865 plan summary booklet 2012-13

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STUDENT

ACCIDENT AND SICKNESS

PLAN

2012-2013

Policy Number PUH201986

Underwritten By

ACE Property and Casualty Insurance Company

Office of Student and Residence Life120 Claremont Avenue

New York, New York 10027-4698

“Your student health insurance coverage,offered by ACE Property and Casualty

Insurance Company, may not meet theminimum standards required by the healthcare reform law for the restrictions onannual dollar limits. The annual dollar limitsensure that consumers have sufficientaccess to medical benefits throughout theannual term of the policy. Restrictions for annual dollar limits for group and individualhealth insurance coverage are $1.25 million

for policy years before September 23, 2012;and $2 million for policy years beginning onor after September 23, 2012 but beforeJanuary 1, 2014. Restrictions for annualdollar limits for student health insurancecoverage are $100,000 for policy yearsbefore September 23, 2012, and $500,000 for policy years beginning on or after September 23, 2012, but before January 1,2014. Your student health insurancecoverage put an annual limit of: $100,000 on“Essential Benefits” described in thisbrochure. If you have any questions or concerns about this notice, contact ACEProperty and Casualty Insurance Companyat 1-800-352-4462. Be advised that you maybe eligible for coverage under a grouphealth plan of a parent’s employer or under a parent’s individual health insurance policyif you are under the age of 26. Contact theplan administrator of the parent’s employer plan or the parent’s individual healthinsurance issuer for more information.”



TABLE OF CONTENTS

Introduction ..............................................................2

Eligibility................................................................2-3

Policy Term................................................................3

Referral Requirement ............................................3-4

Premium Refund Policy ............................................4

Dependents ............................................................4-5

Other Coverage Options ............................................5

Enrollment Period ..................................................5-6

Definitions..............................................................6-9

Schedule of Benefits ..........................................10-15

PHCS Network ........................................................16

Prescribed Medicines Expense ................................17

Covered Medical Expenses ................................18-34

Travel Assistance Program ......................................34

Accidental Death and Dismemberment ..................35

Exclusions and Limitations ................................36-37

Appeal Procedure ..............................................37-38

Claim Procedure ................................................38-39

Coordination of Benefits ........................................39

Reimbursement and Subrogation ............................39

Important Notice......................................................40Important Numbers..................................................41

Limited Benefits Health Insurance - The insuranceevidenced in this brochure provides limited benefitshealth insurance only. It does NOT provide basichospital, basic medical, major medical insurance,Medicare supplement, long term care insurance,nursing home insurance only, home care insuranceonly, or nursing home and home care insurance asdefined by the New York State Insurance

Department.



State, written in English, and cover the student

continuously through an entire academic year.

Part-Time Students

Voluntary enrollment is available to part-time students.To enroll on a voluntary basis, go online towww.cirstudenthealth.com/msmnyc. Annual coverageis effective on August 18, 2012 or January 1, 2013for new incoming students for Spring Semester.The last date to enroll for Fall Semester isJuly 25, 2012 and for Spring Semester for newlyenrolled students is December 2, 2012.

POLICY TERM

Accident and Sickness Medical Expense BenefitThe insurance coverage under the Base Plan becomeseffective at 12:01 a.m. on August 18, 2012 andcontinues until 12:01 a.m. on August 18, 2013 for eligible students.

REFERRAL REQUIREMENT

When at school, in the absence of a MedicalEmergency, and during regular office hours, thestudent's first visit must be with University MedicalPractice Associates, which is affiliated with St. Luke's-Roosevelt Hospital Center, in order to avoid adeductible per policy year. Insured students will berequired to pay a $5 per visit copayment at the time of the University Medical Practice Associates office visit.See page 39 for physician's address, office hours, andthe number to call for appointments.

If you are referred by University Medical PracticeAssociates to a PHCS Network provider, no deductiblewill be required. If you are referred by UniversityMedical Practice Associates to a provider who isoutside of the PHCS Network, a $100 deductible per policy year will be required.

In the case of an emergency, there are no extra charges

for treatment performed outside the PHCS Provider Network of doctors.

Non-Emergency Medical conditions treated without

referral from St. Luke’s-Roosevelt Hospital Center are

subject to a $200 deductible per policy year, whether

INTRODUCTION

This brochure is a brief description of the Student

Accident and Sickness Insurance Plan for students at

Manhattan School of Music. The exact provisionsgoverning this insurance are contained in the Master

Policy issued to the School. The Master Policy shall

control in the event of any conflict between the Policy

and this brochure.

We suggest that you retain this brochure so you will

have a ready reference to the benefits of the Plan. Any

provision of the Policy or the brochure which is in

conflict with the statutes of the state in which the

Policy is issued will be administered to conform with

the requirements of such state statutes.

Under HIPAA's Privacy Rule We are required to

provide you with notice of our legal duties and privacy practices with respect to personal health information.

You should receive a copy of this notice with your

insurance ID card. If, at anytime, you wish to request a

copy of ACE Property and Casualty Insurance

Company’s Privacy Notice, write to:

ACE Property and Casualty Insurance Company, RE:

HIPAA Notice, 200 Schultz Drive, Suite 403, Red

Bank, N.J. 07701, call: 732-945-2300, or e-mail:

[email protected].

ELIGIBILITY

Student Health Insurance Plan

Accident and Sickness Medical Expense Benefit

All full-time students, while enrolled at the School, are

automatically covered in the Plan as described under

the Schedule of Benefits (Page 9-14) of this brochure.

Waiver

Those who have comparable coverage under another

policy may waive such coverage by completing the

online insurance waiver process at

www.cirstudenthealth.com/msmnyc. Online waivers

must be completed by July 25, 2012 for returning and

new students for Fall Semester (or new incomingstudents for Spring Semester by December 2, 2012).

Waivers must be completed annually. The outside

coverage must be: comparable to this plan, valid in NY

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treatment is rendered within or outside of the PHCS

Network.

When Manhattan School of Music is not in session

and if the student is at a home located outside themetropolitan New York City area, the referral

requirement will not be enforced. The referral

requirement does not apply to Maternity, to female

students with acute gynecological conditions, or the

treatment of Mental and Nervous Conditions.

Dependents are not required to meet the referral

requirement.

PREMIUM REFUND POLICY

Except for medical withdrawal due to an Injury or Sickness, any student withdrawing from the school

during the first 31 days of the period for which

coverage is purchased shall not be covered under this

Plan and a full refund of the premium will be made.

Students withdrawing after 31 days will remain

covered under this Plan for the full period for which

the premium has been paid and no refund will be made

available. Premiums received by the Company are fully

earned upon receipt.

Coverage for an Insured Student entering the Armed

Forces of any country will terminate as of the date of

such entry. Those Insured Students withdrawing from

the school to enter military service will be entitled to a pro-rata refund of premium upon written request within

90 days. Contact Collegiate Insurance Resources for

more information.

DEPENDENTS

Students enrolled in the Base Accident and Sickness

Medical Expense Benefits of this Plan may also enroll

their dependent children up to and including 26 years

spouses or domestic partners who reside with the

Insured Student. Dependents must enroll by July 25,

2012 for Fall Semester or by December 2, 2012 for Spring Semester.

Coverage for newborn children will consist of coverage

for Sickness or Accident, including necessary care or

treatment of congenital defects, birth abnormalities, or

premature birth. Such coverage will start from the

moment of birth, if the Insured Student is already

insured for dependent child(ren) coverage when the

child is born. If the Insured Student does not havedependent child(ren) coverage when the child is born,

We cover the newborn child for dependent benefits for

the first 31 days from and after the moment of birth, or

any minor child placed with an Insured Student for

adoption for dependent benefits for the first 31 days

from and after the moment the child is placed in the

physical custody of the Insured Student for adoption.

To continue the newborn child's dependent benefits

past the first 31 days, the Insured Student must

complete the Dependent Enrollment Form and pay

the necessary premium within 31 days of the child's

birth. Contact Collegiate Insurance Resources for a

Dependent Enrollment Form and pro-rated rates.

OTHER COVERAGE OPTIONS

Insured Students (and their Insured Dependents) who

are not eligible to re-enroll in the Student Accident and

Sickness Insurance Plan after coverage expires should

contact Collegiate Insurance Resources for possible

options prior to the expiration date under the Student

Insurance Plan.

Students in need of specialized coverage (International

Travel) should contact Collegiate Insurance Resources

for possible options.

ENROLLMENT PERIOD

To purchase coverage for Dependents, you must enroll

during the open enrollment period at the beginning

of the Fall Semester. The Spring Semester open

enrollment period is available only for new students

(and their eligible dependents) first entering MSM for

the Spring Semester.

Late enrollment is considered only if a change has

occurred in your insured status regarding coverage that

was in-force during the open enrollment period. Lateenrollment must be completed within 30 days of the

termination of other coverage. Contact Collegiate

Insurance Resources for rates and forms.

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function or structure in any part of the body occurring

after the Insured Person’s Effective Date of coverage.

Elective Treatment includes, but is not limited to: tubal

ligation; vasectomy; breast implants; breast reduction;voluntary sterilization procedure or any sterilization

reversal process; sexual reassignment surgery;

impotence (organic or otherwise); non-cystic acne;

non-prescription birth control; submucous resection

and/or other surgical correction for deviated nasal

septum, other than for required treatment of acute

purulent sinusitis; circumcision; gynecomastia;

hirsutism; treatment for weight reduction; treatment of

temporomandibular joint dysfunction and associated

myofacial pain; radial keratotomy; learning disabilities

or disorders or Attention Deficit Disorder; and

treatment of infertility.

Experimental or Investigational Care means a

service or supply: (a) that is not commonly and

customarily recognized as being safe and effective for

the particular diagnosis or treatment; or (b) which

requires approval by any governmental authority and

such approval has not been granted before the service

or supply is furnished. The advice of medical

consultants and commonly recognized national medical

organizations may be relied upon in determining which

services or supplies are experimental or investigational.

Injury means bodily injury caused by an Accident

which is the sole cause of the Loss. All injuries due to

the same or a related cause are considered one Injury.

Insured Person means an Insured Student and his or

her covered Dependent(s) while insured under this

Policy.

Insured Student means a student of the Policyholder

who is eligible and insured for coverage under this

Policy.

Loss means medical expense covered by this Policy as

a result of Injury or Sickness as defined in this Policy.

Medical Emergency means the sudden onset of an

Injury or Sickness which arises out of a medical or

behavioral condition which is sudden, that manifestsitself by symptoms of sufficient severity, including

severe pain, that a prudent layperson possessing an

average knowledge of medicine and health, could

reasonably expect the absence of immediate medical

DEFINITIONS

Autism Spectrum Disorder means a neurobiological

condition that includes autism, asperger syndrome,

rett’s syndrome, or pervasive development disorder.

Biologically Based Mental Illness means a mental,

nervous, or emotional condition that is caused by a

biological disorder of the brain and results in a

clinically significant, psychological syndrome or

pattern that substantially limits the functioning of the

person with the illness. Such biologically based mental

illnesses are defined as schizophrenia/psychotic

disorders, major depression, bipolar disorder,

delusional disorders, panic disorder, obsessive

compulsive disorder, bulimia, and anorexia.

Copayment means the specified dollar amount an

Insured Person must pay for specified charges. TheCopayment is separate from and not a part of the

Deductible or Coinsurance.

Covered Charge or Expense as used herein means

those charges for any treatment, services or supplies

that are: (a) for Network Providers, not in excess of the

Preferred Allowance; (b) for Non-Network Providers,

not in excess of the Reasonable and Customary

Expenses; (c) not in excess of the charges that would

have been made in the absence of this insurance; and

(d) incurred while this Policy is in force as to the

Insured Person except with respect to any expense

payable under the Extension of Benefits.Covered Percentage means that part of the Covered

Charge that is payable by the Company after the

Deductible or Copayment has been met.

Deductible means the amount of Expenses for covered

services and supplies which must be incurred by the

Insured Person before specified benefits become

payable.

Doctor as used herein means: (a) a legally qualified

physician licensed by the state in which he or she

practices; or (b) a practitioner of the healing arts

performing services within the scope of his or her

license as specified by the laws of the state of residenceof such practitioner; or (c) a certified nurse midwife

while acting within the scope of that certification.

Elective Treatment means medical treatment, which

is not necessitated by a pathological change in the

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attention to result in (a) placing the health of the person

afflicted with such condition in serious jeopardy; or in

the case of a behavioral condition placing the health of

such person or others in serious jeopardy, or (b) seriousimpairment to such person’s bodily functions; (c)

serious dysfunction of any bodily organ or part of such

person; or (d) serious disfigurement of such person.

Medically Necessary means that a service, drug or

supply is needed for the diagnosis or treatment of an

Injury or Sickness in accordance with generally

accepted standards of medical practice in the United

States at the time the service, drug or supply is

provided. A service, drug or supply shall be considered

needed if it: is ordered by a licensed Doctor; and is

commonly and customarily recognized through the

medical profession as appropriate for the particular

Injury or Sickness for which it was ordered. A service,drug or supply shall not be considered as Medically

Necessary if it is investigational, experimental, or

educational.

Mental, Nervous or Emotional Disorders means

those conditions listed in the standard nomenclature of

the American Psychiatric Association.

Policy Aggregate Maximum means for each Insured

Person, the maximum amount of benefits payable for

all Injuries and Sicknesses combined under the Student

Health Insurance Policy each Policy Year.

Preferred Allowance means the amount a Network

Provider will accept as payment in full for Covered

Charges.

Reasonable and Customary Expenses means fees

and prices generally charged within the locality where

performed for Medically Necessary services and

supplies required for treatment of cases of comparable

severity and nature.

Sickness means sickness or disease which is the sole

cause of the Loss. Sickness includes both normal

pregnancy and Complications of Pregnancy. All

sicknesses due to the same or a related cause are

considered one Sickness.Network Providers are

doctors, hospitals and other healthcare providers who

have contracted to provide specific medical care at

negotiated prices.

Non-Network providers have not agreed to any pre-

arranged fee schedules.

We, Us and Our mean ACE Property and Casualty

Insurance Company.

You and Your mean the Insured Student.

8 9



SCHEDULE OF BENEFITS

When an Insured Person uses the services of the PHCS

Network, the Covered Medical Expenses incurred will

be payable at 100% of the Preferred Allowance and nodeductible will be required. The student must obtain a

referral from University Medical Practice Associates.

When treatment is rendered by providers outside the

PHCS Network, after satisfying a $100 deductible per

policy year if referred by University Medical Practice

Associates, the Covered Medical Expenses will be

payable at 70% of the Reasonable and Customary

Expense incurred.

In the case of a Medical Emergency, if an Insured

Person goes to a Non Network Provider, We will waive

the Out-of-Network Deductible. Covered Expenses

will be payable at 100% of the Reasonable andCustomary Expense incurred.

Please see REFERRAL REQUIREMENT on page 3.

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COVERAGE NETWORK

PROVIDER

NON-NETWORK PROVIDER

Policy Aggregate Maximum

(Only applies to Essential Benefits)

$100,000 per Insured Person

per Policy Year

Deductible per Policy Year –

With Referral

(Not applicable to Preventive

Services Benefits)

$0 per Insured

Person

$100 per

Insured

Person

Deductible per Policy Year –

Without Referral

(Not applicable to Preventive

Services Benefits)

$200

per Insured

Person

$200

per Insured

Person

ESSENTIAL BENEFITS

Hospital Room and Board 100% of

Preferred

Allowance

70% of R&C

Miscellaneous Hospital

Expense

100% of

Preferred

Allowance

70% of R&C

Doctor Expense

(In-hospital and Doctor Office

fees)

100% of

Preferred

Allowance

70% of R&C

Surgery Expense Benefit

R&C fee based upon the

MDR survey of surgical fees,

valued at the 80th percentile

Multiple Surgical ProceduresExpense Benefit

See COVERED MEDICAL

EXPENSES

Anesthesia Expense Benefit100% of

Preferred

Allowance

70% of R&C

Assistant Surgeon ExpenseBenefit

100% of

Preferred

Allowance

70% of R&C

Second Surgical Opinion

Expense Benefit

100% of

Preferred

Allowance

70% of R&C



Emergency Room Expense

Treatment of a Medical

Emergency.

100% of

Preferred

Allowance

70% of R&C

Chiropractic Care Expense 100% of

PreferredAllowance

70% of R&C

Miscellaneous Outpatient

Expense

100% of

Preferred

Allowance

70% of R&C

Prescription Drug Expense

Benefit

(Includes Contraceptive

Services)

Retail 30-Day Supply:

$5.00 Copayment per

generic prescription

$10.00 Copayment per

brand name prescription

Mail Order Delivery 90-day

Supply:

$10.00 Copayment per

generic prescription$20.00 Copayment per

brand name prescription

Mental Illness, Biologically

Based and Serious

Emotional Disturbances of

Children Expense

Benefit

100% of

Preferred

Allowance

70% of R&C

Mental, Nervous, or Emotional

Inpatient Hospital

Confinement Expense

Limited to 30 days per

Policy Year

100% of

Preferred

Allowance

70% of R&C

Mental, Nervous, or Emotional

Outpatient Expense

Limited to 30 Visits per

Policy Year

100% of

Preferred

Allowance

70% of R&C

NOTE: If an Insured Person

goes to the Emergency Room at

a Non-Network Provider in the

case of a Medical Emergency as

defined in this Policy, We will

waive the $100 Out-of-Network

deductible. Covered Expenses

will be payable at 100% of the

Usual and Customary Expense

incurred.

Chemical Abuse and

Chemical

Dependence

Inpatient ExpenseLimited to 30 days per

Policy Year

100% of

Preferred

Allowance

70% of R&C

Chemical Abuse and

Chemical

Dependence

Outpatient Expense

Limited to 60 visits per

Policy Year

100% of

Preferred

Allowance

70% of R&C

Maternity Expense Benefit

Including Newborn

Infant Care

100% of

Preferred

Allowance

70% of R&C

Accidental Dental InjuryExpense

100% of Preferred

Allowance

70% of R&C

Pre-Hospital Medical

Emergency Services Expense

Benefit/

Ambulance Services

100% of

Preferred

Allowance

70% of R&C

Durable Medical Equipment

Expense Benefit

100% of

Preferred

Allowance

70% of R&C

Prosthetic Appliance And

Orthotic Devices

100% of

Preferred

Allowance

70% of R&C

Home Health Care Expense

Benefit

Limited to 40 visits per

Policy Year

100% of

Preferred

Allowance

70% of R&C

Licensed Nurse Expense

Benefit

100% of

Preferred

Allowance

70% of R&C

Hospice Expense Benefit100% of

Preferred

Allowance

70% of R&C

Skilled Nursing FacilityExpense Benefit

100% of

Preferred

Allowance

70% of R&C

Diabetes Expense Benefit100% of

Preferred

Allowance

70% of R&C

12 13



Enteral Food Formula

Expense Benefit

100% of

Preferred

Allowance

70% of R&C

Temporomandibular Joint

Dysfunction Expense Benefit

100% of

Preferred

Allowance

70% of R&C

Pre-Admission Tests Expense

Benefit

100% of

Preferred

Allowance

70% of R&C

Initial Diagnostic

Psychological Interview

100% of

Preferred

Allowance

70% of R&C

PREVENTIVE SERVICESCovered charges for Preventive Services do not apply to the

Policy Aggregate Maximum for Essential Benefits.

Preventive Services For

Adults Expense Benefit

100% of

Preferred

Allowance

70% of R&C


Women Expense Benefit

100% of

Preferred

Allowance

70% of R&C


Children Expense Benefit

100% of

Preferred

Allowance

70% of R&C

STATE MANDATED BENEFITSIn addition to any requirement s specified in the Patient Protection

and Affordable Care Act or in this Policy, We will also pay

benefits in accordance with any applicable State Insurance Law(s).

Bone Mineral Density

Measurements

and Tests Expense Benefit

100% of

Preferred

Allowance

70% of R&C

Early Intervention Services

Expense Benefit

Benefit Maximum: $1,000 per Policy Year

100% of

Preferred

Allowance

70% of R&C

Autism Spectrum Disorder

Expense Benefit

100% of

Preferred

Allowance

70% of R&C

Eating Disorder Expense

Benefit

100% of

Preferred

Allowance

70% of R&C

Reconstructive Breast

Surgery Expense Benefit

100% of

Preferred

Allowance

70% of R&C

Cancer - Second Opinion

Expense Benefit

100% of

Preferred

Allowance

70% of R&C

Diagnostic Screening For

Prostatic Cancer

100% of

Preferred

Allowance

70% of R&C

End of Life Care Expense

Benefit

100% of

Preferred

Allowance

70% of R&C

Nutritional Supplements

Expense Benefit

100% of

Preferred

Allowance

70% of R&C

“OTHER” BENEFIT PROVISIONSCovered charges for “Other” Benefit Provisions do not apply to

the Policy Aggregate Maximum for Essential Benefits.

Emergency MedicalEvacuation Expense Benefit

100% of actual Expense;Benefit Maximum: $10,000

Repatriation of Remains

Expense Benefit

100% of actual Expense;

Benefit Maximum: $7,500

Accidental Death And

Dismemberment

Principal Sum: $10,000

1514



PHCS NETWORK

Please see Important Numbers on page 39.

Persons insured under this plan may choose to be

treated within or outside of the PHCS Network. PHCS

consists of hospitals, physicians, and other health care

providers organized into a network for the purpose of

delivering quality health care at affordable rates.

Reimbursement rates will vary according to the source

of care as described under the Schedule of Benefits.

Referral to a network physician does not guarantee

eligibility or right to student health benefits. Providers

may be periodically added or deleted as participants in

the PHCS Network. Not all physicians practicing ata hospital elect to participate in the PHCS Network.

Insureds are responsible to verify that a provider is a

participant prior to services being rendered.

In order to use the services of a participating provider,

you must present your insurance identification card.

You may contact PHCS for a list of participants:

Toll Free Phone.....................................1-800-922-4362

Website..........................................www.multiplan.com

While living in the New York city area, if the situation

is not an emergency, You make initial appointments

with the University Medical Practice Associates and

obtain referrals, if appropriate, to PHCS Network

participants.

Please see Important Numbers on page 39.

After a copayment of $5 for generic or $10 for a brand

name drug per prescription, the cost of prescription

drugs is payable in full and is included in the plan

maximum.

Prescriptions must be filled at a Medco participating

pharmacy. Covered Persons will be given an

insurance ID card to show to the pharmacy as proof of

coverage. A directory of participating pharmacies is

available online at www.medco.com.

Before you receive your insurance ID card, and if you

need to have a prescription filled, go to any pharmacy, pay for the medication in full and save the receipt. Your

insurance ID card will include instructions on how to

file for reimbursement for prescriptions filled before

you received your card. Reimbursement will be at the

Medco contracted discount rate and will probably be

less than the rate charged by the pharmacy.

After you receive your insurance ID card, no claim

forms need to be completed. After you receive the card

you may call the toll-free customer service number

listed on your card for assistance with pharmacy

locations at 1-800-400-0136. This number is effective

for enrolled members only. You will need the groupnumber and member number printed on the card.

Not all medications are covered. For a list of covered

medications and exclusions after you receive your

insurance ID card, contact Medco at 1-800-400-0136.

Home Delivery Pharmacy Service is available for

medication for the treatment of ongoing health

conditions. Instructions will be included with your

insurance ID card.

PRESCRIBED MEDICINES EXPENSE

16 17



Network Providers, the Insured is entitled to a secondmedical opinion from a non-participating specialist, atno additional cost beyond that which the Insured wouldhave paid for services from a participating specialist, provided the Insured's attending Doctor provides awritten referral. A second medical opinion provided bya non-participating specialist absent a written referralwill be covered subject to the payment of additionalcoinsurance. We treat such charges the same way Wetreat Covered Charges for any other Sickness.

Chemical Abuse and Chemical Dependence

Inpatient Expense Benefit: If on account of Chemical Dependence or Chemical Abuse, an InsuredPerson requires inpatient treatment, We will pay for such treatment as follows: (a) when the Insured Personis confined as an inpatient in a Hospital or aDetoxification Facility, We will pay benefits for detoxification on the same basis as any other Sickness.But, We will not cover more than seven (7) days of active treatment in any one calendar year; (b) when theInsured Person is confined in a Hospital or ChemicalAbuse Treatment Facility, We will pay benefits for rehabilitation services on the same basis as any other Sickness. But, We will not cover more than thirty (30)days of inpatient care for such services in any onecalendar year.

As used in this provision, the term "Chemical AbuseTreatment Facility" means a facility: (a) in New York State, which is certified by the Office of Alcoholism

and Substance Abuse Services; or (b) in other states,which is accredited by the Joint Commission onAccreditation of Hospitals as alcoholism, substanceabuse, or chemical dependence treatment programs.

Chemical Abuse and Chemical Dependence

Outpatient Expense Benefit: If on account of Chemical Abuse or Chemical Dependence, an InsuredPerson requires outpatient treatment, We will pay for diagnosis and treatment of Chemical Abuse andChemical Dependence on the same basis as any other Sickness. But, We will not cover more than 60 visitsduring any one calendar year, for the diagnosisand treatment of Chemical Abuse and Chemical

Dependence. Coverage will be limited to facilities in New York State, which are certified by the Officeof Alcoholism and Substance Abuse Services asoutpatient clinics or medically supervised ambulatorysubstance programs. In other states, coverage is

COVERED MEDICAL EXPENSES

Covered Medical Expenses consist of the followingsubject to the benefit limits described in this brochure.

Autism Spectrum Disorder Expense Benefit: Wewill pay the Covered Percentage of the CoveredCharges incurred by an Insured Person for diagnosis or treatment of Autism Spectrum Disorder. Diagnosis or treatment for medical services, drugs and supplies must be Medically Necessary and prescribed by a Doctor.We cover such charges the same way We treat coveredcharges for any other sickness.

Bone Mineral Density Measurements and Tests

Expense Benefit: We will pay the Covered Percentageof the Covered Charges incurred for Bone MineralDensity Measurements or Tests for the prevention,diagnosis, and treatment of osteoporosis when

requested by a health care provider for a QualifiedIndividual. A Qualified Individual means an InsuredPerson who meets the following criteria: (1) previouslydiagnosed as having osteoporosis or having a familyhistory of osteoporosis; (2) symptoms or conditionsindicative of the presence, or the significant risk, of osteoporosis; (3) on a prescribed drug regimen posinga significant risk of osteoporosis; (4) with lifestylefactors to such a degree as posing a significant risk of osteoporosis; and (5) with age, gender, and/or other physiological characteristics which pose a significantrisk for osteoporosis. Coverage includes bone mineraldensity measurements or tests as covered under the

Federal Medicare program as well as those inaccordance with the criteria of the National Institute of Health, including dual-energy x-ray absorptiometry.If this Policy includes coverage for outpatient prescription drugs, then We also will cover drugs anddevices for bone mineral density that have beenapproved by the United States Food and DrugAdministration or generic equivalents as approvedsubstitutes in accordance with the above criteria. Wecover such charges the same way We treat CoveredCharges for any other Sickness.

Cancer-Second Opinion Expense Benefit: We cover charges for a second medical opinion by an

appropriate specialist, including but not limited to aspecialist affiliated with a specialty care center, in theevent of a positive or negative diagnosis of cancer or arecurrence of cancer or a recommendation of a courseof treatment for cancer. If this Plan requires the use of

18 19



limited to those facilities, which are accredited by theJoint Commission on Accreditation of Hospitals asalcoholism, substance abuse, or chemical dependencetreatment programs. Outpatient Services consisting of consultant or treatment sessions will not be payableunless these services are furnished by a Doctor or Psychotherapist who: (a) is licensed by the state or territory where the person practices; and (b) devotes asubstantial part of his or her time treating intoxicated persons, substance abusers, alcohol abusers, or alcoholics. Outpatient coverage includes up to 20outpatient visits during any one calendar year, for covered family members, even if the Insured Person inneed of treatment has not received, or is not receivingtreatment for Chemical Abuse and ChemicalDependence provided that the total number of suchvisits, when combined with those of the Insured

Person in need of treatment, do not exceed 60outpatient visits in any one calendar year, and providedfurther that the 60 visits shall be reduced only by thenumber of visits actually utilized by the coveredfamily members. We treat such charges the same wayWe treat Covered Charges for any other Sickness.

"Chemical Abuse and Chemical Dependence" meansan illness characterized by a physiological or psychological dependency, or both, on a controlledsubstance and/or alcoholic beverages. It is further characterized by a frequent or intense pattern of pathological use to the extent the user exhibits a lossof self-control over the amount and circumstances of

use; develops symptoms of tolerance or physiologicaland/or psychological withdrawal if the use of thecontrolled substance or alcoholic beverage is reducedor discontinued; and the user's health is substantiallyimpaired or endangered or his or her social or economic function is substantially disrupted.

Chiropractic Care Expense: We will pay for anInsured Person's Covered Charges for non-surgicaltreatment to remove nerve interference and its effects,which is caused by or related to Body Distortion. BodyDistortion means structural imbalance, distortion, or incomplete or partial dislocation in the human body which: (a) is due to or related to distortion,

misalignment, or incomplete or partial dislocation of or in the vertebral column; and (b) interferes with thehuman nerves. We treat such charges the same way Wetreat Covered Charges for any other Sickness.

Contraceptive Services Expense Benefit: We will

pay the Covered Percentage of the Covered Chargesfor Contraceptive Drugs and Devices. Such Drugs andDevices must be approved by the United States Foodand Drug Administration and prescribed legally by anauthorized health care provider. Covered services aresubject to applicable co-payments under thePrescription Drug Benefit Plan.

Diabetes Treatment Expense Benefit: We cover charges for the following Medically Necessary diabetesequipment services and supplies for the treatment of diabetes, when recommended by a Doctor or other licensed health care provider. We treat such charges thesame way We treat any other Covered Charges for aSickness. Such supplies include: blood glucosemonitors, blood glucose monitors for the legally blind,data management systems, test strips for glucosemonitors and visual reading, urine test strips, insulin,injection aids, cartridges for the legally blind, syringes,insulin pumps and appurtenances thereto, insulininfusion devices or oral agents for controlling bloodsugar. We also cover charges for expenses incurred for diabetes self-management education. Coverage for self-management education and education relating todiet shall be limited to medically necessary visits uponthe diagnosis of diabetes, where a Doctor diagnoses asignificant change in the Insured Person's symptomsor conditions which necessitates changes in a patient's self-management or upon determination thatreeducation or refresher education is necessary.Diabetes self-management education may be provided

by a Doctor or other licensed healthcare provider; theDoctor's office staff, as part of an office visit; or by acertified diabetes nurse educator, certified nutritionist,certified dietician, or registered dietician. Educationmay be limited to group settings wherever practicable.Coverage for self-management education andeducation relating to diet includes Medically Necessary home visits.

Diagnostic Screening for Prostate Cancer Expense

Benefit: We cover charges for Diagnostic Screeningfor Prostate Cancer as follows: (a) standard diagnostictesting including, but not limited to, a digital rectalexamination and a prostate-specific antigen test at any

age for men having a prior history of prostatecancer; and (b) an annual standard diagnosticexamination including, but not limited to, a digitalrectal examination prostate-specific antigen test for men: (1) age fifty and over who are asymptomatic; and

20 21



We will continue to provide coverage for care providedin the facility. The decision of the external appeal agentwill be binding on both Us and the Insured Person."Advanced Cancer" means a diagnosis of cancer by theInsured Person's attending health care practitioner certifying that there is no hope of reversal of primarydisease and that the person has fewer than sixty days tolive. We cover such charges the same way We treatCovered Charges for any other Sickness.

Miscellaneous Hospital Expense: If an InsuredPerson incurs Expense during a hospital confinement,or day surgery on an outpatient basis, We will paythe Covered Charges incurred. Such Expenses include:(a) anesthesia, anesthesia supplies and services; (b)operating, delivery, and treatment rooms andequipment; (c) diagnostic x-ray and laboratorytests; (d) lab studies; (e) oxygen tent; (f) blood and blood services; (g) inpatient prescribed drugs andmedicines; (h) medical and surgical dressings, supplies,casts, and splints; (i) radiation therapy, intravenouschemotherapy, kidney dialysis, and inhalationtherapy; (j) chemotherapy treatment with radioactivesubstances; (k) intravenous injections and solutions,and their administration; (l) physical and occupationaltherapy; and (m) other necessary and prescribedhospital expenses.

Accidental Dental Expense: When an Insured Personincurs expenses for dental treatment for Injury to soundnatural teeth, We will pay for the Covered Percentage

of the Covered Charges incurred on the same basis asany other injury.

Durable Medical Equipment Expense Benefit: If, byreason of Injury or Sickness, an Insured Person requiresthe use of Durable Medical Equipment, We will paythe Covered Percentage of the Covered Chargesincurred by the Insured Person for such DurableMedical Equipment, subject to the Deductible shown inthe Plan of Insurance. We pay the Covered Percentageof the Covered Charges incurred by the Insured Personfor the purchase of such Durable Medical Equipmentwhen the purchase price is expected to be less costlythan rental.

Temporomandibular Joint Dysfunction ExpenseBenefit: We will pay the Covered Percentage of theCovered Charges incurred for any diagnostic or surgical procedure involving bones or joints of the jawand facial region, if, under accepted medical standards,such procedure or surgery is Medically Necessary to

(2) age forty and over with a family history of prostatecancer or other prostate cancer risk factors. We treatsuch charges the same way We treat Covered Chargesfor any other Sickness.

Doctor Office Expense: If an Insured Person, requirescare and treatment by a Doctor, both in and out of thehospital, for non-surgical services, We will pay theCovered Charges incurred, limited to one visit per day.

Early Intervention Services: We cover charges for Medically Necessary Early Intervention Services. Wewill cover 70% of Reasonable and Customary incurredup to $100 per visit, limited to $1,000 per policy year for the prevention of repetitive stress disorders.Visits used for Early Intervention Services shall notreduce the number of visits otherwise available under the policy.

Eating Disorders: If an Insured Person requirestreatment for an Eating Disorder Condition such as: binge eating disorder including anorexia nervosa, and bulimia nervosa, and treatment has been provided by astate identified Eating Disorder Center or aComprehensive Health Care Center, We will pay theCovered Percentage of the Covered Chargesincurred by the Insured Person for such treatment.Covered treatment includes psychological services, andinpatient medical and surgical treatment. We cover such charges the same way We treat covered Chargesfor any other Sickness.

Emergency Room Expense: Treatment of a MedicalEmergency. If an Insured Person goes to theEmergency Room at a Non-Network Provider in thecase of a Medical Emergency as defined in this Policy,We will waive the $100 Out-of-Network deductible.Covered Expenses will be payable at 100% of theUsual and Customary Expense incurred.

End of Life Care Expense Benefit: If an InsuredPerson is diagnosed with Advanced Cancer, We willcover services provided by a facility or programspecializing in the treatment of terminally ill patients if the Insured Person's attending health care practitioner,in consultation with the medical director of the facilityor program determines that the Insured Person's carewould appropriately be provided by such a facility or program. If We disagree with the admission of theInsured Person into the facility, or the provision or continuation of care by the facility, We will initiate anexpedited external appeal. Until a decision is rendered,

22 23



one payment for the delivery and postnatal care provided. We also cover charges for parent education,assistance, and training in breast or bottle feeding andthe performance of any necessary maternal andnewborn clinical assessments. Covered services may be provided by a certified nurse-midwife under qualified medical direction if he or she is affiliated withor practicing in conjunction with a licensed facility. Wecover such charges the same way We treat CoveredCharges for any other Sickness.

Newborn Infant Care: Newborn infant care iscovered when the infant is confined in the Hospital andhas received continuous Hospital care from themoment of birth. This includes: (a) nursery charges; (b)charges for routine Doctor's examinations andtests; and (c) charges for routine procedures, exceptcircumcision. This benefit also includes the necessarycare and treatment of medically diagnosed congenitaldefects and birth abnormalities of newborn childrencovered from birth.

Mental Illness, Biologically Based and Serious

Emotional Disturbances of Children Expense

Benefit: If an Insured Person requires treatment for Biologically Based Mental Illness, We will pay for such treatment of a person of any age and for SeriousEmotional Disturbances of a Child under the sameterms and conditions applied to other medicalconditions. The benefits shall include the following: (a)inpatient Hospital services; (b) outpatient services; (c)

prescription drugs, if this Policy includes thePrescription Drug Expense Benefit. We cover suchcharges the same way We treat Covered Charges for any other Sickness.

Mental, Nervous, or Emotional Inpatient Hospital

Confinement Expense Benefit: If an Insured Personrequires treatment for a Mental, Nervous or EmotionalDisorders, We will pay for such treatment as follows:When the Insured Person requires HospitalConfinement for treatment of a Mental, Nervous or Emotional Disorder, We will pay the CoveredPercentage of the Covered Charges incurred for suchHospital Confinement on the same basis as any other

Sickness, Hospital Room and Board Expense of theHospital Expense Benefit. However, We will not cover more than thirty (30) days of inpatient care for suchservices in any one calendar year. Such confinementmust be in a licensed or certified facility, includingHospitals. What We pay is shown in the Plan of Insurance.

treat conditions caused by congenital or developmentaldeformity, Injury, disease or Sickness.

Benefits are not provided for the care or treatment of

the teeth or gums, for intraoral prosthetic devices, or for surgical procedures for cosmetic purposes.

We cover such charges the same way We treat CoveredCharges for any other Sickness.

Hospital Room and Board Expense: If an InsuredPerson requires confinement in a hospital, We will pay the Covered Charges incurred up to the dailysemi-private room rate.

Mammographic Examination Expense Benefit: Wewill pay the Covered Percentage of the CoveredCharges incurred for a Mammographic exam. Thecharges must be incurred while the Insured Person is

insured for these benefits. Benefits will be paid for thefollowing: (a) one Mammogram at any age for anInsured Person who has a prior history of breast cancer or who has a first degree relative with a prior history of breast cancer, upon recommendation of a Doctor; (b)one baseline Mammogram for an Insured Personage thirty-five through thirty-nine; and (c) oneMammogram annually for an Insured Person age fortyyears or older. We cover such charges the same wayWe treat Covered Charges for any other Sickness.

Maternity Expense Benefit: We will pay benefits for an Insured Person's Covered Charges for maternitycare, including hospital, surgical, and medical care. We

treat such charges the same way We treat CoveredCharges for any other Sickness.

We cover charges for a minimum of 48 hours of inpatient care following an uncomplicated vaginaldelivery and a minimum of 96 hours of inpatient carefollowing an uncomplicated cesarean section for anInsured Person and her newborn child in a health carefacility, unless the attending Doctor in consultationwith the mother, makes a decision for an earlier discharge from the Hospital. If so, We will cover charges for one home health care visit. The visit must be requested within 48 hours of the delivery (96 hoursin the case of a cesarean section) and the services must

be delivered within 24 hours: (a) after discharge; or (b)of the time of the mother's request, whichever islater. Charges for the home health care visit arenot subject to any Deductible, Coinsurance, or Copayments. Covered Charges include at least two payments, at reasonable intervals, for prenatal care and

24 25



Mental, Nervous, or Emotional Outpatient Expense

Benefit: When an Insured Person is not so Hospitalconfined, We will pay the Covered Percentage of theCovered Charges incurred for at least 30 days of activetreatment in any calendar year, as shown in the Plan of Insurance, for covered outpatient services for thetreatment of Mental, Nervous, or Emotional Disorders.

The Mental, Nervous, or Emotional Disorder must, inthe professional judgment of health care providers, betreatable, and the treatment must be Medically Necessary.

Outpatient Treatment and Doctor services includecharges made in a facility operated by the Office of Mental Health, or by a psychiatrist or psychologistlicensed to practice in this state or a professionalcorporation or university faculty practice corporation.

We cover such charges the same way We treat CoveredCharges for any other Sickness. What We pay is shownin the Plan of Insurance.

Miscellaneous Outpatient Expense: If an InsuredPerson incurs expenses for the cost of diagnostic x-raysand laboratory tests, and other reasonable expenses for services or supplies, necessary for treatment of theInjury or Sickness as required by the attendingDoctor for which no other policy benefits are payable,We will pay the Covered Charges incurred.

Multiple Surgical Procedures Expense Benefit:

When Injury or Sickness requires multiple SurgicalProcedures through the same incision, We will payan amount not less than that for the most expensive procedure being performed. Multiple SurgicalProcedures performed during the same operativesession but through different incisions shall bereimbursed in an amount not less than the CoveredPercentage of the Covered Charge of the mostexpensive Surgical Procedure then being performed,and with regard to the less expensive SurgicalProcedure in an amount equal to 50 percent of theCovered Percentage of the Covered Charge for these procedures.

Licensed Nurse Expense Benefit: If by reason of Injury or Sickness, an Insured Person requires theservice of a licensed nurse or licensed practical nurseduring a Hospital Confinement, We will pay theCovered Charges incurred.

Pre-Hospital Medical Emergency Services: When,

by reason of Injury or Sickness, an Insured Personrequires the use of a community or Hospital ambulancein a Medical Emergency, We will pay benefits for theCovered Percentage of the Covered Charges incurredin excess of the deductible shown in the Plan of Insurance. Covered Charges include Pre-HospitalMedical Emergency Services provided by a licensedambulance service. As used in this provision, Pre-Hospital Medical Emergency Services means the prompt evaluation and treatment of a MedicalEmergency condition, and/or non-airbornetransportation of an Insured Person to a HospitalReimbursement for non-airborne transportation will be based on whether a prudent layperson, possessing anaverage knowledge of medicine and health, couldreasonably expect the absence of such transportationto result in: (1) placing the health of the person affected

with such condition in serious jeopardy, or in the caseof a behavioral condition placing the health of such person or others in serious jeopardy; (2) seriousimpairment to such person's bodily functions; (3)serious dysfunction of any bodily organ or part of such person; or (4) serious disfigurement of such person.Ambulance Service is transportation by a vehicledesigned, equipped, and used only to transport the sick and injured from home, scene of accident, or MedicalEmergency to a Hospital or between Hospitals. Surfacetrips must be to the closest local facility that can provide the covered service appropriate to thecondition. If there is no such facility available,

coverage is for trips to the closest facility outside thelocal area. Air transportation is covered whenMedically Necessary because of a life threateningInjury or Sickness. Air ambulance is air transportation by a vehicle designed, equipped and used only totransport the sick and injured to and from a Hospitalfor inpatient care.

Enteral Food Formula Expense Benefit: We will pay

for an Insured Person’s Covered Charges for enteral

formulas when prescribed by a Doctor or licensed

health care provider. The prescribing Doctor or health

care provider must issue a written order stating that the

enteral formula is Medically Necessary and has been

proven as a disease-specific treatment for thoseindividuals who are or will become malnourished or

suffer from disorders, which if left untreated will cause

chronic physical disability, mental retardation or death.

26 27



We cover enteral formulas and food products required

for persons with inherited diseases of amino acid and

organic acid metabolism, Crohn’s Disease,

gastroesophageal reflux with failure to thrive, disorders

of the gastrointestinal motility such a chronic intestinal

pseudo-obstruction and multiple, severe food allergies

which if left untreated will cause malnourishment,

chronic physical disability, mental retardation or death.

We also cover modified solid food products that are

low protein or which contain Medically Necessary

modified protein.

Home Health Care Expense Benefit: When, by

reason Injury or Sickness, an Insured Person incurs

expenses for covered home health care services, We

will pay the Covered Percentage of the Covered

Charges incurred subject to the Deductible shown inthe Plan of Insurance, up to a maximum of 40 visits per

calendar year. Covered Home Health Care are the

services and supplies, to the extent that the charges are

reasonable and customary, subject to the following

conditions: (a) The Home Health Care must be

medically necessary; (b) The Home Health Care must

be provided under a home care plan. This plan must be

established pursuant to the written order of a Doctor;

and (c) The Home Health Care must be provided by a

certified home health agency possessing a valid

certificate of approval issued pursuant to Article 36 of

the Public Health Law; and shall consist of one or more

of the following: (1) Part-time or intermittent homenursing care by or under the supervision of a registered

professional nurse (R.N.); (2) Part-time or intermittent

home health aide services which consist primarily of

caring for the patient; (3) Physical, occupational or

speech therapy is approved by the home health service

agency; or (4) Medical supplies, drugs and medications

prescribed by a physician, and laboratory services by or

on behalf of a certified home health agency to the

extent such items would have been covered under this

Policy if the Insured Person had been Hospital

Confined or confined in a skilled nursing facility as

defined in subchapter XVIII of the federal Social

Security Act, 42 U.S.C. Sections 1395 et seq.Hospice Expense Benefit: If an Insured Person is

Terminally Ill and requires a coordinated plan of home

and inpatient care, We will cover charges for hospice

services furnished to the Insured Person on the same

basis as any other Sickness. The services must be under

active management through a licensed hospice and

approved by Us. Covered Services will include: (a) part-time intermittent home nursing care by or under

the direction of a graduate Registered Nurse; (b)

medical supplies, equipment, and medication required

to maintain the comfort and manage the pain of the

Terminally Ill Insured Person. (c) counseling, including

dietary counseling, for the Terminally Ill Insured

Person; (d) Family Counseling for the immediate

family and the family caregiver before the death of the

Terminally Ill Insured Person; (e) Bereavement

Counseling for the immediate family or family

caregiver of the Insured for at least the 6 month period

following the Insured Person’s death or 15 visits,whichever occurs first.

Nutritional Supplement Expense Benefit: If an

Insured Person incurs charges for nutritional

supplements taken at the direction of the attending

Doctor, and for the therapeutic treatment

of phenylketonuria, branched-chain ketonuria,

galactosemia, or homocystinuria, We will cover such

charges the same way We treat Covered Charges for

any other Sickness. What We pay is shown in the Planof Insurance.

Pre-Admission Test: We will pay benefits for Covered

Charges made by a Hospital for use of its outpatient

facilities for tests ordered by a Doctor. The tests must be performed as a planned preliminary to the Insured

Person’s admission as an inpatient for surgery in that

same Hospital. However: (a) the test must be necessary

for, and consistent with, the diagnosis and treatment of

the condition for which surgery is to be performed; (b)

reservations for a Hospital bed and for an operating

room must be made prior to the date the tests are done;

(c) the surgery actually takes place within five days of

pre-surgical tests; and (d) the Insured Person is

physically present at the Hospital for the tests. No

benefit shall be payable under this provision in excess

of either: (1) the benefits that would have been

provided under this Policy had the Insured Personreceived those tests while confined in the Hospital as a

resident bed-patient; or (2) the Miscellaneous Hospital

Expense Maximum shown in the Plan of Insurance for

28 29



the Miscellaneous Hospital Expense Benefit. If, by

reason of similar benefit provisions elsewhere

contained, the Policy provides for reimbursement for

the same charges, no benefits shall be payable under

these provisions, except to the extent by which the

amount of benefit produced under those provisions for

a given charge exceeds the amount of benefits

produced for that same charge under this provision.

This provision shall apply with respect to the Insured

Person only to the extent that the Insured Person is

insured under this Policy for Hospital Expense

Benefits.

Preventive Service For Adults Expense Benefit: We

cover charges for preventive services expenses for

adults. These are for services rendered to an adult

Insured Person. These services are limited to thefollowing: (1) Abdominal Aortic Aneurysm one-time

screening for men of specified ages who have ever

smoked (2) Alcohol Misuse screening and counseling

(3) Aspirin use for men and women of certain ages (4)

Blood Pressure screening for all adults (5) Cholesterol

screening for adults of certain ages or at higher risk (6)

Colorectal Cancer screening for adults over 50 (7)

Depression screening for adults (8) Type 2 Diabetes

screening for adults with high blood pressure (9) Diet

counseling for adults at higher risk for chronic disease

(10) HIV screening for all adults at higher risk

(11) Immunization vaccines for adults-doses,

recommended ages, and recommended populationsvary: (a) Hepatitis A (b) Hepatitis B (c) Herpes Zoster

(d) Human Papillomavirus (e) Influenza (f) Measles,

Mumps, Rubella (g) Meningococcal (h) Pneumococcal

(i) Tetanus, Diphtheria, Pertussis (j) Varicella (k) HPV

(12) Obesity screening and counseling for all adults

(13) Sexually Transmitted Infection (STI) prevention

counseling for adults at higher risk (14) Tobacco Use

screening for all adults and cessation interventions for

tobacco users (15) Syphilis screening for all adults at

higher risk

Preventive Service For Woman Expense Benefit:

We cover charges for preventive services expenses for

women. These are for services rendered to an womanInsured Person. These services are limited to the

following: (1) Anemia screening on a routine basis for

pregnant women (2) Bacteriuria urinary tract or other

infection screening for pregnant women (3) BRCA

counseling about genetic testing for women at higher

risk (4) Breast Cancer Mammography screenings:(a)

One Mammogram at any age for an Insured Person

who has a prior history of breast cancer or who has a

first degree relative with a prior history of breast

cancer, upon recommendation of a Doctor; (b) One

baseline Mammogram for an Insured Person aged

thirty-five through thirty-nine; and (c) One

Mammogram annually for an Insured Person aged

forty years or older. (5) Breast Cancer

Chemoprevention counseling for women at higher risk

(6) Breastfeeding comprehensive support and

counseling from trained providers, as well as access to

breastfeeding supplies, for pregnant and nursing

women (7) Cervical Cancer screening for women age18 and older (8) Chlamydia Infection screening for

younger women and other women at higher risk (9)

Contraception: Food and Drug Administration-

approved contraceptive methods, sterilization

procedures, and patient education and counseling, not

including abortifacient drugs (10) Domestic and

interpersonal violence screening and counseling for all

women (11) Folic Acid supplements for women who

may become pregnant (12) Gestational diabetes

screening for women 24 to 28 weeks pregnant and

those at high risk of developing gestational diabetes

(13) Gonorrhea screening for all women at higher risk

(14) Hepatitis B screening for pregnant women at their first prenatal visit (15) Human Immunodeficiency

Virus (HIV) screening and counseling for sexually

active women (16) Human Papillomavirus (HPV)

DNA Test: high risk HPV DNA testing every three

years for women with normal cytology results who are

30 or older (17) Osteoporosis screening for women

over age 60 depending on risk factors (18) Rh

Incompatibility screening for all pregnant women and

follow-up testing for women at higher risk (19)

Tobacco Use screening and interventions for all

women, and expanded counseling for pregnant tobacco

users (20) Sexually Transmitted Infections (STI)

counseling for sexually active women (21) Syphilisscreening for all pregnant women or other women at

increased risk (22) Well-woman visits to obtain

recommended preventive services for women under 65.

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Preventive Services For Children Expense Benefit:

We cover charges for preventive services expenses for

children. These are for services rendered to a child

Insured Person. These services are limited to the

following: (1) Alcohol and Drug Use assessments for

adolescents (2) Autism screening for children at 18 and

24 months (3) Behavioral assessments for children of

all ages (4) Blood Pressure screening for children (5)

Cervical Dysplasia screening for sexually active

females (6) Congenital Hypothyroidism screening for

newborns (7) Depression screening for adolescents (8)

Developmental screening for children under age 3, and

surveillance throughout childhood (9) Dyslipidemia

screening for children at higher risk of lipid disorders

(10) Fluoride Chemoprevention supplements for

children without fluoride in their water source (11)Gonorrhea preventive medication for the eyes of all

newborns (12) Hearing screening for all newborns (13)

Height, Weight and Body Mass Index measurements

for children (14) Hematocrit or Hemoglobin screening

for children (15) Hemoglobinopathies or sickle cell

screening for newborns (16) HIV screening for

adolescents at higher risk (17) Immunization vaccines

for children from birth to age 18 —doses,

recommended ages, and recommended populations

vary: (a) Diphtheria, Tetanus, Pertussis (b)

Haemophilus influenzae type b (c) Hepatitis A (d)

Hepatitis B (e) Human Papillomavirus (f) nactivated

Poliovirus (g) Influenza (h) Measles, Mumps, Rubella(i) Meningococcal (j) Pneumococcal (k) Rotavirus (l)

Varicella (18) HPV vaccines for children from age 7 to

age 18 (19) Iron supplements for children ages 6 to 12

months at risk for anemia (20) Lead screening for

children at risk of exposure (21) Medical History for

all children throughout development (22) Obesity

screening and counseling (23) Oral Health risk

assessment for young children (24) Phenylketonuria

(PKU) screening for this genetic disorder in newborns

(25) Sexually Transmitted Infection (STI) prevention

counseling and screening for adolescents at higher risk

(26) Tuberculin testing for children at higher risk of

tuberculosis (27) Vision screening for all childrenProsthetic Appliance And Orthotic Device Expense

Benefit: If, by reason of Injury or Sickness, an Insured

Person requires the use of a Prosthetic Appliance or

Orthotic Device, We will pay the Covered Percentage

of the Covered Charges incurred by the Insured Person

for the purchase, initial fitting, and needed adjustment

of such appliances or devices, as shown in the Plan of

Insurance.

Skilled Nursing Facility Expense Benefit: If an

Insured Person requires continuing treatment in a

Skilled Nursing Facility following hospitalization, We

will pay the Covered Percentage of the Covered

Charges incurred by the Insured Person for treatment in

such Skilled Nursing Facility. The services must be

Medically Necessary as a continuation of treatment for

the condition for which the Insured Person was

previously hospitalized. The Insured Person must be

admitted to the Skilled Nursing Facility within twenty–

four (24) hours following a Medically Necessary

Hospital stay. We cover such charges the same way Wetreat Covered Charges for any Hospital Confinement.Reconstructive Breast Surgery Expense Benefit: Wecover charges for inpatient hospital care for an InsuredPerson undergoing: (a) a lumpectomy or a lymph nodedissection for the treatment of breast cancer; or (b) amastectomy which is covered under this Plan.Coverage is limited to a time frame determined by theInsured Person's Doctor to be medically appropriate.We also cover charges for breast reconstructionsurgery after a mastectomy including: (a) all stagesof reconstruction of the breast on which themastectomy has been performed; and (b) surgery andreconstruction of the other breast to produce symmetry.Surgery and reconstruction will be provided in amanner determined by the attending Doctor and theInsured Person to be appropriate. We treat such chargesthe same way We treat Covered Charges for any other Sickness.

Surgical Expense: We will pay the Covered Chargesincurred for surgery performed by a licensed Doctor (in or out of the Hospital) and expenses in connectionwith a surgery and the Insured Person requires theservices of an anesthetist or assistant surgeon. Benefitswill be paid in accordance with the MDR Schedule(Medical Data Research) survey of surgical fees,

valued at the 80th percentile for Reasonable andCustomary Expense.

Second Surgical Opinion Expense Benefit: We will pay the Covered Percentage of the Covered Charges

32 33



ACCIDENTAL DEATH ANDDISMEMBERMENT

If an Injury sustained while insured results in any of

the following losses within 365 days after the date of the accident, a benefit will be paid in accordance with

the schedule below. If two or more losses occur as a

result of one accident, only one benefit will be paid.

That benefit will be for the loss to which the largest

Benefit Amount applies.

For Loss Of: Benefit Amount:

Life.................................................................$ 10,000

Two Hands or Two Feet or Sight of Two Eyes..$ 10,000

One Hand and One Foot ................................$ 10,000

One Hand and Sight of One Eye....................$ 10,000

One Foot and Sight of One Eye.....................$ 10,000One Hand or One Foot or Sight of One Eye..$ 5,000

Loss of hands and feet means the loss at or above

the wrist or ankle joints. Loss of eyes means total

irrecoverable loss of the entire sight.

This provision does not cover the loss if it in any way

results from or is caused or contributed by: (1)

physical or mental illness; medical or surgical

treatment except treatment that results directly from a

surgical operation made necessary solely by an Injury

covered by this Plan; (2) an infection, unless it is

caused solely and independently by a covered accident;

(3) or participation in felony.

EXCLUSIONS AND LIMITATIONS

The Policy does not cover nor provide benefits for:

1. Expense incurred as the result of dental treatment,except as provided in the Sickness Dental ExpenseBenefit, if included in this Policy, or the DentalCare Expense Benefit Rider. This exclusion doesnot apply to treatment resulting from Injury tosound, natural teeth;

2. Services normally provided without charge by the

Policyholder health service, infirmary, or Hospital,or by Health Care Providers employed by thePolicyholder;

incurred for a Second Surgical Opinion consultation by a board certified specialist on the need for non-emergency surgery, which has been recommended by the Insured Person’s Doctor. The specialist must be board certified in the medical field relating to thesurgical procedure being proposed.

ACE TRAVEL ASSISTANCE SERVICES

Your Student Insurance Plan provides access to ACE’sTravel Assistance Services. These services areavailable on a 24-hour basis worldwide. To accessthese services students simply contact ACE’sAssistance Provider’s multilingual call center at thenumbers below. The following emergency services areincluded in this Plan:

• Medical Assistance including referral to a doctor or medical specialist, medical monitoring whenyou are hospitalized, emergency medicalevacuation to an adequate facility, medicallynecessary repatriation and return of mortalremains.

• Personal Assistance including pre-trip medicalreferral information and while you are on a trip:emergency medication, embassy and consular information, lost document assistance, emergencymessage transmission, emergency cash advance,emergency referral to a lawyer, translator or interpreter access, medical benefits verification

and medical claims assistance.

• Travel Assistance including emergency travelarrangements, arrangements for the return of your traveling companion or dependents and vehiclereturn.

To access ACE’s Travel Assistance Portal go towww.acetravelassistance.com and register your nameusing the Group ID and Activation code: listed below.

Group ID: aceah

Activation Code: security

In the event of an emergency call:1-800-243-6124 toll

free in the USA or Canada; or 1-202-659-7803 collectoutside of the USA.

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3. Eyeglasses, contact lenses, hearing aids, or prescriptions or examinations therefor, except as provided in the Vision Care Expense Benefit

Rider;

4. Injury due to participation in a riot;

5. Injury or Sickness resulting from declared or undeclared war; or any act thereof;

6. Injury or Sickness for which benefits are paidunder any Workers Compensation or OccupationalDisease Law;

7. Injury sustained or Sickness contracted while inservice of the Armed Forces of any country, exceptas specifically provided. Upon the Insured Personentering the Armed Forces of any country, We will

refund the unearned pro-rata premium to suchInsured Person;

8. Treatment provided in a government hospitalunless there is a legal obligation to pay suchcharges in the absence of insurance;

9. Elective Treatment or elective surgery, except asspecifically provided;

10. Cosmetic surgery, except as the result of an Injuryoccurring while this Policy is in force as to theInsured Person. This exclusion shall also notapply to cosmetic surgery, which is reconstructivesurgery when such service is incidental to or follows surgery resulting from trauma, infectionor other disease of the involved body part; andreconstructive surgery because of congenitaldisease or anomaly of a covered Dependent childwhich has resulted in a functional defect;

11. Injuries sustained as the result of a motor vehicleaccident to the extent that benefits are recoveredor recoverable under mandatory no-fault benefitsinsurance;

12. Expense incurred after the date insuranceterminates for an Insured Person except as may bespecifically provided in the Extension of BenefitsProvision, when applicable;

13. For expenses as a result of participation in afelony;

14. Mental health benefits or services for individualswho are presently incarcerated, confined or committed to a local correctional facility or a

prison, or a custodial facility for youth operated bythe Office of Children and Family Services;

15. Mental health benefits or services solely becausesuch services are ordered by a court;

16. Benefits or services deemed cosmetic in nature onthe grounds that changing or improving anindividual’s appearance is justified by theindividual’s mental health needs.

This insurance does not apply to the extent that trade or

economic sanctions or other laws or regulations

prohibit Us from providing insurance, including, but

not limited to, the payment of claims.

APPEAL PROCEDURE

Internal Appeal

If Your claim is denied You will be notified of the

reason with a description of any additional information

necessary to appeal the denial.

If You or Your provider would like additional

information or have a complaint concerning the

denial, please contact the Insurer's Third Party

Administrator, Administrative Concepts, Inc. (ACI) at

1-888-293-9229. ACI will address concerns and

attempt to resolve the complaint. If ACI is unable to

resolve the complaint over the phone, You may file awritten internal appeal by writing to ACI. Please

include Your name, social security number, home

address, policy number, and any other information or

documentation to support the appeal.

The appeal must be submitted within 60 days of the

event that resulted in the complaint. ACI will

acknowledge Your appeal within 10 working days of

receipt or within 72 hours if the appeal involves a

life-threatening situation. A decision will be sent to You

within 30 days. If there are extraordinary circumstances

involved, ACI may take up to an additional 60 days

before rendering a decision.External Appeal

Under New York State Law, You have the right to an

External Appeal ONLY when a claim is denied because

services are not Medically Necessary or the services

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4. Direct all questions regarding benefits available

under this Plan, claim procedures, status of asubmitted claim, or payment of a claim to

ACI. Online claim status is available at

www.visit-aci.com or by calling 888-293-9229.

Select option “2” for Customer Service.

5. Itemized medical bills must be attached to the

claim form at the time of submission. Subsequent

medical bills received after the initial claim form

has been submitted should be mailed promptly to

ACI. No additional claim forms are needed as long

as the Insured Person’s name and identification

number are included on the bill.

6. We strongly encourage you to make copies of all

bills, invoices, and claim forms you submit.

COORDINATION OF BENEFITS

Expenses for an Injury and for a Sickness will be paid

according to the New York State Coordination of

Benefits Provision as outlined in the Master Policy.

REIMBURSEMENT AND SUBROGATION

If the Insurer pays covered expenses for an accident or

injury You incur as a result of any act or omission of a

third party, and You later obtain recovery from the third

party, You are obligated to reimburse the Insurer for the

expenses paid. The Insurer may also take subrogationaction directly against the third party. The Insurer's

Reimbursement rights are limited by the amount You

recover.

The Insurer's Reimbursement and Subrogation rights

are subject to deduction for the pro-rata share of Your

costs, disbursements, and reasonable attorney fees. You

must cooperate with and assist the Insurer in exercising

the Insurer's rights under this provision and do nothing

to prejudice the Insurer's rights.

are Experimental or Investigational AND You or

Your provider must have received a Final Adverse

Determination on Your internal appeal OR You and the

Plan must have agreed to waive the internal appeal process. A "Final Adverse Determination" means

written notification that an otherwise covered health

care service has been denied through the internal

appeal process. If a service was denied as Experimental

or Investigational, You must have a life-threatening or

disabling condition or disease to be eligible for an

external appeal AND Your attending physician must

submit an Attending Physician Attestation form. An

external appeal may only be requested if the denied

service is a covered benefit under the plan. Instructions,

forms, and the fee required for an External Appeal may

be found at:

http://www.ins.state.ny.us/extapp/extappqa.htm

You must file an External Appeal within 45 days of

receipt of a notice of Final Adverse Determination or

within 45 days of receiving notice that the internal

appeal procedure has been waived. An expedited

external appeal will be decided within 3 days of

receiving a request from the state. A standard external

appeal will be decided within 30 days of receiving the

request from the state.

CLAIM PROCEDURE

In the event of an Injury or Sickness the Insured Personshould:

1. Obtain a claim form from:

the MSM Office of Student Life,

St. Luke’s-Roosevelt Hospital Center, or

Administrative Concepts, Inc., ACI, at

888-293-9229 or www.visit-aci.com. Claim

Forms may be downloaded from ACI's website.

2. The physicians and hospitals may submit itemized

bills directly to ACI electronically using Payor #

22384 or mailing them to the address below.

3. Written proof of loss must be given within 90 days

after the date of the loss, or as soon thereafter as

possible. Mail the claim form to Administrative

Concepts, Inc., 994 Old Eagle School Road, Suite

1005, Wayne, PA 19087-1802.

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IMPORTANT NOTICE

ACE Property and Casualty Insurance Company, a

member of the ACE Group of Companies (ACE)maintains that the Student Health Insurance Plan

presented in this brochure is intended to comply with

the requirements of the Patient Protection and

Affordable Care Act (PPACA). ACE continues to

monitor federal and state healthcare reform laws and

regulations to determine any impact on its products.

Should there be any change that requires modification

of this plan, we reserve the right to change the plan and

rates accordingly.

IMPORTANT NUMBERS

GENERAL INSURANCE QUESTIONS

3070 Riverside Drive, Columbus, OH 43221

Phone.............................................800-322-9901Fax..................................................614-481-2400Website........www.cirstudenthealth.com/msmnyc

REFERRAL REQUIREMENT page 3

Insured students will be required to pay a $5copayment per visit at the time of the office visit.All students must make an appointment with:University Medical Practice Associates............................................................877-420-42091090 Amsterdam Avenue, 4th Floor 114th Street at Amsterdam AvenueHours: Monday through Friday.........9 a.m. - 5 p.m.Please call for an appointment.

TRAVEL ASSISTANCE page 34

Toll Free from U.S. and Canada.......1-800-243-6124Call Collect Worldwide..................1-202-659-7803Assistance Portal......www.acetravelassistance.com

PARTICIPATING PROVIDER page 16

For a list of PHCS participants:

Toll Free..............................................800-922-4362Website......................................www.multiplan.com

PARTICIPATING PHARMACY page 17

You will need your current ID number and insurancecard to use the pharmacy benefits and to accessinformation about participating pharmacies.

.............................................800-400-0136Website...........................................www.medco.com

CLAIM ADMINISTRATOR page 38

For claim and benefit questions:ADMINISTRATIVE CONCEPTS, INC.994 Old Eagle School Road, Suite 1005

Wayne, PA 19087-1802 Payor ID # 22384Toll Free.............................................888-293-9229Website........................................www.visit-aci.com

THE SINGLE SOURCE FOR ALL OF YOUR INQUIRIES

DIRECT CONTACT INFORMATION

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865 plan summary booklet 2012-13

Documents