
physical therapy and occupational therapy to the type of expense that you to the type of expense that you
services under this benefit will be no greater incurred incurred
than a physician’s office visit copay
Applied behavior analysis Covered according to the type of Covered according to the type of
benefit and the place where the benefit and the place where the
service is received. Refer to the service is received. Refer to the
specific cost-sharing in this specific cost-sharing in this
schedule of benefits that applies schedule of benefits that applies
to the type of expense that you to the type of expense that you
incurred incurred
Mental health treatment
Mental health treatment – inpatient
Inpatient hospital mental disorders $200 copayment then the plan 50% (of the recognized charge)
treatment (room and board and other pays 80% (of the balance of the per admission
miscellaneous hospital services and supplies) negotiated charge) per
admission
Inpatient residential treatment facility
mental disorders treatment (room and
board and other miscellaneous residential
treatment facility services and supplies)
Subject to semi-private room rate unless
intensive care unit is required
Mental disorder room and board intensive
care
Mental health treatment - outpatient
Outpatient mental disorders treatment office $20 copayment then the plan 50% (of the recognized charge)
visits to a physician or behavioral health pays 80% (of the balance of the per visit
provider negotiated charge) per visit
(includes telemedicine consultations) thereafter
Other outpatient mental disorders treatment 80% (of the negotiated charge) 50% (of the recognized charge)
(includes skilled behavioral health services in per visit per visit
the home)
Partial hospitalization treatment
Intensive Outpatient Program
University of Missouri – Kansas City 2019-2020 Page 21Eligible health services In-network coverage Out-of-network coverage
Substance abuse related disorders treatment-inpatient
Inpatient hospital substance abuse $200 copayment then the plan 50% (of the recognized charge)
detoxification (room and board and other pays 80% (of the balance of the per admission
miscellaneous hospital services and supplies) negotiated charge) per
admission
Inpatient hospital substance abuse
rehabilitation (room and board and other
miscellaneous hospital services and supplies)
Inpatient residential treatment facility
substance abuse (room and board and other
miscellaneous residential treatment facility
services and supplies)
Subject to semi-private room rate unless
intensive care unit is required
Substance abuse room and board intensive
care
Substance abuse related disorders treatment-outpatient: detoxification and rehabilitation
Outpatient substance abuse office visits to a $20 copayment then the plan 50% (of the recognized charge)
physician or behavioral health provider pays 80% (of the balance of the per visit
negotiated charge) per visit
(includes telemedicine consultations) thereafter
Other outpatient substance abuse services 80% (of the negotiated charge) 50% (of the recognized charge)
per visit per visit
Partial hospitalization treatment
Intensive Outpatient Program
Reconstructive surgery and supplies
Reconstructive surgery and supplies (includes Covered according to the type of Covered according to the type of
reconstructive breast surgery) benefit and the place where the benefit and the place where the
service is received. Refer to the service is received. Refer to the
specific cost-sharing in this specific cost-sharing in this
schedule of benefits that applies schedule of benefits that applies
to the type of expense that you to the type of expense that you
incurred incurred
University of Missouri – Kansas City 2019-2020 Page 22Eligible health services In-network In-network Out-of-network
coverage coverage (Non- coverage
(IOE facility) IOE facility)
Transplant services
Inpatient and outpatient transplant facility Covered according to Covered according to Covered according to
services the type of benefit the type of benefit the type of benefit
and the place where and the place where and the place where
the service is the service is the service is
received. Refer to the received. Refer to the received. Refer to the
specific cost-sharing specific cost-sharing specific cost-sharing
in this schedule of in this schedule of in this schedule of
benefits that applies benefits that applies benefits that applies
to the type of to the type of to the type of
expense that you expense that you expense that you
incurred. incurred. incurred.
Inpatient and outpatient transplant physician Covered according to Covered according to Covered according to
and specialist services the type of benefit the type of benefit the type of benefit
and the place where and the place where and the place where
the service is the service is the service is
received. Refer to the received. Refer to the received. Refer to the
specific cost-sharing specific cost-sharing specific cost-sharing
in this schedule of in this schedule of in this schedule of
benefits that applies benefits that applies benefits that applies
to the type of to the type of to the type of
expense that you expense that you expense that you
incurred. incurred. incurred.
Eligible health services In-network In-network Out-of-network
coverage coverage (Non- coverage
(IOE facility) IOE facility)
Transplant services (continued)
Maximum Benefit for donor searches for $30,000 per transplant
bone marrow/ stem cell transplants for a
covered Transplant procedure
Maximum Benefit for Dose intensive $100,000 per transplant
chemotherapy/autologous bone marrow
transplants for stem cell transplants for
breast cancer treatment incurred while
covered under any Aetna or Aetna-
affiliated plan:
Human Leukocyte Antigen Testing for A, B Covered according to the type of benefit incurred and
and DR Antigens: the place where the service is received. Refer to the specific cost-
sharing in this schedule of benefits that applies to the type of expense
that you incurred.
University of Missouri – Kansas City 2019-2020 Page 23Eligible health services In-network coverage Out-of-network coverage
Treatment of infertility
Basic infertility services Inpatient and Covered according to the type of Covered according to the type of
outpatient care - basic infertility benefit and the place where the benefit and the place where the
service is received. Refer to the service is received. Refer to the
specific cost-sharing in this specific cost-sharing in this
schedule of benefits that applies schedule of benefits that applies
to the type of expense that you to the type of expense that you
incurred. incurred.
Specific therapies and tests
Outpatient diagnostic testing
Diagnostic complex imaging services 80% (of the negotiated charge) 50% (of the recognized charge)
performed in the outpatient department of a
hospital or other facility
Diagnostic lab work and radiological services 80% (of the negotiated charge) 50% (of the recognized charge)
performed in a physician’s office, the
outpatient department of a hospital or other
facility
Chemotherapy
Chemotherapy 80% (of the negotiated charge) 50% (of the recognized charge)
per visit per visit
Important Note: Coverage for orally
administered anti-cancer medication will be
provided under the same terms and
conditions as intravenously administered or
injected anti-cancer medication.
Outpatient infusion therapy
Outpatient infusion therapy performed in a Covered according to the type of Covered according to the type of
covered person’s home, physician’s office, benefit and the place where the benefit and the place where the
outpatient department of a hospital or other service is received. Refer to the service is received. Refer to the
facility specific cost-sharing in this specific cost-sharing in this
schedule of benefits that applies schedule of benefits that applies
to the type of expense that you to the type of expense that you
incurred. incurred.
Outpatient radiation therapy
Outpatient radiation therapy 80% (of the negotiated charge) 50% (of the recognized charge)
per visit per visit
Outpatient respiratory therapy
Respiratory therapy 80% (of the negotiated charge) 50% (of the recognized charge)
per visit per visit
University of Missouri – Kansas City 2019-2020 Page 24You can also read
