STUDENT HEALTH PLAN 2020-2021 - NYU
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
2020-2021
STUDENT HEALTH PLAN
BASIC PLAN
COMPREHENSIVE PLAN
("the Policyholder")
Policy Number: WNY2021NYSHIP03
Group Number: ST0645SH
Effective: 8/21/2020 – 8/20/2021
Underwritten By: Provider Network: Administered By:
Wellfleet Group, LLC
Wellfleet New York Insurance
Co. ("the Company")
NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN
WHAT’S INSIDE (Click on section header below to go to section in brochure.)
Student Health and Insurance at NYU ...........................................................................................................................3
Confidentiality ...............................................................................................................................................................3
Patient Protection and Affordable Care Act (PPACA) ....................................................................................................4
Student Health Insurance Plans Overview ....................................................................................................................4
Information for Graduate Employees NYU/UAW Local 2110 ........................................................................................5
Schedules of Basic Plan (pp. 5-24) and Comprehensive Plan (pp. 25-43) Benefits .......................................................5
Accidental Death and Dismemberment ..............................................................................................................43
Referral Requirements.........................................................................................................................................44
Preauthorization/Notification Procedure ............................................................................................................45
Student Health Insurance Plan Costs ...................................................................................................................45
Insurance Payment Options ................................................................................................................................46
Insurance Cards ...................................................................................................................................................47
Enrolling in the NYU Sponsored Plans .........................................................................................................................47
Eligibility...............................................................................................................................................................47
Automatic Enrollment .........................................................................................................................................47
Voluntary Enrollment ..........................................................................................................................................48
Dependents .........................................................................................................................................................48
How to Enroll .......................................................................................................................................................48
Enrollment Deadlines ..........................................................................................................................................49
Important Enrollment Rules for Matriculated Students ......................................................................................49
Fall 2020/Spring 2021 Automatic Enrollment Guide ...........................................................................................50
Special Enrollment Periods ..................................................................................................................................51
Waiving the Student Health Insurance Plans ..............................................................................................................51
Waiver Criteria Applicable to All Students ..........................................................................................................51
How to Waive Online ...........................................................................................................................................52
Waiver Deadlines .................................................................................................................................................52
Important Waiver Rules .......................................................................................................................................52
International Students in F-1 or J-1 Visa Status ...........................................................................................................53
International Students Waiver Process ...............................................................................................................53
Information for Parents ...............................................................................................................................................54
Exclusions and Limitations ...........................................................................................................................................55
Claim Procedures .........................................................................................................................................................57
Grievances, Utilization Review, and Appeals...............................................................................................................57
Definitions ...................................................................................................................................................................58
Contact Information (pp. 63-64) ..................................................................................................................................63
Students Studying Away Insurance Program ...............................................................................................................65
Additional Information for Graduate Employees NYU/UAW Local 2110 ....................................................................65
Stu-Dent Dental Health Program .................................................................................................................................65
2
Wellfleet Student PO Box 15369 Springfield, MA 01115-5369NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN
Student Health and Insurance at NYU
New York University values the health of its students and is committed to offering all students access to quality
healthcare and reasonably priced health insurance plans to help protect against financial hardships that may result
from high healthcare expenses.
While most undergraduate and graduate students are in good health and face few serious illnesses while in school,
medical and psychological issues can arise at any time, sometimes without warning. There are also certain health
concerns that may become apparent for the first time in early adulthood.
The high cost of healthcare in the United States presents a potentially serious financial risk to students. The absence
of adequate insurance coverage can result in temporary or permanent interruption of Your education; therefore,
NYU requires that all students registered in degree-granting programs maintain health insurance.
Most students are automatically enrolled in and charged a Premium for an NYU sponsored student health insurance
plan (NYU sponsored plan) as part of the course registration process. Students who maintain alternate health
insurance coverage that meets the University’s minimum health insurance criteria may waive the NYU sponsored
student health insurance plan entirely (see Waiving the Student Health Insurance Plans section).
This brochure has been prepared to help You understand the benefits and levels of coverage the NYU sponsored
student health insurance plans offer.
Student Health Center Locations
Manhattan
726 Broadway, 2nd, 3rd, and 4th Floors
New York, NY 10003
(212) 443-1000
Brooklyn
6 MetroTech Center, ROG-B020
Brooklyn, NY 11201
(646) 997-3456
Confidentiality
Your privacy is Our priority. The Student Health Center (SHC) is legally and ethically obligated to protect the privacy
of a student’s health information.
Treatment of student health information is governed by the Family Educational Rights and Privacy Act (FERPA) and
the requirements of applicable New York State law. The SHC will only disclose this information in limited
circumstances in accordance with applicable law.
The SHC will not release medical information to anyone, including family, parents/legal guardians, NYU faculty/staff,
or outside agencies, without the written authorization of the student, except in emergency situations or to comply
with a subpoena or judicial order. In the case of a minor, the authorization of a parent or legal guardian is required
to release medical records. In a medical emergency, only relevant health information will be released to another
healthcare Provider.
The underwriter and administrator of the NYU-sponsored student health insurance plans also handle student health
information in connection with the operation of those plans. Treatment of such information is governed by the
Health Insurance Portability and Accountability Act (HIPAA) and the requirements of applicable New York State law.
3
Wellfleet Student PO Box 15369 Springfield, MA 01115-5369NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN
Patient Protection and Affordable Care Act (PPACA)
The Affordable Care Act (ACA) was enacted to increase the availability of health insurance coverage to more
Americans. There are a multitude of medical coverage requirements and it is important for You to know that the
NYU sponsored student health insurance plans are fully ACA compliant.
Here’s additional information about the ACA to assist You in making coverage decisions:
Students are eligible to remain on a parent’s plan until age 26. However, You should compare the cost and benefits
of coverage under a parent’s plan to those of the NYU sponsored student health insurance plans.
Employer plans held by You or Your parents may be local HMO’s that are not appropriate for a student attending
school out of state.
The ACA created health insurance marketplaces for individuals to obtain coverage. However, You should carefully
review the terms of the coverage to compare with any other alternatives including in terms of: Deductibles,
Copayments, Coinsurance, and limited Provider networks. If You are interested in exploring this option, the web site
is www.healthcare.gov. You will be directed to the appropriate online marketplace for Your home state of residence.
Generally, international students holding an F-1 or J-1 visa are not eligible to purchase insurance through the
marketplaces because they must show permanent residency.
Student Health Insurance Plans Overview
Wellfleet Student Health Insurance Plans
The NYU sponsored student health insurance plans, administered by Wellfleet Group, LLC, are designed to provide
reasonably priced healthcare coverage. The student health insurance plans supplement the free services (as does
any other health insurance) provided at the SHC. The NYU sponsored student health insurance plans cover most
medical treatments and procedures provided at the SHC, for which there is a fee, as well as national coverage for
medically necessary healthcare services.
All matriculated students are eligible for enrollment in the Student Health Insurance Plans sponsored by NYU. See
Voluntary Enrollment section for more information about enrolling Dependents and other eligible enrollees.
The NYU sponsored student health insurance has two plans designed to provide reasonably priced healthcare
coverage:
1. Basic Plan
2. Comprehensive Plan
The Basic and Comprehensive Plans cover the same medical/surgical, mental health and substance use services.
However, they have different:
• reimbursement levels,
• coinsurance,
• out-of-pocket expenses,
• and premiums
Both plans offer coverage for services rendered by healthcare Providers who participate in the Cigna PPO network.
Referrals are required for services in Manhattan (outside the SHC). Visit www.wellfleetstudent.com/nyu to search
for Cigna PPO Providers. Out-of-network Providers are also covered but at a lower reimbursement level. (See
Schedules for Basic Plan and Comprehensive Plan Benefits).
Please note: The SHC is an in-network Preferred Provider under the NYU sponsored student health insurance plan
underwritten by Wellfleet New York Insurance Company. (See Referrals/Authorizations.)
4
Wellfleet Student PO Box 15369 Springfield, MA 01115-5369NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN
Information for Graduate Employees NYU/UAW Local 2110
Effective September 1, 2015, the University began providing its student health insurance plan (Basic Health Plan –
Individual Coverage) at 10% of the applicable premium rate to eligible graduate student employees. In addition,
eligible graduate student employees will be covered by the Stu-Dent Plan for NYU at no cost and will be automatically
enrolled in the Stu-Dent Plan upon confirmation of union eligibility.
This provision does not apply to graduate employees who are covered under the Comprehensive Plan paid for by
NYU.
For eligible Washington Square graduate student employees, a Basic Health Plan or Comprehensive Health Plan
insurance charge may initially appear on the graduate student employee’s tuition bill, but will be adjusted when the
student’s union eligibility is confirmed. At that time the insurance charge on the Bursar account will be adjusted to
10% of the Basic Health Insurance Plan charge for that term. If the graduate student employee is enrolled in the
Comprehensive Plan, the insurance charge will be adjusted to 10% of the Basic Health Insurance Plan charge, plus
the additional cost for the Comprehensive Health Insurance premium.
Option to Upgrade Individual Coverage
Eligible graduate student employees so covered may elect to upgrade their individual coverage to the
Comprehensive Health Plan –Individual Coverage, at its additional cost. This must be accomplished by the September
30th enrollment deadline. In the case where an eligible graduate student employee is automatically enrolled in the
Comprehensive Health Insurance Plan (see Automatic Enrollment Guide), and wishes to change to the Basic Health
Insurance Plan, the graduate student employee may do so during the online enrollment process (see Automatic
Enrollment Guide section for more details).
Dependent Coverage Premium Support Plan
Effective September 1, 2015, the University established a Graduate Employee Student Health Insurance Dependent
Premium Support Plan. For Academic Year 2019-2020, the Plan will be funded with $200,000, divided equally
between the fall and spring semesters.
Those eligible graduate employees who are doctoral candidates who actually purchase dependent coverage under
the Basic Health Insurance Plan, or if enrolled in the Comprehensive Plan, paid for by NYU, for individual coverage,
purchase dependent coverage under the Comprehensive Plan, and provide proof thereof, may, during the subject
semester, apply for up to 75% reimbursement of dependent coverage premiums. Actual reimbursement will depend
on the number of applications and the funds allocated for that semester. Unused funds, if any, will not carry over to
a future semester. The application deadline for reimbursement for fall 2019 is January 8, 2020 and for spring 2020
is August 20, 2020.
Please note, eligible graduate student employees who are doctoral candidates and are enrolled in the
Comprehensive Plan, paid for by NYU, for individual coverage, may only purchase Comprehensive Plan dependent
care coverage, and in accordance with the agreement between NYU and Local 2110, the premium for such
Comprehensive Plan dependent coverage will be at the same rate as the premium for dependent coverage under
the Basic Student Health Insurance Plan.
Schedules of Basic Plan (pp. 5-24) and Comprehensive Plan (pp. 25-43)
Benefits
One Schedule for BASIC Plan and one Schedule for COMPREHENSIVE Plan
Availability of services at SHC locations varies, please verify location when making appointments.
For a more complete description of plan benefits, general terms and conditions, Preauthorization and Referral
requirements, etc., please review the 2020-2021 Student Health Insurance Certificate at
www.wellfleetstudent.com/nyu.
5
Wellfleet Student PO Box 15369 Springfield, MA 01115-5369NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN
NEW YORK UNIVERSITY
BASIC PLAN
Metal Level: Gold
COST-SHARING Student Health Preferred In- Network Out-of-Network
Center Provider Responsibility for Responsibility for Cost-
Responsibility Responsibility Cost-Sharing Sharing
for Cost-Sharing for Cost-Sharing
Deductible None None None None
Out-of-Pocket $7,350 $7,350 $7,350 $14,700
Limit: Individual $14,700 $14,700 $14,700 $29,400
Family
See section IV of this
Certificate for a
description of how We
calculate the Allowed
Amount. Any charges
of a Non- Participating
Provider that are in
excess of the Allowed
Amount do not apply
towards the Out- of-
Pocket Limit. You must
pay the amount by
which the Non-
Participating Provider's
charge exceeds Our
Allowed Amount.
Benefits Subject to
Annual and Lifetime
Limits
Emergency $250,000
Medical Evacuation Annual
Limit
Repatriation of $250,000
Remains Annual
Limit
Accidental Death $10,000
and Annual and
Dismemberment Lifetime
Maximum
6
Wellfleet Student PO Box 15369 Springfield, MA 01115-5369NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN
OFFICE VISITS Student Health Preferred In-Network Out-of-Network Limits
Center Provider Responsibility for Responsibility for Cost-
Responsibility Responsibility Cost-Sharing Sharing
for Cost-Sharing for Cost-Sharing
Primary Care Office Covered in full N/A $35 Copayment per 50% Coinsurance See
Visits (or Home Visit then Benefit For
Visits) 20% Coinsurance Description
Specialist Office $20 Copayment N/A $35 Copayment per 50% Coinsurance See
Visits (or Home per Visit Visit then Benefit For
Visits) 20% Coinsurance Description
PREVENTIVE CARE Student Health Preferred In-Network Out-of-Network Limits
Responsibility for Provider Responsibility for Responsibility for Cost-
Cost- Responsibility Cost- Sharing
Sharing for Cost- Sharing Sharing
• Well Child Visits See Benefit
and For
Immunizations* Description
Students Covered in full N/A Covered in full 50% Coinsurance
Dependents N/A N/A Covered in full 50% Coinsurance
• Adult Annual
Physical
Examinations*
Students Covered in full N/A Covered in full 50% Coinsurance
Dependents N/A N/A Covered in full 50% Coinsurance
• Adult
Immunizations*
Students Covered in full N/A Covered in full 50% Coinsurance
Dependents N/A N/A Covered in full 50% Coinsurance
• Routine
Gynecological
Services/Well
Woman Exams*
Students Covered in full Covered in full Covered in full 50% Coinsurance
Dependents N/A Covered in full Covered in full 50% Coinsurance
7
Wellfleet Student PO Box 15369 Springfield, MA 01115-5369NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN
PREVENTIVE CARE Student Health Preferred In-Network Out-of-Network Limits
Responsibility for Provider Responsibility for Responsibility for Cost-
Cost- Responsibility Cost- Sharing
Sharing for Cost- Sharing Sharing
• Mammography
Screening and
Diagnostic
Imaging for the
Detection of
Breast Cancer
Students N/A N/A Covered in full 50% Coinsurance
Dependents N/A N/A Covered in full 50% Coinsurance
• Sterilization
Procedures for
Women*
Students N/A N/A Covered in full 50% Coinsurance
Dependents N/A N/A Covered in full 50% Coinsurance
• Vasectomy
Students N/A N/A Covered in full 50% Coinsurance
Dependents N/A N/A Covered in full 50% Coinsurance
• Bone Density
Testing*
Students N/A N/A Covered in full 50% Coinsurance
Dependents N/A N/A Covered in full 50% Coinsurance
• Screening for
Prostate Cancer
Students Covered in full N/A Covered in full 50% Coinsurance
Dependents N/A N/A Covered in full 50% Coinsurance
8
Wellfleet Student PO Box 15369 Springfield, MA 01115-5369NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN
PREVENTIVE CARE Student Health Preferred In-Network Out-of-Network Limits
Responsibility for Provider Responsibility for Responsibility for Cost-
Cost- Responsibility Cost- Sharing
Sharing for Cost- Sharing Sharing
• All other preventive
services required by
USPSTF and HRSA.
Students Covered in full N/A Covered in full 50% Coinsurance
Dependents N/A N/A Covered in full 50% Coinsurance
• *When preventive Use Cost Sharing Use Cost Sharing Use Cost Sharing for Use Cost Sharing for
services are not for appropriate for appropriate appropriate service appropriate service
provided in service (Primary service (Primary (Primary Care Office (Primary Care Office
accordance with the Care Office Visit; Care Office Visit; Visit; Visit; Specialist Office
comprehensive Specialist Office Specialist Office Specialist Office Visit; Diagnostic
guidelines Visit; Diagnostic Visit; Diagnostic Visit; Diagnostic Radiology Services;
supported by Radiology Radiology Radiology Services; Laboratory Procedures
USPSTF and HRSA. Services; Services; Laboratory & Diagnostic Testing)
Laboratory Laboratory Procedures &
Procedures & Procedures & Diagnostic Testing)
Diagnostic Diagnostic Testing
Testing)
EMERGENCY CARE Student Health Preferred In-Network Out-of-Network Limits
Responsibility for Provider Responsibility for Responsibility for Cost-
Cost-Sharing Responsibility Cost-Sharing Sharing
for Cost-Sharing
Pre-Hospital N/A N/A Covered in full Covered in full See Benefit
Emergency Medical For
Services (Ambulance Description
Services)
Non-Emergency N/A N/A Covered in full Covered in full See Benefit
Ambulance Services For
Description
Emergency N/A N/A $250 Copayment per $250 Copayment per See Benefit
Department Visit then Visit then For
20% Coinsurance 20% Coinsurance Description
Health care forensic
examinations
performed under
Public Health Law §
2805-I are not
subject to Cost-
Sharing
Urgent Care Center N/A N/A $35 Copayment per 50% Coinsurance See Benefit
Visit then For
20% Coinsurance Description
9
Wellfleet Student PO Box 15369 Springfield, MA 01115-5369NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN
PROFESSIONAL Student Health Preferred In-Network Out-of-Network Limits
SERVICES AND Responsibility for Provider Responsibility for Responsibility for Cost-
OUTPATIENT Cost-Sharing Responsibility Cost-Sharing Sharing
CARE for Cost-Sharing
Advanced Imaging See Benefit
Services For
Description
• Performed in a N/A N/A 20% Coinsurance 50% Coinsurance
Specialist Office
• Performed in a N/A N/A 20% Coinsurance 50% Coinsurance
Freestanding
Radiology Facility
• Performed as N/A N/A $40 Copayment per 50% Coinsurance
Outpatient Hospital Visit then
Services 20% Coinsurance
Preauthorization
Required
Allergy Testing & See Benefit
Treatment For
Description
• Performed in a PCP 20% Coinsurance N/A 20% Coinsurance 50% Coinsurance
Office
• Performed in a N/A N/A 20% Coinsurance 50% Coinsurance
Specialist Office
Ambulatory Surgical N/A N/A $40 Copayment 50% Coinsurance See Benefit
Center Facility Fee per Visit then For
20% Coinsurance Description
Preauthorization
Required
Anesthesia Services N/A N/A 20% Coinsurance 50% Coinsurance See Benefit
(all settings) For
Description
Preauthorization
Required
Autologous Blood N/A N/A 20% Coinsurance 50% Coinsurance See Benefits
Banking For
Description
10
Wellfleet Student PO Box 15369 Springfield, MA 01115-5369NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN
PROFESSIONAL Student Health Preferred In-Network Out-of-Network Limits
SERVICES AND Responsibility for Provider Responsibility for Responsibility for Cost-
OUTPATIENT Cost-Sharing Responsibility Cost-Sharing Sharing
CARE for Cost-Sharing
Cardiac & See Benefits
Pulmonary For
Rehabilitation Description
• Performed in a N/A N/A $35 Copayment per 50% Coinsurance
Specialist Office Visit then
20% Coinsurance
• Performed as N/A N/A $40 Copayment per 50% Coinsurance
Outpatient Hospital Visit then
Services 20% Coinsurance
• Performed as N/A N/A Included As Part of Included As Part of
Inpatient Hospital Inpatient Hospital Inpatient Hospital
Services Service Cost- Sharing Service Cost-Sharing
Chemotherapy See Benefit
• Performed in a PCP N/A N/A 20% Coinsurance 50% Coinsurance For
Office Description
• Performed in a N/A N/A 20% Coinsurance 50% Coinsurance
Specialist Office
• Performed as N/A N/A $40 Copayment per 50% Coinsurance
Outpatient Hospital Visit then
Services 20% Coinsurance
Preauthorization
Required
Chiropractic Services N/A N/A $35 Copayment per 50% Coinsurance See Benefit
Visit then For
Preauthorization 20% Coinsurance Description
Required
Clinical Trials Use Cost- Sharing N/A Use Cost- Sharing for Use Cost- Sharing for See Benefit
for appropriate appropriate service appropriate service For
service Description
11
Wellfleet Student PO Box 15369 Springfield, MA 01115-5369NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN
PROFESSIONAL Student Health Preferred In-Network Out-of-Network Limits
SERVICES AND Responsibility for Provider Responsibility for Responsibility for Cost-
OUTPATIENT Cost-Sharing Responsibility Cost-Sharing Sharing
CARE for Cost-Sharing
Diagnostic Testing See Benefit
For
• Performed in a PCP 20% Coinsurance N/A 20% Coinsurance 50% Coinsurance Description
Office
• Performed in a 20% Coinsurance N/A 20% Coinsurance 50% Coinsurance
Specialist Office
• Performed as N/A N/A $40 Copayment per 50% Coinsurance
Outpatient Hospital Visit then
Services 20% Coinsurance
Dialysis See Benefit
For
• Performed in a PCP N/A N/A 20% Coinsurance 50% Coinsurance Description
Office
• Performed N/A N/A 20% Coinsurance 50% Coinsurance
in a
Specialist
Office
• Performed in a N/A N/A 20% Coinsurance 50% Coinsurance
Freestanding Center
• Performed as N/A N/A $40 Copayment 50% Coinsurance
Outpatient Hospital per Visit then
Services 20% Coinsurance
• Performed at Home N/A N/A 20% Coinsurance 50% Coinsurance
Habilitation Services 60 visits
per condition
(Physical Therapy, $20 Copayment N/A $35 Copayment per 50% Coinsurance per Plan Year
Occupational Therapy) per Visit Visit then (combined
20% Coinsurance therapies)
(Speech or Hearing N/A N/A $35 Copayment per 50% Coinsurance
Therapy) Visit then
20% Coinsurance
Home Health Care N/A N/A 20% Coinsurance 20% Coinsurance 40 Visits per
Plan Year
Preauthorization
Required
12
Wellfleet Student PO Box 15369 Springfield, MA 01115-5369NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN
PROFESSIONAL Student Health Preferred In-Network Out-of-Network Limits
SERVICES AND Responsibility for Provider Responsibility for Responsibility for Cost-
OUTPATIENT Cost-Sharing Responsibility Cost-Sharing Sharing
CARE for Cost-Sharing
Infertility Services Use Cost Sharing N/A Use Cost Sharing for Use Cost Sharing for See Benefit
for appropriate appropriate service appropriate service For
service (Office (Office Visit; (Office Visit; Diagnostic Description
Visit; Diagnostic Diagnostic Radiology Radiology Services;
Radiology Services; Surgery; Surgery; Laboratory &
Services; Surgery; Laboratory & Diagnostic Procedures)
Laboratory & Diagnostic
Diagnostic Procedures)
Procedures)
Infusion Therapy See Benefit
For
• Performed in a PCP $20 Copayment N/A $35 Copayment per 50% Coinsurance Description
Office per Visit then Visit then
20% Coinsurance 20% Coinsurance
• Performed in $20 Copayment N/A $35 Copayment per 50% Coinsurance
Specialist Office per Visit then Visit then
20% Coinsurance 20% Coinsurance
• Performed as N/A N/A $40 Copayment per 50% Coinsurance Home infusion
Outpatient Hospital Visit then counts toward
Services 20% Coinsurance home health
care visit limits
• Home Infusion N/A N/A 20% Coinsurance 50% Coinsurance
Therapy
Inpatient Medical N/A N/A 20% Coinsurance 50% Coinsurance See Benefit
Visits For
Description
Interruption of
Pregnancy
Unlimited
• Medically N/A N/A Covered in full 50% Coinsurance
Necessary
Abortions
• Elective Abortions N/A N/A 20% Coinsurance 50% Coinsurance One (1)
procedure per
Plan Year
13
Wellfleet Student PO Box 15369 Springfield, MA 01115-5369NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN
PROFESSIONAL Student Health Preferred In-Network Out-of-Network Limits
SERVICES AND Responsibility for Provider Responsibility for Responsibility for Cost-
OUTPATIENT Cost-Sharing Responsibility Cost-Sharing Sharing
CARE for Cost-Sharing
Laboratory Procedures See Benefit
For
• Performed in a PCP 20% Coinsurance N/A 20% Coinsurance 50% Coinsurance Description
Office
• Performed in a N/A N/A 20% Coinsurance 50% Coinsurance
Specialist Office
• Performed in a N/A N/A 20% Coinsurance 50% Coinsurance
Freestanding
Laboratory Facility
• Performed as N/A N/A $40 Copayment per 50% Coinsurance
Outpatient Hospital Visit then
Services 20% Coinsurance
Maternity & Newborn See Benefit
Care For
Description
• Prenatal Care N/A Covered in full Covered in full 50% Coinsurance
provided in
accordance with the
comprehensive
guidelines supported
by USPSTF and HRSA
• Prenatal Care that is Use Cost-Sharing Use Cost-Sharing Use Cost-Sharing for Use Cost-Sharing for
not provided in for appropriate for appropriate appropriate service appropriate service
accordance with the service (Primary service (Primary (Primary Care Office (Primary Care Office
comprehensive Care Office Visit, Care Office Visit, Visit, Specialist Visit, Specialist Office
guidelines supported Specialist Office Specialist Office Office Visit, Visit, Diagnostic
by USPSTF and HRSA Visit, Diagnostic Visit, Diagnostic Diagnostic Radiology Radiology Services,
Radiology Radiology Services, Laboratory Laboratory Procedures
Services, Services, Procedures and and Diagnostic Testing)
Laboratory Laboratory Diagnostic Testing)
Procedures and Procedures and
Diagnostic Diagnostic Testing)
Testing)
• Inpatient Hospital N/A Covered in full 20% Coinsurance 50% Coinsurance One (1) home
Services and Birthing care visit is
Center Covered at no
Cost- Sharing
if mother is
discharged
from Hospital
early
14
Wellfleet Student PO Box 15369 Springfield, MA 01115-5369NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN
PROFESSIONAL Student Health Preferred In-Network Out-of-Network Limits
SERVICES AND Responsibility for Provider Responsibility for Responsibility for Cost-
OUTPATIENT Cost-Sharing Responsibility Cost-Sharing Sharing
CARE for Cost-Sharing
Maternity & Newborn Maternity &
Care (continued) Newborn Care
(continued)
• Physician and N/A Covered in full 20% Coinsurance 50% Coinsurance
Midwife Services for
Delivery
• Breastfeeding N/A N/A Covered in full 50% Coinsurance Covered for
Support, Counseling duration of
and Supplies, breast feeding
Including Breast
Pumps
• Postnatal Care N/A Covered in full 20% Coinsurance 50% Coinsurance
Preauthorization
Required for Inpatient
Services; Breast Pump
Outpatient Hospital N/A N/A $40 Copayment 50% Coinsurance See Benefit
Surgery Facility per Visit then For
Charge 20% Coinsurance Description
Preauthorization
Required
Preadmission N/A N/A 20% Coinsurance 50% Coinsurance See Benefit
Testing For
Description
Prescription Drugs See
Administrated in Office or Benefit For
Outpatient Facilities Description
• Performed in a PCP 20% Coinsurance N/A 20% Coinsurance 50% Coinsurance
Office
• Performed in 20% Coinsurance N/A 20% Coinsurance 50% Coinsurance
Specialist Office
• Performed in N/A N/A 20% Coinsurance 50% Coinsurance
Outpatient Facilities
15
Wellfleet Student PO Box 15369 Springfield, MA 01115-5369NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN
PROFESSIONAL Student Health Preferred In-Network Out-of-Network Limits
SERVICES AND Responsibility for Provider Responsibility for Responsibility for Cost-
OUTPATIENT Cost-Sharing Responsibility Cost-Sharing Sharing
CARE for Cost-Sharing
Diagnostic See Benefit
Radiology Services For
Description
• Performed in a PCP 20% Coinsurance N/A 20% Coinsurance 50% Coinsurance
Office
• Performed in a N/A N/A 20% Coinsurance 50% Coinsurance
Specialist Office
• Performed in a N/A N/A 20% Coinsurance 50% Coinsurance
Freestanding
Radiology Facility
• Performed as N/A N/A $40 Copayment per 50% Coinsurance
Outpatient Hospital Visit then
Services 20% Coinsurance
Preauthorization
Required
Therapeutic See Benefit
Radiology Services For
Description
• Performed in a N/A N/A 20% Coinsurance 50% Coinsurance
Specialist Office
• Performed in a N/A N/A 20% Coinsurance 50% Coinsurance
Freestanding
Radiology Facility
• Performed as N/A N/A $40 Copayment per 50% Coinsurance
Outpatient Hospital Visit then
Services 20% Coinsurance
Preauthorization
Required
Rehabilitation Services: 60 visits per
condition per
(Physical Therapy, $20 Copayment N/A $35 Copayment per 50% Coinsurance Plan Year
Occupational Therapy) per Visit Visit then (combined
20% Coinsurance therapies)
(Speech or Hearing N/A N/A $35 Copayment per 50% Coinsurance
Therapy) Visit then
20% Coinsurance
16
Wellfleet Student PO Box 15369 Springfield, MA 01115-5369NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN
PROFESSIONAL Student Health Preferred In-Network Out-of-Network Limits
SERVICES AND Responsibility for Provider Responsibility for Responsibility for Cost-
OUTPATIENT Cost-Sharing Responsibility Cost-Sharing Sharing
CARE for Cost-Sharing
Second Opinions on the $20 Copayment N/A $35 Copayment per 50% Coinsurance See Benefit
Diagnosis of Cancer, per Visit Visit then For
Surgery & Other 20% Coinsurance 20% Coinsurance Second Opinions on Description
Diagnosis of Cancer are
Covered at
participating Cost-
Sharing for non-
participating Specialist
when a Referral is
obtained.
Surgical Services See Benefit
(Including Oral For
Surgery, Reconstructive Description
Breast Surgery; Other
Reconstructive and
Corrective Surgery; and
Transplants)
• Inpatient Hospital N/A N/A 20% Coinsurance 50% Coinsurance
Surgery
• Outpatient Hospital N/A N/A 20% Coinsurance 50% Coinsurance
Surgery
• Surgery Performed N/A N/A 20% Coinsurance 50% Coinsurance
at an Ambulatory
Surgical Center
• Office Surgery 20% Coinsurance N/A 20% Coinsurance 50% Coinsurance
ADDITIONAL SERVICES, Student Health Preferred In-Network Out-of-Network Limits
EQUIPMENT & Center Provider Responsibility for Responsibility for Cost-
DEVICES Responsibility Responsibility Cost-Sharing Sharing
for Cost-Sharing for Cost-Sharing
ABA Treatment for $20 Copayment N/A $35 Copayment per 50% Coinsurance See Benefit
Autism Spectrum per Visit then Visit then For
Disorder 20% Coinsurance 20% Coinsurance Description
Assistive $20 Copayment N/A $35 Copayment per 50% Coinsurance See Benefit
Communication Devices per Visit then Visit then For
for Autism 20% Coinsurance 20% Coinsurance Description
Spectrum Disorder
17
Wellfleet Student PO Box 15369 Springfield, MA 01115-5369NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN
ADDITIONAL SERVICES, Student Health Preferred In-Network Out-of-Network Limits
EQUIPMENT & Center Provider Responsibility for Responsibility for Cost-
DEVICES Responsibility Responsibility Cost-Sharing Sharing
for Cost-Sharing for Cost-Sharing
Diabetic Equipment, See Benefit
Supplies and Self- For
Management Education Description
• Diabetic Equipment, $20 Copayment N/A $20 Copayment per 30% Coinsurance See
Supplies and Insulin per prescription prescription Prescription
(30-Day Supply) Drug Benefit
• Diabetic Education 20% Coinsurance N/A 20% Coinsurance 50% Coinsurance
Durable Medical 20% Coinsurance N/A 20% Coinsurance 20% Coinsurance See Benefit
Equipment & Braces For
Description
External Hearing N/A N/A 20% Coinsurance 20% Coinsurance Single
Aids Purchase Once
Every three (3)
Years
Cochlear Implants N/A N/A 20% Coinsurance 50% Coinsurance One (1) Per
Ear Per Time
Preauthorization Covered
Required
Hospice Care 210 days per
Plan Year
• Inpatient N/A N/A Covered in full Covered in full
Preauthorization
Required
• Outpatient N/A N/A Covered in full Covered in full Five (5) Visits
for Family
Bereavement
Counseling
Medical Supplies 20% Coinsurance N/A 20% Coinsurance 50% Coinsurance See Benefit
For
Description
Prosthetic Devices
• External 20% Coinsurance N/A 20% Coinsurance 20% Coinsurance One (1)
prosthetic
device, per
limb, per
lifetime
• Internal N/A N/A 20% Coinsurance 20% Coinsurance Unlimited; See
Benefit For
Description
18
Wellfleet Student PO Box 15369 Springfield, MA 01115-5369NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN
INPATIENT SERVICES Student Health Preferred In-Network Out-of-Network Limits
and FACILITIES Center Provider Responsibility for Responsibility for Cost-
Responsibility Responsibility Cost-Sharing Sharing
for Cost-Sharing for Cost-Sharing
Inpatient Hospital for a N/A N/A 20% Coinsurance 50% Coinsurance See Benefit
Continuous For
Confinement (including Description
an Inpatient Stay for
Mastectomy Care,
Cardiac & Pulmonary
Rehabilitation, and End
of Life Care)
Preauthorization
Required. However,
Preauthorization is not
required for emergency
admissions or services
provided in a neonatal
intensive care unit of a
Hospital certified
pursuant to Article 28 of
the Public Health Law.
Observation Stay N/A N/A 20% Coinsurance 50% Coinsurance See Benefit
For
Description
Skilled Nursing Facility N/A N/A 20% Coinsurance 50% Coinsurance 200 days per
(Includes Cardiac & Plan Year
Pulmonary
Rehabilitation)
Preauthorization
Required
Inpatient Habilitation N/A N/A 20% Coinsurance 50% Coinsurance
Services (Physical,
Speech & Occupational
therapy)
Preauthorization
Required
Inpatient Rehabilitation N/A N/A 20% Coinsurance 50% Coinsurance
Services (Physical,
Speech & Occupational
therapy)
Preauthorization
Required
19
Wellfleet Student PO Box 15369 Springfield, MA 01115-5369NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN
MENTAL HEALTH Student Health Preferred In-Network Out-of-Network Limits
& SUBSTANCE USE Center Provider Responsibility for Responsibility for Cost-
DISORDER Responsibility Responsibility Cost-Sharing Sharing
SERVICES for Cost-Sharing for Cost-Sharing
Inpatient Mental Health N/A Covered in full 20% Coinsurance 50% Coinsurance See Benefit
Care for a continuous For
confinement when in a Description
Hospital (including
Residential Treatment)
Preauthorization
Required. However,
Preauthorization is not
required for emergency
admissions or for
admissions at
Participating OMH-
licensed Facilities for
Members under 18.
Outpatient Mental Use Cost-Sharing $5 Copayment per 20% Coinsurance 50% Coinsurance See Benefit
Health Care (Including for appropriate Visit (For neuropsych (For neuropsych testing For
Partial Hospitalization & service (Copayment testing only, only, Covered in full.) Description
Intensive Outpatient (For neuropsych waived for Covered in full.)
Program Services) testing only, neuropsych
Covered in full.) testing only.)
Except for Office Visits,
Preauthorization
Required.
Inpatient Substance N/A N/A 20% Coinsurance 50% Coinsurance See Benefit
Use Services for a For
continuous confinement Description
when in a Hospital
(including Residential
Treatment)
Preauthorization
Required. However,
Preauthorization is Not
Required for Emergency
Admissions or for
Participating OASAS-
certified Facilities
20
Wellfleet Student PO Box 15369 Springfield, MA 01115-5369NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN
MENTAL HEALTH Student Health Preferred In-Network Out-of-Network Limits
& SUBSTANCE USE Center Provider Responsibility for Responsibility for Cost-
DISORDER Responsibility Responsibility Cost-Sharing Sharing
SERVICES for Cost-Sharing for Cost-Sharing
Outpatient Substance N/A N/A Covered in full Covered in full Up to 20 visits
Use Services (including a Plan Year
Partial Hospitalization, may be Used
Intensive Outpatient For Family
Program Services, and Counseling
Medication Assisted
Treatment)
Except for Office Visits,
Preauthorization
Required. However,
Preauthorization is not
required for
Participating OASAS-
certified Facilities.
PRESCRIPTION DRUGS Student Health Preferred In-Network Out-of-Network Limits
Center Provider Responsibility for Responsibility for Cost-
Responsibility for Responsibility for Cost-Sharing Sharing
Cost-Sharing Cost-Sharing
You may request a copy of the Wellfleet Rx/KPP Formulary. The Formulary is also available on the Wellfleet Rx website at
www.WellfleetRx.com. You may inquire if a specific drug is Covered under the Certificate by contacting Wellfleet Student
at the number on Your ID card, (877) 373-1170.
*Certain Prescription Drugs are not subject to Cost-Sharing when provided in accordance with the comprehensive
guidelines supported by HRSA or if the item or service has an “A” or “B” rating from the USPSTF
Retail Pharmacy
Supply Limits. Except for contraceptive drugs, devices, or products, We will pay for no more than a 30-day supply of a
Prescription Drug purchased at a retail pharmacy. You are responsible for one (1) Cost-Sharing amount for up to a 30-day
supply.
You may have the entire supply (of up to 12 months) of the contraceptive drug, device, or product dispensed at the same
time. Contraceptive drugs, devices, or products are not subject to Cost-Sharing
when provided by a Participating Pharmacy.
Please refer to Certificate of coverage for details.
30 Day Supply See Benefit
(except contraceptive For
drugs or devices)* Description
Tier 1 (Including $15 Copayment per N/A $15 Copayment per 30% Coinsurance
Enteral Formulas) prescription prescription
Tier 2 (Including $40 Copayment per N/A $40 Copayment per 30% Coinsurance
Enteral Formulas) prescription prescription
Tier 3 (Including $60 Copayment per N/A $60 Copayment per 30% Coinsurance
Enteral Formulas) prescription prescription
21
Wellfleet Student PO Box 15369 Springfield, MA 01115-5369NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN
PRESCRIPTION DRUGS Student Health Preferred In-Network Out-of-Network Limits
Center Provider Responsibility for Responsibility for Cost-
Responsibility for Responsibility for Cost-Sharing Sharing
Cost-Sharing Cost-Sharing
*Contraceptive Drugs
or Devices: Up to a 90
Day Supply
Tier 1 Covered in full N/A Covered in full 30% Coinsurance
Tier 2 Covered in full N/A Covered in full 30% Coinsurance
Tier 3 Covered in full N/A Covered in full 30% Coinsurance
If You have an
Emergency Condition,
Preauthorization is not
required for a five (5)
day emergency supply
of a Covered
Prescription Drug used
to treat a substance
use disorder, including
a Prescription Drug to
manage opioid
withdrawal and/or
stabilization and for
opioid overdose
reversal.
WELLNESS BENEFITS Student Health Preferred In-Network Out-of-Network
Center Provider Responsibility for Responsibility for Cost-
Responsibility Responsibility Cost- Sharing
for Cost- Sharing for Cost- Sharing Sharing
Gym Reimbursement N/A N/A Up to $200 per six Up to $200 per six (6) Up to $200
(6) month period; up month period; up to an per six (6)
to an additional additional $100 per six month period;
$100 per six (6) (6) month period for up to an
month period for Covered Dependents additional
Covered Dependents $100 per six
(6) month
period for
Covered
Dependents
22
Wellfleet Student PO Box 15369 Springfield, MA 01115-5369NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN
DENTAL and ROUTINE Student Health Preferred In-Network Out-of-Network
VISION CARE Center Provider Responsibility for Responsibility for Cost-
Responsibility Responsibility Cost-Sharing Sharing
for Cost-Sharing for Cost-Sharing
Pediatric Dental One (1) dental
Care (Members exam and
through the end of cleaning per
the month in which six
the Member turns 19 (6)- month
years of age) period
Full mouth x-
• Preventive Dental N/A N/A $40 Copayment per 40% Coinsurance rays or
Care Visit then 20% panoramic x-
Coinsurance rays at
36 month
intervals and
• Routine Dental N/A N/A $40 Copayment per 40% Coinsurance bitewing x-
Care Visit then 20% rays at six
Coinsurance (6) - month
intervals
• Major Dental N/A N/A $40 Copayment per 40% Coinsurance
(Endodontics, Visit then 20%
Periodontics. Oral Coinsurance
Surgery and
Prosthodontics)
• Orthodontia N/A N/A $40 Copayment per 40% Coinsurance
Visit then 20%
Orthodontics and Coinsurance
Major Dental Require
Preauthorization;
Referral
23
Wellfleet Student PO Box 15369 Springfield, MA 01115-5369NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN
Pediatric Vision Care
(Members through the
end of the month in
which the Member
turns 19 years of age):
Exams Covered in full N/A $30 Copayment per 40% Coinsurance One (1) exam
Visit then 20% per Plan Year
Coinsurance
Lenses and Frames $30 Copayment N/A $50 Copayment then 40% Coinsurance One (1)
then 20% 20% Coinsurance prescribed
Coinsurance lenses and
frames per
Contact Lenses $30 Copayment N/A $50 Copayment then 40% Coinsurance Plan Year
then 20% 20% Coinsurance
Coinsurance
Contact Lenses
Require
Preauthorization
Adult Vision Care One (1) exam
(Members over age per Plan Yea
18)
Exams $20 Copayment per N/A Not Covered Not Covered
Visit
Benefits Subject to
Limits
Emergency N/A $250,000
Medical Evacuation Annual
Limit
Repatriation of N/A $250,000
Remains Annual
Limit
Accidental Death N/A $10,000
and Annual and
Dismemberment Lifetime
Maximum
For a more complete description of plan benefits, general terms and conditions, Preauthorization and Referral
requirements, etc., please review the 2020-2021 Student Health Insurance Certificate at
www.wellfleetstudent.com/nyu.
24
Wellfleet Student PO Box 15369 Springfield, MA 01115-5369NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN
NEW YORK UNIVERSITY
COMPREHENSIVE PLAN
Metal Level: Platinum
COST-SHARING Student Health Preferred In- Network Out-of-Network
Center Provider Responsibility for Responsibility for
Responsibility for Responsibility for Cost-Sharing Cost-Sharing
Cost-Sharing Cost-Sharing
Deductible None None None None
Out-of-Pocket $5,000 $5,000 $5,000 $10,000
Limit: Individual Family $10,000 $10,000 $10,000 $20,000
See section IV of
this Policy for a
description of how
We calculate the
Allowed Amount.
Any charges of a
Non-
Participating
Provider
that are in excess
of the Allowed
Amount do not
apply towards the
Out- of-Pocket
Limit. The Member
must pay the
amount by which
the Non-
Participating
Provider's charge
exceeds Our
Allowed Amount.
Benefits Subject to
Annual and Lifetime
Limits
Emergency $1,000,000
Medical Evacuation Annual
Limit
Repatriation of $1,000,000
Remains Annual
Limit
Accidental Death $10,000
and Annual and
Dismemberment Lifetime
Maximum
25
Wellfleet Student PO Box 15369 Springfield, MA 01115-5369NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN
OFFICE VISITS Student Health Preferred Provider In-Network Out-of-Network Limits
Center Responsibility Responsibility for Responsibility for
Responsibility for Cost-Sharing Cost-Sharing Cost-Sharing
for Cost-Sharing
Primary Care Office Covered in full N/A $30 Copayment per 40% Coinsurance See Benefit
Visits (or Home Visit then For
Visits) 10% Coinsurance Description
Specialist Office Visits $20 Copayment per N/A $30 Copayment per 40% Coinsurance See Benefit
(or Home Visits) Visit Visit then For
10% Coinsurance Description
PREVENTIVE CARE Student Health Preferred Provider In-Network Out-of-Network Limits
Responsibility for Responsibility Responsibility for Responsibility for
Cost-Sharing For Cost-Sharing Cost-Sharing Cost-Sharing
• Well Child Visits See Benefit
and For
Immunizations* Description
Students Covered in full N/A Covered in full 40% Coinsurance
Dependents N/A N/A Covered in full 40% Coinsurance
• Adult Annual
Physical
Examinations*
Students Covered in full N/A Covered in full 40% Coinsurance
Dependents N/A N/A Covered in full 40% Coinsurance
• Adult
Immunizations*
Students Covered in full N/A Covered in full 40% Coinsurance
Dependents N/A N/A Covered in full 40% Coinsurance
• Routine
Gynecological
Services/Well
Woman Exams*
Students Covered in full Covered in full Covered in full 40% Coinsurance
Dependents N/A Covered in full Covered in full 40% Coinsurance
26
Wellfleet Student PO Box 15369 Springfield, MA 01115-5369NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN
PREVENTIVE CARE Student Health Preferred Provider In-Network Out-of-Network Limits
Responsibility for Responsibility Responsibility for Responsibility for
Cost-Sharing For Cost-Sharing Cost-Sharing Cost-Sharing
• Mammography
Screening and
Diagnostic
Imaging for the
Detection of
Breast Cancer
Students N/A N/A Covered in full 40% Coinsurance
Dependents N/A N/A Covered in full 40% Coinsurance
• Sterilization
Procedures for
Women*
Students N/A N/A Covered in full 40% Coinsurance
Dependents N/A N/A Covered in full 40% Coinsurance
• Vasectomy
Students N/A N/A Covered in full 40% Coinsurance
Dependents N/A N/A Covered in full 40% Coinsurance
• Bone Density
Testing*
Students N/A N/A Covered in full 40% Coinsurance
Dependents N/A N/A Covered in full 40% Coinsurance
• Screening for
Prostate Cancer
Students Covered in full N/A Covered in full 40% Coinsurance
Dependents N/A N/A Covered in full 40% Coinsurance
27
Wellfleet Student PO Box 15369 Springfield, MA 01115-5369NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN
PREVENTIVE CARE Student Health Preferred Provider In-Network Out-of-Network Limits
Responsibility for Responsibility Responsibility for Responsibility for
Cost-Sharing For Cost-Sharing Cost-Sharing Cost-Sharing
• All other preventive
services required by
USPSTF and HRSA.
Students Covered in full N/A Covered in full 40% Coinsurance
Dependents N/A N/A Covered in full 40% Coinsurance
• *When preventive Use Cost Sharing for Use Cost Sharing Use Cost Sharing for Use Cost Sharing
services are not appropriate service for appropriate appropriate service for appropriate
provided in (Primary Care Office service (Primary (Primary Care Office service (Primary
accordance with the Visit; Care Office Visit; Visit; Specialist Office Care Office Visit;
comprehensive Specialist Office Specialist Office Visit; Diagnostic Specialist Office
guidelines supported Visit; Diagnostic Visit; Diagnostic Radiology Services; Visit; Diagnostic
by USPSTF and HRSA. Radiology Services; Radiology Services; Laboratory Procedures Radiology Services;
Laboratory Laboratory & Diagnostic Testing) Laboratory
Procedures & Procedures & Procedures &
Diagnostic Testing) Diagnostic Testing) Diagnostic Testing)
EMERGENCY CARE Student Health Preferred Provider In-Network Out-of-Network Limits
Responsibility for Responsibility Responsibility for Responsibility for
Cost-Sharing for Cost-Sharing Cost-Sharing Cost-Sharing
Pre-Hospital N/A N/A Covered in full Covered in full See Benefit
Emergency Medical For
Services (Ambulance Description
Services)
Non-Emergency N/A N/A Covered in full Covered in full See Benefit
Ambulance Services For
Description
Emergency N/A N/A $100 Copayment per $100 Copayment See Benefit
Department Visit then per Visit then For
10% Coinsurance 10% Coinsurance Description
Health care forensic
examinations
performed under
Public Health Law §
2805-I are not subject
to Cost-Sharing
Urgent Care Center N/A N/A $30 Copayment per 40% Coinsurance See Benefit
Visit then For
10% Coinsurance Description
28
Wellfleet Student PO Box 15369 Springfield, MA 01115-5369NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN
PROFESSIONAL Student Health Preferred Provider In-Network Out-of-Network Limits
SERVICES AND Responsibility Responsibility Responsibility for Responsibility for
OUTPATIENT CARE for Cost-Sharing for Cost-Sharing Cost-Sharing Cost-Sharing
Advanced Imaging See Benefit
Services For
Description
• Performed in a N/A N/A 10% Coinsurance 40% Coinsurance
Specialist Office
• Performed in a N/A N/A 10% Coinsurance 40% Coinsurance
Freestanding
Radiology Facility
• Performed as N/A N/A $35 Copayment per 40% Coinsurance
Outpatient Hospital Visit then
Services 10% Coinsurance
Preauthorization
Required
Allergy Testing & See Benefit
Treatment For
Description
• Performed in a PCP 10% Coinsurance N/A 10% Coinsurance 40% Coinsurance
Office
• Performed in a 10% Coinsurance N/A 10% Coinsurance 40% Coinsurance
Specialist Office
Ambulatory Surgical N/A N/A $35 Copayment per 40% Coinsurance See Benefit
Center Facility Fee Visit then For
10% Coinsurance Description
Preauthorization
Required
Anesthesia Services N/A N/A 10% Coinsurance 40% Coinsurance See Benefit
(all settings) For
Description
Preauthorization
Required
Autologous Blood N/A N/A 10% Coinsurance 40% Coinsurance See Benefit
Banking For
Description
29
Wellfleet Student PO Box 15369 Springfield, MA 01115-5369NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN
PROFESSIONAL Student Health Preferred Provider In-Network Out-of-Network Limits
SERVICES AND Responsibility Responsibility Responsibility for Responsibility for
OUTPATIENT CARE for Cost-Sharing for Cost-Sharing Cost-Sharing Cost-Sharing
Cardiac & See Benefit
Pulmonary For
Rehabilitation Description
• Performed in a N/A N/A $30 Copayment per 40% Coinsurance
Specialist Office Visit then
10% Coinsurance
• Performed as N/A N/A $35 Copayment per 40% Coinsurance
Outpatient Hospital Visit then
Services 10% Coinsurance
• Performed as N/A N/A Included As Part of Included As Part of
Inpatient Hospital Inpatient Hospital Inpatient Hospital
Services Service Cost-Sharing Service Cost-
Sharing
Chemotherapy See Benefit
• Performed in a PCP N/A N/A 10% Coinsurance 40% Coinsurance For
Office Description
• Performed in a N/A N/A 10% Coinsurance 40% Coinsurance
Specialist Office
• Performed as N/A N/A $35 Copayment per 40% Coinsurance
Outpatient Hospital Visit then
Services 10% Coinsurance
Preauthorization
Required
Chiropractic Services N/A N/A $30 Copayment per 40% Coinsurance See Benefit
Visit then For
Preauthorization 10% Coinsurance Description
Required
Clinical Trials Use Cost-Sharing for N/A Use Cost-Sharing for Use Cost-Sharing See Benefit
appropriate service appropriate service for appropriate For
service Description
30
Wellfleet Student PO Box 15369 Springfield, MA 01115-5369You can also read
