pln ummry · 2019-08-01 · pln ummry underwritten by: national guardian life insurance company,...

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Plan Summary Underwritten by: National Guardian Life Insurance Company, Madison, WI National Guardian Life Insurance Company is not affiliated with Guardian Life Insurance Company of America aka The Guardian or Guardian Life. Policy Number: 2019E4A19 Revised 08/01/2019 4:45 PM Student Health Insurance Plan (SHIP) www.4studenthealth.com/tuca 2019–2020 2019E4A19 – C

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Page 1: Pln ummry · 2019-08-01 · Pln ummry Underwritten by: National Guardian Life Insurance Company, Madison, WI ... Student Insurance Division, Commercial Travelers Building 70 Genesee

Plan Summary

Underwritten by:National Guardian Life Insurance Company, Madison, WI

National Guardian Life Insurance Company is not affiliated with Guardian Life Insurance Company of Americaaka The Guardian or Guardian Life.

Policy Number:2019E4A19Revised 08/01/2019 4:45 PM

Student Health Insurance Plan (SHIP)www.4studenthealth.com/tuca

2019–2020

2019E4A19 – C

Page 2: Pln ummry · 2019-08-01 · Pln ummry Underwritten by: National Guardian Life Insurance Company, Madison, WI ... Student Insurance Division, Commercial Travelers Building 70 Genesee

Important Contact Information and Resources

Insurance CompanyNational Guardian Life Insurance Company, Madison, WI

Policy Number2019E4A19

PPO NetworkTo locate PPO Physicians and facilities, visit the website, or call the number listed.

Cigna, Choice Fund PPOwww.cigna.com

Pharmacy Benefits ManagerThe Pharmacy Benefits Manager for this plan is Express Scripts. Only Prescriptions filled at an Express Scripts Pharmacy are covered.

Express Scripts(800) 447-9638www.express-scripts.com

Benefits and Claims AdministratorFor questions regarding benefits or claims status, contact the claims and benefits administrator.

Relation Insurance AdministratorsP.O. Box 6040Agoura Hills, CA 91376-6040(877) 358-3727Monday–Friday, 8:00 a.m. to 5:00 p.m. (4:00 p.m. on Fridays) Pacific Time

Claims SubmissionFor submitting claims by mail, make a copy of your insurance ID card and the bill(s) and mail to this address within 90 days.

Relation Insurance AdministratorsP.O. Box 6040Agoura Hills, CA 91376-6040Fax: (818) 735-3567

Travel Assistance ServicesScholastic Emergency Services(877) 488-9833 (in the U.S.)Call collect +1 (609) 452-8570 (outside U.S.)Email: [email protected] Number: 01-SES-SUM-08123Available 24/7/365

Plan AdministratorFor questions about eligibility, enrollment, and waivers.

Relation Insurance Services(800) 537-1777Monday–Friday, 8:00 a.m. to 5:00 p.m. Pacific Time

This Plan is Underwritten by National Guardian Life Insurance Company, 2 East Gilman Street, Madison, WI 53703 As Policy Form No.: NBH-280 (2019) CA PPO et al.

For a copy of the Company’s Privacy Notice, you may go to: www.studentplanscenter.com/privacy/NGLIC, or request one from the Health Office at your school, or from the Plan Administrator, or by writing to the address below:

National Guardian Life Insurance Companyc/o Privacy OfficerStudent Insurance Division, Commercial Travelers Building70 Genesee Street, Utica, NY 13502

(Please indicate the school you attend with your written request.)Representations of this Plan must be approved by the Company.

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Touro University, California / 2019–2020 Plan Summary / 3 /

NoticeThis is not the Policy. Rather, it is a brief description of the benefits and other provisions of the Policy. The Policy is governed by the laws and regulations of the state in which it is issued. Subject to Insurance Department Approval. Any provisions of the Policy, as described in this summary, that may be in conflict with the laws of the state where the school is located will be administered to conform with the requirements of that state’s laws, including those relating to mandated benefits.

The information contained in this summary is accurate at the time of publication, but may change in accordance with state and federal insurance regulations during the course of the Policy Year. The most current version of this document will be posted online at the website listed on the cover. In the case of a discrepancy between two versions of the summary, the most recent will apply.

Eligibility and Enrollment

StudentsAll on campus full-time students (6 credit hours or more) who are registered and attending classes at the University, excluding nursing and education students, will be automatically insured under this plan, unless proof of comparable coverage is provided and a waiver is completed and submitted by the Waiver Deadline Date.

All students who meet Eligibility requirements above and who have not waived coverage by the Waiver Deadline Date listed will be automatically enrolled in the plan.

Except in the case of medical withdrawal due to Sickness or Injury, students must actively attend classes for at least the first 31 days of the period for which coverage is purchased. Insureds withdrawing after such period will remain covered under the Policy for the term purchased and no refund will be allowed, except as otherwise specified herein.

The Company maintains its right to investigate student status and attendance records to verify that the Policy Eligibility requirements have been met. If and whenever the Company discovers that the Policy Eligibility requirements have not been met, its only obligation is refund of premium, less claims paid.

DependentsCoverage for Spouse/ Domestic Partner and Child(ren) is not offered under this plan.

ID CardYou will receive your insurance ID card in the mail after the start of your first term of coverage for the year. If you need to seek medical treatment prior to receiving your ID card in the mail, download your insurance ID card from www.4studenthealth.com/tuca.

Carry your ID card with you at all times! You will need your card when you visit the doctor’s office, urgent care, or hospital.

Seeking Medical CareIf you experience an Injury or Sickness:

1. If you need to seek medical treatment, using PPO providers that are part of the Cigna, Choice Fund PPO Network could decrease your costs. For a complete listing of PPO physicians, hospitals, and other facilities, visit www.cigna.com.

2. In case of an Emergency, go to the nearest hospital or call 911.

3. If it is not an Emergency but you need to seek medical treatment right away, using an Urgent Care Center instead of a Hospital ER may decrease your out-of-pocket expenses. To locate a local Urgent Care Center, visit www.cigna.com.

4. After you receive treatment at a PPO provider, your provider will usually submit a claim to the insurance company. You will receive an Explanation of Benefits from Relation, detailing what the insurance paid and what is your responsibility to pay. If you have questions about your Explanation of Benefits or what is your responsibility to pay, please call (877) 358-3727. Do not ignore any medical bills you receive.

5. If your provider bills you directly or asks you to pay up front, you will need to submit a claim.

Please visit www.4studenthealth.com/tuca and see Claims under the USE YOUR INSURANCE section for information about how to submit a claim.

Preferred Provider OrganizationThis plan includes a network of medical professionals, including doctors and hospitals, known as the Preferred Provider Organization (PPO). This PPO

is available through Cigna, Choice Fund PPO Network. If you need to see a provider, you should utilize a PPO provider. While you are allowed to visit any provider of your choosing, if you use a PPO doctor or facility, you will pay less money out-of-pocket.

Network access provides benefits nationwide for Eligible Expenses incurred at 100% of the Preferred Allowance (PA) when treated by network providers (PPO). Benefits are provided worldwide for Eligible Expenses incurred at 60% of Usual & Reasonable Charge (U&R) when treated by non-network providers (non-PPO). Note: Charges in excess of U&R are still the responsibility of the Plan Participant.

Preferred Providers have contracted to provide specific medical care at negotiated prices. The availability of specific providers is subject to change without notice. The Plan Participant should always confirm that a Preferred Provider is participating at the time services are required by checking the Preferred Provider Network website or calling the Preferred Provider Network and by asking the provider when he or she makes an appointment for services. Non-network providers have not agreed to any prearranged fee schedules. You may incur significant out-of-pocket expenses with these providers. Charges in excess of the insurance payment are your responsibility.

Please be aware that if you are treated at a PPO Hospital, it does not mean that all providers at that Hospital are PPO providers. If you are referred by a PPO provider to another provider or facility, it does not necessarily mean that the provider or facility to which you are referred is also a PPO provider. For example, when a network provider refers you to a lab for tests, be sure it is a network lab. This information can be found on the network website.

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Touro University, California / 2019–2020 Plan Summary/ 4 /

Filing a Claim andGetting Your Medical Bills Paid

If the provider does not file a claim directly with the insurance company on your behalf, you will need to complete a claim form in order to be reimbursed (paid back) by the insurance company.

Download a claim form from www.4studenthealth.com/tuca, and send the completed form with all bills and receipts for medical treatment to:

Relation Insurance AdministratorsP.O. Box 6040Agoura Hills, CA 91376-6040

Fill out the form completely so your claim will be processed promptly.

Keep copies of all the documents you submit for claims

To check the status of a claim you submitted, call Relation at (877) 358-3727, Monday–Friday, 8:00 a.m. to 5:00 p.m. (4:00 p.m. on Fridays) Pacific Time.

Premium RefundsPremiums received by the Company are fully earned upon receipt. Refund of premium will be considered only:

1. For any student who does not attend school during the first 31 days of the period for which coverage is purchased. Such a student will not be covered under the Policy and a full refund of premium will be made.

2. For Insured Persons entering the Armed Forces of any country. Such persons will not be covered under the Policy as of the date of his/her entry into service. A pro rata refund will be made for such person upon written request if made within 90 days of withdrawal from school.

Benefit HighlightsActuarial Value: 90.51%Equivalent or next lowest coverage level: Platinum

IN-NETWORK NON-NETWORK

Plan Maximum Unlimited

Coinsurance 100% of PPO Allowance 60% of Usual & Reasonable Charge (U&R)

Preventive ServicesPlease visit www.healthcare.gov/coverage/preventive-care-benefits/for more information about Preventive Services.

100% of PPO AllowanceDeductible, Coinsurance, and Copay do not apply

60% of U&R

DeductibleWaived for services at student health center $250 per Policy Year $500 per Policy Year

Office Visit CopayWaived for services at student health center $20 per visit None

(coinsurance applies)

Urgent Care Copay $20 per visit $40 per Visit

Emergency Service ExpenseCopayment waived if admitted to Hospital

100% of PPO Allowance$150 Copay per visit

100% of PPO Allowance$150 Copay per visit

Out-of-Pocket Maximum

• Includes Copays, Deductibles, & Prescription Drug Copays

• Any Coinsurance paid by the Insured Person is applied to the Out-of-Pocket Limit per Policy Year

• Once the Out-of-Pocket Limit is reached by the Insured Person, the Coinsurance paid by the Company will increase to 100% of PPO Allowance for In-Network services or 100% of U&R for Non-Network services

$4,000 per Policy Year

(CONTINUED)

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Touro University, California / 2019–2020 Plan Summary / 5 /

Benefits listed here have been truncated. See the Certificate or Policy for full information on each benefit, including limitations and included services. Definitions for terms used throughout this summary are included in the Certificate or Policy.

BENEFIT IN-NETWORK NON-NETWORK

Primary Care Visits 100% of PPO Allowance$20 Copay per visit 60% of U&R

Emergency Service ExpenseCopayment waived if admitted to Hospital

100% of PPO Allowanceafter $150 Copay per visit

100% of PPO Allowance, after $150 Copay per visit

Ambulance Service 100% of PPO Allowance 100% of U&R

Inpatient Services (other than Surgery or Maternity) 100% of PPO Allowance 60% of U&R

Surgical Services (Inpatient and Outpatient) 100% of PPO Allowance 60% of U&R

Prescription DrugsIncludes injectable drugs.

100% of PPO Allowanceafter copay

(Deductible waived)

Generic: $20 copayPreferred Brand: $35 copay

Non-Preferred Brand: $60 copay

No Benefit

Rehabilitation Therapy 100% of PPO Allowanceafter $20 Copay per visit

60% of U&Rafter $40 Copay per visit

Preventive ServicesNetwork Provider: The Deductible, Coinsurance, and anyCopay are not applicable to Preventive Services.

Non-Network Provider: The Deductible, Coinsurance, and anyCopay are applicable to Preventive Services providedthrough a Non-Network Provider.

100% of PPO AllowanceDeductible, Coinsurance, and

Copay do not apply60% of U&R

Pediatric Dental Care BenefitRefer to the pediatric vision services and pediatric dental services in the Certificate for a complete list of covered services, including applicable limitations and exclusions.

100% of U&Rfor Preventive Services

Limited to two (2) examsevery 12 months

See Certificate for limitations

100% of U&Rfor Preventive Services

Limited to two (2) examsevery 12 months

See Certificate for limitations

Pediatric Vision Care BenefitRefer to the pediatric vision services and pediatric dental services in the Certificate for a complete list of covered services, including applicable limitations and exclusions.

100% of PPO Allowance 60% of U&R

Accidental Injury Dental Treatment 100% of PPO Allowance 100% of U&R

Benefit Highlights (continued)

Accidental Death and Dismemberment (AD&D) Benefit

Principal Sum for Double Dismemberment or Loss of Life .............................................................................................................. $10,000½ Principal Sum for Single Dismemberment ....................................................................................................................................... $5,000

Loss must occur within 180 days of the date of a covered Accident. Only one benefit will be payable under this provision, that providing the largest benefit, when more than one loss occurs as the result of any one Accident. This benefit is payable in addition to any other benefits payable under the Certificate.

Loss of hand or foot means the complete severance through or above the wrist or ankle joint. Loss of eye means the total permanent loss of sight in the eye. The principal sum is the largest amount payable under this benefit for all losses resulting from any one Accident.

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Touro University, California / 2019–2020 Plan Summary/ 6 /

1. The Policy does not cover loss nor provide benefits for any of the following, except as otherwise provided by the benefits of the Policy and as shown in the Schedule of Benefits.

2. Routine physical or other examinations where there are no objective indications of impairment of normal health or except as specifically provided under the Policy.

3. Medical services rendered by a provider employed for or contracted with the School, including team physicians or trainers, except as specifically provided in the Schedule of Benefits.

4. Dental treatment including orthodontic braces and orthodontic appliances, except as specified for accidental Injury to the Insured Person’s Sound, Natural Teeth or as specifically covered in the Policy under Laboratory Services, Hospitalization – Inpatient Services, Dental Services in Preparation for Radiation Therapy, or Pediatric Dental.

5. Professional services rendered by an Immediate Family Member or any who lives with the Insured Person.

6. Services or supplies hearing aids, except those resulting from a covered accidental Injury or as specifically covered under the Policy.

7. Weak, strained or fl at feet, corns, calluses, or ingrown toenails.

8. Diagnostic or surgical procedures in connection with infertility unless such infertility is a result of a Covered Injury or Covered Sickness.

9. Treatment or removal of nonmalignant moles, warts, boils, actinic or seborrheic keratosis, dermatofibrosis or nevus of any description or form, hallus valgus repair, varicosity, or sleep disorders including the testing for same.

10. Charges of an institution, health service or infirmary for whose services payment is not required in the absence of insurance or services provided by Student Health Fees.

11. Any expenses in excess of Usual and Reasonable charges.

12. Treatment, services, supplies or facilities in a Hospital owned or operated by the Veterans Administration or a national government or any of its agencies, except when a charge is made which the Insured Person is required to pay.

13. Services that are duplicated when provided by both a certified nurse-midwife and a Physician.

14. Expenses incurred during a Hospital emergency room visit which is not of an emergency nature.

15. Expenses incurred after:

a) The date insurance terminates as to the Insured Person; and

b) The Maximum Benefit for each Covered Injury or Covered Sickness has been attained.

16. Elective Surgery or Treatment unless such coverage is otherwise specifically covered under the policy.

17. Charges incurred for massage, in any form, except to the extent provided in the Schedule of Benefits.

18. Expenses for weight increase or reduction except Medically Necessary bariatric surgery, and hair growth or removal unless otherwise specifically covered under the policy.

19. Expenses for radial keratotomy and services in connection with eye examination, eye glasses or contact lenses or hearing aids, except as required for repair caused by a Covered Injury or as specifically covered under the Policy.

20. Expenses incurred for Plastic or Cosmetic Surgery, unless needed to repair conditions resulting from an accidental injury or for the improvement of the physiological functioning of a malformed body member, except for services related to orthognathic surgery, osteotomy or any other form of oral surgery, dentistry, or dental processed to the teeth and surrounding tissue. For the purposes of this provision, Plastic or Cosmetic Surgery means surgery that is performed to alter or reshape normal structures of the body in order to improve the patient’s appearance) In no event will any care and services for breast reconstruction or implantation or removal of breast prostheses be covered unless such care and services are performed solely and directly as a result of a Medically Necessary mastectomy.

21. Treatment to the teeth, including surgical extractions of teeth and any treatment of Temporomandibular Joint Dysfunction (TMJ) other than a surgical procedure for those covered conditions affecting the upper or lower jawbone or associated bone joints. Such a procedure must be considered Medically Necessary based on the Policy definition of same. This exclusion does not apply to the repair of Injuries caused by a Covered Injury to the limits shown in the Schedule of Benefits or to services specifically covered under the Policy.

22. An Insured Person’s:

a) committing or attempting to commit a felony, or

b) being engaged in an illegal occupation.

23. Custodial care service and supplies.

24. Expenses that are not recommended and approved by a Physician.

25. Respite care, day care, recreational care, residential treatment, social services, custodial care or education services of any kind do not qualify as habilitative services.

General Exclusions and Limitations

Exclusion Disclaimer: Any exclusion in conflict with the Patient Protection and Affordable Care Act will be administered to comply with the requirements of the Act.

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Touro University, California / 2019–2020 Plan Summary / 7 /

Key Services • Medical consultation, evaluation and referral

• Hospital admission assistance

• Emergency medical evacuation

• Medical monitoring

• Emergency medical evacuation and repatriation of remains

• Prescription assistance

• Compassionate visit

• Care of minor children

• Emergency trauma counseling

• Lost luggage assistance

• Interpreter and legal referrals

• Pre-trip information

• Return of vehicle

• And much more...

All services must be arranged and provided by SES. No claims for reimbursement will be accepted.

How to Access ServicesIf you require medical assistance and are more than 100 miles from your permanent residence or campus or are in another country, call the SES Operations Center at (877) 488-9833 (inside USA), +1 (609) 452-8570 (outside USA), or email [email protected]. Please download an ID card from www.4studenthealth.com/tuca and carry it with you at all times.

Please provide the following information when you call:

• Your name, telephone number, and relationship to the patient

• Patient’s name, age, gender, reference number, and school

• Name, location, and telephone number of hospital or treating doctor if applicable

• Reference Number 01-SES-SUM-08123

Global Emergency Services

The following services are not part of the Plan Underwritten by National Guardian Life Insurance Company. These value added options are provided by Relation Insurance Services, in partnership with Scholastic Emergency Services.

National Guardian Life complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

(Arabic) بالمجان. تصل برقمإذا آنت تتحدث اذآر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك

.+1 )877 (358-3727 (Chinese-S)

如果您说中文,您可以免费费得语言援助服务。请致电 +1 (877) 358-3727.

(Chinese-T)

如果您使用繁體中文,您可以免費獲得語言援助服務。請致電

+1 (877) 358-3727. (French)

Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le +1 (877) 358-3727.

(French Creole-Haitian)

Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele +1 (877) 358-3727.

(German) Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer +1 (877) 358-3727.

(Italian)

In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero +1 (877) 358-3727.

(Japanese)

日本語を話される場合、無料の言語支援をご利用いただけます。

+1 (877) 358-3727 まで、お電話にてご連絡ください.

(Korean) 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실

수 있습니다. +1 (877) 358-3727 번으로 전화해 주십시오.

(Persian-Farsi) اگر به زبان فارسی گفتگو می کنيد، تسهيالت زبانی بصورت رايگان برای شما فراهم می باشد. با

تماس بگيريد. 358-3727 (877) 1+ (Polish)

Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer +1 (877) 358-3727.

(Portuguese)

Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para +1 (877) 358-3727.

(Russian)

Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните +1 (877) 358-3727.

(Spanish)

Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al +1 (877) 358-3727.

(Tagalog)

Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa +1 (877) 358-3727.

(Vietnamese)

Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số +1 (877) 358-3727.

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Certificate of Creditable CoverageIf you are no longer eligible to be insured under the plan and need to obtain proof of insurance, you may request a Certificate of Creditable Coverage from the Plan Administrator, Relation Insurance Services. This request can be made by phone or in writing, and it must include the name of the school and the name of each person who is no longer eligible to be insured under the plan.

Authorized RepresentationIn accordance with state and federal rules and regulations, we will not disclose individual information without authorization. This includes disclosures to family members for insured individuals who have reached the age of majority. If you would like to authorize an additional party to act as a personal representative for matters pertaining to this insurance plan, we must have an Authorization Form on file. To request a form, please contact Relation at the address below or download a form at www.4studenthealth.com/privacy-policy and mail it to the address below.

Summary of Privacy PolicyIf you are covered under one of our insurance plans, we are committed to protecting your privacy. We strongly believe in maintaining the confidentiality of the personal information we obtain and/or receive about you. We do not disclose any nonpublic information about you to anyone, except as permitted or required by law. We do not sell or otherwise disclose your personal information to anyone for purposes unrelated to our products and services. We maintain physical, electronic, and procedural safeguards that comply with federal and state regulations to protect information about you from unauthorized disclosure. We may disclose any information we believe necessary to conduct our business as is legally required. You have the right to access, review, and correct all personal information collected. You may review this Privacy Policy in its entirety, or the Privacy Policies of other entities servicing the Policy, by writing to the address or visiting the website below. You may also submit a request to review your information, in writing, to the address below.

Marcos Rolon, Privacy Officer Relation Insurance AdministratorsP.O. Box 6040Agoura Hills, CA [email protected]

Plan Administered By Relation Insurance ServicesCA License No. 0G55426

EDUCATION SOLUTIONS