rice university basic plan
TRANSCRIPT
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7/29/2019 Rice University Basic Plan
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Aetna Student Health: Rice University Coverage Period: beginning on or after 8/15/2013Summary of Benefits and Coverage:What this Plan Covers & What it Costs Coverage for: Individual Plan Type: PPO
Questions: Call 1-877-375-7908 or visit us athttp://www.aetnastudenthealth.com/rice. 500499-912071-900196If you arent clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossaryatwww.healthreformplanSBC.com.
Common
Medical EventServices You May Need
Your cost if you use an
Limitations & ExceptionsPreferred Provider
Non-PreferredProvider
If you have outpatientsurgery
Facility fee (e.g., ambulatory surgerycenter)
25% Coinsurance 50% Coinsurance ---none---
Physician/surgeon fees 25% Coinsurance 50% Coinsurance ---none---
If you needimmediate medicalattention
Emergency room services$150 Copay/25% Coinsurance
$150 Copay/25% Coinsurance
---none---
Emergency medical transportation 25% Coinsurance 25% Coinsurance ---none---
Urgent care 25% Coinsurance 50% Coinsurance ---none---If you have a hospitalstay
Facility fee (e.g., hospital room) 25% Coinsurance 50% Coinsurance Requires pre-certification.
Physician/surgeon fee 25% Coinsurance 50% Coinsurance ---none---
If you have mentalhealth, behavioralhealth, or substanceabuse needs
Mental/Behavioral health outpatientservices
25% Coinsurance 50% CoinsuranceCoverage is limited 60 visits perPolicy Year.
Mental/Behavioral health inpatientservices
25% Coinsurance 50% CoinsuranceCoverage is limited to 30 days percondition per Policy Year. Requirespre-certification.
Substance use disorder outpatientservices
25% Coinsurance 50% CoinsuranceCoverage is limited 60 visits perPolicy Year.
Substance use disorder inpatient services 25% Coinsurance 50% CoinsuranceCoverage is limited to 30 days percondition per Policy Year. Requirespre-certification.
If you are pregnant
Prenatal and postnatal care
Prenatal NoCharge, Postnatal -
$20 Copay per visit/25% Coinsurance,Diagnostic Tests-25% Coinsurance
Prenatal andpostnatal - $20
Copay per visit/50% Coinsurance,Diagnostic Tests-50% Coinsurance
---none---
Delivery and all inpatient services
Inpatient-25% CoinsuranceDelivery-25% Coinsurance
Inpatient-50% CoinsuranceDelivery-50% Coinsurance
Requires pre-certification.
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Aetna Student Health: Rice University Coverage Period: beginning on or after 8/15/2013Summary of Benefits and Coverage:What this Plan Covers & What it Costs Coverage for: Individual Plan Type: PPO
Questions: Call 1-877-375-7908 or visit us athttp://www.aetnastudenthealth.com/rice. 500499-912071-900196If you arent clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossaryatwww.healthreformplanSBC.com.
Common
Medical EventServices You May Need
Your cost if you use an
Limitations & ExceptionsPreferred Provider
Non-PreferredProvider
If you need helprecovering or haveother special healthneeds
Home health care 25% Coinsurance 50% CoinsuranceCoverage is limited to 40 visits perPolicy Year.
Rehabilitation services 25% Coinsurance 50% CoinsuranceIncludes physical, occupational, andspeech
Habilitation services 25% Coinsurance 50% CoinsuranceIncludes physical, occupational, andspeech
Skilled nursing care 25% Coinsurance 50% Coinsurance Requires pre-certification.
Durable medical equipment 25% Coinsurance 50% Coinsurance ---none---
Hospice service 25% Coinsurance 50% Coinsurance Requires pre-certification.
If your child needsdental or eye care
Eye exam Not Covered Not Covered ---none---
Glasses Not Covered Not Covered ---none---
Dental check-up Not Covered Not Covered ---none---
Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isnt a complete list. Check your policy or plan document for otherexcluded services.)
Acupuncture Bariatric surgery Cosmetic surgery Dental care (Adult) Dental care (Child)
Glasses Hearing aids Infertility treatment Long term care
Private-duty nursing Routine eye care (Adult) Routine eye care (Child) Routine foot care Weight loss programs
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7/29/2019 Rice University Basic Plan
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Aetna Student Health: Rice University Coverage Period: beginning on or after 8/15/2013Summary of Benefits and Coverage:What this Plan Covers & What it Costs Coverage for: Individual Plan Type: PPO
Questions: Call 1-877-375-7908 or visit us athttp://www.aetnastudenthealth.com/rice. 500499-912071-900196If you arent clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossaryatwww.healthreformplanSBC.com.
Other Covered Services (This isnt a complete list. Check your policy or plan document for other covered services and your costs for these services.)
Chiropractic care
Non-emergency care when travelingoutside the U.S.
Your Rights to Continue Coverage:
Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay yourpremium. There are
exceptions, however, such as if: You commit fraud The insurer stops offering services in the State You move outside the coverage area
For more information on your rights to continue coverage, contact the insurer at 1-877-375-7908. You may also contact your state insurance departmentat1-800-252-3439.
Your Grievance and Appeals Rights:If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. Forquestions about your rights, this notice, or assistance, you can contact Aetna at1-877-375-7908. You may also contact your state insurance department at1-800-252-3439.
Language Access Services:
Para obtener asistencia en Espaol, llame al 1-877-375-7908.Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-877-375-7908.
1-877-375-7908.Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-877-375-7908.
To see examples of how this plan might cover costs for a sample medical situation, see the next page.
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Aetna Student Health: Rice University Coverage Period: beginning on or after 8/15/2013Summary of Benefits and Coverage:What this Plan Covers & What it Costs Coverage for: Individual Plan Type: PPO
Questions: Call 1-877-375-7908 or visit us athttp://www.aetnastudenthealth.com/rice. 500499-912071-900196If you arent clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossaryatwww.healthreformplanSBC.com.
Having a baby
(normal delivery)
Managing type 2 diabetes
(routine maintenance ofa well-controlled condition)
About these Coverage
Examples:These examples show how this plan might covermedical care in given situations. Use theseexamples to see, in general, how much financialprotection a sample patient might get if they arecovered under different plans.
Amount owed to providers:$7,540Plan pays$5,410Patient pays$2,170
Sample care costs:
Hospital charges (mother) $2,700
Routine obstetric care $2,100
Hospital charges (baby) $900
Anesthesia $900
Laboratory tests $500
Prescriptions $200
Radiology $200
Vaccines, other preventive $40Total $7,540Patient pays:
Deductibles $250
Co-pays $60
Co-insurance $1,710
Limits or exclusions $150
Total $2,170
Amount owed to providers:$5,400Plan pays$3,920Patient pays$1,500
Sample care costs:
Prescriptions $2,900
Medical Equipment and Supplies $1,300
Office Visits and Procedures $700
Education $300
Laboratory tests $100
Vaccines, other preventive $100
Total $5,400
Patient pays:
Deductibles $250
Co-pays $620
Co-insurance $550
Limits or exclusions $80
Total $1,500
This isnot a costestimator.
Dont use these examples to
estimate your actual costsunder this plan. The actualcare you receive will bedifferent from theseexamples, and the cost ofthat care will also bedifferent.
See the next page forimportant information aboutthese examples.
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