Aetna Student Health Plan Design and Benefits Summary
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Quality health plans & benefits Healthier living Financial well-being Intelligentsolutions Aetna Student Health Plan Design and Benefits Summary Rice University Policy Year: 2020 – 2021 Policy Number: 890436 www.aetnastudenthealth.com (877) 480-4161 Rice University 2020-2021
This is a brief description of the Student Health Plan. The Plan is available Rice University 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 issued to you and may be viewed online at
www.aetnastudenthealth.com. If there is a difference between this Benefit Summary and the Certificate, the Certificate
will control. If you would like to obtain information about coverage under the Plan, please contact us at 877-480-4161,
or call the Member Services number on the back of your ID card, or write to us at:
Aetna, Student Health
151 Farmington Avenue
Hartford, CT 06156
RICE UNIVERSITY HEALTH SERVICES
The Rice Student Health Center is the University's on-campus health facility, which provides preventative and outpatient
clinical care for students. Staffed by nurse practitioners and registered nurses, it is open weekdays from 8:00 a.m. to
5:00 p.m., during the Fall and Spring semesters and Monday – Wednesday from 9:00 a.m. to 3:00 p.m., during the
summer. A Physician and nurse practitioner are on call at all times and conduct clinics during the week. The Student
Health Center does not file or bill insurance. However, students that are enrolled in the Aetna Student Health Insurance
plan will be able to submit a claim for reimbursement for specific services. To see the services that are eligible for
reimbursement, please visit health.rice.edu or studenthealthinsurance.rice.edu
For more information, call the Health Services at (713) 348-4966. In the event of an emergency, call 911 or the Campus
Police at (713) 348-6000.
Coverage Periods
Students: Coverage for all insured students enrolled in the Plan for the following Coverage Periods. 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.
Enrollment/Waiver
Coverage Period Coverage Start Date Coverage End Date Deadline
Annual 08/01/2020 07/31/2021 08/28/2020
Fall 08/01/2020 12/31/2020 08/28/2020
Spring 01/01/2021 07/31/2021 01/15/2021
Rice University 2020-2021 Page 2Eligible Dependents: Coverage for dependents eligible under the Plan for the following Coverage Periods. 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 Certificate of Coverage.
Coverage Period Coverage Start Date Coverage End Date Enrollment/Waiver Deadline
Annual 08/01/2020 07/31/2021 08/28/2020
Fall 08/01/2020 12/31/2020 08/28/2020
Spring 01/01/2021 07/31/2021 01/15/2021
Rates
The rates below include both premiums for the Plan underwritten by Aetna Life Insurance Company (Aetna), as well as Rice
University administrative fee.
Rates
Undergraduates and Graduate Students
Spring/Summer
Annual Fall Semester Semester
Student $2,580 $1,082 $1,498
Spouse $2,580 $1,082 $1,498
1 Child $2,580 $1,082 $1,498
2 or more Children $5,160 $2,164 $2,996
Student Coverage
Who is eligible?
All registered, degree-seeking students are required to have health insurance through the Aetna Student Health Plan or
through another qualifying medical plan. Students must actively attend classes for at least the first 31 days, after the date
when coverage becomes effective. If a student withdraws from Rice University on or prior to 09/01/2020 for fall, or
01/31/2021 for spring, the student will be dropped from the insurance plan. Previously covered students must re-enroll in
coverage for the new policy year, including dependent coverage, prior to the enrollment deadline date.
All registered students are required to maintain health insurance coverage while enrolled at Rice University with the
exception of visiting students, auditors, students enrolled in the Glasscock School of Continuing Studies (excluding full-
time Masters of Arts in Teaching) and all students enrolled in online programs.
Enrollment
Rice University 2020-2021 Page 3All students are required to maintain health insurance through the school or provide proof of comparable coverage. To ensure compliance with this University policy all students are required to either enroll in the Aetna Student Health Plan or request a waiver of insurance indicating that other coverage is active. Students that do not complete an online enrollment or waiver request by 08/28/2020 for Fall or 1/15/2021 for Spring will be automatically enrolled into coverage and responsible for the full premium amount. Eligible students will have the insurance premium placed on their student account. Students that submit and have an approved waiver of coverage prior to the deadline will have the insurance premium credited to their student account. Students that do not enroll in or waive the insurance coverage prior to the deadline will be automatically enrolled in the annual student insurance plan and charged the full premium. An approved waiver applies to the entire 2020-2021 academic year during which it is filed. Anyone enrolled in the Aetna Student Health Plan cannot cancel coverage for any reason. If we find out that you do not meet this eligibility requirement, we are only required to refund any premium contribution minus any claims that we have paid. To enroll online or request a waiver of coverage, log onto https://www.aetnastudenthealth.com, enter Rice University in the search tool, then follow the link to make your insurance selection. You can also access the link by visiting the Student Health Insurance website: http://studenthealthinsurance.rice.edu. Exception: A Covered Person entering the armed forces of any country will not be covered under the Policy as of the date of such entry. A pro rata refund of premium will be made for such person, and any covered dependents, upon written request received by Aetna within 90 days of withdrawal from school. Certain qualifying life events allow special enrollment in coverage outside of the open enrollment period. You have 30 days from the date of the qualifying life events to enroll in coverage. The following are examples of qualifying life events: • Loss of current coverage • Marriage/Divorce • Birth of a Child/Adoption • Spouse/Child arrival from another country If you experience a qualifying life event and need to enroll in coverage, please email: StudentInsurance@rice.edu. Documentation to support the qualifying life event is required. Premiums are pro-rated according to the remainder of the semester and/or plan year. Dependent Coverage Eligibility Covered students may also enroll their lawful spouse/domestic partner (same or opposite sex) and the covered student’s child who is under 26 years of age. The term "child" includes: • Your biological children • Your adopted children • Your stepchildren • For health expense coverage, your grandchild whom you support on the date of his or her initial application for coverage Enrollment Rice University 2020-2021 Page 4
• To enroll the eligible dependent(s), a covered student may enroll them at the same time enrolling themselves
when visiting www.aetnastudenthealth.com and selecting the school name. Dependent enrollment will not be
accepted after 8/28/2020 (or 1/15/2021 for Spring) unless there is a qualifying life change that directly affects
their insurance coverage. (An example of a qualifying life change would be the birth of a child).
• 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 provide written or verbal notification to us (or our agent) of the birth
and pay any required premium contribution during that 31 day period. You can provide verbal or written notice.
• 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.
• 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, or domestic partner adopts or is placed with you for adoption, is
covered on your plan for the first 31 days after the adoption or the placement is complete.
• To keep your child covered, we must receive your completed enrollment information within 31 days after the
adoption or placement for adoption.
• 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.
• A child that you, or that you and your spouse, or domestic partner adopts or is placed with you for adoption, is
covered on your plan for the first 31 days after the adoption or the placement is complete.
• To keep your child covered, we must receive your completed enrollment information within 31 days after the
adoption or placement for adoption.
• 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 877-480-4161.
Medicare 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.
Rice University 2020-2021 Page 5Coordination of Benefits (COB) The Coordination of Benefits (“COB”) provision applies when a person has health care coverage under more than one 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). The order of benefit determination rules tell you the order in which each plan will pay a claim for benefits. The plan that pays first is called the primary plan. The primary plan must pay benefits in accordance with its policy terms. Payment is made without regard to the possibility that another plan may cover some expenses. The plan that pays after the primary plan is the secondary plan. The secondary plan may reduce the benefits it pays so that payments from all plans do not exceed 100% of the total allowable expense. 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 Rice University, and may be viewed online at www.aetnastudenthealth.com. In-network Provider Network Under your plan, you can choose to receive care from an in-network provider or an out-of-network provider. An in- network provider is a provider who is listed in the directory for your plan and provides services at negotiated/reduced rates as agreed to with Aetna. An out-of-network provider is not an in-network provider, is not listed in the directory for your plan, and does not provide negotiated/reduced rates for their services. 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 a situation where there is are an inadequate number of network providers, Aetna may issue a pre-approval for you to receive the care from an Out-of-network Provider at the same benefit level that is provided for care received from In-network Providers. Preauthorization You need pre-approval from us for some eligible health services. Pre-approval is also called preauthorization. Preauthorization for medical services and supplies In-network care Your in-network physician is responsible for obtaining any necessary preauthorization before you get the care. If your in- network physician doesn't get a required preauthorization, 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 preauthorization. If your in-network physician requests preauthorization 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 preauthorization from us for any services and supplies on the preauthorization list. If you do not preauthorize, 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 preauthorization appears later in this section Rice University 2020-2021 Page 6
Preauthorization call
Preauthorization should be secured within the timeframes specified below. To obtain preauthorization, 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
preauthorization at least 3 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 3 days before the outpatient
requiring preauthorization: care is provided, or the treatment or procedure is scheduled.
Delivery: You, your physician, or the facility must call within 48 hours of the birth
or as soon thereafter as possible. No penalty will be applied for the
first 48 hours after delivery for a routine delivery and 96 hours for a
cesarean delivery.
We will provide a written notification to you and your physician of the preauthorization decision, where required by state
law. If your preauthorized 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 preauthorized, 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 preauthorization 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 preauthorization
decision. See the When you disagree - claim decisions and appeals procedures section of Certificate of Coverage.
What if you don’t obtain the required preauthorization?
If you don’t obtain the required preauthorization:
• Your benefits may be reduced, or the plan may not pay any benefits. See the schedule of benefits Preauthorization
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.
Rice University 2020-2021 Page 7What types of services and supplies require preauthorization?
Preauthorization is required for the following types of services and supplies:
Inpatient services and supplies Outpatient services and supplies
ART services Applied behavior analysis
Gene-based, cellular and other innovative therapies Certain prescription drugs and devices*
(GCIT)
Obesity (bariatric) surgery Complex imaging
Stays in a hospice facility Comprehensive infertility services
Stays in a hospital Cosmetic and reconstructive surgery
Stays in a rehabilitation facility Emergency transportation by airplane
Stays in a residential treatment facility for treatment of Gene-based, cellular and other innovative therapies (GCIT)
mental disorders and substance abuse
Stays in a skilled nursing facility 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
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 preauthorization, 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 atwww.aetnastudenthealth.com.
Rice University 2020-2021 Page 8Description 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 Texas Insurance Law(s).
Policy year In-network coverage Out-of-network coverage
deductible
You have to meet your policy year deductible before this plan pays for benefits.
Student $250 per policy year $1,000 per policy year
Spouse $250 per policy year $1,000 per policy year
Each child $250 per policy year $1,000 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
• In-network care for Newborn Hearing Screenings,
• Childhood Immunizations from birth through age 6,
• Pediatric Preventive Dental
• In-network care, and out-of-network care for Pediatric Care Vision Services
Maximum out-of-pocket limits
Maximum out-of-pocket limit per policy year
Student $6,000 Combined limit per policy year
Spouse $6,000 Combined limit per policy year
Each child $6,000 Combined limit per policy year
Family $12,000 Combined limit per policy year
Preauthorization covered benefit penalty
This only applies to out-of-network coverage:
The certificate of coverage contains a complete description of the preauthorization program. You will find details on
preauthorization requirements in the Medical necessity and preauthorization requirements section.
Failure to preauthorize 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 preauthorization 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.
The 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.
Rice University 2020-2021 Page 9Eligible health services In-network coverage Out-of-network coverage
Preventive care and wellness
Routine physical exams
Performed at a physician’s 100% (of the negotiated charge) per 70% (of the negotiated charge) per visit
office visit Policy year deductible applies
No policy year deductible applies
Covered persons age 18 and 1 visit
over: Maximum visits per
policy year
The following services apply to Routine physical exams for covered persons age 18 or more Maximum age and visit
limits per policy year
Routine physical exams for covered persons age 18 or more
• Abdominal aortic aneurysm – a one-time screening for men who have ever smoked
• Alcohol misuse screening and counseling in a primary care setting
• Blood pressure screening
• Cholesterol screening for adults at increased risk for coronary heart disease
• Colorectal cancer screening for adults over 50
• Depression screening for adults when staff-assisted depression care supports are in place to assure accurate
diagnosis, effective treatment, and follow-up
• Prostate specific antigen (PSA) tests
• Diabetes (Type 2) screening for adults with high blood pressure
• HIV screening for all adults at higher risk
• Obesity screening and counseling for all adults
• Tobacco use screening for all adults and cessation interventions for tobacco users
• Syphilis screening for all adults at higher risk
• Sexually transmitted infection prevention counseling for adults at higher risk
• Diet counseling for adults with hyperlipidemia and other known risk factors for cardiovascular and diet-related
chronic disease
• Screening for aspirin use for the primary prevention of cardiovascular disease and colorectal cancer as
recommended by their physician
The following services apply to Routine physical exams for covered persons from birth to age 18
• Autism screening
• Behavioral assessments
• Cervical dysplasia screening for sexually active females
• Congenital hypothyroidism screening for newborns
• Developmental screening, and surveillance throughout childhood
• Dyslipidemia screening at higher risk of lipid disorders
•Hearing screening for all newborns
• Hematocrit or hemoglobin screening
• Hemoglobinopathies or sickle cell screening for newborns
• HIV screening for adolescents at higher risk
• Lead screening for covered persons at risk of exposure
• Obesity screening and counseling
• Phenylketonuria (PKU) screening for this genetic disorder in newborns
• Tuberculin testing for covered persons at higher risk of tuberculosis
• Hearing and vision screening to determine the need for hearing and vision correction
Rice University 2020-2021 Page 10• Alcohol and drug use assessments for adolescents • Fluoride chemoprevention supplements for children without fluoride in their water source • Gonorrhea preventive medication for the eyes of all newborns • Height, weight and body mass index measurements • Iron supplements for covered persons ages 6 to 12 months at risk for anemia • Medical history throughout development • Oral health risk assessment • Sexually transmitted infection prevention counseling for adolescents at higher risk • Depression screening for adolescents • Blood pressure screening Routine physical exams for women • Anemia screening on a routine basis for pregnant women • Bacteriuria urinary tract or other infection screening for pregnant women • BRCA counseling about genetic testing for women at higher risk • Breast cancer mammography screenings • Breast cancer chemoprevention counseling for women at higher risk • Breastfeeding comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women • Cervical cancer screening for sexually active women • Pap smear; or screening using liquid-based cytology methods, either alone or in conjunction with a test approved by the United States Food and Drug Administration • A gynecological exam that includes a rectovaginal pelvic exam for women who are at risk of ovarian cancer) • Chlamydia infection screening for younger women and other women at higher risk • Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, not including abortifacient drugs (see the contraception sections, below for more detail) • Diagnostic exam for the early detection of ovarian cancer, cervical cancer, and the CA 125 blood test • Domestic and interpersonal violence screening and counseling for all women • Folic acid supplements for women who may become pregnant • Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes • Gonorrhea screening for all women at higher risk • Hepatitis B screening for pregnant women at their first prenatal visit • Human Immunodeficiency Virus (HIV) screening and counseling for sexually active women • Human Papillomavirus (HPV) DNA test: high risk HPV DNA testing • Osteoporosis screening for women depending on risk factors • Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk • Tobacco use screening and interventions for all women, and expanded counseling for pregnant tobacco users • Sexually transmitted Infections counseling for sexually active women • Syphilis screening for all pregnant women or other women at increased risk • Well-woman visits to obtain recommended preventive services Eligible health services also include: • 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 • Services as recommended in the American Academy of Pediatrics/Bright Futures/Health Resources and Services Administration guidelines for children and adolescents • Screenings and counseling services as provided for in the comprehensive guidelines recommended by the Health Resources and Services Administration. • Radiological services, lab and other tests given in connection with the exam Rice University 2020-2021 Page 11
• For covered newborns, an initial hospital checkup
For additional 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 the back of your ID card.
Eligible health services In-network coverage Out-of-network coverage
Preventive care immunizations
Performed in a facility or at a 100% (of the negotiated charge) per 70% (of the recognized charge) per visit
physician's office visit.
Your plan does not cover No policy year deductible applies
immunizations that are not No policy year deductible applies
considered preventive care No policy year deductible or
except for those required due No policy year deductible, copayment copayment applies for children from
to travel. or coinsurance applies for children birth through age 6
from birth through age 6
No policy year deductible or
copayment applies for
children from birth through
age 6
Maximums Subject to any age and visit limits provided for in the comprehensive 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 member website at www.aetnastudenthealth.com or calling the number on
the back of your ID card.
Well woman preventive visits
Routine gynecological exams (including Pap smears and cytology tests)
Performed at a physician’s, 100% (of the negotiated charge) per 70% (of the recognized charge) per visit
obstetrician (OB), visit Policy year deductible applies
gynecologist (GYN) or No policy year deductible applies
OB/GYN office
Maximums Subject to any age limits provided for in the comprehensive guidelines supported
by the Health Resources and Services Administration.
1 Pap smear every 12 months for women age 18 and older
1 exam every 12 months for women over age 25 who are at risk for ovarian cancer
1 exam every 12 months for women age 18 and older
For women over age 60 depending on risk factors
Preventive screening and counseling services
Obesity and/or healthy diet 100% (of the negotiated charge) per 70% (of the recognized charge) per visit
counseling office visits visit Policy year deductible applies
No policy year deductible applies
Maximum visits per policy 26 visits (however, of these only 10 visits will be allowed under the plan for healthy
year (This maximum applies diet counseling provided in connection with Hyperlipidemia (high cholesterol) and
only to covered persons age other known risk factors for cardiovascular and diet-related chronic disease)
22 and older.)
Rice University 2020-2021 Page 12Eligible health services In-network coverage Out-of-network coverage
Misuse of alcohol and/or 100% (of the negotiated charge) per 70% (of the recognized charge) per visit
drugs counseling office visits visit Policy year deductible applies
No policy year deductible applies
Maximum visits per policy 5 visits
year
Use of tobacco products 100% (of the negotiated charge) per 70% (of the recognized charge) per visit
counseling office visits visit Policy year deductible applies
No policy year deductible applies
Maximum visits per policy 8 visits
year
Depression screening 100% (of the negotiated charge) per 70% (of the recognized charge) per visit
counseling office visits visit Policy year deductible applies
No policy year deductible applies
Maximum visits per policy 1 visit
year
Sexually transmitted infection 100% (of the negotiated charge) per 70% (of the recognized charge) per visit
counseling office visits visit Policy year deductible applies
No policy year deductible applies
Maximum visits per policy 2 visits
year
Genetic risk counseling for 100% (of the negotiated charge) per 70% (of the recognized charge) per visit
breast and ovarian cancer visit Policy year deductible applies
counseling office visits No policy year deductible applies
Rice University 2020-2021 Page 13Eligible health services In-network coverage Out-of-network coverage
Routine cancer screenings performed at a physician’s office, specialist’s office or facility.
Routine cancer screenings 100% (of the negotiated charge) per 70% (of the recognized charge) per visit
visit Policy year deductible applies
No policy year deductible applies
Maximums 1 low-dose mammogram every 12 months for covered persons age 35 or older
1 Prostate Specific Antigen (PSA) test every 12 months for covered persons age 50
and older
1 PSA test every 12 months for covered persons age 40 and older with a family
history of prostate cancer, or other risk factor
1 fecal occult blood test every 12 months for covered persons age 50 or older
1 flexible sigmoidoscopy every 5 years for covered persons age 50 or older
1 colonoscopy every 10 years for covered persons age 50 or older
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 member website at www.aetnastudenthealth.com or calling the number on
the back of your ID card.
Lung cancer screening 1 screening every 12 months*
maximums
*Important note: Any lung cancer screenings that exceed the lung cancer screening maximum above are covered
under the Outpatient diagnostic testing section.
Rice University 2020-2021 Page 14Eligible health services In-network coverage Out-of-network coverage
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) per 70% (of the recognized charge) per visit
visit Policy year deductible applies
No 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 100% (of the negotiated charge) per 70% (of the recognized charge) per visit
- facility or office visits visit Policy year deductible applies
No policy year deductible applies
Lactation counseling services 6 visits
maximum 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 100% (of the negotiated charge) per 70% (of the recognized charge) per item
accessories item Policy year deductible applies
No policy year deductible applies
Important note:
See the Breast feeding durable medical equipment section of the certificate of coverage for limitations on breast
pump and supplies.
Family planning services –contraceptives
Contraceptive counseling 100% (of the negotiated charge) per 70% (of the recognized charge) per item
services item Policy year deductible applies
office visit No policy year deductible applies
Maximum Contraceptive counseling services maximum visits per policy year either in a group
or individual setting: 2
Contraceptives (prescription drugs and devices)
Contraceptive prescription 100% (of the negotiated charge) per 70% (of the recognized charge) per item
drugs and devices provided, item Policy year deductible applies
administered, or removed, by No policy year deductible applies
a physician during an office
visit
Rice University 2020-2021 Page 15Eligible health services In-network coverage Out-of-network coverage
Voluntary sterilization
Inpatient provider services 100% (of the negotiated charge) per 70% (of the recognized charge) per item
item Policy year deductible applies
No policy year deductible applies
Outpatient provider services 100% (of the negotiated charge) per 70% (of the recognized charge) per item
item Policy year deductible applies
No policy year deductible applies
Physicians and other health professionals
Physician and specialist services
Office hours visits $20 copayment then the plan pays 75% $20 copayment then the plan pays 50%
(non-surgical and (of the balance of the negotiated (of the balance of the recognized
non-preventive care by a charge) per visit thereafter charge) per visit thereafter
physician and specialist, Policy year deductible applies Policy year deductible applies
includes telemedicine or
telehealth consultations)
Allergy testing and treatment
Allergy testing performed at Covered according to the type of Covered according to the type of
a physician’s or specialist’s benefit and the place where the service benefit and the place where the service
office is received. is received.
Allergy injections treatment Covered according to the type of Covered according to the type of
performed at a physician’s, or benefit and the place where the service benefit and the place where the service
specialist office is received. is received.
Allergy sera and extracts Covered according to the type of Covered according to the type of
administered via injection at benefit and the place where the service benefit and the place where the service
a physician’s or specialist’s is received. is received.
office
Physician and specialist - inpatient surgical services
Inpatient surgery performed 75% (of the negotiated charge) 50% (of the recognized charge)
during your stay in a hospital Policy year deductible applies Policy year deductible applies
or birthing center by a
surgeon
(includes anesthetist and
surgical assistant expenses)
Physician and specialist - outpatient surgical services
Physician and specialist 75% (of the negotiated charge) per visit 50% (of the recognized charge) per visit
outpatient surgical services - Policy year deductible applies Policy year deductible applies
Outpatient surgery
performed at a physician’s or
specialist’s office
or outpatient department of
a hospital or surgery center
by a surgeon
(includes anesthetist and
surgical assistant expenses)
Rice University 2020-2021 Page 16Eligible health services In-network coverage Out-of-network coverage
In-hospital non-surgical physician services
In-hospital non-surgical 75% (of the negotiated charge) per visit 50% (of the recognized charge) per visit
physician services Policy year deductible applies Policy year deductible applies
Consultant services (non-surgical and non-preventive)
Office hours visits 75% (of the negotiated charge) per visit 50% (of the recognized charge) per visit
(non-surgical and Policy year deductible applies Policy year deductible applies
non-preventive care includes
telemedicine or telehealth
consultations)
Second surgical opinion Covered according to the type of Covered according to the type of
benefit and the place where the service benefit and the place where the service
is received. is received.
Alternatives to physician office visits
Walk-in clinic visits (non 75% (of the balance of the negotiated $20 copayment then the plan pays 50%
emergency visit) charge) per visit thereafter (of the balance of the recognized
Policy year deductible applies charge) per visit thereafter
Policy year deductible applies
Hospital and other facility care
Inpatient hospital 75% (of the negotiated charge) per 50% (of the recognized charge) per
(room and board) and other admission admission
miscellaneous services and Policy year deductible applies Policy year deductible applies
supplies)
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 and the place where the service benefit and the place where the service
is received. is received.
Rice University 2020-2021 Page 17Eligible health services In-network coverage Out-of-network coverage
Alternatives to hospital stays
Outpatient surgery (facility charges)
Facility charges for surgery 75% (of the negotiated charge) per 50% (of the recognized charge) per
performed in the outpatient admission admission
department of a hospital or Policy year deductible applies Policy year deductible applies
surgery center
For physician charges, refer
to the Physician and specialist
- outpatient surgical services
benefit
Home health care
Outpatient 75% (of the negotiated charge) per 50% (of the recognized charge) per
admission admission
Policy year deductible applies Policy year deductible applies
Maximum visits per policy
year 60
Hospice care
Inpatient facility 75% (of the negotiated charge) per 50% (of the recognized charge) per
(room and board and other admission admission
miscellaneous services Policy year deductible applies Policy year deductible applies
and supplies)
Maximum per day of unlimited
confinement policy year
Outpatient 75% (of the negotiated charge) per 50% (of the recognized charge) per
admission admission
Policy year deductible applies Policy year deductible applies
Respite care-maximum 30
number of days per 30 day
period
Skilled nursing facility
Inpatient facility 75% (of the negotiated charge) per 50% (of the recognized charge) per
(room and board and admission admission
miscellaneous inpatient Policy year deductible applies Policy year deductible applies
care services and supplies)
Subject to semi-private room
rate unless intensive care unit
is required
Room and board includes
intensive care
Maximum days of
confinement per policy year unlimited
Rice University 2020-2021 Page 18Eligible health services In-network coverage Out-of-network coverage
Emergency services and urgent care
Emergency services
Hospital emergency room $150 copayment then the plan pays 75% Paid the same as in-network coverage
(of the balance of the negotiated
charge) per visit
Policy year deductible applies
Non-emergency care in a Not covered Not covered
hospital emergency room
Complex imaging services, 75% (of the negotiated charge) 50% (of the recognized charge)
lab work and radiological Policy year deductible applies Policy year deductible applies
services performed during a
hospital emergency room
visit
Lab work and radiological 75% (of the negotiated charge) 50% (of the recognized charge)
services performed during a Policy year deductible applies Policy year deductible applies
hospital emergency room
visit
Non-emergency care in a Not covered Not covered
hospital emergency 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.
• 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.
Rice University 2020-2021 Page 19Eligible health services In-network coverage Out-of-network coverage
Urgent care
Urgent medical care provided 75% (of the negotiated charge) per visit 50% (of the recognized charge) per visit
by an urgent care provider Policy year deductible applies Policy year deductible applies
Non-urgent use of an urgent Not covered Not covered
care provider
Pediatric dental care (Limited to covered persons through the end of the month in which the person turns
age 19) The payment or reimbursement for services rendered by a dentist of a non-contracting dental provider
shall be reimbursed the same as a contracting dental provider
Type A services 100% (of the negotiated charge) per 100% (of the recognized charge) per
visit visit
No deductible applies No deductible applies
Type B services 70% (of the negotiated charge) per visit 70% (of the recognized charge) per visit
No deductible applies No deductible applies
Type C services 50% (of the negotiated charge) per visit 50% (of the recognized charge) per visit
No deductible applies No deductible applies
Orthodontic services 50% (of the negotiated charge) per visit 50% (of the recognized charge) per visit
No deductible applies No deductible applies
Dental emergency treatment Covered according to the type of benefit Covered according to the type of
and the place where the service is benefit and the place where the service
received is received.
Specific conditions
Birthing center (facility charges)
Inpatient (room and board Paid at the same cost-sharing as Paid at the same cost-sharing as
and other miscellaneous hospital care. hospital care.
services and supplies)
Diabetic services and supplies (including equipment and training)
Diabetic services and Covered according to the type of Covered according to the type of
supplies (including benefit and the place where the service benefit and the place where the service
equipment and training) is received. is received
Impacted wisdom teeth
Impacted wisdom teeth 75% (of the negotiated charge) 75% (of the recognized charge)
Policy year deductible applies Policy year deductible applies
Accidental injury to sound natural teeth
Accidental injury to sound 75% (of the negotiated charge) 75% (of the recognized charge)
natural teeth Policy year deductible applies Policy year deductible applies
Blood and body fluid exposure
Blood and body fluid Covered according to the type of benefit Covered according to the type of
exposure and the place where the service is benefit and the place where the service
received. is received.
Temporomandibular joint dysfunction (TMJ) and craniomandibular joint dysfunction (CMJ) treatment
TMJ and CMJ treatment Covered according to the type of benefit Covered according to the type of
and the place where the service is benefit and the place where the service
received. is received.
Rice University 2020-2021 Page 20Eligible health services In-network coverage Out-of-network coverage
Dermatological treatment
Dermatological treatment Covered according to the type of benefit Covered according to the type of
and the place where the service is benefit and the place where the service
received. is received.
Maternity care
Maternity care (includes Covered according to the type of benefit Covered according to the type of
delivery and postpartum care and the place where the service is benefit and the place where the service
services in a hospital or received. is received.
birthing center)
Well newborn nursery care in 75% (of the negotiated charge) 50% (of the recognized charge)
a hospital or birthing center No policy year deductible applies No policy year deductible applies
Note: If applicable, the per admission copayment and/or policy year deductible amounts 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
Pregnancy complications Covered according to the type of Covered according to the type of
benefit and the place where the service benefit and the place where the service
is received. is received.
Family planning services – other
Voluntary sterilization for males
Inpatient physician or 50% (of the negotiated charge) per visit 50% (of the recognized charge) per visit
specialist No policy year deductible applies No policy year deductible applies
surgical services
Outpatient physician or 50% (of the negotiated charge) per visit 50% (of the recognized charge) per visit
specialist surgical services No policy year deductible applies No policy year deductible applies
Gender reassignment (sex change) treatment
Surgical, hormone Covered according to the type of benefit Covered according to the type of
replacement therapy, and and the place where the service is benefit and the place where the service
counseling treatment received. is received.
Autism spectrum disorder
Autism spectrum disorder Covered according to the type of benefit Covered according to the type of
treatment and the place where the service is benefit and the place where the service
(includes physician and received. is received.
specialist office visits,
diagnosis and testing)
Physical, occupational, and Covered according to the type of benefit Covered according to the type of
speech therapy associated and the place where the service is benefit and the place where the service
with diagnosis of autism received. is received.
spectrum disorder
Applied behavior analysis Covered according to the type of benefit Covered according to the type of
and the place where the service is benefit and the place where the service
received. is received.
Services for children with Covered according to the type of benefit Covered according to the type of
developmental delays and the place where the service is benefit and the place where the service
received. is received.
Rice University 2020-2021 Page 21Eligible health services In-network coverage Out-of-network coverage Mental health treatment Mental health treatment – inpatient Inpatient hospital mental 75% (of the negotiated charge) per 50% (of the recognized charge) per disorders treatment admission admission (room and board and other Policy year deductible applies Policy year deductible applies miscellaneous hospital services and supplies) 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 disorder 75% (of the negotiated charge) per visit 50% (of the recognized charge) per visit treatment office visits to a Policy year deductible applies Policy year deductible applies physician or behavioral health provider Other outpatient mental 75% (of the negotiated charge) per 50% (of the recognized charge) per disorders treatment (includes visit visit skilled behavioral health Policy year deductible applies Policy year deductible applies services in the home) Partial hospitalization treatment Intensive Outpatient Program Rice University 2020-2021 Page 22
Eligible health services In-network coverage Out-of-network coverage Substance abuse related disorders treatment-inpatient Inpatient hospital substance 75% (of the negotiated charge) per 50% (of the recognized charge) per abuse detoxification admission admission (room and board and other Policy year deductible applies Policy year deductible applies miscellaneous hospital services supplies) Inpatient hospital substance abuse rehabilitation (room and board and other miscellaneous hospital services supplies) Inpatient residential treatment 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 75% (of the negotiated charge) per visit 50% (of the recognized charge) per visit office visits to a physician or Policy year deductible applies Policy year deductible applies behavioral health provider Other outpatient substance 75% (of the negotiated charge) per visit 50% (of the recognized charge) per visit abuse services (includes Policy year deductible applies Policy year deductible applies skilled behavioral health services in the home) Partial hospitalization treatment Intensive Outpatient Program Oral and maxillofacial 75% (of the negotiated charge) per visit 50% (of the recognized charge) per visit treatment (mouth, jaws, Policy year deductible applies Policy year deductible applies and teeth) Reconstructive surgery and supplies Reconstructive surgery and Covered according to the type of benefit Covered according to the type of supplies (includes and the place where the service is benefit and the place where the service reconstructive breast surgery) received. is received. Rice University 2020-2021 Page 23
Eligible health services In-network coverage In-network coverage Out-of- network
Network (IOE facility) Network (Non-IOE coverage Network
facility) Non-IOE facility and
out-of-network facility
Transplant services
Inpatient and outpatient Covered according to the Covered according to the Covered according to the
transplant facility services type of benefit and the type of benefit and the type of benefit and the
place where the service is place where the service is place where the service is
received. received. received.
Inpatient and outpatient Covered according to the Covered according to the Covered according to the
transplant physician and type of benefit and the type of benefit and the type of benefit and the
specialist services place where the service is place where the service is place where the service is
received. received. received.
Eligible health services In-network coverage Out-of-network coverage
Treatment of infertility
Basic infertility services
Basic infertility services Covered according to the type of benefit Covered according to the type of
Inpatient and outpatient care and the place where the service is benefit and the place where the service
- basic infertility received. is received.
Specific therapies and tests
Outpatient diagnostic testing
Diagnostic complex imaging 75% (of the negotiated charge) 50% (of the recognized charge)
services performed in the Policy year deductible applies Policy year deductible appl
outpatient department of a
hospital or other facility
Diagnostic lab work and 75% (of the negotiated charge) 50% (of the recognized charge)
radiological services Policy year deductible applies Policy year deductible appl
performed in a physician’s
office, the outpatient
department of a hospital or
other facility
Diagnostic follow-up care Covered according to the type of benefit Covered according to the type of
related to newborn hearing and the place where the service is benefit and the place where the service
screening received. is received.
Cardiovascular disease 75% (of the negotiated charge) per visit 50% (of the recognized charge) per visit
testing Policy year deductible applies Policy year deductible applies
Maximum visits per policy 1 screening every 5 years
year
Limited to:
Men age 45 and over but less than 76 and women age 55 and over but less than 76
Chemotherapy
Chemotherapy Covered according to the type of benefit Covered according to the type of
and the place where the service is benefit and the place where the service
received. is received.
Oral anti-cancer prescription Covered according to the type of benefit Covered according to the type of
drugs and the place where the service is benefit and the place where the service
received. is received.
Rice University 2020-2021 Page 24Eligible health services In-network coverage Out-of-network coverage
Outpatient infusion therapy
Outpatient infusion therapy Covered according to the type of Covered according to the type of
performed in a covered benefit and the place where the service benefit and the place where the service
person’s home, physician’s is received. is received.
office, outpatient department
of a hospital or other facility
Outpatient radiation therapy
Outpatient radiation therapy Covered according to the type of benefit Covered according to the type of
and the place where the service is benefit and the place where the service
received. is received.
Outpatient respiratory therapy
Respiratory therapy Covered according to the type of benefit Covered according to the type of
and the place where the service is benefit and the place where the service
received. is received.
Transfusion or kidney dialysis of blood
Transfusion or kidney Covered according to the type of Covered according to the type of
dialysis of blood benefit and the place where the service benefit and the place where the service
is received. is received.
Short-term cardiac and pulmonary rehabilitation services
Cardiac rehabilitation Covered according to the type of benefit Covered according to the type of
and the place where the service is benefit and the place where the service
received. is received.
Pulmonary rehabilitation Covered according to the type of benefit Covered according to the type of
and the place where the service is benefit and the place where the service
received. is received.
Short-term rehabilitation and habilitation therapy services
Outpatient physical, 75% (of the negotiated charge) per visit 50% (of the recognized charge) per visit
occupational, speech, and Policy year deductible applies Policy year deductible applies
cognitive therapies
Combined for short-term
rehabilitation services and
habilitation therapy services
Acquired brain injury Covered according to the type of Covered according to the type of
benefit and the place where the service benefit and the place where the service
is received. is received.
Alzheimer’s disease Covered according to the type of Covered according to the type of
benefit and the place where the service benefit and the place where the service
is received. is received.
Chiropractic services
Chiropractic services 75% (of the negotiated charge) per visit 50% (of the recognized charge) per visit
Policy year deductible applies Policy year deductible applies
Rice University 2020-2021 Page 25You can also read
